Newly Diagnosed CDK Kitty - Lexi

[rabernet]

Hi folks - I introduced Lexi as a kitten in 2008 and here we are almost 15 years later and she has been diagnosed with CKD. This isn't my first "rodeo" with a CKD kitty - but it's been 8 years, so I'm re-learning what we face ahead of us. It was a quick decline for my other CKD kitty, but Lexi actually seems to be improving. This may be long, but what I'm hoping for is some feedback on questions I should ask our vet when she goes back on Monday the 13th.

A little background about the vet. This is the same office that treats my two golden retrievers, and I adore their vet, but usually have to get on a wait list to see him. He is the owner of the hospital and has quite a large staff of other vets - from holistic vets to cat vets - in fact - the cats have their own clinic in a separate building - but walking distance. So, her first visit, she got whoever was available (it was a matter of calling Monday morning and getting an appointment for the afternoon). Her first visit was on 1/23 and then she was supposed to go back in 2 weeks for a follow up - but this vet called and asked me to come back a week later for a follow up. This vet is a very young new vet. She wanted Lexi to come back on the 13th. As I was about to leave, I realized we hadn't scheduled that and went in and they asked who I wanted to see. What? Is Dr. Zack available in two weeks? He's my normal vet. Yes - so I'm also going to be getting a second opinion. Anyway - the history.

Two weeks ago tomorrow - Lexi had thrown up 2 x during the night. All day on Sunday, she was very lethargic, and she slept on the stairs going to our bonus room. She had been losing some weight, but she's always been a small cat who is very picky with food. I spent so much money trying different foods to tempt her to eat - she feel in love with Reveal shredded chicken - and would also nibble on some kibble. I know that Reveal canned isn't considered a complete meal, so was trying to find some kibble for her to eat - but she turned most everything down. I even broke down and got "junk food" Meow Mix.

Take her in and they do a blood panel and exam. Kidneys feel a little small. We also did an x-ray, because the liver values were elevated as well. The x-rays were sent to a radiologist - no cancer was detected. Her white blood cells were quite high - so she was given a 14 day antibiotic injection, a few cans of Royal Canin loaf and a bag of Royal Canin dry. Also a shot of Cerenia.

By that evening, she had eaten about a 1/4 cup of the Royal Canin S (dry) and some of the Royal Canin loaf. The next day she didn't eat all day. I called the vet, asked if they could prescribe some more Cerenia and asked if there was such a thing as an appetite stimulant - and they prescribed transdermal Mirataz. Why didn't any vet recommend that when I went though this 8 years ago, watching my cat waste away? We were even at a cat only clinic back then (we lived in a different city then). I underestimated the fight in my girl when I tried to give her the Cerenia - we did three fighting matches until I was able to get it in her.

The Mirataz definitely did its job - she was on me every time I turned over in the middle of the night "oh hi! Are you awake? Isn't it time to get up and feed me???" Within a week, she gained 1/2 a lb. We also tried the other two canned Royal Canin as well as the Hills stews. She really likes the stews.

OK - so what bothered me about this vet was she was always asking me if I just want to do palliative care with her, did I want to hospitalize her, do I want to do an ultrasound - but could never articulate to me why she wanted to hospitalize and for how long, why did she want me to do a $400 ultrasound and what information it would give us and would it change her current treatment plan, etc. All her values had improved in one week except for the liver values which worsened - but she also said that could be because she had eaten in the previous hour before coming in. This is why I'm very happy that she gets to see the vet I have a good relationship with and who has years of experience over her (she's a recently graduated vet - not to discount that - I just prefer more experience in this case).

Related to the infection
WBC
First reading 26.74
A week later 15.56 - back in normal range

Neutrophils
First reading 10.35
A week later - still elevated at 10.31 - should be below 10.29 according to the paperwork

Lymphocytes
First reading 13.20
A week later 4.49

Monocytes
First reading 2.55
A week later .23

Basophils
First reading .32
A week later .10

Regarding kidney disease
Creatinine .
First reading 2.9
A week later 2.3

BUN
First reading 58
A week later 47

I am not sure which value is liver - there are tons (to me) of all sorts of other readings and I forget which one she said was liver. Maybe the ALP? It went from 59 to 144, but the jaundice was improving/fading in one week.

At some point she said that the undetermined infection (as in - we don't know what the infection is/was) could have raised both kidney and liver values.

She has me giving Lexi 100 ml of Ringers lactaid a day, and other than that - no medication other than the Cerenia and Mirataz - I haven't given Mirataz since last Monday - but she's starting to eat a little less this weekend - so I'm about to give her a dose this morning.

I know this is LONG - and if you've read it all - you are a super star! I am familiar with Tanya's website and have been re-familiarizing myself with it and going down tons of rabbit holes.

If you were me - what questions should I ask my favorite vet in a week? Is there a benefit to hospitalizing her for IV fluids that I'm not aware of? Is there a benefit to her long term care to spend $400 for an ultrasound? The original vet couldn't articulate WHY she recommended it when she basically told me that there's not much we can do other than keep her comfortable for however long she has.

Sadly - money IS a concern - we've already spent over $1000 in just a week of visits. This economy isn't helping my wallet - but I need to understand whether treatments/tests are actually something that will help her improve - or whether I need to focus more on supportive care with hopes of best case scenario of a year or more of happy and relatively healthy life.

She's our princess, with princess rules (there are no rules - other than the ones she makes). We feel encouraged that she seems to be feeling so much better, is acting like her old self - bossing the goldens around, holding their muzzles in her paws while she grooms their faces, smacking them in the face when they sniff her a little too long for her liking, following me around the house, demanding to be fed frequently, walking all over me in the middle of the night with her "oh hi - you're awake?" routine.

 

[Furballsmom]

Hi
I don't recall that we did an ultrasound when my angel Poppycat got triaditis back in 2019. I'm not saying that's what's happening here, but looking at the numbers my thought -- although I'm not a vet, is that your baby needs support for the liver with denamarin or milk thistle (I think there's a liquid denamarin available now). Regarding the hospitalization, hopefully not but see what your other vet thinks.


Anyway, your new vets' comments sound just like the one we had to deal with in a very difficult situation, which just made things that much more difficult. I'm glad you're able to see the more experienced vet.

 

[rabernet]

Hi
I don't recall that we did an ultrasound when my angel Poppycat got triaditis back in 2019. I'm not saying that's what's happening here, but looking at the numbers my thought -- although I'm not a vet, is that your baby needs support for the liver with denamarin or milk thistle (I think there's a liquid denamarin available now). Regarding the hospitalization, hopefully not but see what your other vet thinks.


Anyway, your new vets' comments sound just like the one we had to deal with in a very difficult situation, which just made things that much more difficult. I'm glad you're able to see the more experienced vet.

Thank you for your feedback, I'll definitely ask my vet about denamarin. Is milk thistle something I can get without a subscription and is there some place to find out doseage? Or should I just wait a week to discuss with my vet first? My brief search for denamarin doesn't yield any results of liquid form. I'd rather not pill her - she has a LOT of fight in that little body.

 

[Twylasmom]

If they rerun bloodwork at the next visit they need to check phosphorus and potassium levels and do a urinalysis to follow up on infection and get a USG level. Even if the phosphorus falls in the higher end of normal range you will want to bring it down through feeding lower phos foods and/or using a phosphorus binder. Controlling phosphorus can go a long way in making kitty feel better and put less stress on the kidneys. Use the tables on Tanya’s CRF site and pick out some samples of different foods to try. You may find she will tire of the renal foods over time.

Is your Cerenia in pill form? If so put it in a small gel cap (size 4 or 5, 5 is smallest) to administer it because it is absolutely foul tasting. There is nothing wrong with giving it long term if needed, same with the Mirataz.

An ultrasound can be useful in assessing the kidneys and liver, but may not be needed to determine treatment. Twyla had an ultrasound when she was diagnosed revealing she has big kidney/little kidney but it didn’t impact her treatment plan. I don’t know much about the liver, though. Twyla’s ALT (liver values) were high when she was first diagnosed with CKD, but gradually went back to normal range.

If you are giving fluids every day and her hydration level is good I don’t see any reason for her to be hospitalized for IV fluids, unless she needs some kind of additional treatment, since she shows improvement on lots of her values.

 

[FeebysOwner]

Hi. It is my guess that the ultrasound would probably be more for taking a look at the liver. ALT, ALP, bilirubin are probably the primary numbers for liver, although there are others, but they are deemed less 'meaningful', as I understand it.

Palliative care, technically speaking, is really what is given to all CKD cats considering the condition is progressive and incurable - so, I don't know if that is what the vet meant by using that term. If you are getting up to speed with Tanya's web site, you will find what you are already doing is a great start for slowing CKD progression/symptoms, and her site will give you even more 'arsenal' for helping.

I would first start by clarifying why the vet used the term, and I think how they answer will probably pave the way for the next set of questions you might need to ask. It could have been used relative to the liver, in the sense that additional testing may be needed to determine exactly what is going on and what that would mean for potential treatments. In my mind, not doing additional testing in the hopes of finding an issue that is treatable, and only offering supplements to support the liver could be considered palliative care too.

I don't have direct personal experience with denamarin or milk thistle, but this is what I know:
Denamarin contains two ingredients - SAM-e (S-adenosylmethionine) and silybin, the latter being a component of silymarin, which is found naturally in milk thistle. Giving it with food can decrease the absorption of SAM-e, so while it can technically be put into food, it might lose some of its efficacy. There is a chewable version, but it does appear to be only for dogs - however, you could ask your vet about it and if they have administered it to cats.

This supplement combination can also be compounded into a liquid, so that might be something to consider if the tablet/pills don't work out.

There is also a SAM-e only pill (Denestra) that might be much smaller in size and you could ask the vet about it and giving milk thistle separately - it does seem the milk thistle can be given with food and not lose effectiveness.

 

[rabernet]

If they rerun bloodwork at the next visit they need to check phosphorus and potassium levels and do a urinalysis to follow up on infection and get a USG level. Even if the phosphorus falls in the higher end of normal range you will want to bring it down through feeding lower phos foods and/or using a phosphorus binder. Controlling phosphorus can go a long way in making kitty feel better and put less stress on the kidneys. Use the tables on Tanya’s CRF site and pick out some samples of different foods to try. You may find she will tire of the renal foods over time.

Is your Cerenia in pill form? If so put it in a small gel cap (size 4 or 5, 5 is smallest) to administer it because it is absolutely foul tasting. There is nothing wrong with giving it long term if needed, same with the Mirataz.

An ultrasound can be useful in assessing the kidneys and liver, but may not be needed to determine treatment. Twyla had an ultrasound when she was diagnosed revealing she has big kidney/little kidney but it didn’t impact her treatment plan. I don’t know much about the liver, though. Twyla’s ALT (liver values) were high when she was first diagnosed with CKD, but gradually went back to normal range.

If you are giving fluids every day and her hydration level is good I don’t see any reason for her to be hospitalized for IV fluids, unless she needs some kind of additional treatment, since she shows improvement on lots of her values.

She is on renal food now (for 2 weeks). The Hills is the renal as is the Royal Canin. She turned up her nose to dry and is exclusively canned now - so I'm rotating between Royal Canin and Hills canned. I'm actually glad she's off the dry - Chewy refunded me and I dropped it off at a cat rescue near me (and spent an hour visiting the cats - it's house that every room has furniture and kitties!!!).

They did do a urinalysis last week - I need to ask about that next week - I was feeling information overload at the time.

Phosphorus
First reading 5
A week later 3.6

Calcium
First reading 10.5
A week later 10.4

Potassium
First reading 4.9
A week later 4.3

Both weeks on those three were in normal levels. I will definitely look into getting those gel caps ordered!

 

[rabernet]

Hi. It is my guess that the ultrasound would probably be more for taking a look at the liver. ALT, ALP, bilirubin are probably the primary numbers for liver, although there are others, but they are deemed less 'meaningful', as I understand it.

Palliative care, technically speaking, is really what is given to all CKD cats considering the condition is progressive and incurable - so, I don't know if that is what the vet meant by using that term. If you are getting up to speed with Tanya's web site, you will find what you are already doing is a great start for slowing CKD progression/symptoms, and her site will give you even more 'arsenal' for helping.

I would first start by clarifying why the vet used the term, and I think how they answer will probably pave the way for the next set of questions you might need to ask. It could have been used relative to the liver, in the sense that additional testing may be needed to determine exactly what is going on and what that would mean for potential treatments. In my mind, not doing additional testing in the hopes of finding an issue that is treatable, and only offering supplements to support the liver could be considered palliative care too.

I don't have direct personal experience with denamarin or milk thistle, but this is what I know:
Denamarin contains two ingredients - SAM-e (S-adenosylmethionine) and silybin, the latter being a component of silymarin, which is found naturally in milk thistle. Giving it with food can decrease the absorption of SAM-e, so while it can technically be put into food, it might lose some of its efficacy. There is a chewable version, but it does appear to be only for dogs - however, you could ask your vet about it and if they have administered it to cats.

This supplement combination can also be compounded into a liquid, so that might be something to consider if the tablet/pills don't work out.

There is also a SAM-e only pill (Denestra) that might be much smaller in size and you could ask the vet about it and giving milk thistle separately - it does seem the milk thistle can be given with food and not lose effectiveness.

When she asked me if I just wanted to do palliative care - it was with a very sad sympathetic face - it felt like "do you want to give up on her and just keep her comfortable"?

And like I mentioned above - she's not very good at articulating why she is recommending something. I had to ask for the urinalysis on the second visit. I don't know why she didn't do it on the first when we knew we had some sort of infection.

 

[Furballsmom]

Is milk thistle something I can get without a subscription and is there some place to find out doseage? Or should I just wait a week to discuss with my vet first? My brief search for denamarin doesn't yield any results of liquid form.

Milk thistle is available without a prescription. I obtained a powdered product with no/few other ingredients. The dosage is on the container. I added it to my angel Poppycat's food.

This is what I found in liquid form;
MILK THISTLE/SAME COMPOUNDED Oral Liquid Tuna Flavored for Dogs and Cats, 9-mg/90-mg/mL, 30 mL - Chewy.com

 

[rabernet]

Oh man - four flavor choices! Is there a forum consensus which flavor most cats seem to prefer?

 

[FeebysOwner]

That option above is prescription, btw. I think you can safely rule out marshmallow (LOL)! If your cat likes fish, tuna might be the way to go (that would be a bomb with my cat). Chicken, and then last beef (although that would likely work best with my cat). That's my input!

 

[Furballsmom]

Here's the one I was using for Poppycat:
https://www.chewy.com/herbsmith-her...G2jnfCqJxNyDNYp85HkyO4XRE_92qZHhoC--IQAvD_BwE

 

[rabernet]

Here's the one I was using for Poppycat:
https://www.chewy.com/herbsmith-her...G2jnfCqJxNyDNYp85HkyO4XRE_92qZHhoC--IQAvD_BwE

For some reason, that link won't open for me, even when I copy and paste it. From what I can read in the link - I think it's the same I ended up ordering yesterday afternoon?

 

[rabernet]

That option above is prescription, btw. I think you can safely rule out marshmallow (LOL)! If your cat likes fish, tuna might be the way to go (that would be a bomb with my cat). Chicken, and then last beef (although that would likely work best with my cat). That's my input!

I ended up deciding on the powdered version - if she won't eat food with it sprinkled on - I did also order empty gel caps that I can give that way (got size 5). Surely 1/8 tsp would fit I'm guessing? If not - I'll order size 4.

 

[rabernet]

The replies here have me realizing other items I needed to have on hand.

Ordered from Amazon empty gel caps, a pill popper, Equadose pill splitter I saw on another thread, 5 ml oral syringes (also want to try the A/D idea for getting medications in - waffled between 5 and 10 ml before settling on 5 ml).

From Chewy I ordered the milk thistle powder, some greenie pill poppers and a cat toy for the princess.

 

[Furballsmom]

think it's the same I ended up ordering yesterday afternoon?

That's the one (sorry about the tech fail).

 

[rabernet]

That's the one (sorry about the tech fail).

No worries! It worked on my personal laptop - but would not work at all on my work laptop (even though I've ordered from Chewy before - even today - during my lunch hour).

 

[epona]

When my Jakey was first diagnosed with kidney disease, he also had liver readings that were a bit off - the vet suggested an ultrasound which we had done, that showed an inflamed pancreas, so it was pancreatitis causing the odd liver readings, rather than problem with the liver itself.
It was the ultrasound that was able to get to the bottom of that.

Jakey still has kidney disease of course and chronic pancreatitis, we are managing his kidney issues with fortekor pill once a day and know to watch out for signs of a pancreas flare-up in case that needs treatment at any point (it can be painful and cause lack of appetite and vomiting if it flares up).

I don't know how long he has left, he's 16 now and obviously elderly but still enjoys his food and a cuddle. I've more or less decided now that when he declines (which he will eventually from the kidney disease despite the medication he is on to slow it down, if something else doesn't go wrong first) that I will give palliative care at home or euthanasia if it is at a point where he is suffering but it is unlikely now I think that I would go into loads of tests - sadly we all have to go sometime and he is elderly and has incurable health conditions.

I do wonder whether the suggestion of ultrasound was to check which it was out of liver or pancreas that was inflamed/deficient and causing the liver numbers to be off, because the management of each is different.

 

[rabernet]

When my Jakey was first diagnosed with kidney disease, he also had liver readings that were a bit off - the vet suggested an ultrasound which we had done, that showed an inflamed pancreas, so it was pancreatitis causing the odd liver readings, rather than problem with the liver itself.
It was the ultrasound that was able to get to the bottom of that.

Jakey still has kidney disease of course and chronic pancreatitis, we are managing his kidney issues with fortekor pill once a day and know to watch out for signs of a pancreas flare-up in case that needs treatment at any point (it can be painful and cause lack of appetite and vomiting if it flares up).

I don't know how long he has left, he's 16 now and obviously elderly but still enjoys his food and a cuddle. I've more or less decided now that when he declines (which he will eventually from the kidney disease despite the medication he is on to slow it down, if something else doesn't go wrong first) that I will give palliative care at home or euthanasia if it is at a point where he is suffering but it is unlikely now I think that I would go into loads of tests - sadly we all have to go sometime and he is elderly and has incurable health conditions.

I do wonder whether the suggestion of ultrasound was to check which it was out of liver or pancreas that was inflamed/deficient and causing the liver numbers to be off, because the management of each is different.

I'm glad that Jakey is doing well! If my trusted vet recommends US also - I will most likely go forward with that.

She is doing so well right now - gaining weight, demanding food every time I walk by the kitchen table (which is where her food bowls are - to keep the dogs from eating it). I have to give her small amounts at a time, because she will just lick gravy and not eat the meaty parts otherwise. If I give her small amounts, she'll clean her dish. Then I offer her a little more. Thankfully I work from home four days a week (today is my office day) and am happy to be her servant. LOL

 

[rabernet]

Hi all - well - the news isn't great with Lexi - though if we didn't have bloodwork, I'd think she was doing well. She's eating about 2 cans of renal food a day, she's interacting with us, has put on a little weight (which my favorite vet said is not something he sees with most CKD kitties). She does sleep a lot, mostly on me as I work from home four days a week and in office one day a week.

Her kidney values continue to improve and her phosphorus was 5.1. BUN has dropped from 58 to 47 to 39. Creatinine has dropped from 2.9 to 2.3 to 2.2. Her ALT though.....386 to 599. Cholesterol has gone from 215 to 325. I don't know which one is pancreas - but he did a specific test for it - maybe it's Spec IPL? It's 6.1 and he said it's inflamed.

So - he had Ursodiol 60mg compounded (there may be a letter before the U - looks like there may be a bit of tape over the first letter. She's to get 1/2 ml once a day. He's added Denamarin once a day on an empty stomach, and he wanted to get her on another round of antibiotics. I asked him if as a shot, was it administered subQ - and if so - could he just give me the injectable 14 day dose instead of me having to fight to get 2 pills a day in her (antibiotic and Denamarin). He agreed, and I've already administered the shot, subQ. He didn't want me to bring her in just for the shot, he wants to minimize her stress level.

He also said he wants her to eat as much as I can get into her every day - he doesn't even care at this point if it's renal food - though she's enjoying the Royal Canin T morsels. Although the D morsels look the same to me - she definitely prefers the T. I have to give her 1/2 tsp at a time though - otherwise, she'll lick the gravy and leave the morsels. If I just feed her 1/2 tsp at a time - like every 5 minutes (again - thankfully work from home) - she'll eat the morsels as well as the gravy. Any more at a time, she'll leave morsels behind. He said if she'll eat the renal food, keep feeding it to her - otherwise, he wants her eating, even if that means grocery store canned.

I know I've seen people say on here, but forgot to notate it - but is it Fancy Feast that many cats can't resist? And what flavor?

If there's any other information from bloodwork - let me know - I can share. We talked about ultrasound, but he said he didn't feel that it would change our current treatment protocol, and he knows we've spent a lot already (US would be $400 plus). She is also on 100 ml of ringer's lactaid (sp?) every day - which is why he was comfortable sending me home with the injectable antibiotic. The antibiotic is Covenia. I'll start the Demarmarin tomorrow morning on an empty stomach, as she's been eating all day.

Anyone know how long after last meal is considered an empty stomach? She'll eat small meals for 2 hours in the morning, then nap, ask for more food around noon, eat small meals for an hour, nap and ask for more food around 5 or 6 pm - again, small meals for about an hour - then sleeps all night until 3:30 when I get up. I've been giving her an all you can eat buffet - as long as she'll eat, I'm her faithful servant at her service.

 

[Mac and Cats]

I don't know if I'll be able to help much, as I'm not knowledgeable in the lab numbers, etc. and I don't know what any of these medications you mentioned are except the fluids. I can give a few suggestions in terms of food though. Have you tried mashing up the renal food? My kitty that passed away last year ate the same food and did the same thing. I started mashing up his food with a fork and he would then eat it instead of licking all the gravy off. For Fancy Feast, honestly, you could try any flavor. I think that food is like crack to cats. Our cats will eat almost any flavor. I know some of the gravy lovers and the grilled versions are "lower" in phosphous. There are several of the petite version that are "lower" as well (but not the pate in either the cans or the petites, they can be higher in phosphorus). Have you checked to see if you can find any of the Weurva low phosphorus foods? My cats have liked several of the flavors. If you can find them locally, you could try a few of those? Maybe try the pate as the other kind is more shreds and our cats tend to leave the shreds. I would recommend mashing the pate up with a fork too as it's sort of like "meat jello". There are also a lot of foods that are lower in phosphorus that you could try. Here is a good resource that may help. Weurva and Hills are really easy to find the phosphorous numbers on their website. Weurva, you just go to the food you want to look at, then "view product nutrition info" and then scroll down to "Detailed Nutrition Information" on the left of the screen. Hills is similar, but you just click nutrition information or something like that and you can see the phos amount in the foods. She may like the Weurva BFF OMG (oh my gravy) flavors if she likes gravy stuff. I can find Weurva at the smaller local pet shops in my area. If you just want her to eat and don't want to worry about the phosphorus right now, I'd honestly just grab any of the fancy feast options. I haven't had our cats turn any of those down except when they were sick due to unrelated reasons.

Also, for an empty stomach, the general rule when a cat needs an x-ray or ultrasound and needs to have an empty stomach is 12 hours without food, but I don't know how "empty" they need to be for medication. Probably not 12 hours. Can you call your vet and ask what "empty" would mean in terms of hours when she last ate? My guess would be overnight would probably be fine. I would have really hesitated to do 12 hours with no food for my boy. So, I probably would have just picked up the food before I went to bed and then given it to him first thing in the morning (6-8 hours).

So sorry I can't be more helpful, but I hope that helps. I'm sorry you're going through this. I would have done just about anything to keep my Bubby around for as long as possible and I did everything within my power to do so. Good luck to you and I hope her numbers improve!