# Fluid Treatments in CRF cat?



## Sammy1 (May 19, 2010)

I’m new to this site, I’m seeking a little support or guidance in with my cats health problems. 

I have a 5 year (approximately - pound find) old fixed female cat. She is a little runt of a thing, and about a month ago I noticed how thin she had gotten. She is about 6 pounds normally but had gotten very bony. I brought her to the vet and realized that she had lost a pound in the last month (20% of her weight!). I cannot believe she lost that much and it took me so long to bring her in, but she has always been super slender.

The vet found a heart murmur that was not there 6 months earlier. We did a bunch of tests on the blood and urine and got the results 4 days later. She lost another .3 pounds in that time and I found out she has Chronic Renal Failure (CRF).

The vet said she has the liver of a 15 year old cat (she is 5), her potassium is low, and her phosphate is high. Blood pressure holding good at this time. I have also started her on an antacid to help with the appetite. The vet said that we will wait on the other medicines until we can stop the weight lose and hopefully get her to put some more weight on.

She eats ok, and now I give her wet food twice daily to help keep her hydrated, and she can self feed on dry food all day, both are for CRF. She drinks normal, litter box is normal too. Her behavior is normal all the way around and if she had not lost weight I would still not know about any of this.

She is not dehydrated, and her urine is very diluted. The vet has told me that the fluid treatments would be a good thing at least twice a week, but if I’m not comfortable with it then that’s ok too. They gave her one while we were at the vet, I can’t say that I noticed any difference since. 

The vet said that we would be very lucky to get a year out of her, assuming the weight loss gets under control, and that we get her on medication that she response to. The murmur is not something the Vet thinks we should bother with, that it is not worth putting the cat through the tests.

I really don’t want to spend the last of her days with her thinking that every time I grab her she is getting stuck with a needle, but I also want all the time (good) I can get with her. We are not at the point of putting her down; again she behaves like normal, but is so skinny.

Do you truly believe that this is so important and worth it that even in a cat that is not currently dehydrated it is worth it? Any advise wourl be great - thanks


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## laurief (Jun 22, 2008)

Welcome to the Cat Forum. I am sorry for the circumstances that have brought you here, but I'm glad you found us. Several of us have experience with CRF, myself included. I have cared for three CRF cats over the last few decades, so I'm very well acquainted with this disease and its accompanying conditions and treatments.

First, I want you to know that CRF is by no means an immediate death sentence. Yes, it is currently incurable, but there is a great deal that can be done to manage the disease and maintain a good quality of life for your cat, sometimes for a number of years. One of my CRF cats died at nearly 23 yrs of age, about 4 yrs after CRF diagnosis. Another died a couple of weeks ago at 20+ yrs of age, about 2 1/2 yrs after diagnosis with both CRF and hyperthyroidism. He also developed skin cancer, hyperparathyroidism, and who knows what else. The point being that with prompt and proper management, CRF cats can live happy, reasonably healthy lives for possibly years to come. So don't panic. Things may not be as dire as you fear for your girl.

A CRF diagnosis can be very overwhelming, I know, and learning about CRF can be even more overwhelming. This is a complex disease that can have effects on all body systems, not just the kidneys, so there's lots to learn and potentially lots to manage. But you don't need to learn or do it all at once. You already know specific areas of concern for your cat right now - low potassium, high phosphorus, weight loss, and something funky going on with her liver. So those are the areas in which you should concentrate your efforts first. 

Here is a link to a comprehensive site on feline CRF that many of us CRF caretakers consider to be our "bible". It provides information on virtually every aspect of CRF, its associated conditions and concerns, and their management or treatment. Bookmark this site and return to it often. Read as much of it as you can handle, then go back and reread and reread and reread. You may find that 90% of what you read goes right in one eye and out the other at first, but the more times you read through this site's pages, the more of it will sink in and "stick". I've been dealing with CRF on and off for well over a decade, and I still refer back to this site several times a week and keep learning new things from it. It's invaluable.

http://www.felinecrf.org/

I also strongly recommend you join the CRF Support Mailing List linked below. This list has a very large membership of folks who have been around the block and back with this disease. They are a phenomenally knowledgeable group of folks who are always willing to listen to your concerns, offer support, and answer questions - often answering questions that even your vet can not. Even if you aren't comfortable posting on the list right away, you'll be amazed how much you can learn just by reading other members' posts and responses.

http://groups.yahoo.com/group/Feline-CRF-Support/

Calcitriol is a CRF treatment with which many vets are unfamiliar, but it can have very positive effects on CRF cats, so it'd be worth your time to join the Calcitriol mailing list as well, just to read up on it:

http://groups.yahoo.com/group/Calcitriol/

One of the things that you'll need in order to get the best possible advice from online resources like those linked above are copies of all of your cat's test results. You will need to know your cat's specific blood and urine values to make sense of a lot of the CRF information you read, so if you don't already have them, get copies of all of the tests from your vet. When you get those results, make sure they include the lab's reference ranges so that you can put your cat's values into proper perspective.

If you already have your cat's test results, please post them to this thread. That'll help us see just how far off from normal her values are right now, and that'll also help us offer more useful opinions regarding her need for fluids and/or other treatments. Without seeing her test results, those sorts of opinions and suggestions would only be uneducated and perhaps even counterproductive guesses.

That said, I can tell you that a CRF cat with low potassium NEEDS potassium supplementation, and high phosphorus NEEDS to be lowered with diet and/or phosphorus binder. 

I will post more later and will happily answer, or try to answer, any questions you may have. In the meantime, please get and post her test results here so we can see where she stands at the moment. 

Take a deep breath. CRF is a rocky ride, but like every roller coaster, it's got its highs and lows. Let's see if we can help you find your way up to the highs.

Laurie


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## Sammy1 (May 19, 2010)

I will post the lab results as soon as can get a copy from the vet. Thank you so much, I'm surfing one of your recommended sites now.

I have been watching every bite she eats lately and worry about every one, if it’s enough or not, why is she not eating right this very second. I’m so worried about her losing more weight. I will be weighing her again early next week to see if she has dropped more or (pray and hope) she might have actually gained some back.

She is on the CRF diet, and an antacid mixed in to the food. The vet discussed the Calcitriol option, but her phosphate is just too high at this moment to start her on it. She will go on a potassium supplement and a phosphorus binder soon; we had hoped the weight loss would stop. But the more I read the more I think that perhaps I need to start the meds.

This cat does eat, but continues to lose weight. I had a roast last night and she was turning herself inside out to get some, and I gave her some, but then I thought OMG, this is nothing but protein. I’m so torn, I want her to gain the weight as does the vet, but I feel as though I am doing nothing right now as she wastes away. The vet said that if we cannot stop the weight lose the meds will not matter. But if the binders can help her feel better, maybe she will eat more.


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## laurief (Jun 22, 2008)

Sammy1 said:


> I will post the lab results as soon as can get a copy from the vet.


Excellent. That will give me a much clearer idea of your cat's condition.



> I’m so worried about her losing more weight.


One thing that you should have done ASAP if your vet hasn't done it already is to have her thyroid function checked with a Total T4 blood test. Weight loss and heart murmur are both common symptoms of hyperT. Like CRF, hyperT is much more common in elderly felines, though it can and does occasionally occur in younger cats, too. It'd be good to rule that out.

CRF cats tend to lose weight for a variety of reasons. One is that they simply lose their appetites, which in itself can be caused by a variety of things. It is important to try to halt and hopefully reverse weight loss, and the best way to do that is to identify and rectify the causes of the weight loss, if possible.



> She is on the CRF diet, and an antacid mixed in to the food.


Which antacid and at what dose? Which CRF diet?



> The vet discussed the Calcitriol option, but her phosphate is just too high at this moment to start her on it.


Calcitriol loses effectiveness when serum phosphorus is above 5.0, and is completely ineffective above 6.0, so your vet is correct that you need to get her phos down before starting Calcitriol.



> She will go on a potassium supplement and a phosphorus binder soon; we had hoped the weight loss would stop. But the more I read the more I think that perhaps I need to start the meds.


A CRF cat with low potassium should be receiving potassium supplementation. Low potassium can badly weaken a CRF cat, and there's no reason I know of to wait until she picks up weight before correcting that problem. High phosphorus can make a CRF cat feel extremely ill and nauseous, and it can severely, negatively impact appetite. Antacid won't fix that. Only bringing down the phosphorus will. She should be put on phos binder (aluminum hydroxide) immediately if her phos is above 6.0. I can't imagine why your vet is waiting, but that's certainly something I'd want to hear the explanation for.



> This cat does eat, but continues to lose weight. I had a roast last night and she was turning herself inside out to get some, and I gave her some, but then I thought OMG, this is nothing but protein.


One of the difficulties of this disease is the juggling it sometimes requires in its management. Management is often a matter of choosing the lesser of two evils. For example, many cats, including each of my CRF cats, refuse to eat any of the renal diets. So my CRF cats have always continued to be fed the garbagy Friskies and Fancy Feast canned foods that they would eat. Not ideal, but what had to be done. In your case, you have a cat with high phos that must be brought down, so avoiding his phos foods like table meat is important. OTOH, you want her to gain weight, so offering any food that she REALLY wants to eat might be worth the risk - esp. once you are adding phos binder to her meals. So get that binder on board so that you have a bit more leeway in terms of feeding her more appetizing foods. BTW, it's not the protein in meat that's the problem; it's the high phosphorus.



> I feel as though I am doing nothing right now as she wastes away.


Get the Total T4 run so that you know whether or not her thyroid is functioning properly. Then get her a potassium supplement and a phos binder. There are also appetite stimulants that can be given if she simply isn't eating enough. My appetite stimulant of choice is cyproheptadine. You can read about it (and potassium supplements and phos binders) on the site I linked for you earlier.



> The vet said that if we cannot stop the weight lose the meds will not matter. But if the binders can help her feel better, maybe she will eat more.


Your vet has it backwards. YOU have it right. She needs phos binder to bring down her phos and make her feel better so she will eat better. She needs potassium supplementation so she will feel stronger and more appetant. 

One thing that many of us CRF caretakers have learned is that we need to be strong and educated advocates for the veterinary care of our cats. My vet learned early in our relationship that I am not his "typical" client. He treats me with respect (when he's not rolling his eyes at his techs wishing I would just drop dead) and knows that I take the time to educate myself on my animals' conditions. When I tell him I want to implement a new treatment or management strategy, he discusses the pros and cons, and ultimately knows it's my decision. Sometimes he sways me to his way of thinking; sometimes he doesn't. But he knows that I make informed decisions that are always in what I believe to be the best interest of my animals, so he doesn't fight me if I choose to counter his recommendations. This is the sort of relationship you need to establish with your vet. If you walk into your vet's office armed with information, you will be in a position to discuss options intelligently and to make informed decisions, even if they aren't necessarily in sync with your vet's recommendations. No one - not you, not your vet - is going to make perfect decisions 100% of the time. Just remember that YOU are ultimately responsible for your cat's caretaking, so all treatment decisions are ultimately YOURS to make. Let your vet know if you want to be proactive in your cat's care.

Laurie


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## Sammy1 (May 19, 2010)

Her labs
Platelet count – 218 (300-800)
Osm, Cal – 332 (270-310)
Total protein – 7.9 (6.0-8.1)
Creatinine – 7.1 (1.0-2.0)
HCT – 29 (30.0-45.0)
Potassium – 4.6 (4.0-5.8)
Phosphorus – 9.2 (3.5-6.1)
BUN – 94 (10-35)
T4 - 1.1 (1.8-4.5)


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## laurief (Jun 22, 2008)

OK, I'm baffled. Did you write down that T4 blood value correctly? If so, your cat is hypothyroid. Typically, the only circumstances in which a cat will become hypothyroid is post-hyperthyroid treatment (either medication or radioactive iodine). Primary hypothyroidism (not the result of hyperthyroid treatment) is extremely rare in cats. If you wrote down that number correctly, I urge you to take your cat back to the vet for a full thyroid panel (Total T4, Free T4, Total T3, and Free T3) to clarify her thyroid status. Since I know nothing about primary hypothyroidism in cats, I have no idea what sort of effect it might be having on her other blood values, if any. Regardless, if she is hypothyroid as a result of any cause, she should be put on thyroid hormone supplementation immediately.

Now, if that's the total extent of the bloodwork that was run on your girl, I don't understand how your vet is making any sort of assessment of her liver health. Apparently her liver enzymes were not tested (very odd). Phos is quite high and should be brought down with a binder (aluminum hydroxide) now. A potassium supplement might be beneficial, but it doesn't look worrisome at this point. She's very slightly anemic and may benefit from extra B vitamins, esp. methylcobalamin and folic acid. Total protein is high enough to imply either mild dehydration or some sort of infection or inflammation.

If I had a cat with kidney values as high as hers, I would be giving subQ fluids daily. In fact, I might be inclined to leave her at the vets for a few days on IV fluids to try to bring those numbers down, then bring her home and continue with daily subQs. SubQs are generally recommended once the creat exceeds 3.0, and your girl's creat is 7.1.

At her age and with those high numbers, my guess is that something triggered acute renal failure a month ago when she started to lose weight, though cats in ARF usually act very ill and stop eating, which I'm sure you would have noticed. Still, it might be worth asking your vet to put her on a round of antibiotics in case she has some sort of acute kidney infection. Was a white blood cell count run to check for infection?

What about the urine test results? Do you have them that you can post?

Laurie


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## Sammy1 (May 19, 2010)

Sorry about not posting all the lab results. I was at work and had only a second, and as I learn more about this I realize that more of the lab results are important.

Originally Sammy was brought to the vet because of the weight loss, the vet believed the probable cause was her thyroid, and noticed the heart murmur at that time. Sammy was at the vet 6 months ago to have a few teeth removed (they believe that she might have that problem where her body has issues with her teeth – Feline stomatitis). I had declined the blood work because she seemed health, she was young, and I had no reason to believe that it was necessary for her. She did not have a murmur at that time.

The vet ruled the thyroid out after the lab results came in. We discussed it, and to be honest I do not remember 100% what she said. We have discussed some many things over the last few days.

I have started the phos binder (aluminum hydroxide) 100mg, I will retest her in 1 month and adjust as needed. Also the potassium chloride gel (I have to look at the amount on that one). She takes ¼ tablet of pepcid in her food too. 

Sammy had slight dehydration, and she was given a fluid treatment at the vet. I asked her to do one so that I could see the process and be more comfortable with it at home. The water consumption, litter usage has remained the same.

I’m very very happy with her eating right now! I gave her some IAM’s CRF canned food this morning and the little runt gobbled it up. She has always only eating a little at a time – she has always been thin, but the wet food I always hover on so the other cat will not come to eat. The other cat is a beast and loves food.

Here are the lab results that are not in the normal range.
HCT – 29 (30-45)
Platelet Count – 218 (300-800)
BUN – 94 (10-35)
Creatinine – 7.1 (1-2)
Carbon Dioxide – 13 (17-24)
Anian Gap – 27 (13-25)
Phosphorus – 9.2 (3.5-6.1)
Osm Calc – 332 (270-310)
ALD – 9 (10-70)
CK – 344 (50-300)
Cholesterol – 217 (75-175)
T4, Feline – 1.1 (1.8-4.5)

Her urine all can back in the normal/negative range. The vet did comment on how dilute it was.


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## laurief (Jun 22, 2008)

> Sorry about not posting all the lab results. I was at work and had only a second, and as I learn more about this I realize that more of the lab results are important.


Actually, ALL of the labs are important, both the values that are out of normal range AND the values that are in normal range. It all helps clarify the bigger picture. Non-blood values are important, too, so you should ask for copies of urine tests or any other tests run, too.



> The vet ruled the thyroid out after the lab results came in. We discussed it, and to be honest I do not remember 100% what she said.


You need to discuss your cat's hypothyroidism and treatment with your vet. Don't let your vet overlook or neglect to treat this condition. Untreated hypothyroidism certainly isn't doing your cat's kidneys any good ... or her other body systems, for that matter. I strongly urge you to join the hyperT mailing list and post your girl's test results there to get the list members' input. Some of them have dealt with secondary hypoT in their cats and can explain the dangers of leaving that condition unmanaged to you. Here's the link to that list:

http://groups.yahoo.com/group/feline-hyperT/



> I have started the phos binder (aluminum hydroxide) 100mg, I will retest her in 1 month and adjust as needed.


Check this link for dosing guidelines for aluminum hydroxide:

http://www.felinecrf.org/treatments.htm#binder_dosage

At your girl's current phosphorus level, the guidelines recommend 100 mg per lb of body weight daily, split between meals throughout the day. So if she weighs 4.7 lbs, that would be 470 mg daily split and mixed into her meals. Al hyd MUST be given with food or it can't do its job.

Be forewarned, also, that al hyd can be very constipating, and constipation can make your girl very ill and inappetant. It's important to be ready to counteract the constipating effects of al hyd by keeping Miralax (OTC) or Lactulose (prescription) on hand - even mixing a little into one or two meals a day as a preventative. Constipation is a common problem in CRF cats, even those not taking al hyd, so you should be prepared to deal with it. 

Supplemental subQ fluids are often a critical management strategy for avoiding or managing constipation in CRF cats. A cat who doesn't have enough fluid in the gut will be chronically constipated, and there isn't much of anything that makes a CRF cat feel more miserable, painful, or inappetant than constipation.



> Also the potassium chloride gel (I have to look at the amount on that one).


Potassium chloride is generally NOT recommended for CRF cats because it may contribute to metabolic acidosis. The potassium supplement of choice for CRF is potassium gluconate. You can buy this in tablet or powdered form at health food stores or most places vitamins are sold. If tablets, they can be crushed and mixed into food. Potassium should be given with food because it is a salt that can upset the stomach if given separately. You can read more about it here:

http://www.felinecrf.org/treatments.htm#low_potassium



> She takes ¼ tablet of pepcid in her food too.


Pepcid AC is quite commonly used in CRF cats, but it does come with some cautions. Read the following link to learn about its use. Pay particular attention to the section regarding drug interactions:

http://www.felinecrf.org/treatments.htm#famotidine



> Sammy had slight dehydration, and she was given a fluid treatment at the vet. I asked her to do one so that I could see the process and be more comfortable with it at home.


I can not stress enough how important fluids are for cats with as high a creatinine as yours. Please discuss this further with your vet. Fluids can make a vast difference in the stability and quality of life in a CRF patient.



> I’m very very happy with her eating right now!


That's fantastic! It's also very unexpected given her high phos. The more she eats, the stronger she'll get.



> Here are the lab results that are not in the normal range.
> HCT – 29 (30-45)


This is worrisome because CRF cats are prone to developing anemia, and that can be life-threatening and difficult to manage if it gets too bad. Since your girl is already just below normal range, you need to be extremely careful NOT to overtest her blood. Every drop of blood she loses now may drop her further into anemia. It's a horrible catch-22 that I just went through with my Billy (RIP). You will, of course, need to continue to monitor your girl's condition with blood testing, but it's important that you NOT do so any more frequently than ABSOLUTELY NECESSARY and only the tests that are ABSOLUTELY NECESSARY. Trust me, your girl's blood supply must be protected now - every single drop. NO UNNECESSARY TESTING.

Platelet Count – 218 (300-800)
BUN – 94 (10-35)
Creatinine – 7.1 (1-2)
Carbon Dioxide – 13 (17-24)
Anian Gap – 27 (13-25)
Phosphorus – 9.2 (3.5-6.1)
Osm Calc – 332 (270-310)
ALD – 9 (10-70)
CK – 344 (50-300)
Cholesterol – 217 (75-175)
T4, Feline – 1.1 (1.8-4.5)

Here's a great link where you can research all of these blood values and their meanings:

http://www.broadwayvh.com/site/view/832 ... 92sm55i901

Laurie


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## Sammy1 (May 19, 2010)

Just an update. I started this post in May, by the end of June I had to put my poor cat down. It was the hardest thing I have had to do, and I greatly worried about this decision. She had stopped eating anything, was drinking a lot, and lost bladder control. She was no longer happy. I could tell, but yet struggled if I was doing enough for her. Thankfully the Vet reassured me that there was nothing but downhill left and this was the most humane thing to do for her. I have to believe that I did all I could and that I saved her from more pain and discomfort. 
Sammy was 5 years old. She was and still is the best animal I have ever had. I miss her daily.


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## Susan (Mar 29, 2010)

I'm so sorry to hear about your loss. I'm fortunate in that I've never had to make the decision you did, and I can only imagine how difficult it must have been for you. I'm sure you did everything you could, and Sammy sounds like she was a wonderful cat. I hope your good memories of her help to ease your pain over time.


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## Shawnita (Sep 16, 2010)

Sorry to hear about the loss of Sammy. What a sad and difficult decision to make. I hope it brings you peace knowing that you did the best you could for her. And how wonderful that she found you and had a loving home in which to spend the last part of her life.


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