Acute Renal Failure in a 6yo cat

Re: Acute Renal Failure in a 6yo cat

Iain McAllister — Tue, 16 Oct 2012 17:39:47 GMT

Bit more history - initial presentation was : vomited 2x lethargic and panting - sudden onset that morning had appeared fine previous night - health had been fine up til that point - no history of nsaid exposure or lily exposure - hadn't been missing or deprived of water - we thought it might have been ethylene glycol but became less convinced as time went on as he remained very bright

To be honest here it was owners who weren't committed to push a few boundaries that was the problem - I was up for the fight for this cat but they weren't...

Re: Acute Renal Failure in a 6yo cat

Rajat — Tue, 16 Oct 2012 17:05:57 GMT

Martin we have excellent inhouse machines, but occas get the odd result, where the pet and the machine dont tally I always double check, because not worth it to make life and death decisions foir the sake of ten or fifteen quid. Most ppl happy to pay, those who aren't I do it as a QC. I agree with you those numbers are awful, just had trouble equating a well, eating cat with those numbers hence the desire to check externally.

I second your comments, I have had so many cats like you describe do well for months on end with SQFT and careful monitoring, attention to tx uremic gastritis, nausea, hydration and hypertension and other secondary badness - worth giving it a shot IMHO if owners are commited.

Re: Acute Renal Failure in a 6yo cat

Martin Atkinson — Tue, 16 Oct 2012 17:02:27 GMT

[quote user="Rajat"]

what a shame for the cat if he was feeling well eating and drinking, I cannot see why PTS now vs when he is actually feeling as ill as the numbers say he should be...and personally I'd be suspicious of those numbers till I had them confirmed externally...

[/quote] I would have thought that those numbers were so extreme even the most dedicated external lab aficionado would find it difficult to question them Raj! Shame the cat was PTS though, we had a cat that the previous vet thought should be PTS with CKD with much lower figures: BUN in the 40's and Crea 400 or so. phos high - >3, UP/C ratio >6. HCT 18%. IME these number mean the cat is not for this plane of existence for much longer than a couple of weeks but it was still bright and the owner wanted it treated so came for 2nd opinion and we kept it going for over 3 months with fluids via a skin button, EPO and Fortekor (sorry didn't mean to mention the F word). Cost a lot but the cat got 3 months of quality life and the client thought it was worth it. Equally though if a cat with similar or lower figures was on its last legs with nephrotic syndrome I wouldn't prolong its life.

Re: Acute Renal Failure in a 6yo cat

Rajat — Tue, 16 Oct 2012 16:55:12 GMT

David I don't disagree that cats with severe azotemia that won't budge and screwed kidneys should not have their lives prolonged unneccessarily..there is no contention here.

.[quote user="David Mills"]Noooo...it was just a generalisation as to what normally happens with these kidney cats that you try to 'reset the values' on. Miserable time it is too for the cat slowly turning back into a husk.[/quote]

See that's the thing- we are talking about a specific case which isdifferent from your generalisation. So you confused me when you went down this route. But I can understand where you are coming from. And I don't where you get 'reset' the values from, I never said this, unless it is another generalisation.

I was talking about giving the kidneys a chance to heal, the damage done by the insult to be fully assesed and then decide on where to go- as a guide to how long one gives renal values to come down- this is actually bit of a moot point- because if cat is maintiaing hydration and intake, the actual number (for azotemia) is a bit irrelevant for the immediate future. The values, may take 4 weeks to come down. naturally if cat looks like crap after 2-3-4 days and they haven't budged at all - not great news (but not particularly awful). Equally depends on the underlying cause- acute episodes or toxins, you can do dialysis while the kidney heals.

for e.g. I had a dog with ARF 2' to lepto whose renal values didnt budge after 3 days of IVFT, ICU care, ins and outs etc etc - creat remained >900 urea>50. Dog was euvolemic. Owner took dog home ( a different story), gave SQFT daily, abs by injection daily, syringe fed, loads of meds incl anti emetics, dog is now back to normal, normal renal values, normal USG. Renal values took >6 weeks to return to normal. While it is likely significant renal injury has occured, so has significant recovery of renal function.

so there is no real 'scheme' just guidelines, with the over riding burden of animal welfare- bit insulted that ypu believe your colleagues would watch the cat turn into a husk or arbitarily follow a set in stone time that one MUST wait before PTS-ing without due concern for the cat and its welfare. No one has suggested that.

. Given the cat was feeling well there is simply no QOL issue other than the need for hospitalisation for a few days on IVFT. Once this is done, fluid therapy can be continued at home- SQFT works well in these situations. I would happily give the cat as long as it needed if it was well and I didn't think I was negatively impacting its QOL. Once hydrated and cta eating, there is no real benefit of IV fluids so no I don't keep them in for weeks on a drip waiting for values to change.

[quote user="David Mills"] but if you're going in with the whole a few weeks in hospital is worth it for the cat then you better be damned sure it is going to be worth it by being able - on concrete evidence - to support your client coercion with some facts rather than a plea to the unknown 'well if we didn't try with some then none would get better'. [/quote]

Again I didn't say few weeks in hospital - please have a read of my post. As I see it the question is how long do you give the cat's renal values to change before saying its a goner?!

And no one is coercing anybody. It is an adult conversation (I am sure I speak for all of us here..) in the consult the client is presented with what we do know, what we think we may find out, and what we definitely don't know- the rough chances of getting better and costs- prognosis is open as no one really knows (yes David, not just me, no one, especially as there is not much history or info in OPs post in case you didnt notice...!) - and as adults, the clients and the vet decide what to do in this given situation in the best interests of the pet and client. And it is true if you PTS every ARF, every GDV, every 'pick your disease' you cannot tell the rates of survival, cures and outcomes for it, Is this not self evident?

[quote user="David Mills"]It's therefore an experiment[/quote]

As is our giving every drug to every animal because we all metabolise things differently and have different genes and drugs have different effects on us. So the rimadyl you just gave to that painful OA dog- an experiment. the profol to the cat spay- an experiment - as I didnt know how much it would need till I had given enough to intubate it. Are you deliberately being dramatic/obtuse?

[quote user="David Mills"]The OP has since posted an eye-rolling emoticon,[/quote]

I'd do more than roll my eyes at someone who didn't give an animal a chance, when it was feeling well,and there was a half decent chance at recovery. Putting animals to sleep on the basis of singular bloods is not good practice.I'd be fairly mad if it was my case. However, if the owner had decided on PTS after an informed chat and a good heart to hear,t fair enough, its their cat and I wont roll my eyes at them.

Re: Acute Renal Failure in a 6yo cat

Iain McAllister — Tue, 16 Oct 2012 16:45:16 GMT

[quote user="David Mills"]

Wait a sec - cat comes in v/d and in a crap state due to ARF (we suppose but don't know) which - unsurprisingly - improves on fluids dramatically. The fluids were keeping this cat alive; its figures were still sky high, but I imagine its pain and suffering (headaches, extreme nausea etc reported in humans) were being kept in check medically. You discharge the cat and it comes back in a week back to badness.

I would say, crystal ball apart, that euthanasia was the kindest thing for this cat in the circumstances. I would far rather have that for my cat than have it suffer gradual deterioration at home. Let's not anthropomorphically invest animals with an interest in quantity of life than any reasonable assessment says they simply don't have.

[/quote]

Have to disagree here - the clinical picture was of a cat who was eating and drinking, who wasn't in pain, nauseous or suffering - purring, rubbing his cheek on your hand all the usual happy cat stuff - he deserved extra time to try and get better - I concede he might not have but there was no reason not to give him another 48-72 hours

I was disappointed that my colleague didn't let that happen...vet's are allowed to disagree aren't they

Re: Acute Renal Failure in a 6yo cat

David Mills — Tue, 16 Oct 2012 15:28:48 GMT

[quote user="Rajat"]

Sorry can you point this bit out in iains post?

[/quote]

Noooo...it was just a generalisation as to what normally happens with these kidney cats that you try to 'reset the values' on. Miserable time it is too for the cat slowly turning back into a husk.

[quote user="Rajat"]

quite right we don't- and prognosis and tx is different for the 2 (ARF vs CRF)

...

If we/owner didn't give this cat a few days on fluids and supportive meds (maybe I am not reading the post correctly) this cat did not have a chance at getting better let alone suffering gradual deterioration and all that stuff.

[/quote]

No doubt. But therein lies your contradiction - we don't know the cause - hence the OP posting on here - and therefore prognosis is impossible to give. Without a prognosis then the cat's options if the owners are not willing to go further (quite fairly) are limited.

Imagine if the OP 'persuaded' the owners to 'give it a go' on your scheme and the figures were still like that in 2 weeks? 4 weeks? 6 weeks? Still going? Yes a few days might be fine - makes us feel good giving a dehydrated cat ivft and watching it perk up - but if you're going in with the whole a few weeks in hospital is worth it for the cat then you better be damned sure it is going to be worth it by being able - on concrete evidence - to support your client coercion with some facts rather than a plea to the unknown 'well if we didn't try with some then none would get better'. By your own admission, you've no idea in this case. It's therefore an experiment. A client-funded one. And if the cat's been PTSd after a 7-day hospital stay, not a great last few days for it either.

[quote user="Rajat"]

No need to get on your high horse about anthropomorphism!

[/quote]

The OP has since posted an eye-rolling emoticon, which, unless I'm reading it incorrectly, is a direct criticism of his colleague. I don't know his colleague, but I thought the post unnecessarily superior in its dismissive tone towards his colleague, and so therefore I felt his colleague's actions needed some representation. I'd have done the same in this case.

Re: Acute Renal Failure in a 6yo cat

Bob Russell — Tue, 16 Oct 2012 15:06:25 GMT

[quote user="Robin Grimmer"]

I tend to agree. How many cases with really shocking renal values have you really seen get better?

Even with cases where the owner has really wanted to try they usually end up PTS

[/quote]

One springs to mind. A 2 yr old black and white Persian cross called 'Sooty'. BUN from memory around 60, cannot remember the Crea levels. She stopped eating and was vomiting. Otherwise bright and alert.

Aggressive fluid therapy etc. It turned out she had eaten a lily plant my delightful brother and his other half brought over as thanks for a Sunday roast!

One of my cats (obviously) and she died at the age of 20 years old!

Re: Acute Renal Failure in a 6yo cat

Rajat — Tue, 16 Oct 2012 14:45:47 GMT

[quote user="David Mills"]You discharge the cat and it comes back in a week back to badness. [/quote]

Sorry can you point this bit out in iains post?

[quote user="David Mills"]cat comes in v/d and in a crap state due to ARF[/quote]

quite right we don't- and prognosis and tx is different for the 2 (ARF vs CRF)

[quote user="David Mills"]Let's not anthropomorphically invest animals with an interest in quantity of life than any reasonable assessment says they simply don't have.[/quote]

I agree though if QOL is poor and cat not getting better PTS is kindest - but it was pointed out cat was doing and feeling well after just a few hours on fluids.

Re: Acute Renal Failure in a 6yo cat

Rajat — Tue, 16 Oct 2012 14:40:46 GMT

[quote user="Robin Grimmer"]

I tend to agree. How many cases with really shocking renal values have you really seen get better?

Even with cases where the owner has really wanted to try they usually end up PTS

[/quote]

It depends on the cause. I have seen renal values halve over 3-4 weeks in acute on chronic patients, where initial vet wanted to PTS and owbner wanted to continue supportive tx. If you PTS them early you'll never see the ones that could have improved!

Re: Acute Renal Failure in a 6yo cat

Rajat — Tue, 16 Oct 2012 14:39:38 GMT

[quote user="Iain McAllister"]Numbers were on different vet test machines one here and one at emergency clinic [/quote]

fair enough, I'll believe them then :)

Re: Acute Renal Failure in a 6yo cat

Robin Grimmer — Tue, 16 Oct 2012 14:31:10 GMT

I tend to agree. How many cases with really shocking renal values have you really seen get better?

Even with cases where the owner has really wanted to try they usually end up PTS

Re: Acute Renal Failure in a 6yo cat

David Mills — Tue, 16 Oct 2012 14:24:39 GMT

[quote user="Rajat"]

[quote user="Iain McAllister"]

I agree totally about treating patient not numbers but not everyone does and cat was pts by a colleague - so difficult

to persuade some owners that some conditions take time to get better - they all want an instant fix these days!

[/quote]

Re: Acute Renal Failure in a 6yo cat

Iain McAllister — Tue, 16 Oct 2012 12:39:15 GMT

Numbers were on different vet test machines one here and one at emergency clinic

[quote user="Rajat"]

...and personally I'd be suspicious of those numbers till I had them confirmed externally...

[/quote]

Re: Acute Renal Failure in a 6yo cat

Rajat — Tue, 16 Oct 2012 12:33:32 GMT

[quote user="Iain McAllister"]

I agree totally about treating patient not numbers but not everyone does and cat was pts by a colleague - so difficult

to persuade some owners that some conditions take time to get better - they all want an instant fix these days!

[/quote]

Re: Acute Renal Failure in a 6yo cat

Iain McAllister — Tue, 16 Oct 2012 09:52:49 GMT

Was sick when we saw it initially - vomiting anorexic etc - improved massively within about 5 hours in fluids

I agree totally about treating patient not numbers but not everyone does and cat was pts by a colleague - so difficult

to persuade some owners that some conditions take time to get better - they all want an instant fix these days!

can't win 'em all...

[quote user="Anthony Todd"]

Er, why did the cat come to you? "Bright and eating"??

What sign did the owner see?

[/quote]

Re: Acute Renal Failure in a 6yo cat

Bob Russell — Mon, 15 Oct 2012 13:32:30 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Robin Grimmer"]An ultrasound might be useful - if the kidneys are small and nobbly then it's CRF, irregular enlarged kidneys could mean lymphoma, and PKD is easily diagnosed.[/quote]

Sorry, I'm in mischievous grumpy dinosaur mode tonight

I'm well appreciative of the usefulness of ultrasound, but unless the cat is really fat then you should be able to determine all that by palpation.

[/quote]

* * * * *

Re: Acute Renal Failure in a 6yo cat

Anthony Todd — Mon, 15 Oct 2012 10:50:04 GMT

Er, why did the cat come to you? "Bright and eating"??

What sign did the owner see?

Re: Acute Renal Failure in a 6yo cat

Martin Atkinson — Mon, 15 Oct 2012 10:09:00 GMT

[quote user="Iain McAllister"]how long would you give the enzymes to shift down [/quote] Isn't the answer to this as long as the cat is bright and eating? - you're treating a patient and its symptoms not numbers. Apart from the obvious normal treatment for renal disease, think about a skin button for additional fluids if it remains chronic.

Re: Acute Renal Failure in a 6yo cat

Evelyn Barbour-Hill — Mon, 15 Oct 2012 01:54:58 GMT

[quote user="Robin Grimmer"]An ultrasound might be useful - if the kidneys are small and nobbly then it's CRF, irregular enlarged kidneys could mean lymphoma, and PKD is easily diagnosed.[/quote]

Sorry, I'm in mischievous grumpy dinosaur mode tonight

I'm well appreciative of the usefulness of ultrasound, but unless the cat is really fat then you should be able to determine all that by palpation.

Re: Acute Renal Failure in a 6yo cat

Rajat — Mon, 15 Oct 2012 01:39:34 GMT

Iain

From what I've read from one specialist, the kidneys can take 4 weeks to reach a stable new GFR after such toxic injury.

Owner getting twitchy does not bode well as this cat will need a fair bit of supportive care IF he pulls through and if he is to pull through..I also read recently of a protocol describing continuing at home SQFT for the first 2-4 months gradually weaned downwards in amounts and frequency to help support badly damaged kidneys.

Is he olig/an/polyuric?

The eating etc is surprising, is it worth confirming the results externally?

I agree with you re phos

Re: Acute Renal Failure in a 6yo cat

Iain McAllister — Sun, 14 Oct 2012 13:37:02 GMT

[quote user="Noweia"]

If Phos is high, isn't that indicative of a more chronic condition?

[/quote]

from Cornell Vet School website - no ultrasound here but kidneys are normal sized and non painful - no history of chronicity here either - haematology normal

Decreased excretion
1) Decreased GFR: This is the most common cause of hyperphosphatemia. Many animals that are azotemic are also hyperphosphatemic. Acute and severe reduction in GFR, as in acute renal failure or severe hypovolemia, is more likely to result in hyperphosphatemia than is chronic renal failure.

Re: Acute Renal Failure in a 6yo cat

Robin Grimmer — Sun, 14 Oct 2012 12:21:35 GMT

[quote user="Noweia"]

If Phos is high, isn't that indicative of a more chronic condition?

[/quote]

And also the fact that the cat is so bright with such high renal values suggests an end-stage CRF.

Have you done urinalysis? What is the haemocrit? If it's low then that again is more evidence for CRF.

An ultrasound might be useful - if the kidneys are small and nobbly then it's CRF, irregular enlarged kidneys could mean lymphoma, and PKD is easily diagnosed.

Re: Acute Renal Failure in a 6yo cat

Noweia — Sun, 14 Oct 2012 11:03:28 GMT

If Phos is high, isn't that indicative of a more chronic condition?