Feline AKI - How do you treat yours?

Re: Feline AKI - How do you treat yours?

Mark Hedberg — Tue, 23 Jul 2013 08:19:27 GMT

[quote user="Emily Rainbow"]Thank you for all the replies, I'll try and answer all your questions! And yep we're taught to use the terms AKI and CKD I'm not sure of the rationale behind. This is a sudden increase in cases over tr last 6 weeks or so. No change in canine renal cases seen. I too wondered if these were chronic cases pushed over the edge by the heat? But the majority of cases are otherwise fit and healthy cats with no major recent medical concerns. I haven't seen an ethylene glycol cat but I've been told these cats 'look' like them but the history/blood/ urinanalysis dont support that diagnosis. The cases began appearing in the same area, PM and toxicology results on 2 out of the first 4 or 5 came back inconclusive. Now there seems to be no pattern spatially, and recent clients haven't been keen on PMs. I think thats most of the questions, thank you ill chat through the comments made with one of the vets. Practice is in the south east.

[/quote]

Can you ring up your neighboring practices, and see if they're also having a surge in kidney cases?

Re: Feline AKI - How do you treat yours?

Andrew Kent — Tue, 23 Jul 2013 08:06:17 GMT

I assume AKI has come from human medicine and is meant to take account of the fact that it is potentially reversible. Though I agree perhaps it is too optimistic for our cases!

other interventions, like peritoneal dialysis, more aggressive diuresis etc etc is possible but I'm not sure they are appropriate in cases that haven't had in depth investigations. You could do peritoneal dialysis as much as you want on an ethylene glycol cat but ultimately the kidneys will never recover. So justifying doing them when we don't know whether the original insult is reversible is difficult for me. Even if the pot of money is quite limited investigations are quite critical.

I think fluid rates are pretty crucial in these cases as David points out so that is something that could be altered in these cases quite quickly.

Re: Feline AKI - How do you treat yours?

Emily Rainbow — Tue, 23 Jul 2013 08:04:45 GMT

Sorry, doesn't look like I can do paragraphs on my phone!

Re: Feline AKI - How do you treat yours?

Emily Rainbow — Tue, 23 Jul 2013 08:03:49 GMT

Thank you for all the replies, I'll try and answer all your questions! And yep we're taught to use the terms AKI and CKD I'm not sure of the rationale behind. This is a sudden increase in cases over tr last 6 weeks or so. No change in canine renal cases seen. I too wondered if these were chronic cases pushed over the edge by the heat? But the majority of cases are otherwise fit and healthy cats with no major recent medical concerns. I haven't seen an ethylene glycol cat but I've been told these cats 'look' like them but the history/blood/ urinanalysis dont support that diagnosis. The cases began appearing in the same area, PM and toxicology results on 2 out of the first 4 or 5 came back inconclusive. Now there seems to be no pattern spatially, and recent clients haven't been keen on PMs. I think thats most of the questions, thank you ill chat through the comments made with one of the vets. Practice is in the south east.

Re: Feline AKI - How do you treat yours?

David Mills — Tue, 23 Jul 2013 00:15:59 GMT

Some thoughts.

- should be resuscitating these cats with fluid boluses at the start, 60ml/kg/hr until perfusion parameters improve.

- maintenance fluids are too low at 4ml/kg/hr - don't know how dehydrated they are but current recommendations in AKi are to assume at least 5% dehydrated (even if paramters are normal - and sounds like yours aren't) and replace this over 2-4h (CV system willing). So you're looking fluid rates of 25-50ml/h for various sizes of cats and timeframes.

- Hartmann's rather than NaCl - some evidence that NaCl worsens acidaemia though this is dependent on a functional renal unit. Colloids can be useful.

- Measure urine output. Catheter ideally, and looking for at least 1ml/kg/h. At the very very least scanning bladder (if can't catheterise) but this is less accurate.

- Frusemide to start if no urine after 2-4h. IV 1-2mg/kg initially then CRI some evidence better than repeated boluses.

- consider dialysis otherwise.

- don't chase the K+ unless there are ECG signs of hyperkalaemic dysrhythmia. A functioning kidney will very quickly normalise K+.

- can only think values are rising because the fluid rates aren't high enough.

- success rates ain't high, and if they remain oliguric or phosphorus remains elevated they're toast. Even then, it all depends on how much tissue has been damaged and how much regeneration/hyperplasia is possible. If you're dealing with EG or vit D toxicosis then the damage is already done and its hopeless. PM renal samples on a few would be useful.

Where's the practice, roughly?

Re: Feline AKI - How do you treat yours?

Virginia Campbell — Tue, 23 Jul 2013 00:02:43 GMT

[quote user="Emily Rainbow"]presented with a cat you suspect has AKI what is your treatment protocol?[/quote]

As you have described- and give the O a grave prognosis.

I wonder if there is a cat poisoner at work. I don't know what else (apart from post renal blockage) other than toxicity would hammer the kidneys hard enough to see a worsening of azotemia and hyperkalemia over the course of a few hours, in the face of IVFT. I would be doing the pins-on-a-map thing with the owners addresses, and look up what histo samples you need for suspected antifreeze tox in case you get a dead 'un that you can convince Os to let you PM. Are you supposed to be able to see the crystals in the urine or am I remembering that wrongly?

If these were acute-on-chronic cases due to the weather, we should all being seeing them, and I would have thought they would be anaemic.

As for the nomenclature - I believe we're supposed to call CRF "CKD" now; "kidney" being less ivory tower than the complicated showy-offy "renal"- even though it has the same number of syllables. "Disease", whilst depressing, less pessimistic than "failure" Calling ARF "AKI" is really looking on the bright side of life. Though for maximum happiness, they should get rid of the "acute", since Joe Public thinks this is synonymous with "severe"

I think we should stick with "acute renal failure"....just to get them prepped for the likely outcome....

Re: Feline AKI - How do you treat yours?

Evelyn Barbour-Hill — Mon, 22 Jul 2013 23:28:37 GMT

[quote user="Andrew Kent"]Michael - Acute Kidney Injury is the preferred term for ARF now to keep us on our toes.[/quote]

Preferred by whom might I ask?

You might have an acute kidney injury without getting into acute renal failure. Then what, eh?

In answer to the original post:

Has peritoneal dialysis gone out of favour?

Has osmotic diuresis (with dextrose or mannitol)gone out of favour?

Re: Feline AKI - How do you treat yours?

Michael Woodhouse — Mon, 22 Jul 2013 22:40:44 GMT

[quote user="Andrew Kent"]Michael - Acute Kidney Injury is the preferred term for ARF now to keep us on our toes. [/quote]

When did we start dumbing down? Kidney rather than renal? mmmmmmmmmm

Thanks for the clarification.

Re: Feline AKI - How do you treat yours?

Francisco Gomez — Mon, 22 Jul 2013 22:30:31 GMT

[quote user="Nicola Lawlor"]

I would personally probably choose saline or glucose saline for a cat in renal failure for iv fluids where the K+ level has been seen to be high on the bloods

[/quote] I would still do Hartmann's I think... Wouldn't they be acidotic? And K+ in Hartmann's is very low, so it would cause 'dilution' anyway...

Re: Feline AKI - How do you treat yours?

Andrew Kent — Mon, 22 Jul 2013 22:28:06 GMT

Michael - Acute Kidney Injury is the preferred term for ARF now to keep us on our toes.

in answer to the OP a few thoughts - most importantly as Nicola says it is a false economy to spend lots of money on therapy for these cases without some additional degree of investigations, because if this is something common like ethylene glycol then the prognosis is hopeless and the cats should be pts. So a detailed history for access to toxins and a minimum inbestigation to include urinalysis should be vital.

second AKI carries a pretty guarded prognosis anyway and so failing to win the majority of cases is not that surprising. It is, however, a pretty rare disease and so runs of cases should be investigated for common factors.

in terms of supportive management those fluid rates are pretty low for severely azotaemic animals so could be increased. And in most cases the placement of a urinary catheter for accurate monitoring of urine output is vital to get a better idea of going on and direct fluid therapy/diuretic therapy. If possible a central line is also useful to measure CVP.

lastly if you have cases like this with very committed owners that don't respond to conventional management then speaking to the RVC about dialysis could be a consideration.

they are tough cases!

Andy

Re: Feline AKI - How do you treat yours?

Nicola Lawlor — Mon, 22 Jul 2013 22:17:37 GMT

Assuming you are talking Acute renal failure here then I would be looking a lot harder to find out what is causing so many cases. What is the calcium levels like in the blood, could you have a spate of ethylene glycol ingestion cats? Lily flowers? Any dogs coming in with similar signs at any point. Are these patients who have been inpatients recently for other issues perhaps and maybe heat related complications have pushed them too far while other factors are at play in their health?

I would personally probably choose saline or glucose saline for a cat in renal failure for iv fluids where the K+ level has been seen to be high on the bloods, but do monitor carefully as this can drop significantly if treatment is effective. Not so sure there is a huge amount more you can do other than supportive care at this point unless you know more about the underlying reasons.

Re: Feline AKI - How do you treat yours?

Michael Woodhouse — Mon, 22 Jul 2013 22:09:41 GMT

Not familiar with the term AKI. You seem to be describing acute renal failure?

Re: Feline AKI - How do you treat yours?

Mark Hedberg — Mon, 22 Jul 2013 22:09:27 GMT

Is it a sudden change? have they always had this level of kidney failure show up, or is this a recent spike?