Hypokalaemia in a Burmese cat with CRF

Re: Hypokalaemia in a Burmese cat with CRF

Rob Davis — Wed, 02 Jul 2014 15:34:28 GMT

[quote user="Caren Stubbington"]He became very hypotensive under the GA. Between his renal insufficiency and tachycardia with some changes on echo due to the hypertension we were unable to increase it sufficiently to continue safely.[/quote]

Sounds like a bit of a nightmare....

[quote user="Caren Stubbington"] Subsequently I referred his sister to Gerhard Putter for total extractions and the idea had been to do the same with Fraser, including dental radiography[/quote]

Gerhard is excellent and definitely the man to send these to locally.

[quote user="Caren Stubbington"]The paper I was referred to re the FHV stomatitis was Vet Clin Am Small Anim Prac 1999 Nov;29(6):1281-90. feline herpes virus 1-associated facial and nasal dermatitis and stomatitis in domestic cats. Harris AM, Ginn PE.[/quote]

I've not seen this paper, but I there have been several more recent studies into FCGS suggesting the association with FCV.

[quote user="Caren Stubbington"] Fraser has started on IFN since I began this thread, but I'm on holiday at the mo so not sure how it's going.[/quote]

Good luck with this one and keep us posted with progress.

Re: Hypokalaemia in a Burmese cat with CRF

Caren Stubbington — Tue, 01 Jul 2014 21:33:28 GMT

Hi Rob, Not a rude question at all. I did Fraser's dental extractions myself and unfortunately I am pretty sure he does have a tooth root remaining. There was also one canine I wanted to extract which I didn't. He became very hypotensive under the GA. Between his renal insufficiency and tachycardia with some changes on echo due to the hypertension we were unable to increase it sufficiently to continue safely. Subsequently I referred his sister to Gerhard Putter for total extractions and the idea had been to do the same with Fraser, including dental radiography. Sadly his sister had recurrent problems despite total extractions. She was then euthanased because of another condition. The paper I was referred to re the FHV stomatitis was Vet Clin Am Small Anim Prac 1999 Nov;29(6):1281-90. feline herpes virus 1-associated facial and nasal dermatitis and stomatitis in domestic cats. Harris AM, Ginn PE. Unfortunately I never managed to get the full paper. That said neither cat has been tested for FCV so I expect that could easily be the cause. Fraser has started on IFN since I began this thread, but I'm on holiday at the mo so not sure how it's going. They had just started his sister on it a week before she was euthanased. They haven't ruled out going to Gerhard but I suspect do not want to put him through too much unless it seems the best thing for him. As far as everything else goes I have never been able to bullsh*t my entire life so thankfully never even tried! I will of course say hi to everyone for you. JBG retired at the end of last year but I still see him most weeks. MAF moved to Aberdeen last year but I am still in touch with her and she has always sung your praises, so I will be sure to let her know we've been in touch. AJP is still working with us and teaching at the vet school. So you will be well remembered. Thanks again for your help.

Re: Hypokalaemia in a Burmese cat with CRF

Rob Davis — Sat, 28 Jun 2014 10:01:09 GMT

[quote user="Caren Stubbington"]Working there has at least taught me the value of a Google search on any Professor before they come in. It has saved me from looking like a fool on a couple of occasions now.[/quote]

Working in Cambridge quickly taught me that you can't get away with bullsh*t!

[quote user="Caren Stubbington"]Periods of inappetance tend to be more associated with oral pain. All teeth except canines removed, inflammation sadly caudal to these. I have taken advice on this from a couple of specialists. It is thought to be associated with his FHV.[/quote]

Nothing to add to Kate's excellent medical advice, but coming from a more dental-orientated perspective.... Without wishing to seem rude, are we certain that all the roots of the caudal teeth have been completely extracted? This is often a difficult procedure, and should ideally be confirmed radiographically if not already done. Root remnants will often cause significant ongoing inflammation in FCGS cases. Assuming there are no roots remaining, have you considered interferon. If you contact Virbac they can give you the most up to date information and protocols (Norman Johnston's website also has an excellent overview of the current thinking on the condition).

As an aside, I am surprised that FHV has been suggested as causing the stomatitis - there appear to be very strong links between FCV and FCGS, but I am not aware of any particular association with FHV.

Say Hi to anybody at the practice who's been there long enough to remember me!

Re: Hypokalaemia in a Burmese cat with CRF

Caren Stubbington — Wed, 25 Jun 2014 23:17:27 GMT

Hi Kate,

All good musings, thank you! BP was 220 originally, now 165. I can not remember the UPC without his notes but follow up checks after semintra have showed good control. Mg levels were normal. Spoke to Nationwide Hormone Labs about the renin and aldosterone and they were happy those levels ruled out Conns so didn't do any imaging. They are using metacam at 5 drops a day currently and oral temgesic as required. Vit B12 levels are fine currently, (tested a couple of weeks ago). No apparent nausea. His sister hadpancreatitis and was on maropitant and mirtazapine at times so they know what to look for with that. Periods of inappetance tend to be more associated with oral pain. All teeth except canines removed, inflammation sadly caudal to these. I have taken advice on this from a couple of specialists. It is thought to be associated with his FHV. He had cefovexin last time I saw him and this appears to have helped. I spoke to the owners yesterday and they seem pleased with him at the moment. They are happy to monitor him for any clinical signs of hypoK+ and continue with his current dosing. They had to euthanase his sister a few weeks ago and I think they just want to make sure he is happy and as comfortable as possible. I just want to make sure I am not missing something with his potassium but i feel reassured by everyone's comments. Many thanks

Re: Hypokalaemia in a Burmese cat with CRF

Caren Stubbington — Wed, 25 Jun 2014 23:02:29 GMT

Hi Rob,

I do indeed! I have heard lots about you, all glowing you'll be pleased to hear. The Professors' in question this time are a population geneticist and a chemist so thankfully I can just about keep up! It usually just means I don't have to explain much to them as they've already looked it all up. Working there has at least taught me the value of a Google search on any Professor before they come in. It has saved me from looking like a fool on a couple of occasions now.

Re: Hypokalaemia in a Burmese cat with CRF

Caren Stubbington — Wed, 25 Jun 2014 22:55:53 GMT

Hi Anthony,

Thankfully they are very sensible owners. His mouth appears to be more comfortable again (as of yesterday) and they are using metacam judiciously and temgesic for his flare ups. The cat is also an incredibly tolerant chap but they are keen not to take advantage of this fact. His welfare definitely comes first so I'm glad to say in this case I couldn't ask for better clients. He is currently happy and eating so hopefully things will stay that way a while longer.

Re: Hypokalaemia in a Burmese cat with CRF

Kate Richardson — Wed, 25 Jun 2014 22:09:44 GMT

Oh and one other thing (probably unlikely in this case) but hypokalaemia that is refractory to treatment can be secondary to hypomagnesaemia.

Re: Hypokalaemia in a Burmese cat with CRF

Kate Richardson — Wed, 25 Jun 2014 22:08:24 GMT

How high was his BP? Is it well controlled now? I had a Conns patient that we never managed to get potassium in the normal range despite +++oral supplementation/spironolactone- off the top of my head I don't know values for aldosterone in cats, in fact I think there is some debate about what the normal reference range in cats is, Have you discussed this further with the lab? I guess without a previous potassium level in this cat it is impossible to know if pre existing- I guess it may have had mild hypokalaemia which has now been exacerbated by the renal disease (rather than causing the renal disease I would suggest?) unless the cat does have Conns and the hypertension has caused/exacerbated the renal disease. If you have proteinuria (what is the UPC?) then again this could be cause or effect! By that I mean if you have tubular disease you might expect increased loss/decreased resorption of things like potassium. Might be worth checking B12 levels as well?

Does his periods of inappetance tie in with lower K levels? Or is it pain related? Is he on any analgesics? If you are reluctant to use meloxicam (which I wouldn't necessarily be for a short course to see effect) or you could use oral buprenorphine. Any nauseus episodes? You could try maropitant or even mirtazipine- 2mg EOD (=1/8 of 15mg tablet- 2mg tablets available through Summit).

So the above is some musings, but getting back to the cat- if K stays sl low but cat happy, then I wouldn't go chasing the numbers BUT sounds as though the OA and oral inflammation (has he had all his teeth including canines removed?) may be playing a bigger role- I would be very tempted to trial meloxicam for a week or 2 and see what the owners think about his general demeanour/appetite- as long as he keeps eating and remains hydrated (sc fluids daily if owners are happy to do so) then I think it is worth trying.

Re: Hypokalaemia in a Burmese cat with CRF

Rob Davis — Wed, 25 Jun 2014 17:03:05 GMT

[quote user="Caren Stubbington"]The clients are both biomedical professors and so have researched the subject thoroughly![/quote]

I see you work in my old practice. I wonder if this is the same client, whom I once spent several minutes explaining what hypokalaemia was and why it was important, before realising that this particular professor had given our second year physiology lectures.... He at least had the decency to listen to me patiently and comment that at least I had been awake during his lectures!

Re: Hypokalaemia in a Burmese cat with CRF

Anthony Todd — Wed, 25 Jun 2014 08:19:02 GMT

[quote user="Caren Stubbington"]has severe OA and his mouth is pretty bad at the moment, [/quote]

Is the cat happy and eating?

Most cats hate being dosed with anything and a "pretty bad" mouth is pretty uncomfortable.

I hope the biomedical owners are not more interested in happy blood values rather than a happy cat.....

Re: Hypokalaemia in a Burmese cat with CRF

Caren Stubbington — Tue, 24 Jun 2014 22:33:45 GMT

Hi Martin,

Sadly not good compliance with the Tumil K. I am starting to feel that if I can keep his potassium levels stable that may be the best I can do. The clients are both biomedical professors and so have researched the subject thoroughly! They are concerned about potentiation of the renal disease with hypokalaemia. They do also appreciate that he is eighteen and doing well all things considered though.

Thank you both for your help.

Re: Hypokalaemia in a Burmese cat with CRF

Caren Stubbington — Tue, 24 Jun 2014 22:29:17 GMT

Hi Neil,

Amazingly they are managing to get that much kaminox in but I'm obviously reluctant to make them give more. The semintra and ipakatine are a bit patchy but they are very dedicated clients. He has some episodes of hindlimb weakness with a mild plantigrade stance and some periods of inappetance. That said is also has severe OA and his mouth is pretty bad at the moment, so I don't think those signs are necessarily attributable to the hypokalaemia.

Re: Hypokalaemia in a Burmese cat with CRF

Martin Atkinson — Tue, 24 Jun 2014 14:48:00 GMT

I wouldn't bust a gut on this, although theoretically problems can occur with this level of hypokalaemia IME old cats seem to tolerate it well. Provided it is eating and not weak and they're getting as much as possible into the cat I think you can live with it. Have you considered Tumil K powder rather than Kaminox?

Re: Hypokalaemia in a Burmese cat with CRF

Neil Wheadon — Tue, 24 Jun 2014 12:21:23 GMT

My honest thought would be are you sure this cat is getting 12ml of a day.

Dosing a cat even once a day on anything is tough, and there are 5 medications involved here.

Is the hypokalaemia causing any adverse clinical signs?

Good Luck

Neil