How long do you leave a cat on fluids on renal failure?

Re: How long do you leave a cat on fluids on renal failure?

Thomas Johnson — Thu, 07 Aug 2014 09:14:15 GMT

[quote user="Andrew Kent"]

Hi Neil,

My feeling on this is that a large proportion of what we achieve with IVFT is correcting the pre-renal component of the azotaemia (i.e. the dehydration) that accompanies cats with CRF. I agree that the evidence that we do any more than that is lacking but that on its own makes fluids worthwhile as the cats will feel much brighter afterwards.

Andy

[/quote]

That was my reading of the article that Neil posted, we should be using fluids in cats with CKD to correct dehydration, electrolyte abnormalities and acid/base balance, but the use of aggressive fluids beyond that is of no benefit. And I don't think it is an arguement against the use of skin buttons, providing supplementary fluids in this way is not really the same as having a cat at the surgery on i/v fluids at rates of several times maintenance.

Re: How long do you leave a cat on fluids on renal failure?

Andrew Kent — Tue, 05 Aug 2014 10:52:49 GMT

[quote user="Neil Wheadon"]

OK resurrected this one.

Is there any evidence that dripping renal cats actually makes a difference?

I've seen this on another forum

No evidence exists in the human or animal literature supporting the notion that aggressive intravenous fluid therapy can promote the rate of excretion of uremic solutes beyond that which can be achieved by restoration of normal physiologic perfusion parameters. Nonetheless, it is common practice to prescribe high intravenous fluid rates with the goal of promoting a uremic solute diuresis. Oftentimes, veterinarians attribute a modest decline in serum or plasma creatinine concentrations to an improved GFR, when a more likely cause of the ‘improvement’ is a dilutional effect from fluid accumulation and overload. A large body of evidence exists in the human literature that documents the negative effect of aggressive fluid therapy and subsequent fluid overload on not only survival, but length of hospital stay and secondary endpoints such as oxygenation status.

While it would be inappropriate for the pendulum to swing to withholding necessary fluid therapy, a happy medium of ‘just enough, but not too much,’ based on careful and repeated physical examination of the patient in conjunction with critical evaluation of objective patient data, should be our goal.

The reference is from http://jfm.sagepub.com/content/14/11/773.full.pdf+html and was published in the journal of Feline Medicine and surgery.

So are we wasting our time driping these cats?

Neil

[/quote]

Hi Neil,

Andy

Re: How long do you leave a cat on fluids on renal failure?

Gareth Dowdeswell — Mon, 04 Aug 2014 22:22:59 GMT

2[quote user="Neil Wheadon"]

OK resurrected this one.

Is there any evidence that dripping renal cats actually makes a difference?

I've seen this on another forum

The reference is from http://jfm.sagepub.com/content/14/11/773.full.pdf+html and was published in the journal of Feline Medicine and surgery.

So are we wasting our time driping these cats?

Neil

[/quote]

This study http://www.ncbi.nlm.nih.gov/pubmed/18691369 showed a better survival time for cats who went from IRIS stage 4 to stage 3 after fluids compared to those who stayed in stage 4. Think that's probably a reflection of remaining renal function rather than the fluids improving things, but it certainly suggests it does no harm.

Re: How long do you leave a cat on fluids on renal failure?

Rob Loxley — Mon, 04 Aug 2014 14:56:17 GMT

[quote user="Neil Wheadon"]Is there any evidence that dripping renal cats actually makes a difference?[/quote]

That's a leap from suggesting aggressive high volume fluid administration may offer no additional benefit, to suggesting that acute/acute-on-chronic renal disease doesn't benefit from putting the cat on some fluids....

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Mon, 04 Aug 2014 10:03:58 GMT

[quote user="Neil Wheadon"]Is there any evidence that dripping renal cats actually makes a difference?[/quote]I feel the modus operendi is rather irrelevant here. We are all aware that cats that would otherwise had died PDQ can be kept going with quality of life for weeks with additional fluids. That is all the evidence you need. The skin button saves the aggro of visits to the vet for IV of even just injected SC fluids.

Now if someone can produce some evidence that there is a better way I'm prepared to try it!

Re: How long do you leave a cat on fluids on renal failure?

Neil Wheadon — Mon, 04 Aug 2014 00:20:09 GMT

OK resurrected this one.

Is there any evidence that dripping renal cats actually makes a difference?

I've seen this on another forum

The reference is from http://jfm.sagepub.com/content/14/11/773.full.pdf+html and was published in the journal of Feline Medicine and surgery.

So are we wasting our time driping these cats?

Neil

Re: How long do you leave a cat on fluids on renal failure?

Neil Wheadon — Mon, 14 Jul 2014 16:11:06 GMT

As an update The kitty cat in question has had repeat bloods and the Urea has returned to 48 and the creatinine 850, so the 4 days fluids was a temporary measure and the owner was continuing with S/C fluids at home and she is urinating well. The conversation home visit and euthanasia has been broached. I saw the owner last Friday with his other 14 year old cat. How is she? I asked. IRIS stage 2 was he reply as he'd had a USG done a month ago and bloods today show a mildly elevated urea and creatinine, so it'll be another urine sample and Semintra I guess, Neil ( The renal consultant and thanks to everyone for their advise on this forum)

Re: How long do you leave a cat on fluids on renal failure?

Aisling McGrath — Sat, 05 Jul 2014 14:07:25 GMT

What about using Periactin as an additional appetite stimulant? You can use it concurrently with Mitarzapine.

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Fri, 04 Jul 2014 14:14:39 GMT

[quote user="Neil Wheadon"]She went home has scoffed a plate of food tanks to diazapam which was used at half the minimum dose recommended by the BSAVA formulary.[/quote] Did you give it I/V? It never ceases to amaze me how they fall off the end off the needle with I/V diazepam then 20 seconds later get up and face plant straight into the food demolishing it ravenously even though they can barely support themselves. Scary but invariably effective.

Re: How long do you leave a cat on fluids on renal failure?

Neil Wheadon — Fri, 04 Jul 2014 09:38:41 GMT

[quote user="Anthony Dennison"]Possibly also give marital in case there is any nausea involved due to the renal disease?[/quote]

She's on maropitant/cerenia 4mg SID

Talking to Zoetis, they've had cats on this for 3 years, with no issues, which backs up the interesting piece of information that I knew in that it can be used in anti-imflammatory bowel disease in cats

Neil

PS She went home has scoffed a plate of food tanks to diazapam which was used at half the minimum dose recommended by the BSAVA formulary.

PPS My colleague joked that the client was paying for my CPD!!

Re: How long do you leave a cat on fluids on renal failure?

Anthony Dennison — Fri, 04 Jul 2014 06:52:31 GMT

Possibly also give marital in case there is any nausea involved due to the renal disease?

Re: How long do you leave a cat on fluids on renal failure?

Neil Wheadon — Thu, 03 Jul 2014 14:48:58 GMT

[quote user="Martin Atkinson"] The cat is going to die anyway so it might as well at least enjoy its food and die of renal failure rather than starvation! Spoil it with some prawns or chicken or whatever.[/quote]

Entirely my view too which is why the owners have trawled the supermarket today for anything fishy and tasty

Neil

Re: How long do you leave a cat on fluids on renal failure?

Andrew Kent — Thu, 03 Jul 2014 14:35:01 GMT

[quote user="Neil Wheadon"]Interestingly the client has been trawling the internet and has said that it takes a week to get going properly in reducing the acid secretion - is this true?[/quote]

It certainly takes a few days to get to maximum effect but causes a fairly profound change even on day 1.

Andy

Re: How long do you leave a cat on fluids on renal failure?

Neil Wheadon — Thu, 03 Jul 2014 14:25:43 GMT

Hi Andrew

On omeprazole, started this 4 days ago.

Interestingly the client has been trawling the internet and has said that it takes a week to get going properly in reducing the acid secretion - is this true?

Neil

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Thu, 03 Jul 2014 14:25:33 GMT

[quote user="Neil Wheadon"]The issue now is that she won't eat much.[/quote]Is that she won't eat much of anything or she she eat much renal diet? If the latter I often feel that in this situation its a bit like the condemned man's last meal. The cat is going to die anyway so it might as well at least enjoy its food and die of renal failure rather than starvation! Spoil it with some prawns or chicken or whatever.

[quote user="Neil Wheadon"]wandering if I added pain relief (buprenorphine orally)[/quote] I would be concerned that if there is no clear indication for analgesia whether giving morphine derivatives would make the cat feel nauseous and more inappetant. If you're concerned about back pain it may be wise to take some X-rays.

Re: How long do you leave a cat on fluids on renal failure?

Andrew Kent — Thu, 03 Jul 2014 14:15:51 GMT

Hi Neil,

Is the cat on any gastro-protectants? With that level of azotamia a uraemic gastritis is possible and would certainly reduce appetite. I would add famotidine (or ranitidine) to the mix if not.

Andy

Re: How long do you leave a cat on fluids on renal failure?

Neil Wheadon — Thu, 03 Jul 2014 13:35:53 GMT

Update and a further query

She's doing OK biochemically.

3 more electrolytes and the potassium has stayed within normal boundaries, bizarrely one showed a sodium of 120, guess the owner was overhydrating

The issue now is that she won't eat much. She's on Mirtazapine every 2 days. It's the inappetance that is the must fix now. She's in today and we are going to try diazepam IV to kick start eating, however the veins are a bit shot in the legs.

We're checking for a UTI, (but need a cysto and she urinates little and often, so no big bladder) and has presented in the past with lumbar pain, so was wandering if I added pain relief (buprenorphine orally) into the mix and covered with Convenia, would this help?

Neil

PS Anabolics as a drug of 'no harm' is a distinct possibility now - thoughts

Neil

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Sat, 28 Jun 2014 11:51:10 GMT

[quote user="Anthony Todd"]

Not all dinovet things are bad

Good heavens, at last....

[/quote]Yeah, but I still won't use depo-corticosteroids or Ovarid!

Re: How long do you leave a cat on fluids on renal failure?

Anthony Todd — Fri, 27 Jun 2014 20:02:44 GMT

[quote user="Martin Atkinson"] Maybe being sole-charge I just have more bonded clients and cats that have got used to me?[/quote]

Lets hope the corporates never realise how true and crucial this is!!

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Fri, 27 Jun 2014 16:23:30 GMT

[quote user="Kate Richardson"]Very interesting- how do you feel the cats cope with such regular visits to the vets or are the cases you use EPO in cats that tolerate this well already? Many of my cats or owners just wouldn't keen on such frequent visits, but there are exceptions.[/quote] I said earlier that you certainly need motivated clients but mine almost universally have been. Those that are, see the results and are happy to continue. Clearly the cat has to vote as well but I can't think of one that has not been happy and compliant.

Indeed the owner of the lymphoma/chemo cat I alluded to has said now that the cat has finally been laid to rest that she won't know what to do with herself 3 times a week she's got so used to coming in even though she drives for 45 mins to get here and the cat was always happy to be here and give up his blood and she may just drop in for a chat. Mind you she does have another cat with stage 1 IRIS CKD so maybe that will next.

I'd say the unwilling owners and cats are the exception. Maybe being sole-charge I just have more bonded clients and cats that have got used to me?

Re: How long do you leave a cat on fluids on renal failure?

Anthony Todd — Fri, 27 Jun 2014 16:04:04 GMT

[quote user="Kate Richardson"]Not all dinovet things are bad![/quote]

Good heavens, at last....

+1 for anabolics too and B12 but who knows whether it helped; cats and clients seemed to think it did....

Re: How long do you leave a cat on fluids on renal failure?

Kate Richardson — Fri, 27 Jun 2014 12:09:12 GMT

Very interesting- how do you feel the cats cope with such regular visits to the vets or are the cases you use EPO in cats that tolerate this well already? Many of my cats or owners just wouldn't keen on such frequent visits, but there are exceptions.

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Fri, 27 Jun 2014 11:49:34 GMT

[quote user="Kara Gibson"]It is also worth considering iron supplementation if the Hct starts to drop again on treatment. Usually antibody formation causes a marked decrease in Hct and actually of the cats I've seen (many of which have been on EPO for 1-2yrs) I have only had 1 case of suspected antibody formation.[/quote] I will often use iron injections as part of my anabolic/B12 cocktail as well especially if MCHC is low on the basis that it will at least do no harm. Not had any cats live as long as 2 years on EPO, they've usually succumbed to the primary condition by then but interesting to know.

Re: How long do you leave a cat on fluids on renal failure?

Kara Gibson — Fri, 27 Jun 2014 10:35:07 GMT

EPO is a bit more affordable over here in Hong Kong and in our practice we use it extensively. We tend to start cats once their Hct falls below 20 on TIW dosing, review after 2 weeks and if sitting nicely in the normal range down to BIW and so. We keep them maintained on SIW dosing if they are stable. I have to say that I often notice a significant improvement in QOL and weight in cats which start on it compared to those that don't.

It is also worth considering iron supplementation if the Hct starts to drop again on treatment. Usually antibody formation causes a marked decrease in Hct and actually of the cats I've seen (many of which have been on EPO for 1-2yrs) I have only had 1 case of suspected antibody formation.

Re: How long do you leave a cat on fluids on renal failure?

Martin Atkinson — Thu, 26 Jun 2014 10:00:08 GMT

[quote user="Kate Richardson"] even though it used to sit on the shelf for months doing no harm when used! (see there is dinovet in me too!) [/quote]This unfortunately applies to a great deal in sole-charge practice, sometimes a degree of common sense has to apply!

[quote user="Kate Richardson"]At what point (HCT wise) do you start EPO treatment? [/quote]Working on a normal HCT range of 24-45 for a cat, I would consider initiating treatment as soon as it went below the 24 mark if it was falling, although if it has been chronically borderline anaemic but clinically normal I may wait until I observe a downward trend. Typically I might see a CKD cat with a HCT of 19-20 and would certainly recommend it in that case. I would then aim to keep it in the upper 20's. They get 3 doses within 7 days then test HCT. If it is unacceptable we continue the protocol until it is or stop if there is no benefit. If it is acceptable then I will check HCT weekly until it falls to 24 again the re-start.

I am aware of the possibility of antibody formation against the exogenous EPO so I will stop and start the course depending on the monitoring. Clearly you need motivated and (relatively) wealthy or insured clients on board. I can't say it is every case as many clients can't/won't pay for the degree of monitoring required.

But we've recently had a chronically anaemic cat on chemo for intestinal lymphoma for 9 months and this approach worked very well with him. Fortunately a very dedicated owner as she's paid over £6,000 for this, surgery and chemo up until the cat was PTS last week at the age of 19.

EPO is such a useful drug in these cases I'm surprised more vets don't take in on board and for a cat it is not horrifically expensive - you can get 2 weeks out of a 1000iu syringe for a 3kg cat which costs less than a tenner from the local pharmacy.