"He's here for his kidney jags"

Re: "He's here for his kidney jags"

Julian Earl — Thu, 01 Sep 2011 11:35:34 GMT

[quote user="Martin Atkinson"]

[quote user="Julian Earl"]

'The evidence from some CP/FAB CPD was that the only treatment that is proven to improve the quality and quantity of a cat's life once they have renal disease is the diet. ACE inhibitors improve the quality of life in that appetite and proteinuria can improve, but they do not lengthen the life'.

I would disagree with that. IME the life expectancy of cats on renal diet and ACEi is more than doubled over those on diet alone. The problem is that many clinicians are being pedantic about not using ACEi until there is proteinuria, hypotonic urine and raised UP/C ratio. IMO this is too late and they should be started BEFORE these changes take place. This is something I have ranted on about before and being criticised, so before someone has a go again I repeat this is my expereince and my opinion and I can't be bothered defending it again.

'At last Martin! There had to be something we agree on'!

[/quote]

Which bit did we agree on Julian?

[/quote]

This bit:

"Martin Atkinson:

...I find RCW Renal Support is the most palatable overall but cat's tastes vary, we send them home after initial diagnosis with a taster pack of several brands, wet and dry, to see which they prefer.. I would like to think the evidence for renal diets is a bit more than anecdotal considering the amount that is put into research. My understanding is that it is the phosphate restriction in the diet which is the most important rather than protein restriction per se although the two go hand in hand. Certainly IME rapidly rising phosphate levels are the most worrying prognostic indicator, whether further phosphate restriction at this stage is relevant or not is another matter. My take on the 'kidney jags' is that: in the time before time itself began, when we didn't have renal diets, ACEi or EPO and had a poorer understanding of the importance of fluids in the treatment of CKD in cats, a shot of B12 and anabolics was about the only tool in the treatment locker. However, even now with our greater understanding I feel there is a place for them in near end stage cases, it does at least brighten them up."

Re. your above comments, I am merely citing the evidence given by the FAB. <Shrugs>

As we all do, I see a lot of cats with renal disease but still would not confidently state the difference in survival rates for with/without ACEi; they do seem to improve the demeanour and appetite of cats but there is no reason why they should significantly slow the progress of the disease. Maybe a reduction in the rate of weight loss due to reduced proteinuria/increased appetite, but otherwise I'm not sure. The diets are reno-protective though.

Re: "He's here for his kidney jags"

Evelyn Barbour-Hill — Thu, 01 Sep 2011 02:56:03 GMT

[quote user="Stephen Courtney"]

Another anecdotal 'can of worms' - I'm sure everyone at least knows of a 'terminal' CRD (chronic kidney disease) cat that was given a shot of steroid as a last resort, and proceeded to do surprisingly well for a while at least.

One thing i remember from days long ago in the path lab, the kidneys of old cats with chronic kidney damage showed a marked interstitial fibrosis as expected, but also often with a florid lymphoplasmacytic inflitrate. Cats get this sort of infiltrate in various organs - skin, guts, conjunctivae, pancreases, livers.......and often treated with steroids to great effect.

Is there something we are missing here?

[/quote]

You won't me saying this, but this post is a perfect illustration of one of the reasons that it drives me mad when people write "steroids". How many different steroid drugs are there? How many different actions do they have?

Re: "He's here for his kidney jags"

Amanda Nicholls — Wed, 31 Aug 2011 21:18:33 GMT

[quote user="Louise Alexander"]

Because I am one of those nightmare owners

[/quote]

not at all - he is lucky to have you

Re: "He's here for his kidney jags"

Louise6732 — Wed, 31 Aug 2011 19:19:05 GMT

I see your point Clive, the creatinine, although within reference range for the lab, according to Iris has always been high. UPC is an indicator which I go on, and this has always been high (despite Fortekor...)

Because I am one of those nightmare owners as well as his vet we went to Langford vet school for a work up, where he had an ultrasound scan about 1 year ago by a very experienced diagnostic imaging clincian, who confirmed his kidneys had the characteristics of chronic renal insufficiency.

So what would you guys have done in this case? If it was a client? And if it was your cat!

Re: "He's here for his kidney jags"

Stephen Courtney — Wed, 31 Aug 2011 19:11:11 GMT

Is there something we are missing here?

Re: "He's here for his kidney jags"

Martin Atkinson — Wed, 31 Aug 2011 18:40:25 GMT

[quote user="Clive Ansell"]

Did he have renal failure in the first place? although urea levels were raised, creatinine was well within range and with an SG1.040 it seems there was good concentrating ability ??

Creatinine has risen more in the month post diet than previously, some of the cynics may argue it is making matters worse ??

[/quote]

I had the same thoughts, but the UP/C ratio was pretty high on the first test - so high I would have thought that was near end stage, but the urine SG was high end rather than anything else, who goes for dehydration there? Phosphate has improved but that didn't seem to have been included in the first profile. It could be the creatinine has gone up because the cat has bulked up a bit due to an improvement in appetite.

Re: "He's here for his kidney jags"

Clive Ansell — Wed, 31 Aug 2011 16:43:24 GMT

[quote user="Louise Alexander"]

Before starting renal diet:

Urea * 21.2 mmol/L High (4.0 -12.0 )

Creatinine 135 umol/L (80.0 -180.0)

3months later, in case the previous results were an anomaly!:

Phosphate 2.30 mmol/L (1.2 -2.6 )

Urea * 27.5 mmol/L High (4.0 -12.0 )

Creatinine 150 umol/L (80.0 -180.0)

Urine protein:creatinine * 3.91 High (0.0 -0.5 )

Specific gravity 1.040

1 month after starting renal diet exclusively:

Phosphate 1.80 mmol/L (1.2 -2.6 )

Urea * 16.3 mmol/L High (4.0 -12.0 )

Creatinine 166 umol/L (80.0 -180.0)

Urine protein:creatinine * 0.53

He has been on renal food for 1yr now, the bloods since then (every 3-4months) have continued to stay relatively stable, as has the UPC. I started him on Fortekor, but the UPC hasn't changed.

[/quote]

Did he have renal failure in the first place? although urea levels were raised, creatinine was well within range and with an SG1.040 it seems there was good concentrating ability ??

Creatinine has risen more in the month post diet than previously, some of the cynics may argue it is making matters worse ??

Re: "He's here for his kidney jags"

Edward Jones — Wed, 31 Aug 2011 16:39:05 GMT

My personal (anecdotally derived) opinion is that the renal diets are the most effective treatment, simply because many animals (cats and dogs) are reported to drink less when started on them, presumably due to reduced renal 'workload'. My reasoning may be completely wrong, but a significant number of clients report reduced thirst on renal diets.

I've never seen reduced thirst with any other treatment.

As an aside, I notice Science plan feline senior diets have reduced phosphorus. Do any other senior (non-prescription) diets feature this?

Re: "He's here for his kidney jags"

Martin Atkinson — Wed, 31 Aug 2011 16:11:46 GMT

[quote user="Julian Earl"]

'At last Martin! There had to be something we agree on'!

[/quote]

Which bit did we agree on Julian?

Re: "He's here for his kidney jags"

Anthony Todd — Wed, 31 Aug 2011 16:09:45 GMT

[quote user="Thomas Johnson"]A retrospective study published in the Vet Record in 2005:[/quote]

Hard to dispute and much better than anecdotes I humbly agree.

Sounds like a jag of B12 and the renal diet would suit all contributers?

What about early ACEi??

Re: "He's here for his kidney jags"

Mark Holmes — Wed, 31 Aug 2011 16:00:20 GMT

With regards to renal diet I would argue that any cat over the age of what? 16 or certainly 18 should be on it. They are all (or certainly most) likely to have renal problems regardless of the presence or absence of azotaemia. Given the time which can be required to accept a diet change and the fact that the change is better made whilst they are well rather than waiting. It would be sensible to preempt the disease rather than wait for it to present.

Re: "He's here for his kidney jags"

Amanda Nicholls — Wed, 31 Aug 2011 15:54:23 GMT

[quote user="Anthony Todd"]

[quote user="amanda nicholls"]The change in his bloods just from switching to renal diet was incredible, and so I'm a big fan. [/quote]

Yes, but do they live longer and would you not get the same improvement with the traditional "kidney jags?

Are you sure there are no other changes or drugs given coincidentally or is it just diet or just "kidney jags" alone?

[quote user="amanda nicholls"]I agree, blood work improves, phosphate especially drops dramatically. The cats eat more, gain weight, stop vomiting, [/quote]

So nothing else at all, no drugs, no advice, just feed this or that??

I am told that RCW is the most palatable of the kidney diets though.

Does make me smile a bit when "kidney jags" are derided yet kidney diet is promoted based on the same totally anecdotal evidence, which, as we all know is a load of old bollards and must be ignored.

[/quote]

I try to follow the IRIS guidelines as closely as possible (finances and cat permitiing), my rationale for following their guidelines - they are the experts, they have research to back up their recommendations, I have had good experiences since I started doing so a few years ago (the staging and recommendations are easy to follow and explain to owners).

I don't use anabolics, often use B12 (in GIT and renal cats). From the IRIS website:

Anabolic steroids are of no proven benefit and may be detrimental.

Re: "He's here for his kidney jags"

Julian Earl — Wed, 31 Aug 2011 15:51:23 GMT

[quote user="Anthony Todd"]

[quote user="amanda nicholls"]The change in his bloods just from switching to renal diet was incredible, and so I'm a big fan. [/quote]

Yes, but do they live longer and would you not get the same improvement with the traditional "kidney jags?

Are you sure there are no other changes or drugs given coincidentally or is it just diet or just "kidney jags" alone?

[quote user="amanda nicholls"]I agree, blood work improves, phosphate especially drops dramatically. The cats eat more, gain weight, stop vomiting, [/quote]

So nothing else at all, no drugs, no advice, just feed this or that??

I am told that RCW is the most palatable of the kidney diets though.

Does make me smile a bit when "kidney jags" are derided yet kidney diet is promoted based on the same totally anecdotal evidence, which, as we all know is a load of old bollards and must be ignored.

[/quote]

The evidence from some CP/FAB CPD was that the only treatment that is proven to improve the quality and quantity of a cat's life once they have renal disease is the diet. ACE inhibitors improve the quality of life in that appetite and proteinuria can improve, but they do not lengthen the life.

[quote user="Martin Atkinson"]

[/quote]

At last Martin! There had to be something we agree on!

Re: "He's here for his kidney jags"

Louise6732 — Wed, 31 Aug 2011 14:01:07 GMT

[quote user="Anthony Todd"]

[quote user="amanda nicholls"]The change in his bloods just from switching to renal diet was incredible, and so I'm a big fan. [/quote]

Yes, but do they live longer and would you not get the same improvement with the traditional "kidney jags?

Are you sure there are no other changes or drugs given coincidentally or is it just diet or just "kidney jags" alone?

[/quote]

Yes I am sure there were no other changes, he is 100% indoors and I only changed his diet. Here are the bloods:

Before starting renal diet:

Total protein 67 g/L (54.0 -80.0 )

Albumin 37 g/L (26.0 -42.0 )

Globulin 30 g/L (25.0 -45.0 )

Sodium 156 mmol/L (125 -160 )

Potassium * 6.4 mmol/L High (3.6 -6.0 )

Urea * 21.2 mmol/L High (4.0 -12.0 )

Creatinine 135 umol/L (80.0 -180.0)

Alk Phos * 38 U/L High (0.0 -25.0 )

ALT * 56 U/L High (0.0 -40.0 )

Total bilirubin 3 umol/L (0 -10.0 )

Glucose 5.3 mmol/L (3.5 -6.6 )

3months later, in case the previous results were an anomaly!:

Total protein 64 g/L (54.0 -80.0 )

Albumin 37 g/L (26.0 -42.0 )

Globulin 27 g/L (25.0 -45.0 )

Sodium 156 mmol/L (125 -160 )

Potassium 4.8 mmol/L (3.6 -6.0 )

Phosphate 2.30 mmol/L (1.2 -2.6 )

Urea * 27.5 mmol/L High (4.0 -12.0 )

Creatinine 150 umol/L (80.0 -180.0)

Alk Phos * 30 U/L High (0.0 -25.0 )

ALT * 54 U/L High (0.0 -40.0 )

Total bilirubin 1 umol/L (0 -10.0 )

Urine protein:creatinine * 3.91 High (0.0 -0.5 )

Specific gravity 1.040

1 month after starting renal diet exclusively:

Total protein 62 g/L (54.0 -80.0 )

Albumin 35 g/L (26.0 -42.0 )

Globulin 27 g/L (25.0 -45.0 )

Sodium 152 mmol/L (125 -160 )

Potassium 4.8 mmol/L (3.6 -6.0 )

Phosphate 1.80 mmol/L (1.2 -2.6 )

Urea * 16.3 mmol/L High (4.0 -12.0 )

Creatinine 166 umol/L (80.0 -180.0)

Alk Phos * 31 U/L High (0.0 -25.0 )

ALT * 80 U/L High (0.0 -40.0 )

Total bilirubin 3 umol/L (0 -10.0 )

Urine protein:creatinine * 0.53

He has been on renal food for 1yr now, the bloods since then (every 3-4months) have continued to stay relatively stable, as has the UPC. I started him on Fortekor, but the UPC hasn't changed.

I have never blood sampled cats pre and post 'kidney jags' although this would make for a very interesting study. I find those clients who opt for 'kidney jags' are those who won't want blood samples taken regularly.

I'm pretty sure that the renal diet will help out the kidneys, and save them from taking such a hit from the protein loss and uraemia, so I would think that this would extend his life, even if only by a few months? He eats the food, it's clearly helping, why are you so sceptical?

May I suggest you read this fantastic article:

Therapies for feline chronic kidney disease: What is the evidence? JFMS (2009) 11, 195-210

Louise

Re: "He's here for his kidney jags"

Thomas Johnson — Wed, 31 Aug 2011 09:43:32 GMT

[quote user="Anthony Todd"]

Can someone give me some references in the dog and cat showing the benefits please, I mean all the dinosaurs know that B12 and Betsolan, Dexafort plus or minus Nandrolin always makes them feel better but does anyone truly believe kidney diets do?

[/quote]

A retrospective study published in the Vet Record in 2005:

http://veterinaryrecord.bmj.com/content/157/7/185.abstract?sid=1bb52046-a8e9-4f9d-8854-8db3a6d1574e

A letter criticising the study:

http://veterinaryrecord.bmj.com/content/157/15/455.3.full?sid=1bb52046-a8e9-4f9d-8854-8db3a6d1574e

A reply from the author:

http://veterinaryrecord.bmj.com/content/157/15/456.1.full?sid=1bb52046-a8e9-4f9d-8854-8db3a6d1574e

Re: "He's here for his kidney jags"

Martin Atkinson — Wed, 31 Aug 2011 09:42:56 GMT

[quote user="Anthony Todd"]

I am told that RCW is the most palatable of the kidney diets though.

Does make me smile a bit when "kidney jags" are derided yet kidney diet is promoted based on the same totally anecdotal evidence, which, as we all know is a load of old bollards and must be ignored.

[/quote]

I find RCW Renal Support is the most palatable overall but cat's tastes vary, we send them home after initial diagnosis with a taster pack of several brands, wet and dry, to see which they prefer.. I would like to think the evidence for renal diets is a bit more than anecdotal considering the amount that is put into research. My understanding is that it is the phosphate restriction in the diet which is the most important rather than protein restriction per se although the two go hand in hand. Certainly IME rapidly rising phosphate levels are the most worrying prognostic indicator, whether further phosphate restriction at this stage is relevant or not is another matter. My take on the 'kidney jags' is that: in the time before time itself began, when we didn't have renal diets, ACEi or EPO and had a poorer understanding of the importance of fluids in the treatment of CKD in cats, a shot of B12 and anabolics was about the only tool in the treatment locker. However, even now with our greater understanding I feel there is a place for them in near end stage cases, it does at least brighten them up.

Re: "He's here for his kidney jags"

Anthony Todd — Wed, 31 Aug 2011 08:23:19 GMT

[quote user="amanda nicholls"]The change in his bloods just from switching to renal diet was incredible, and so I'm a big fan. [/quote]

Yes, but do they live longer and would you not get the same improvement with the traditional "kidney jags?

Are you sure there are no other changes or drugs given coincidentally or is it just diet or just "kidney jags" alone?

[quote user="amanda nicholls"]I agree, blood work improves, phosphate especially drops dramatically. The cats eat more, gain weight, stop vomiting, [/quote]

So nothing else at all, no drugs, no advice, just feed this or that??

I am told that RCW is the most palatable of the kidney diets though.

Does make me smile a bit when "kidney jags" are derided yet kidney diet is promoted based on the same totally anecdotal evidence, which, as we all know is a load of old bollards and must be ignored.

Re: "He's here for his kidney jags"

Anonymous — Wed, 31 Aug 2011 07:49:38 GMT

Thanks for the replies - seems not quite so unfashionable amongst GPs than academics.

Does anyone have any anecdotes regarding observations of efficacy of nandrolone given alone (without B12) or of improved efficacy having given nandrolone in addition to B12 rather than just B12?

It's the nandrolone that I'm dubious about.

My anecdote is that 3 to 4 years ago when I worked in a practice with branch practices, a fair proportion of these cats seemed to turn up at a small branch which frequently didn't have a bottle or Laurabolin/Retarbolin present - so I gave them B12 alone. If they turned up a different month or at a different branch, they may have got the anabolic as well. I don't remember noting any difference in client reports dependent on whether they got B12+nandrolone or B12 on its own. Some clients believed that the injections were keeping the cat alive and must be effective as cat was still alive, sometimes many years after being 'diagnosed' with renal failure, some noted a genuine subjective impression of improvement having received the injections.

Re: "He's here for his kidney jags"

Robin Grimmer — Tue, 30 Aug 2011 22:59:00 GMT

Renal diets have improved a lot over the years in terms of palatability. My cat likes k/d biscuits and this is the only dry food she has, plus k/d pate tins.

I do give other wet food sometimes as a treat.

Re: "He's here for his kidney jags"

Amanda Nicholls — Tue, 30 Aug 2011 22:23:06 GMT

[quote user="Louise Alexander"]

. The change in his bloods just from switching to renal diet was incredible, and so I'm a big fan. When you see it working with your own eyes it changes your opinions!

Louise

[/quote]

I agree, blood work improves, phosphate especially drops dramatically. The cats eat more, gain weight, stop vomiting, I too am a big fan of renal diets and the RCW diets seem to be palatable (and the owners like the fact they come in different flavours!)

If you can encourage senior cat blood and urine tests as part of the annual health check (perhaps instead of vaccines) you can introduce the diets when the cats are eating well and still feel ok and they seem to accept them better than waiting until stage 3 or 4 CRF when as Martin says they need fluids, fluids and more fluids.

Re: "He's here for his kidney jags"

Richard Carter — Tue, 30 Aug 2011 21:47:48 GMT

[quote user="Anthony Todd"]B12's got such a therapeutic colour too[/quote]

and reaction from the patient - so it must be strong and efficient

Re: "He's here for his kidney jags"

Anthony Todd — Tue, 30 Aug 2011 20:50:14 GMT

[quote user="Stephen Courtney"]I agree diets are potentially the biggest help[/quote]

I'm sure all you people wouldn't be recommending these kidney diets without the usual reams of sponsored research proving health wealth and longevity but I seem to remember a trial at Penn which showed that low protein diets in kidney dogs actually shortened their lives.

A prominent vet and his assistant used to do a B12 and Betsolan dance at social events in celebration of the vast mansion in St Johns Wood paid for by the aforementioned cocktail.

B12's got such a therapeutic colour too........

Re: "He's here for his kidney jags"

Martin Atkinson — Tue, 30 Aug 2011 19:18:53 GMT

Anabolic steroids and B12 IME do have some benefit in appetite stimulation in cats in terminal CKD. Some vets seem to use the cocktail as a receipe for anaemia in CKD cats when EPO is far more effective although an assumption may be made that a lot of old cats may have also have pernicious anaemia due to poor absorption of B12 from the gut so if may be beneficial for that. The Atkinson formula for treatment for CKD in cats is, in order of progressive severity of symptoms: 1) renal diet, 2) ACEi (before the the point pedants would suggest when there is proteinuria, UP/C ratio is high and urine SG low), 3) Fluids, 4) more fluids, 5) yet more fluids - get the idea, 6) EPO (poss B12) if anaemic, 6.5) antacid treatment if vomiting or seem nauseous, 7) phosphate binder if phos is high despite diet or if cat won't eat renal food - they generally won't take either Ipakitine or Renalzin anyway but at least I try, 8) even yet more fluids, 9) anabolics and B12 once the appetite is poor and they are cachectic, 9) loads more fluids 10) pentobarbitone.

Re: "He's here for his kidney jags"

Louise6732 — Tue, 30 Aug 2011 18:04:55 GMT

[quote user="Michael Woodhouse"]The renal diets must taste crap as most cats don't like them and the ones that do don't eat them very well. [/quote]

I think having this attitude sets you up for failure, you must go into these things thinking the cat won't eat renal food, and that is bound to be communicated to the owner, either obviously or inadvertently.

My cat has renal insufficiency as has been eating renal diet for over a year now and is still eating it fine. He gets the occasional Sheba or other treats, when I feel guilty for feeding him the same flavour for life. The change in his bloods just from switching to renal diet was incredible, and so I'm a big fan. When you see it working with your own eyes it changes your opinions!

Louise

Re: "He's here for his kidney jags"

CatherineThomas — Tue, 30 Aug 2011 14:30:22 GMT

The previous owner at my practice, who left just before I started, used to give any old cats his "old cat cocktail", even if they'd just been off thier food for 24hrs. A lot of them seem to have had no work up at all. His cocktail includes Laurabolin, Vitbee and dexafort. I would have thought that you wouldn't want to give laurabolin and dexafort together? So when they come back in for a "repeat cocktail inj" I miss out the dexafort. I've tried convincing people to try without it or do a work up, but they believe the injection does wonders for the cat and they won't be convinced otherwise. Fortunately now a lot of these old cats are dying off so I'm not having to do so many.