Recovering from DKA, how to manage diabetes + CKD

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Aobw

Aobw

Member Since 2019
Hi everyone,
My 16 y/o baby, Alistair, was diagnosed with diabetes at the end of September after going into diabetic ketoacidosis. It was very sudden--his glucose was fine three months earlier and he hadn't shown any symptoms like weight loss or increased appetite. He was hospitalized for 3 days. He already had a a heart murmur but it was asymptomatic. However, the DKA treatment exacerbated that into congestive heart failure and he is now on furosamide. His CKD has been stable at stage 2 for a year and a half, but the furosamide is rapidly exacerbating that. He was at stage 3 within 2 weeks, and they said a renal panel last week was worse.

Since he left the hospital, recovery has been slow, at least in part because of side effects from the medication and because it was incredibly hard to get him to eat. He started metoclopramide (on top of cerenia and mirtazapine) for his GI issues on Thursday, and has been eating better since then. I still have to present his food to him frequently to get him to eat, but I think he's FINALLY approximately taking in a normal calorie count.

I need to figure out what to feed him. He loves Royal Canin renal diet kibble and usually refuses to touch any wet, or even damp, food. Of course, that food is all carbs, but whatever food I give him needs to be appropriate for how rapidly his kidneys are failing,

His regular vet referred him to an internal medicine specialist to manage his diabetes and CKD. His BG is still quite elevated, so his vet has been increasing his insulin dose (Lantus) super quickly. I have put his numbers in the spreadsheet.

His insulin dosing has been as follows:
9/29-10/7: 1 unit/day (in one dose)
10/7-10/15: 2 units/day (in 2 doses)
10/15-10/20: 4 units/day (in 2 doses)
10/20-present: 6 units/day (in 2 doses)

Any advice anyone can give is so welcome! I have already learned more from the members of this forum than I was able to get out of three separate vets.

Thank you!
Alexander
 
Waving to you from up the road in the Kawarthas.

@Bron and Sheba (GA) gave you some good information in your introductory post.

Tagging @Wendy&Neko for you who has experience with heart problems. She may not be around until late in the day.

With DKA in the recent past, it is important that Alistair eats. DKA = lack of insulin + lack of food + an infection/inflammation/something else going on.


That is quite the step up in insulin. Lantus is a depot insulin, meaning that a little bit of the insulin is stored by the body and slowly builds up a depot. So, It is extremely important to test him, especially mid-cycle right now. I will let other, more experienced members comment in detail on the dosage.

Just in case, here is the information about what to do for a hypo.
The bible for CKD is http://www.felinecrf.org – a steep learning curve.

If you can get copies of the lab work from your vet, we have people here who can interpret them.

Are you giving a phosphorus binder? or subq fluids? or meds for the CKD?
 
Hi there!

I'll test as much as I can what with having to be out of the house for work.

He actually isn't on any treatment for CKD at the moment. The cerenia and mirtazapine have only been since he got out of the hospital because furosamide upsets his stomach. Not sure if any of that is due to CKD progression. He does have hypercalcemia. I was previously giving him psyllium fiber mixed with his food to bind it. However, I've cut that out, for now at least, in the interest of making his food maximally palatable. Otherwise, his electrolytes have historically been pretty good. Because of his heart, he can't tolerate subq fluids (60 ml of subq fluids were what landed him in CHF in the first place) but his hydration has typically been reasonable. We've been managing the CKD for almost 2 years now (with lots of gratitude for the felinecrf site!), and his numbers had actually improved in the last 6 months or so to the point that his BUN and creatinine were in the high-normal range :-/ It's so heartbreaking to see this rapid decline now.

I'll request his last labs. I don't even want to look at his renal panel from last week but obviously I can't avoid it forever :(
 
There is no dry food available in Canada that is low carb.
Here is a link to how to transition a cat to wet food. It helps to crumble a few pieces of the dry on top of the wet food offering. The link I posted earlier regarding how to get a cat to eat has suggestions as well.

Powdered aluminum hydroxide can be used to bind the phosphorus. It is mixed into the wet food and is tasteless. (The phosphorus binder gel from the vet contains sugar.) You can find it at thrivingpets.com.
 
Believe me, I've spent quite a bit of time and effort trying to transition him to wet food in the past. He's so stubborn that he won't even eat dry food that has touched wet food. I'll certainly take a look at the tips and keep trying, but I'd like to figure out a backup option for dry. Which wet food do you recommend for diabetes + CKD?

Is the phosphorus binder recommendation for if I switch him to a wet food that is higher in phosphorus than the renal diet? His phosphorus hasn't been elevated in the past.
 
The neighbourhood ferals had a veritable four star restaurant on our front porch as I tried to find food that Rover would eat.
Here is a link to a list of low carb foods under 250mg phosphorus last updated in 2017.
https://docs.google.com/spreadsheets/d/1nMBzt57Zi0PcAJ-gSt0NxrTyc3Twi7A0L8o2H2gGkoM/edit#gid=0

I'm glad that phosphorus has not been an issue so far, but something to keep in mind for when the CKD progresses.

If you make frequent trips across the border to the US, there is Dr. Elcey's Clean Protein dry food low in carbs. I do not know the phosphorus content. The other dry food available in the US is Young Again – online orders only and they do not ship to Canada. Someone from the US will have to chime in on these foods.
 
When do you see the internal medicine specialist? I found that really helpful for Neko. She started out with diabetes due to acromegaly, added CKD, and adding fluids caused her heart to complain too. Have you ever seen a cardiologist vet? Once Neko got on the right meds, her heart and appetite improved. Her cardio and IM vet worked closely together. We did manage to avoid furosemide for quite a while, she was on Plavix (clopidogrel) and Vetmedin.

Have you ever tried freeze dried raw food? We had one kibble addict transition to freeze dried raw, then gradually had more water added. Since you can’t give fluids, oral liquid is very important and kibble won’t give you that. Neko was on low phosphorus raw.
 
In addition to Wendy's suggestion, another option may be ZiwiPeak. They make an air dried food that is low in carbs and high in protein. I don't see information on phosphorus in the analysis but if you contact them, I'm sure they would provide the information. It's more the texture of a jerky-style treat so maybe that will be palatable for Alistair.

Also, please get a before bed test every night. It looks like Alistair's starting to respond to Lantus and it's important that he's in safe numbers when you turn in for the night.
 
I'm so sorry for the delayed response! I never saw these messages.

Alistair's numbers today have been the lowest I've seen so far. This may be in part because he didn't eat much today (I tried not giving him a medication for stomach upset to see if he still needed it, and I guess he did). Also though, he's definitely starting to respond to the Lantus. Since he's on such a large dose (3 units BID), and it was raised so quickly (from 1 unit a day a month ago), I'm a little concerned about still giving him his evening shot. I will be sending today's glucose curve to his internal medicine specialist who has been setting his insulin doses.

Given how low his numbers have been today, should I give him his full dosage if BG isn't back to its typical +12? What if he eats a large amount at that time?
 
Wendy&Neko said:
When do you see the internal medicine specialist? I found that really helpful for Neko. She started out with diabetes due to acromegaly, added CKD, and adding fluids caused her heart to complain too. Have you ever seen a cardiologist vet? Once Neko got on the right meds, her heart and appetite improved. Her cardio and IM vet worked closely together. We did manage to avoid furosemide for quite a while, she was on Plavix (clopidogrel) and Vetmedin.

Have you ever tried freeze dried raw food? We had one kibble addict transition to freeze dried raw, then gradually had more water added. Since you can’t give fluids, oral liquid is very important and kibble won’t give you that. Neko was on low phosphorus raw.
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Thank you for the suggestions. I'll be emailing the IM specialist tonight with his latest glucose curve.

So far, I've only tried a variety of wet food with almost no success and since the best food is the one he'll eat, I've gone back to the renal support kibble for now <shrug>. I will look into the freeze-dried and the ZiwiPeak. We've had a lot of ups and downs lately, so I stopped trying to make changes to things that were not acute problems. He has seen a cardiologist but she wants to keep him on this relatively high dose of furosemide for another week or so. It makes me nervous! Vetmedin made him absolutely sick and miserable. I may try reintroducing a very small amount and seeing if he can tolerate a slow introduction.
 
Hi Alexander,
Are you able to get any tests in during the PM cycles. They are just as important as the AM cycles. Always try and get a before bed test done to see Alistair will be safe overnight.
Also it would be helpful if you could put what food you feed and when, into the remarks column of the SS please.

Aobw said:
No pre-shot yet. I just did his +10 and got 8 mmol/L/144 mg/dL.
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You shot a 142 yesterday morning.
I'd get a +11 to see if the number is rising.

His numbers are looking better. He hasn't earned a reduction in dose so he should stay on that dose until he drops under 90 (SLGS) or 50 (TR). Have a look at both the dosing methods ..yellow stickies..on the top of the lantus page for details.
When increasing or decreasing the dose we recommend doing it is 1/4 unit increments not 1 unit increments which most vets tend to do.
 
Please let us know where Alstair's numbers are closer to shot time. If numbers are on the rise, in all likelihood, you'll be able to shoot. (Although, I always want to be sure that you can monitor, have extra strips, and high carb food on hand if it's needed.)
 
Yesterday when I shot at 142, he ate an enormous breakfast after I tested but before I shot, so I thought it would be safe. I added his food information to the SS. Basically, he's still eating that very high carb kibble because he's been resistant to trying anything else and getting him to eat period was such a nightmare for a few weeks. I give it in two meals, but let him graze in between.

I will let you know his updated numbers.
 
Are you able to test tonight?
Do you have some high carb food at home and plenty of strips?
If yes. I would shoot.
Please get a +1 and a +2 and post results.
Then a+4
 
The +1 is likely a food spike -- especially if you're still feeding the dry stuff. Lantus onset begins at around +2.

Any chance we can convince Alstair of the evils of kibble?
 
Ok, I'm sorry to keep asking so many questions, but he's at 158 this morning. I have to go to work in a little bit and won't be able to monitor him. He hasn't eaten much so far today and I don't know if his appetite is going to get better. Shoot a reduced dose?
 
I take it there is no way for you to get home to test at lunch time? If so, since you think his appetite is a bit diminished, you could give a reduced shot of 2.5u for this one dose and leave kibble down for him to munch on as needed.
 
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