many quick thoughts, in no particular order. i have to get back to bed; morning comes in 4 hrs for me *sigh*
imo, part of this does belong in the main health forum, linda. not general cat health one that has low traffic (i do read that), but feline diabetes health, the high-traffic one. bear's a sugarkitty with other health issues. i'm not saying this to ask you not to post in LL - this is bear's and your home - but there are different and valuable insights that can be gained from those who have been or are on the CKD journey, but who are not LL regulars. they may not all agree, but the different perspectives are food for thought.
first things first - i took a quick look at his b/w, and i am very concerned about his phos level. linda, if i converted this correctly, his Ca x P is 9.84 x 7.43 = 73. (would you confirm if the conversion is correct?) that product is too high. there is a general rule of thumb that the product of serum total calcium x phosphorus be kept below 60 to 70; above that level, there is a risk of soft tissue mineralization, or calcification, if you have heard those terms. imho, bear's phos needs to be reduced right away. if this is one of my kitties, even if i have feed higher-carb in order to get to lower phos, i would do it. this could be a peculiarity of mine, i probably need to discuss with dr lisa, but i am more terrified of soft tissue calcification than i am of a higher creatinine level. i don't know if this is a rational fear of mine; latte does have calcification in one of her kidneys, i think. i should probably check with carolyn on its implications. there is some information on mineralization/calcification on VIN but the site is down right now. this one, i managed to pull up earlier before my nap
http://www.veterinarypartner.com/Conten ... C=0&A=2622
you know of course i'm not a veterinary professional, so this is jmho.
ps: i would absolutely not give a calcium-based phos binder b/c of the min/calc. concern above. i hope your vet is getting you an aluminium-based binder. do you know what brand? the flavourless ones are easier to use, imho - although some folks have had success with compounded chicken flavoured ones too.
I am hearing things like phosphorus binders have to be given a separate time from other meds and that they must be given with each meal. We can't do that. I do meds and put down food and leave for work, and Bear free feeds all day.
is true for only certain meds, not so much for others. best to talk to a good pharmacist who is knowledgeable in such stuff. meds that al. hydroxide can interfere with include the fluoroquinolones - so yes, his baytril will need to be given apart with some time in between - and benazepril. there are likely others, but these are the more common meds CKD kitties are on. possibly iron too, but i'm not sure? vague recollection of discussing that with dr S.
phos binders should be given with each meal, correct. it does not have to be "in" the meal, but i think i've read that it should be given right before or right after, before the phos in food has a chance to make its way out of the gut, into the body. al. hydroxide works by binding phos in the gut before it leaves, and that bound phos is then excreted.
i agree with lisa on most of what she wrote.
Lisa and Merlyn (GA) said:
... If sub qs are out, you can try watering down his food more.
i don't remember, does he care for soupy food? i've been thinking about bear all day at tbp, and a thought crossed my mind. its extreme - i don't even know if it's a good idea - but i wonder if a feeding tube would help. it will get all the fluids you want into him (within reason, of course), and you can get enough calories into him with binder mixed in so there's less of a concern whether he'll eat. how long it stays in may depend on if his appy picks up after that phos level comes down; but then again he's always had a finicky appy, so i don't know. i did say it's kind of an extreme idea - just throwing it out there.
I personally think the low protein RX foods are junk and are not needed until "end stage". Cats are obligate carnivores and still need protein.
On Janet and Binkys charts, generally for phos you are looking for around 250 or lower. Sounds like theres finickyness in your house, so you can mix a higher phos food with a lower one if need be, to get them to eat. IMH, I think the phos issue is more important than the protein issue, but some people try for moderate protein. I know that several people feed Friskies Special diet canned flavors.
There is another chart here that doesnt get updated as often so newer flavors/brands wont be on it..
http://webpages.charter.net/katkarma/canfood.htm and on this chart you would be looking at phos around 1% sl higher.
i'm on the fence about rx food, otoh, yes they are junky. very junky. and not high enough in protein. but on the other hand, there are studies to prove that renal kitties on rx diets do seem to live longer. but i think it was jess who pointed out, nobody knows what it is in the rx diet that may actually be helping, in addition to being low-protein, it is also low in phos and sodium, and generally supplemented with potassium. any of those could be the key, instead of or in addition to low-protein (i personally don't buy the low-protein diet in the beginning stages - jojo has several kitties with renal issues now i think, and has had others before, and they seem to not fare any worse on raw diets, and you can't go higher-protein than raw.) then again, there are kitties that seem to be stable on rx foods over on the yahoo list.
found the
recent discussion on rx renal food on health
there is a longer, thought-provoking thread on think tank, i can look for it later if you're interested.
mixing higher phos and lower phos to average lower is a good approach and definitely worth trying if bear will go for it.
Given Bears phos numbers, I do think he needs a binder. Tanyas site
http://www.felinecrf.org has lots of amazing info. Doubling potassium is good too. You might talk to your vet about Calcitriol, not sure if you have compounding pharmacies that can do that near you.
i fully agree here that he needs a binder. at this level of phos, 7.4, he is fast approaching the threshold where calcitriol will not be effective, if you're considering its use. calcitriol is most effective with phos below 6.0, but is believed to have partial effect, all the way up to a reading of 8.0. beyond that, the folks on the calcitriol group encourage to work on getting phos down before even restarting calcitriol.
Linda and Bear Man said:
- I don't have a urine protein/creatinine ratio.
- Vet says it is hard to quantify his spilling protein as he always has large amounts of cellular infiltrates in his urine
- BP has been measured, not lately, I don't know what it is, but he takes amlodipine for hypertension
- T4 has been re-run and is in normal range ...
- The Royal Canin renal food that my vet can order is "chunks and gravy" - sounds high carb
any chance of getting a urine protein/creatinine ratio in the somewhat near to medium-term? i am not familiar with cellular infiltrates in urine (are those casts?? too late and tired to look up - this is jojo's area) but i think the up:c is the tests most vets use to determine if he's spilling protein. according to our vet, kitties that are spilling protein have a poorer prognosis; if he is, your vet will likely want to start him on benazepril. not sure how that works in conjunction with amlodipine, but i think the first step is to see if he even is.
wondering if his kidney function had been diminishing for some time and the overactive hyper-t masked it. has been known to happen.
i can look up which RC foods we have here. i understand however that there's been a recent change to the formula and what we have may be the older formula. (no, we don't feed it on a regular basis, have only used two cans in the last 4-5 months).
I will have a big problem giving the binder properly. It will inhibit absorption of his other meds, particularly his steroids. The vet suggests (only after I asked the question that someone here brought to my attention) that I give the binder then wait 1 - 2 hours to give his other meds. That will be all but impossible with my schedule, so it looks like treating his CKD has potential for causing problems with his other illnesses. Bear free nibbles all day, and I don't know how effective the binder will be given bid, but not necessarily with "meals".
see my comment at the beginning. talk to a knowledgeable pharmacist; they may be able to help you i/d which drugs need to be given apart. i've never seen it written that roids have to be given apart, but then i've wasn't specifically looking for roid-binder issues. i assume anything that is injectable isn't a concern b/c the binder works in the gut, and injectable bypasses the gut? i could be wrong.
this is probably the discussion carolyn referred to re: al hydroxide interfering with absorption of meds; it occured in
cleo's condo
Cyn and Cosmo said:
Hi Linda,
I really would encourage a phone consult with Dr Lisa. She will ask that you fax or email her the last 2-3 sets of lab work ups, plus some other info so she can look at them before talking to you. She would be able to give an opinion about phos binders, calcitriol, SQ fluids, and diet... esp since Bear man has other issues than just CRF.
phone consult with dr lisa would probably be helpful just to get a grasp of how she thinks ckd should be managed. i don't know how much help she can be with diet, b/c i think bear is the king of finicky kitties (and i say that affectionately). sasha and meowzi are in the running for queen of finicky kitties :roll: but if you don't know where to start, a conversation with her may be helpful. i found i got the most value out of the calls by reading up ahead of time, and having a list of questions that i sent her and she could respond to, in addition to her general thougths on ckd mgmt.
His phos level (on this lab report) isn't out of range yet, but I wonder what it was last time you got bloodwork done? Like I said before, Cosmo isn't on phos binders... and has been dx with CRF for over 20 months now.
cyn, i have to disagree here. lab ref ranges for phos are viewed the same way as lab ranges for the T4, among others - the values are an average for what should be normal for a wide range of ages, from kittens to adults. his phos level needs to come down,
yesterday, as they say at tbp. folks on the calcitriol and the general crf lists tend to start supplementing per dr nagode's protocol when phos goes above 6.0, regardless of whether kitty is on calcitriol therapy or not. bear's is above 7. iirc, carolyn had mentioned that latte's internist pushes to start calcitriol when phos climbs above 5 or 4.5 - it caught my interest b/c it was a lower threshold than dr n's protocol.
and now i have to get to bed. i have to be up in 3 hrs *sigh*
usual disclaimer: just layperson, not a veterinary professional, talk to your vet.
ps: one more thought or non-thought. am still stumped over his cbc, isn't consistent with what i've observed for this range. but maybe i haven't seen enough. another reason why i think you may want to start a thread on health - more eyes.
