Advice on Food (CKD+DM) and BG Levels for A Newbie

[C_Star]

Hi All!

Kit was diagnosed with DM 1 month ago, and we've been doing a lot of research, but would really appreciate any input on a few questions that we still have. We're still learning

Background: Kit also has Stage 1 Kidney Disease (CKD), he’s approx 15 years old DSH neutered male, very active, good weight at 5.44kg. Under advisement from our vet, we’re doing twice daily BG testing (AlphaTrak II) and twice daily 1u shots of Lantus (as needed).


1. Food: how can I balance his CKD needs with his diabetic needs?
I know he needs low-carb for his diabetes, and low-phosphorus for his CKD, but what about protein? Some sites say that CKD cats should have protein-restricted diets, while other sites say DM cats need high-protein. Other sites say ALL cats need high-protein. Help!

My vet recommended he stay on his usual Royal Canin Renal Support E wet food, for its low phosphorus count (90mg) but I see that it has relatively high-carb (21%) and low-protein (24%) (http://catinfo.org/chart/index.php). The other food I was considering is Tiki Cat Koolina Luau which has 0% carbs and higher protein (84%) but a higher phosphorus count (149mg).

He’s very food-motivated, so finickiness is not an issue. What should I be feeding him? How much protein should he be getting to satisfy both his DM, CKD, and general nutritional needs? Are there other foods I should be considering? I trust my vet, but worry about all those carbs in the Royal Canin Renal...


2. Blood Glucose levels: Kit started out quite high when diagnosed 4 weeks ago (29mmol) but now his numbers are consistently very low. My vet advised me to give 1u of Lantus when he’s above 4.5mmol. But when I give him his dose, he drops to low 3mmol. Isn’t this getting too low? He hasn’t had hypoglycemic symptoms like shakiness or confusion, but is often very hungry, meowing for food. I worry about hypoglycemia especially since I have to leave him alone while I’m at work all day.


3. Remission: fingers crossed we get there!
How do you know if/when a cat has reached diabetic remission? Kit is often within safe levels (hasn't been above 7.0 mmol in 14 days). How do we know if the diabetes goes into remission?


Again, thank you for this wonderful resource – it’s so great to have this support system.

 

[Idjit's mom]

The best way for members to answer the last two questions would be to review all the testing data you have. You can get the spreadsheet going and plug in the information you have to this point. We usually try to get in additional testing at different times of the day and night, to determine the insulin effects, and the nadir (lowest BG point) of the cycle. Lantus dosage is based on the lowest BG in the cycle and not on the pre-shot level. The pre-shot test is to insure that it's safe to shoot. You are using a pet meter, AlphaTrak so:
Hypoglycemia/Hypoglycaemia (low blood sugar) levels are: Below 65 mg/dL (3.6 mmol/L) for adult cats and dogs.
Please use this link, read and print out about Hypoglycemia, http://www.felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/
and it's very advisable to have a Hypo Tool Box ready, just in case:
http://www.felinediabetes.com/FDMB/threads/jojo-and-bunnys-hypo-tool-box.2354/
You may wish to go over the stickies in the top of the Lantus forum, and get more familiar with the different protocols.
I have been reading different threads for a kitty that wasn't feeling well after a dental and then a URI, and remembered posts about Weruva food and lower phosphorus. Here is a link to @Chris & China thread where this discussion occurs.

 

[C_Star]

The best way for members to answer the last two questions would be to review all the testing data you have. You can get the spreadsheet going and plug in the information you have to this point.

I tried to put Kit's spreadsheet in my signature. Is it not showing up?
Sorry -- still learning how to use the message board!
Kit's Spreadsheet

Lantus dosage is based on the lowest BG in the cycle and not on the pre-shot level. Hypoglycemia/Hypoglycaemia (low blood sugar) levels are: Below 65 mg/dL (3.6 mmol/L) for adult cats and dogs.

Thank you! I never knew this about Lantus. My vet tech told me that below 4.5 is hypo, so I was very concerned. That makes me feel better about his numbers. He's still below 3.6 for a part of the day according to our glucose curve 2 days ago, but not by much (his lowest was 3.1mmol +3 after 1u).
Should I be testing more than twice a day then? We try to do a 12 hr glucose curve every 2 weeks, but should be doing it more frequently?
I went over the Lantus stickies but am still a bit confused on this.

Please use this link, read and print out about Hypoglycemia, http://www.felinediabetes.com/FDMB/threads/how-to-treat-hypos-they-can-kill-print-this-out.15887/
and it's very advisable to have a Hypo Tool Box ready, just in case:
http://www.felinediabetes.com/FDMB/threads/jojo-and-bunnys-hypo-tool-box.2354/

Thank you, we'll build our Hypo Tool Box tonight and pray that we never have to use it!

 

[Red & Rover (GA)]

Meters:
The AlphaTrak strips are crazy expensive. You will be doing more testing that you can imagine, especially if Kit is hitting low(ish) numbers.

The strips for human meters are a bit cheaper. If you travel to the US, you can pick them up cheaper. A lot of folks use the FreeStyle Lite meter. Save up those Shoppers/PC points and use them on Senior's Day at Shoppers. If you are not a senior, get one to do it for you.

There is no correlation between the AlphaTrak and human meters. One or the other is just fine. The take action number on the AlphaTrak is 68 (3.7). The take action number on a human meter is 50 (2.7). Folks here are accustomed to both.

Food:
Kidney disease and diabetes is a question of balance. It can be done. This is the bible for kidney disease in cats. Like kidney disease, feline diabetes is a steep learning curve but it becomes second nature very quickly. And we are all here to help.

A low protein diet for kidney cats in the early stages of kidney disease is outdated and leads to an early loss of muscle mass.

Below is the link for food charts. You can (1) search for low phos / low carbs that are available in Canada; (2) add a powdered phosphorus binder to a low carb food; (3) make your own cat food.

When Rover's phos numbers warranted it, I choose to add phosphorus binder to his Fancy Feast pates.

http://www.felinediabetes.com/FDMB/threads/links-to-food-charts.174182/

If you could get the lab reports from your vet and post them on your spreadsheet, there are people here who can help you interrupt the results.

 

[C_Star]

Thank you! This is very helpful.

Yes, those AlphaTrak test strips are insanely expensive, so I'll consider making the switch to a human meter once I've used up these test strips that might as well be made of gold for their price (I'm paying around $2.68 per strip!).

When Rover's phos numbers warranted it, I choose to add phosphorus binder to his Fancy Feast pates.

How do you know when his phosphate numbers go up? Is this just through vet blood tests, or something that I can monitor at home?

If you could get the lab reports from your vet and post them on your spreadsheet, there are people here who can help you interrupt the results.

I've just asked the vet to send me Kit's lab work from last month. So good to know that there are people who can help me interpret! Feels empowering to be able to learn what all the numbers mean

 

[Red & Rover (GA)]

Oh sheesh, in my haste last night I forgot to copy the kidney bible link. Here it is: https://www.felinecrf.org A lot of information there.

Phosphorus monitoring is done through blood tests. If there comes a point when phosphorus cannot be controlled through diet, then a phosphorus binder is needed. The great tasting gel that vets prescribe is full of sugar. thrivingpets.com sells powdered aluminum hydroxide (binder) that can be mixed in with food. A few ounces of the powder will last a long time.

Kit was diagnosed Stage 1 two years ago. Have his numbers increased? or is he holding steady?

Please get some mid cycle tests in. The more information you have about how Kit typically responds to insulin, the better you can look for patterns and interpret what you are seeing.

If you do enough testing, you can skip the costly glucose curve done at the vet. Take a day when you are home all day and test every 2 or 3 hours for one cycle.

If regularly testing at home, there is no need for a fructosamine test either. The test gives you an average of the last 2-3 weeks. If you are testing regularly, there is no need for the test.

The next time you have to buy Lantus, it is cheaper to do so from a pharmacy – about $120 for a 5 pen vial box. In Canada, humans need an Rx but cats do not. Just tell them it is for a diabetic cat.

If Kit becomes hard to test, a freeze dried chicken treat helps. They have no carbs and are low phos (not sure about the phos content of the fishy ones).

 

[Idjit's mom]

Good morning, I would like to see you post in the Lantus forum, C_Star and get those more experienced members input. I looked at the spreadsheet and noted that you are not dosing consistently. I am no expert at all, but I have been told that it's better to dose consistently, and that reduction of doses is determined by the nadir (lowest BG in the cycle), not the pre-shot BG. Also that dose decreases should be done by small increments, as small as 0.25 U. I second Red & Rover's suggestion to test more often, this board is data driven and the more information you can provide, the better. The Lantus users are going to be able to explain things better and help you more.

 

[C_Star]

I would like to see you post in the Lantus forum

Thanks! I'll post there as well. I've updated my spreadsheet to include all his latest lab work, as you suggested, so hopefully that will help.

I looked at the spreadsheet and noted that you are not dosing consistently.

I asked my vet about the non-consistent dosing and she said that from this point on, we'll try staying with 0.5 units AM and PM with no fluctuation (unless he's too low for insulin).
Originally, I was given this chart to follow at 2u BID (which is why I was varying the doses so much):

It seems very different from what I've been reading on the site, which concerns me. I hope all that variation didn't have any negative effects.
And we're going to test before every shot, not just for the first 7 days.

Please get some mid cycle tests in. The more information you have about how Kit typically responds to insulin, the better you can look for patterns and interpret what you are seeing.

Totally agree! Thank you! I'm going to do curves each weekend and any day I'm home. I definitely see why more data equals a better understanding of what's going on, especially while we're still learning how his system responds. Kit won't like it, but if it keeps him healthy, that's the most important thing.

He's not a fan of the testing, so I've been using freeze-dried chicken to lure him over, as you suggested. I've been buying Crumps Naturals, which seems good and is made in Canada. The pieces are nice and small, and it's reasonably priced. Before we were using freeze-dried beef liver (which he LOVED) but then I read that liver contains carbs because of the sugar processing the liver does, so we'll save that for if his BG is low.

Kit was diagnosed Stage 1 two years ago. Have his numbers increased? or is he holding steady?

I was just looking at his lab work, and I see that his phosphorus is actually within the normal range (it's updated in my spreadsheet, embedded within my signature). The reason the vet said he has stage 1 CKD is because he has elevated SDMA. His Creatine levels seem to be normal though.
Do you have any experience with SDMA? Is this a reliable method for diagnosis?
I've read up on it through the IDEXX website, but would like to know more: https://ca.idexx.com/en-ca/veterinary/reference-laboratories/sdma/sdma-faqs/


Thank you all again for the support and guidance. It really makes navigating all of this so much easier

 

[Veronica & Babu-chiri]

Welcome and congratulations on home testing and all that you have already done, you are really off to a very good start!!

You'll get the hang of all this in no time

The SDMA is supposed to detect loss of kidney function earlier (when only 40% is lost) than what the creatinine results would (when there's over 66% lost) so that you can start treatment earlier and get a better prognosis, that is why SDMA indicates he's stage 1 even though his creatinine level is within normal range still, I haven't used it because we do not have it available where I live but I whish I could have know earlier and started treatment earlier.

It is very good that his phosphorus levels are still with in range but since phosphorus can contribute to his kidney problem to advance it may be good if you start considering using a low carb low phosphorus diet (not a kidney diet because those are very high in carbs which you do not want and very low in protein which is not good for him at this point either )

Here's a link with a lot of very good informacion about CKD (http://www.felinecrf.org/how_bad_is_it.htm#iris_sdma)

 

[C_Star]

Thanks Veronica!

It's good to know we're off to a good start. It can be overwhelming at first, trying to make sure I'm doing everything right.

And thank you for the SDMA/CKD info -- that clarifies a lot.

Even though my vet recommended that Kit stay on his Royal Canin Renal E diet, I agree that he should probably move to a low carb, low phosphorus diet. RC Renal E wet has the lowest phosphorus count but has 21% carbs

I noticed that on Tanya's great site that you sent me, it advises that "In order to keep your cat eating, you may have to have a less ambitious goal, at least to start with, of, say, feeding a food with less than 0.75%." but according to Dr. Pierson's chart (http://catinfo.org/chart/index.php) there is no food that low in phos on the market. The lowest is RC Renal E, which is 80mg per 100kcal (I believe that's 0.8% if my terrible math is right... which it might not be!)

So, by following the chart, I'm considering switching to one of these:

And maybe if I combine it with a Phosphorus binder, we can satisfy both the DM and CKD requirements?
Does anyone know if that seems like an ok diet for my furry friend?
Obviously I'll check with my vet too, but I really value and appreciate opinions from the FDMB.


Wow, it's such a balancing act trying to find the right diet, right dose, right schedule!
I can't tell you how many spreadsheets and comparative charts I've made trying to figure out what's best for Kit!

I feel like I now have a second full-time job, but at least this one pays me in Kitty Kisses <3

 

[Veronica & Babu-chiri]

He's at a very early stage so all your measures are more preventive than corrective so in Dr. Lisa's list as long as you are under 200 phos you will be ok (you could go as much as 250 but the lower the better), so the ones you posted look fine ( with luck he likes one of them )

One thing you do not want is to do get his diabetes out of control ( which could happen with renal diets because the high carbs ) because an uncontrolled diabetes will eventually damage his kidneys more than a little phosphorus and at this point you do not want a diet low in protein (most renal diets achieve the very low phos usually by drastically reducing the protein) since he does not need it yet because that could cause muscle loss and that is not good.

By looking at the labs in your SS his phosphorus levels right now are quite good so you do not want to give him phosphorus binders yet (hopefully never )