Hima's Check-Up: High ALT, high creatine. What is going on?

[daftcat75]

For managing a cat’s vet stress, I feel it’s best to do as many procedures as you can in a single visit rather than metering it out over many visits. Putting things off have a habit of coming due when you’re least prepared for them.

 

[MissClouseau]

They stick a needle into her bladder and extract urine into a syringe. It’s no more uncomfortable than having blood extracted. Maybe less so. The few times Krista was too feisty for blood and urine tests, it was the blood she put up a fight over. But that may also be because they took it from her back legs (weak and arthritic.)

Thank you! That sounds horrifying in typed form but then again all medical procedures do! Yet most are painless in practice.

 

[FeebysOwner]

I have a question if I may. Have you ever had a cat’s urine taken at the clinic? And if yes, what method did they use to take it. I have no experience in that. I don’t want to take Hima to the clinic more than necessary so it may be nice to get the urine test done too.

They just did the needle urine aspiration on Feeby's bladder, it was no different really than a blood draw. They just laid Feeby down on her side, and the vet extracted the urine while his tech gently held her down. Feeby is pretty much a 'freeze' cat too. I watched it and she didn't even flinch. Feeby's blood draw is done on the inside of the back leg, for less impact to her.

 

[MissClouseau]

They just did the needle urine aspiration on Feeby's bladder, it was no different really than a blood draw. They just laid Feeby down on her side, and the vet extracted the urine while his tech gently held her down. Feeby is pretty much a 'freeze' cat too. I watched it and she didn't even flinch. Feeby's blood draw is done on the inside of the back leg, for less impact to her.

It’s very helpful to know, thank you for sharing.

 

[MissClouseau]

Some updates. I spoke to the vet to book an appointment for ultrasound and blood test, SMDA, urine test. She said it could be better to first do the other tests and try a medicine and then check the liver enzymes again and then do ultrasound if needed. Because, she said, if the medicine doesn’t work she will need ultrasound so that would mean getting it done twice. (She was more concerned about it financially for me as ultrasound is expensive. I am more concerned about Hima going through the shaved belly and the stress of the procedure twice.)

Unless there is something else I don’t know the possibilities are inflammation, IBD and things on that line, gallstones, benign tumor, or cancer. I don’t think (and hope not) it’s cancer because Hima isn’t lethargic at all and every cancer patient I know was lethargic by the time things changed in the bloodwork. It could be gallstones / bile ludge and I think she would prescribe the same thing for both anyway. Ursodiolic acid. If it’s inflammation, I guess we would see a significant improvement in the blood test next week. (I’m not optimistic. Hima gets a few minutes long tummy ache after eating sometimes. That also makes me suspect of gallstones.)

I will ask for Bile Acid test in addition to re-checking the liver and kidney enzymes. And SDMA. I will discuss testing urine for bacteria as they will take it to check for kidneys-gravity. Is there anything else I should ask for?

 

[daftcat75]

Some updates. I spoke to the vet to book an appointment for ultrasound and blood test, SMDA, urine test. She said it could be better to first do the other tests and try a medicine and then check the liver enzymes again and then do ultrasound if needed. Because, she said, if the medicine doesn’t work she will need ultrasound so that would mean getting it done twice. (She was more concerned about it financially for me as ultrasound is expensive. I am more concerned about Hima going through the shaved belly and the stress of the procedure twice.)

Unless there is something else I don’t know the possibilities are inflammation, IBD and things on that line, gallstones, benign tumor, or cancer. I don’t think (and hope not) it’s cancer because Hima isn’t lethargic at all and every cancer patient I know was lethargic by the time things changed in the bloodwork. It could be gallstones / bile ludge and I think she would prescribe the same thing for both anyway. Ursodiolic acid. If it’s inflammation, I guess we would see a significant improvement in the blood test next week. (I’m not optimistic. Hima gets a few minutes long tummy ache after eating sometimes. That also makes me suspect of gallstones.)

I will ask for Bile Acid test in addition to re-checking the liver and kidney enzymes. And SDMA. I will discuss testing urine for bacteria as they will take it to check for kidneys-gravity. Is there anything else I should ask for?

Krista never seemed like she had cancer. Except she kept losing weight despite more than adequate food intake. And the liquid stools which is common for intestinal lymphoma.

As long as you are doing blood work, have her tested for pancreatitis. It’s better to have added the test and not need it (tested negative) than to need it and not have it. Krista had undiagnosed pancreatitis for too long. It made it that much longer to get her IBD under control.

I think you’re making too much out of the shaved belly. If she needs an ultrasound, she needs an ultrasound regardless of the belly shave. It will grow back (albeit very slowly.) And in the meantime, having that area shaved will make it easier for the both of you to keep her clean of fleas and ticks.

 

[daftcat75]

Also if the vet suspects inflammation, you’ll want to do an ultrasound before you do steroids. Otherwise, she needs to be off of the steroids for some period of time to get an accurate ultrasound result. Thus trying steroids before ultrasound means there will be a necessary delay and a steroids wash out period before she can get an ultrasound. Be sure you discuss this before starting steroids.

 

[MissClouseau]

Krista never seemed like she had cancer. Except she kept losing weight despite more than adequate food intake. And the liquid stools which is common for intestinal lymphoma

Didn’t Krista also have lethargy? It’s tricky when the cat is senior and/or have arthritis how much decreased activity is about that, I know, but what I mean is that Hima still gets the zoomies. Still runs after toys couple times a day. Doesn’t sleep more. All the pets and humans I know with cancer (except for skin cancer) had some level of lethargy / drowsiness. It may not be the rule but it makes me think cancer would be unlikely.

As long as you are doing blood work, have her tested for pancreatitis

Good idea. I want to ask for thyroid too.

Also if the vet suspects inflammation, you’ll want to do an ultrasound before you do steroids

She didn’t say what she suspects of really. We’ll do blood test again and urine, if the levels are still up try medicine for liver, re-check the values at the end of treatment and if they are still up do ultrasound. That’s her suggestion.

 

[MissClouseau]

UPDATES, and confusion.

We went to the vet to get more tests done yesterday. Hima’s creatinine that was 2mg three weeks ago went down to normal range, to 1,4mg. Big problem here our vet told me creatinine as high as 2 wouldn’t go down to normal range. I was the one who insisted to get it checked yesterday. Earlier she also told me SDMA would go high before creatinine as if it the test was unnecessary, I asked for test. And even her SDMA result is normal. How can I trust her judgement and diagnostic skills now really? Anyway I asked for pancreatitis test, she said they use pancreatic amylase and that’s more than 3 times higher than normal.



We also did a liver enzymes test. Her ALT is still high but on April 5 it was 815, yesterdy it was 583 so there’s improvement. I’ve been using a milk thistle-turmeric supplement since April 5. That might be it.


We still don’t have a certain diagnosis.She prescribed this holistic supplement Hima hated...

This brand is popular among vets in Turkey but the fact Hima hated makes me get iffy. How can something have so many ingredients but not something to make it palatable for cats? Why not?

Hima’s normal diet is Purina Gourmet Gold pate turkey, Miamor trout pate, Acana Wild Prairie dry food in between. The vet wants us to use only Hepatic dry food for a month, use this Veda Vet supplement for 50 days, and the milk thistle-turmeric one. Then re-check the liver and if they are still high, get ultrasound done.

I bought Purina’s Hepatic prescription food ( https://www.purina.co.uk/cat/cat-food/product-proplan-veterinary-diets-hepatic-management-dry ) but honestly I very much doubt this will go well with Hima. She never tolerated grainy foods well. And she has trouble drinking water, she sucks at it, I don’t know how cutting off wet food will help. I don’t think I will get rid of the wet food.

I’m really confused about all these. Any thoughts on the test results?

 

[MissClouseau]

Oh and, we couldn’t get urine test done. Hima didn’t have any. She went to pee around 1am at the latest (not sure) and she drank water at 09:00am but they couldn’t get urine out at 09:45-10:00am.

 

[FeebysOwner]

I can't be of much help, but I do know my vet doesn't seem to think SDMA is all that reliable, and also believes creatinine is a more reliable indicator. However, that being said, I can't explain much of the rest of your vet's thought process. I personally would not want to see Hima on a dry food only diet.

I suppose you could tell the vet that Hima won't take the supplement or eat the food (likely to be the case anyway) and ask for other options. You might also consider getting a second opinion. You are good at keeping the test results, so you could share those with another vet and ask for their ideas, without it being as expensive as having all the tests re-ran by another vet.

 

[MissClouseau]

I can't be of much help, but I do know my vet doesn't seem to think SDMA is all that reliable, and also believes creatinine is a more reliable indicator. However, that being said, I can't explain much of the rest of your vet's thought process. I personally would not want to see Hima on a dry food only diet.

I suppose you could tell the vet that Hima won't take the supplement or eat the food (likely to be the case anyway) and ask for other options. You might also consider getting a second opinion. You are good at keeping the test results, so you could share those with another vet and ask for their ideas, without it being as expensive as having all the tests re-ran by another vet.

I appreciate your input. I want to get a second opinion from an internist in the same neighborhood but we are going into a Covid lockdown tomorrow so the timing could make things challenging.

 

[daftcat75]

I would recommend a second opinion. I don't know if the fPL/fPLI tests are available in turkey. But this comment worries me:

Elevated amylase levels are of little significance in cats.

Source: Why Is My Cat or Dog's Blood Amylase Level High?

Another site says the following:

Decreased GFR: This can cause increased amylase (up to 2-3 x normal) in the absence of significant pancreatic disease. If an azotemic patient has amylase values greater than 2 to 3 times the reference values, pancreatitis should receive consideration as a diagnosis. Amylase is variably increased in cats with disorders associated with renal azotemia.

Source: Amylase | eClinpath.

So you may still have a kidney issue developing. Or you may have a useless test result.

I would seek a more reliable test for pancreatitis and perhaps push for the ultrasound sooner than later. I sure hope you can get that appointment with the internist.

 

[MissClouseau]

I would recommend a second opinion. I don't know if the fPL/fPLI tests are available in turkey. But this comment worries me:



Source: Why Is My Cat or Dog's Blood Amylase Level High?

Another site says the following:



Source: Amylase | eClinpath.

So you may still have a kidney issue developing. Or you may have a useless test result.

I would seek a more reliable test for pancreatitis and perhaps push for the ultrasound sooner than later. I sure hope you can get that appointment with the internist.

The vet’s opinion on pancreatitis is that the cat would be visibly ill, or at least have a symptom like frequent puking if it was that. But she’s been wrong about several different things this check-up so who knows

 

[daftcat75]

The vet’s opinion on pancreatitis is that the cat would be visibly ill, or at least have a symptom like frequent puking if it was that. But she’s been wrong about several different things this check-up so who knows

If she's eating willingly, not lethargic, and not throwing up, then she probably does not have pancreatitis. You would also likely see the squint/hunch of pain after eating with panc.

 

[FeebysOwner]

The vet’s opinion on pancreatitis is that the cat would be visibly ill, or at least have a symptom like frequent puking if it was that. But she’s been wrong about several different things this check-up so who knows

It probably isn't going to help you any, but Feeby had a high amalyse back in 8/2020 (1321 / range 100 - 1200) and her Precision PSL was high as well (53 / range 8 -26). But, the vet said the same thing yours did - since Feeby had no outward signs, he wasn't going to entertain pancreatitis. He said elevations can happen and are not always attributable to pancreatitis.

A follow up blood testing was done 11/2020, Feeby's readings were back in 'normal' range 1045 & 16 respectively. At the time of the 11/2020 reading Feeby had been on thyroid meds for a month - which can mask kidney issues. Since then, Feeby has had 3 more blood tests run and both numbers have fluctuated but still are within range. While it is possible there could be an underlying issue associated with the kidneys - I would have expected these numbers to have increased again. Her creatinine is at 1.8 (range 0.6 - 2.4) and has stayed between 1.8 & 1.9 throughout all of these tests. So, I guess what I am saying is don't jump to a conclusion that Hima's kidneys are affecting her numbers.

 

[MissClouseau]

It probably isn't going to help you any, but Feeby had a high amalyse back in 8/2020 (1321 / range 100 - 1200) and her Precision PSL was high as well (53 / range 8 -26). But, the vet said the same thing yours did - since Feeby had no outward signs, he wasn't going to entertain pancreatitis. He said elevations can happen and are not always attributable to pancreatitis.

A follow up blood testing was done 11/2020, Feeby's readings were back in 'normal' range 1045 & 16 respectively. At the time of the 11/2020 reading Feeby had been on thyroid meds for a month - which can mask kidney issues. Since then, Feeby has had 3 more blood tests run and both numbers have fluctuated but still are within range. While it is possible there could be an underlying issue associated with the kidneys - I would have expected these numbers to have increased again. Her creatinine is at 1.8 (range 0.6 - 2.4) and has stayed between 1.8 & 1.9 throughout all of these tests. So, I guess what I am saying is don't jump to a conclusion that Hima's kidneys are affecting her numbers.

Lab results are always useful I would be surprised if Hima had kidney disease. What I also read was if creatinine is less than 1mg higher than the normal range, it’s not reliable and most certainly it should be re-tested in couple weeks and more tests should be done. And in fact Hima’s Crea went down to normal range on its own.

If she's eating willingly, not lethargic, and not throwing up, then she probably does not have pancreatitis. You would also likely see the squint/hunch of pain after eating with panc

She eats, is playful, puked once this month (and year so far.) But she seems to get some pain for a few minutes sometimes after she eats and occasionally early in the morning when her stomach is probably empty.

 

[daftcat75]

It doesn't sound like Hima has panc. Or if she does, it's a mild case.

The treatment for pancreatitis is often supportive medicine and feed them back to health. Dry food should be avoided because of the demands it makes on the pancreas. If she eats and isn't puking, there isn't much need for the supportive medicine. If she eats dry food, I would reduce or eliminate that. If you do that much, you'll be treating her pancreatitis whether it gets diagnosed or not. Pancreatitis is usually the acute stage of an underlying chronic condition like IBD. This is why I still suggest an ultrasound to rule out IBD or any large cell masses.

So then I have to circle back and believe the high ALT may be a reflection of her dental disease. I hope it continues to go in the right direction so you can have that addressed sooner than later.

 

[MissClouseau]

So then I have to circle back and believe the high ALT may be a reflection of her dental disease. I hope it continues to go in the right direction so you can have that addressed sooner than later.

I doubt it's dental issues. Two different vets said periodontal disease doesn't cause that much increase in ALT - Hima's was 8 times more than normal in early April and now still almost 6 times normal.

I'm adding everything in case it's helpful to someone who searches for the same thing...

I found someone on Twitter from the USA whose adult cat (not senior) has had her ALT levels been going up since October. She's asymptomatic. She also got the blood tests done like me, but also ultrasound which gave no explanation, and a fine needle liver biopsy (still waiting for the result on that.) Apparently since the vet didn't find a cause, he's aggressively treating for bartonella. I asked about bartonella to my vet and she doesn't think Hima would have it because "so far in Istanbul I saw no positive result for it in my career."

Our vet did see toxoplasmosis cases here though and so far Hima caught two rats this year alone. She never eats, just holds in her mouth and that's all. But I wonder if she may have toxoplasmosis and if she does, could it raise ALT without causing sickness? Google says either the cat gets (visibly) sick or nothing happens.

Our vet doesn't outrule hepatic lipidosis. I asked "doesn't it happen to anorexic cats or cats with obesity?" She said usually yes but there could be other causes including genetic disposition.

She doesn't think it's cancer because her ALT went down a bit from early April to this date. Usually with cancer things get worse without treatment.

I asked about gallstones and because Hima's gallbladder enzymes look normal, she doesn't suspect of gallstones.

I'm not sure but if I'm not mistaken she's also not outruling parasites / bacteria as their effect might be complex. But if it's the cause, Hima's levels should be normal after this "detoxing" supplements and hepatic food. (Another vet said parasites might increase ALT but usually only if they can physically go up to liver and that typically doesn't happen without a serious infestation.)

Also note, Hima almost most certainly had intestinal worms in October 2020. Stronghold failed us (or she got a type of worm Stronghold doesn't treat.) I then applied Profender as it's more inclusive and it went horrible. She was lethargic for days, had water-level liquid diarrhea, and ate only little for 2 days. I don't want to put all the blame on Profender but I do wonder if at the least it made things worse. 6 months is a long time I know but maybe her ALT has been high at some level all this time. And maybe gets worse occasionally over other challenges?

We will get more answers when this supplement ends.

 

[MissClouseau]

UPDATES, and some useful info.

I spoke to a UK vet about liver enzymes online. I actually found him through another person whose cat also had high ALT and has been high for months. The vet told the other person he wouldn't rule out a toxic cause in their case "because of the extent of the elevation in ALT, and lack of corresponding increase in GGT/ALP/TBil and lack of white blood cell changes." I then showed him Hima's check-up results. She also only has ALT high as her liver enzyme although GGT is right on the edge of the normal with 5 U/L. He said liver enzymes can be very reactive and even stress can cause some mild elevations. He gave a great perspective on what mild means. With round numbers,

Mild elevation: 1-3x the normal reference range. e.g. 60-300 U/L
Moderate elevation: 3-6x reference range like 300-600U/L
Severe elevation: 6-10x reference range like 600-1000U/L

So Hima's 815 last month (and by the end of the month, 583) would be severe elevation and that it would be unlikely that level of increase would be caused by parasites like intestinal worms. The UK vet also suggested hyperthyroidism test although it would indeed be unlikely for a cat Hima's age to have it, high cholesterol is another symptom of H-T and Hima's cholesterol was high at 265 last month.

On Hima updates...

She's been on Purina Pro Plan Hepatic dry food for over a week. It's going better than I expected. No stomach noises from her tummy as it always happened with grainy foods. If she has increased stool volume / loose stools I can't know (she deos it in the yard.) I still give her her wet foods despite what the vet said.

On April 5 she got a dewormer pill. She got her hunched pose after some meals a few more times that week but since then it significantly decreased. Making me suspect she did have worms and the deworming drops fail us.