Older cat - heart disease and CKD

trishia42

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Hi there,

I have a 16-year old female cat domestic shorthair that has heart and now kidney issues. Fair warning LONG...

About a year and a half ago (July 2020), she briefly lost function of her hind legs; she was diagnosed with hypertension and advanced heart disease possibly CHF (Nt-proBNP levels at 400 pmol/L, blood pressure 280/206). We started her on 0.625 mg amlopidine, Semintra (dosage for weight) and 18.75 mg of clopidrogrel. She slowly recovered over the next few weeks and apart some weakness in her hind legs and hips, returned for the most part to her old self. In January 2021, her blood tests were fairly normal. Over the last couple of months, we noticed a drop in appetite and that she was licking her lips a lot - brought her for a vet visit in January 2022, and her creatinine was way high (497 umol/L when it was 160 umol/L the previous year). See a copy of the last three bloowork results here ). This sharp and rapid rise was a little surprising, but there is nothing in her environement that could support acute kidney injury, so the best guess was that perhaps her heart issues caused the kidney's function to degrade at a unusually fast rate over the last year. I am absolutely eaten up by guilt that I didn't bring her in 6 months ago since perhaps we could have caught it at an earlier level and been able to treat it then. I feel this stage 4 is a lost cause and it's mostly my fault; every time I think about it it makes me feel sick.

We were sent home with k/d food and subQ fluids, as well as potassium gluconate (her levels were a little low, and we're also hoping it will help her hind legs and colon). Initial prescription for subQ fluids was between 100-200 mL every two days but after reading that subQ fluids in cats with heart disease could make matters worse and discussing it with the vet, we took it back to 75 mL every two days (asked about smaller doses more frequently, but was told it would have the same effect if not worse?). It is my understanding that this may still be a dangerous thing to do given her heart issues? We are using lactated ringers; I did bring up the possibility of using another fluid lower in sodium but the vet said lactated ringers what they generally used and since her blood pressure and sodium levels were currently under control. We have had an insane amount of trouble trying to get her to eat over the last week-end - she was not a fan of the k/d food, despite using Fortiflora and trying to introduce it slowly. Her previous diet was Royal Canin weight loss dry food and half-to-three-quarters of a can of Fancy Feast at night (whatever she would eat). On Monday, she threw up four times and it became clear she was constipated (straining, not pooping) - we switched her back Fancy Feast with Miralax and added Cerenia for a couple of days following the vet's advice. She started eating more on Tuesday and then eating a normal amount on Wednesday and Thursday (just the Fancy Feast, tuna water, or Churu's - nothing else she would touch) but she still had not pooped by Friday morning. Brought her to the vet again and he said there was a decent amount in her colon that were probably too big and dry so he manually broke them up through palpation and was able to get a bit out manually (she was in there maybe 15 minutes; no sedative or anasthesia was used so I assume what he did couldn't have been that drastic?). He told us this may keep happening and that the general solution would be to up the subQ fluids but that we should do an ultrasound to assess her heart condition beforehand to see if it is safe to do. She pooped some more throughout the day and had diarrhea this morning - her back area seems quite swollen, almost like there are two lumps just below? I'm not sure if this is normal and/or if I should be concerned that something went wrong during the procedure, especially given the fact that she was still 'leaking' this morning (although maybe that's from all the Miralax we gave her finally making its way through?)
  1. Anyone have more information about subQ fluids and heart disease, and the type of subQ fluid that would be best?
  2. I'm not sure I understand how an ultrasound will tell us whether we can use more subQ fluids or not - I did not know that the type of heart disease could be diagnosed this way and I also did not know that some of the types of heart disease could handle more subQ fluids? Would an echocardiogram be superior to an ultrasound if not performed by a cardiologist (
  3. Any tips to try and get her to eat the stupid k/d food? We have tried a few of them, and even gotten a couple off of Tanya's list but she is being awfully picky.
  4. Is tuna water (the water from low-salt canned tuna packed in water only) bad for her? What about Churus and cat milk? We also use Temptations treats to give her some meds, although we know those are not recommended, we have yet to find treats low in protein and phosphorus... We have also used the Fancy Feast broths - she mostly just eats the broth so we assume it can't be too bad despite the high protein content of those?
A very, very worried cat owner. She is honestly my closest friend and although I know I can't keep her forever, I want to do everything I can for her. Any advice, suggestions, previous experiences would be greatly appreciated as I feel quite lost and devastated right now - I've just been an utter mess for the last week.

Thank you.
 
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trishia42

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I forgot to mention that at the last vet visit, her blood pressure was relatively good at 160/125 so the hypertensive drugs seem to keep that under control.
 

FeebysOwner

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Hi. Aside from the creatinine, her numbers don't look alarming. I do know dehydration can also affect creatinine, so something to consider. Have you read this section of Tanya's web site - certain meds like Semintra can elevate creatinine too. Tanya's Comprehensive Guide to Feline Chronic Kidney Disease - Blood Chemistry Panel (felinecrf.org)

I wonder if you would benefit from joining the CKD forum and discussing all of this with them. I do know from joining that group and reading posts that there are many who have cats that are on a regular regimen of Miralax, so that might be what you need to do from that aspect. They also would have some input regarding sub-Q fluids as well as related heart conditions.
[email protected] | Home. It does help if you are familiar with Tanya's web site as this forum does prefer you have basic knowledge before you engage with them.

The fact that her phosphorus level looks decent, I personally would forget about the k/d food and feed her what she will eat. I am pretty sure the CKD forum would tell you the same. And low protein is no longer really considered such a good idea for older cats with CKD.

Are you sure the vets aren't using the term ultrasound in lieu of echocardiogram? The latter is actually a form of ultrasound.

Lastly, these two lumps you are talking about - anal glands, perhaps? With the constipation, it is possible her anal glands are becoming clogged and may need to be expressed. Ask the vet about this.

EDIT: It is also fairly common for CKD cats to be on a regular dose of Cerenia, as well as an appetite stimulant, such as Mirtazapine.
 
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fionasmom

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I was unclear from your post if you are seeing specialists. If not, I do recommend a cardiologist and/or an internal medicine specialist at the least. You may get more help more quickly without spending repeated amounts of money. Your vet is probably very competent; however, my cat vet was extremely happy that I wanted the referral to the cardiologist.

ECGs are ultrasounds, as was stated above. My Jamie who is just 5 was diagnosed with kidney disease and HCM at about 2. The kidney disease came first, although ultrasounds of the kidneys showed nothing, and he continues to have high BUN readings. His cat vet hoped that the kidney disease might be caused by the HCM, so that triggered the first ECG. He then was referred to a cardiologist who has told me repeatedly that the two conditions have nothing to do with each other. I can't say if they do or do not in your cat, but that is the consensus on Jamie.

ECGs can show valve, muscle, and problems in the heart. More than one heart condition can be diagnosed from having one done. It may not show electrical problems in the heart. An xray will probably show fluid in the chest lungs.

Sub Q fluids have to be used carefully in cats with heart conditions. However, I do have to say that before we were aware of the HCM, Jamie went to the vet for 10 days in a row for sub Q fluids. He did not suffer any ill affects from having received them. Since then, his cat vet who is still in charge of the kidney part of his condition has not wanted to use them.

Jamie eats no prescription food and does not seem to want any of the foods which might be better for him. This is not advice, clearly, and I am not happy about it. After buying one of every can in the store that might have been an improvement and systematically watching him refuse to eat, his vet said that he should just be given his regular food....which is mostly fish based.....as he has to eat.
 
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trishia42

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Thank you for the replies. I had read about the Semintra but it seems that would generally be a side-effect when starting the medication that would eventually taper off and since she has been on it for close to a year and a half, I didn't think this could be the issue (especially because her levels were fine a year ago).

I am quite familiar with Tanya's site and just joined the forum, so I will also be inquiring there.

She is still 'leaking' today but maybe it is slowing down a bit; the area looks a little less swollen I think? She hasn't had a normal poop since we brought her home after the 'procedure' on Friday morning. But we have also been having trouble getting her to eat despite trying everything... Both things are starting to be alarmingly concerning...

I read about the mirtazapine, but also that it can cause toxicity - lower doses seems to be okay in CKD cats, but there is not a lot of information/studies for cats with both CKD and heart disease.

Thanks for the information regarding the echocardiogram. It was offered to us initially but was to be performed by a technician at our vet's office and then the results returned to our vet - I don't think there was a vet cardiologist involved but perhaps I should ask for a referral for one? I assume the cardiologist would be preferable as a referral overall to an internal medecine specialist (would like to limit the visits as she is quite distressed every time she leaves the house). If we can get her stabilized this week (pooping normally and eating normally), I will definitely look into this. We've kept her on the 75 mL every two days of subQ fluids for now since we assume she might actually be dehydrated due to the diarrhea and not eating much, but I do worry about them a fair amount.

Again, thank you for the replies. Just knowing someone read my post really helps make me feel less lost and alone. I'm just so heartbroken and worried sick.
 

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I had read about the Semintra but it seems that would generally be a side-effect when starting the medication that would eventually taper off and since she has been on it for close to a year and a half, I didn't think this could be the issue (especially because her levels were fine a year ago).
I see...that might be a good question for the CKD forum, just to see if anyone has experienced what you have with this. I wonder if it is possible that long term use of Simintra could cause an elevation over time - just a curiosity on my part with nothing to base it on.
Thanks for the information regarding the echocardiogram. It was offered to us initially but was to be performed by a technician at our vet's office and then the results returned to our vet - I don't think there was a vet cardiologist involved but perhaps I should ask for a referral for one? I assume the cardiologist would be preferable as a referral overall to an internal medecine specialist (would like to limit the visits as she is quite distressed every time she leaves the house).
Another option to consider is a specialty vet group - usually through a referral from your vet. These groups typically have multiple specialty vets on staff, enabling various vets to consult with one another if it is deemed necessary. The specialty groups also look at the records/test results provided by your vet and determine which specialist would be the most appropriate to start with - but can always bring in other specialists in the group as appropriate.

Feeby was seen by a specialty group because her vet felt she had multiple conditions that needed to be considered jointly - hyperthyroidism, early CKD, and possible heart issues. The latter was not clear to the regular vet through x-rays that were done. So, while the latter issue was 'first and foremost' to the regular vet, the specialty group still recommended she first be seen by an internal med specialist. Long story, still long (sorry) - an echocardiogram was done and reviewed by one of the cardiology staff, as a side consult. Feeby did not have to actually be seen by a cardiologist because it was determined her only issue was a leaky heart valve that doesn't require treatment. Whether or not a similar scenario would play out for your cat, I cannot say. But I thought it was a good idea to go to a group that has so many specialists available.

At any rate, we would love for you to keep us posted!
 

fionasmom

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The cardiologist we see is very emphatic about not liking it when vet techs, radiologists, or regular vets do echocardiograms. At first, it sounded high handed, but when she reviewed Jamie's case, she changed all meds which were prescribed by the vet owner of the practice which did the first ECG. If you are going to try for specialists, I think that you should do what FeebysOwner FeebysOwner suggests in order that a cardiologist look at whatever is going on with your cat.
 
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trishia42

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I don't think there are any specialty vet group where I am located but there is a vet cardiologist, so if we can get her stabilized I will request an appointment with him.

Right now, we're just trying to get her to eat enough and we are getting terribly concerned that she is still leaking liquid poop out of butt constantly. It doesn't feel like this should still be ongoing 48 hours after the vet procedure. We're not sure if it means she's still constipated, if it's all the Miralax she was given over the last week, or if damage was done to her anal muscles but it's definitely quite concerning at this point. We will be calling the vet the minute they open tomorrow and hopefully they will have advice to address this current crisis.

I just feel it's crisis after crisis and that everything we are doing keeps getting worse. : (
 
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trishia42

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I just wanted to update in case someone came across this in a web search. We did take her in the vet the next day - she took two small poops 10 minutes before, but she was still leaking and had barely eaten over the week-end so we thought it best to bring her in. The vet was worried that she could have developed incontinence (my heart), but after an exam, she was fairly confident that it would bounce back and was mostly due to the irritation and mild trauma. She was given a shot of B12 and we were sent home with more Cerenia, metrodinazole (apparently an antibiotic that should help with colon inflammation?), and mirtazapine (2 mg pills). We held off on the metrodinazole since if she's been having trouble with constipation, we didn't want to risk making this worse and wanted to wait the extra day to see if things got better by themselves, we did give her 1/2 pill of mirtazapine. The next day, she had thankfully stopped leaking! The mirtazapine also seems to have helped, although we are cautious with the dose. If anyone has experience with the topical vs oral mirtrazapine, I would sure love to hear it!

We are still working on appetite and k/d food introduction but she looks like she feels a lot better? Would be nice if we were able to ask her how she feels for sure. We are being very cautious with additional medications (since she's on so many right now), as well as with the administration of subQ fluids (we do the three tests to assess and keep them at 50-75 mL only every 2-3 days and only when it seems necessary; we're trying instead to encourage her to consume more fluids orally with Churus, tuna water, broths). We were able to get an appointment for a cardiac consult and echocardiogram within the next two weeks, so hopefully that will tell us more.
 

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Thanks for the update. It would seem things are headed in the right direction, thankfully!!
If anyone has experience with the topical vs oral mirtrazapine, I would sure love to hear it!
Is that 1/2 of a 15mg or 7.5mg pill? Most folks start out with 1.8mg - or even less - to help to reduce the possibility of side effects. So, that would essentially be 1/4 of a 7.5mg pill or 1/8th of a 15 mg pill. I would most certainly reduce the amount you are giving her either way. The primary benefit, as I understand it, to using Mirataz (transdermal version) is that it does not have to enter the digestive system, thereby helping to avoid stomach distress sometimes seen with Mirtazapine (oral). I have also heard it might be a tad bit less effective due to it being topical.

While I have not used the oral med, I do use Mirataz (transdermal) for Feeby. Every cat is different, so it really is a matter of 'experimenting' to find the proper dosage for your cat. For now, Feeby receives 1/2 dose (0.75" - 1 mg - of ointment vs 1.5" - 2mg) every third day. But many others find they need to use it every day or every other day - and they generally start with the half dose until they can determine what best works for the cat.
 
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trishia42

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1/2 of a 2 mg pill (they come in 2 mg here in Canada). They are just really hard to cut due to the shell and the size of the pill, which is why we're thinking the transdermal might be a better option going forward.
 

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1/2 of a 2 mg pill (they come in 2 mg here in Canada). They are just really hard to cut due to the shell and the size of the pill, which is why we're thinking the transdermal might be a better option going forward.
Good for you having a small dose like that available to you!
I actually got a pill cutter from CVS (so most any pharmacy should carry similar ones) that enables me to cut Feeby's Felimazole in half. Those pills are rounded and have a hard coating on them but cutting in half is OK. Now, when I have to cut one into quarters, it gets a bit trickier!
 
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