[growler~GateKeeper]

Is Smokey still on 2 Azodyl/day? Are you refridgerating the pills?

These last 2 blood test was there anything else that was out of normal?

In the 22 Oct test (Cre 414) & the 29 Oct (Cre 185) test do you have the numbers & ref ranges for Phosphorus (Phos), Calcium (Ca), Sodium (Na+), Potassium (K+), Chloride (Cl) and Bicarbonate (HCO3)?

Did they do a urine test? I'd like to see a timeline of the Urine Specific Gravity (USG) for the times a blood test was done if possible. USG is important for determining how much water is being excreted to flush out the kidneys. Obviously once fluid therapy is started the test is not as reliable as prior, but with a consistant fluid schedule and tests in between you can still get a good sense of when the kidneys need more water to remove the same toxins.

Originally Posted by nemesis

As you might recall, on October 22nd Smokey had a sort of mini-crisis were he refused to eat, became very lethargic and nauseous, and was generally acting quite sick. His blood test showed Creatinine 414, BUN 21. He received IV fluids for 2 days, then came home, and received subq’s every day up until October 29th, when Smokey had his follow up blood test. His test results from that day showed that his creatinine went back to down to 185, and his BUN back down to 15. So good news there.

The creatinine at 185 is great, that is actually just inside high normal for your lab , the drop in BUN is good too.

The BUN : Creatinine ratio however is higher now than it was before. Metabolic acidosis can be a contributing factor to this being high.

Originally Posted by nemesis

What I’m confused about that is the vet wants to do fluids every 72 hours, which is very nearly the same as twice a week, which we were doing on Tuesday and on Friday. I suppose there will be less time between each session, but not really a big difference, since there were 2 days between Tuesday and Friday and 3 days between Friday and Tuesday, whereas now there’ll be 2 days between each session. This change doesn’t seem significant enough to me to compensate for how Smokey was behaving and the rise in his numbers, and how much they dropped after we gave fluids more often.

Did she want you to continue with the same volume 150mL? When does the vet want to do the next blood test?

One thing to consider now is Smokey's Cre number is lower than it was when you were doing twice a week and considerably lower than it was during his mini-crisis.

If you were to look at the numbers alone Cre 185 BUN 15 - if this was a just diagnosed cat it wouldn't even be put on fluids at this point - again based on numbers alone.

It's hard for me to advise which way to go because I've not seen how Smokey's acting/how he's feeling etc. My based on the high levels at the start & this recent mini-crisis I would go with every other day see how Smokey does for 2 weeks, if he's showing any signs of over hydration, lethargy, starts fighting the fluid procedure or the fluids don't absorb as quickly anymore then cut back to every 72 hours. I'd also have another blood test likely a mini panel done at that point too.

Originally Posted by nemesis

However, the most confusing part is the vet’s rationale for this. She says that over-hydration can be harmful. Of course this I know, having read about it. But I’m not seeing any signs of over-hydration, and she hasn’t indicated that she’s seen any either. He’s not sluggish or lethargic after fluids, quite the contrary. He doesn’t feel squishy. The water hump doesn’t take longer than a few hours to disappear. He’s not peeing more than usual. In fact, I can clearly see a difference in how he’s behaving now, having been receiving more fluids for a while, compared to how he was behaving in the few weeks before his mini-crisis. It seems to me that if his numbers were twice as high, then surely he wasn’t receiving enough fluids at that point? In other words, the degradation of his kidneys must have progressed to the point where he was becoming dehydrated sooner?

I think the reason she is concerned about over hydration is in part due to the creatinine now being back in high normal range. Smokey has cleared enough of the toxins to drop the cre back to normal (after all those extra fluids), so he doesn't need as much fluids for that particular purpose right now, he does still needs fluids for dehydration.

Originally Posted by nemesis

The vet’s explanation for this is that the mini-crisis may have been caused by stomach irritation/acid, so in fact it may not be necessary to increase his fluids very much. But I don’t understand this. How could stomach irritation CAUSE his higher numbers on the blood work? Isn’t it the other way around? That is, doesn’t stomach irritation, acid, nausea, etc, arise BECAUSE the kidneys are working less well, and thus filtering out fewer waste products (represented in creatinine numbers, for example)? I’ve never understood the causal relationship to flow in the other direction from my reading on the topic.

If the reason behind all this was over production of stomach acid, more fluids won't really fix that issue, the fluids will flush out the BUN & Cre but it doesn't reach/go through the stomach - so not much help there. Remember you've also just added back in the antacid to take care of that.

Increase in stomach acid/irritation etc won't cause higher Cre BUN bloodwork numbers, but the increase in creatinine or BUN also won't cause stomach acid levels to increase either. High levels of BUN, phosphorus etc may produce the feeling of lethargy/feeling sick/nauseous but the physical substance of stomach acid is caused by changes in the hormone gastrin.

Gastrin is a gastro-intestinal hormone which stimulates the secretion of gastric acid, which helps the stomach digest food. The kidneys are responsible for the excretion of gastrin, but in CRF this function may not work so well, resulting in the gastrin remaining in the stomach and stimulating the production of too much gastric (stomach) acid.

Your vet may have just had trouble explaining the relationship btwn high bloodwork & nausea, especially if she has not experienced/treated many cases of CRF . Generally when cats have high blood work they also have high levels of stomach acid, it's not that high blood values cause it, but they are concurrent issues both related to (different areas of) kidney function. The higher the BUN value the higher chances are the cat will feel nauseous & vomit.

Originally Posted by nemesis

It sounds like the vet is suggesting that Smokey’s kidneys are more or less the same as they were before, and so he doesn’t need more fluids. He just needed to get over his stomach upset. But if that were the case, why even put him on IV fluids? Why was there such an obvious and dramatic improvement in his behaviour after getting fluids more often?

I'm wondering if this mini crisis was brought on by metabolic acidosis (thats why I asked at the top of this post for the Na+, K+ etc), may show similair signs to standard stomach acid but may account for the severity.

Smokey was put on IV specifically to flush the Cre & BUN out of the blood while the stomach issues were being worked out with antacids

Dramatic improvement because the blood toxins that made him feel super crappy were now gone. Most likely the blood toxins were causing him to feel worse than the increase in actual stomach acid was.

Originally Posted by nemesis

If he was/is suffering from more stomach irritation, nausea, etc, doesn’t this basically show that his kidneys are continuing to degrade, and that he might therefore need more fluids?

Was his mini-crisis caused by stomach upset, or by worsening numbers? If it’s the former, then why did blood tests show worsening values? How can stomach upset by itself cause a 200% increase in creatinine, without there being worsening kidney functioning that justifies increased fluids?

As above stomach acid is not neccessarily caused/fully connected to the degree of kidney function. It can also be a symptom of a pancreatitis inflammation. Sometimes with high values they crash and there is not always a pinpoint explaination for why at that particular point, sometimes it's just the breaking point for an overloaded body.

Rant away if you need to