tests to confirm CRF diagnosis? (long)

Kotyo is almost 9 years old. He's a big cat with lots of muscles, weighs
6 kg. He does not show any of the usual symptoms of CRF - he has a great
appetite, his coat is silky and soft, he is playful and perky. Two weeks
ago he showed signs of some pain while eating - he was pawing at his
mouth and chewing weirdly. Took him to the vet, she said we should do a
dental. As he is almost 9, she did a blood test first. The blood test
showed normal BUN of 40 (normal range 30 - 65) but creatinine of 2.11
(normal range 0.5 - 1.5). I'll put the full test results at the bottom
of this post. So, the vet told me he had CRF and wants to put him
immediately on Hill k/d, Fortekor and Ipakitine. The problem is that due
to her prescribing an potentially lethal overdose of Metacam to my
Kotyo, I have absolutely no confidence in this vet. I think she means
well, but she seems to just not have a very clear idea of how to deal
with cats - she's more of a dog vet. So I am looking for a new vet.

But regardless of which vet I end up with, I want to run additional
tests in order to either confirm Kotyo's diagnosis of CRF, or disprove it.

My reasons for thinking the high creatinine might not mean he has CRF
are these:
- as I said, Kotyo is a big cat - 6 kg, all muscle and no fat. I read on
the www.felinecrf.org site that large cats with lots of muscle may
naturally have higher levels of creatinine.
- Kotyo fought savagely to prevent having his blood drawn - he shredded
my hands and the hands of the vet tech trying to hold him. So possibly
this might have lead to a higher level of creatinine in his blood at the
time it was drawn.
- on his previous blood test, which was done in Canada 4 years ago when
he had a urinary blockage, his creatinine showed as 209 (2.36), with a
normal range of 83-181 (0.94-2.05). At that time his BUN was also normal
(7.7 with a normal range of 5.0 to 12.5). My Canadian vet at the time
never mentioned this elevated creatinine result at all. I only noticed
it last week after I got the results of the new blood test and dug into
Kotyo's records to do a comparison with the last test results. So is it
possible that the vet thought this value was not signifacant? Also, from
this result, his creatinine was actually higher 4 years ago then it is
now. I did show these old test results to the current vet and asked her
if the high creatinine from 4 years ago didn't mean that he normally has
a higher value, but she said it actually supports her current CRF
diagnosis - his kidneys had already been showing signs of damage 4 years
ago.

So, what tests can I ask for which can help us get a clearer picture of
what is going on with Kotyo's kidneys?

We are going to schedule an ultrasound for him in the next couple of
weeks, to look at his kidneys. But if there is no visual shrinking or
other damage to the kidneys, that's not going to tell us much.

I have read about measuring the GFR (Glomerular Filtration Rate). I
would like to do this test, but according to the vet it is not available
in Spain. I will be visiting the Veterinary Faculty of the local
university to ask them if it is possible for them to run the test, but
if they say they can't, then there's no way to get this test done.

One test that is available in Spain is the Urine Proteine:Creatinine
Ratio test by Idexx Laboratories. I asked the vet if we should run it
and she said there was no point, because the creatinine was a better
indication of kidney damage. Should I insist on having this test run
anyway? How good is it in confirming a CRF diagnosis for stage 2 CRF?
(according to IRIS a creatinine level of 2.11 means stage 2 CRF)

I know we can also do a urinalysis to measure the urine specific
gravity. However I am not sure how reliable this test will be for Kotyo.
He drinks a lot of water with his wet food, and that will show as low
USG on the test. Since he was blocked in 2006, I have been adding
roughly 45 ml of water to his wet food at each meal, which comes to
about 135 ml of water per day. He is eating wet food exclusively, and he
always finishes all his food and drinks up all the added water. So I am
afraid that him drinking all this water might affect the USG results. At
his last urinalysis in Canada (October 2006), his USG was 1.015. The vet
remarked on this, but when I told her I was giving him extra water she
said that this could explain the low USG. If I were to stop adding water
to his food for a while, and then do a urinalysis, would the USG result
be more reliable? If so, would it be enough to just not give him
additional water for 24 hours before I get the urine sample? I don't
want to stop with the additional water for long because he has the bad
habit of not peeing until his bladder is really really full. So when I
don't give him extra water, he pees only once every 24 hours. With the
water added, I can get him to go twice per 24 hours, sometimes even 3
times. If he only goes once per 24 hours, he gets a cystitis flare-up. I
have been controlling his cystitis with a glucosamine supplement and the
added water - he hasn't had a flare-up in over a year and half.

Should I also have a 2nd blood test run? This time trying to get blood
without Kotyo fighting us, so that doesn't affect the test results?

Are there any other tests I can ask for which will tell us if Kotyo
really has CRF or not?

Here are the full results of Kotyo's blood test done March 9, 2010. I've
tried to translate them from Spanish as best as I could - for terms I'm
not sure of I put a question mark next to the word:
urea/BUN 40 mg/100 ml normal 30-65
creatinine 2.11 mg/100 ml normal 0.5-1.5
GOT (AST) (???) 14 U/l normal 10-29
ALT (SGPT) 22 U/l normal 20-67
total Protein 8.5 g/100 ml normal 5.8-8.0
Alkaline Phosphatase 78 U/l normal up to 55
glucose 78 mg/100 ml normal 60-100
Gamma Glutamil Transpeptidasa (GGTP?) 4 U/l normal 0-10
Amylase 669 U/l normal 150-1500
total Bilirubin 0.14 mg/100 ml normal 0.2-0.7
Albumin 3.60 g/100 ml normal 2.5-4
Globulin 4.9 g/100 ml normal 2.8-5.5
Cociente Albumin/Globulin (A/G Ratio?) 0.73 normal 0.6-1.1
LDH 328 U/l normal up to 500
calcium 10.6 mg/100 ml normal 7.2-12.0
Phosphorus 5.61 mg/100 ml normal 4-8
Cholesterol 364 mg/100 ml normal 75-250
Sodium 147 mEq/l normal 145-157
creatin fosfo quinasa (???) 128 U/l normal 150-798
Potassium 4.5 mEq/l normal 3.6-5.5

Hematies (RBC?) 9.20 10^6/ul normal 6*10^6 - 10*10^6
Hemoglobin 15.2 g/dl normal 8-15
Hematocrit 43.9% normal 30-45
VCM (???) 47.7 u3 normal 39-55
HCM (???) 16.5 pg normal 12.5-17.5
CCMH (???) 34.6 g/dl normal 30-36
leucocitos (WBC?) 11.3 10^3/ul normal 5.5*10^3-19.5*10^3
placuqetas (Platelets?) 211 10^3/ul normal 200*10^3-500*10^3
Eosinophils 1% normal 2-10%
Basophils 0% normal 0
cayados (???) 1% normal 0-3%
segmentados (???) 70% normal 35-75%
Lymphocytes 26% normal 20-55%
Monocytes 2% normal 1-4%

Any help with these questions will be greatly appreciated.

Nadia and Kotyo
--
Little Monster pictures: http://picasaweb.google.com/nnakova/Kotyo
Sweety pictures: http://picasaweb.google.com/nnakova/Sweety
Kotyo and Sweety together:
http://picasaweb.google.com/nnakova/KotyoAndSweety

"Nadia N." wrote

Kotyo is almost 9 years old. He's a big cat with lots of muscles, weighs

Nadia I wish I could answer but the level of detail you need here can
probably only come from a PHD type veterinarian and there arent any here.

At best, you can expect folks with cats who have related issues tell you how
they dealt with it.

The only clear thing to me is you need a new vet as you lack confidence in
the current one.

Let me add one other thing. Over many years I've had many pets. I didnt
dump the vet because the news was bad and I was looking for a 'tell me what
I want to hear'. When told my beloved Roscoe wouldnt see his 5th birthday,
we just enjoyed all the time we had with him. He lived to be 14.

I currently have a rescue dog who the vets warn me won't live long. I didnt
dump the vets over this, to find one that agreed with my desires that i
would otherwise despirately seek. I've learned better.

While you may have a need for a new vet, dont discount the training they
have in general.

cshenk wrote:
"Nadia N." wrote

Nadia I wish I could answer but the level of detail you need here can
probably only come from a PHD type veterinarian and there arent any here.

At best, you can expect folks with cats who have related issues tell you
how they dealt with it.


Yes, I probably went a little overboard on the details in that post. I
have been reading up on CRF for the last week and a half, trying to
learn as much as I can so that I can make sure Kotyo has the best
possible care. Having people share their experiences of their cats who
were diagnosed with early CRF would be helpful, and I am also hoping to
get a reply from Phil, who, while not a PhD type veterinarian, has a lot
of knowledge about this stuff.


I currently have a rescue dog who the vets warn me won't live long. I
didnt dump the vets over this, to find one that agreed with my desires
that i would otherwise despirately seek. I've learned better.

While you may have a need for a new vet, dont discount the training they
have in general.


I am not looking for a new vet because I disagree with her diagnosis of
CRF. I am looking for a new vet because when I brought Kotyo to her last
week, she prescribed oral Metacam for him - 12 drops per day, for 5
days. She gave us the dog version of Metacam, which is 3 times stronger
than the cat version. If I had given him this, it would have killed him
and I wouldn't be here asking about CRF right now. I was extremely lucky
that I mentioned the oral Metacam in a post here asking about the
antibiotic Kotyo had been prescribed, and Phil replied saying that
giving cats oral Metacam is not a good idea. This got me to take another
look at the bottle the vet gave us and to read through the leaflet that
was inside, which clearly said not to give this medicine to cats. Then I
started googling and found tons of stories about cats dying after taking
it. I also found recommendations that older cats (like my Kotyo) should
not be given this drug before a blood test has been done to confirm they
do not have kidney problems because the drug is known to cause kidney
damage. In addition to prescribing the oral Metacam the vet also
injected Kotyo with a dose of it - again, before any blood tests were
done to check for renal problems. If he does have CRF, this could have
caused further damage to his kidneys.

I want to have a vet that I can trust not to kill my cat if I bring him
to her in an emergency, when I don't have the time or opportunity to
double-check every single drug she gives him. Just the thought that if I
had given my baby that Metacam I would have been killing him with my own
two hands... I can't describe how it makes me feel, but it is a most
horrible feeling.

I'm sorry about your dog. I hope you get as many good days, weeks, or
months with him as possible.

Nadia and Kotyo

--
Little Monster pictures: http://picasaweb.google.com/nnakova/Kotyo
Sweety pictures: http://picasaweb.google.com/nnakova/Sweety
Kotyo and Sweety together:
http://picasaweb.google.com/nnakova/KotyoAndSweety

"Nadia N." wrote
cshenk wrote:

Nadia I wish I could answer but the level of detail you need here can
probably only come from a PHD type veterinarian and there arent any here.

Yes, I probably went a little overboard on the details in that post. I

It's ok and i didnt mean to castigate you you anything. Just explain no one
here can help to that level of detail.

have been reading up on CRF for the last week and a half, trying to

Reading up is always good.

possible care. Having people share their experiences of their cats who
were diagnosed with early CRF would be helpful, and I am also hoping to

I've had some 20 cats over my 50 years, but have no experince sorry, with
that one to share.
(before you freak, multi-cat household normally and this includes
childhood).

I currently have a rescue dog who the vets warn me won't live long. I
didnt dump the vets over this, to find one that agreed with my desires
that i would otherwise despirately seek. I've learned better.

While you may have a need for a new vet, dont discount the training they
have in general.

I am not looking for a new vet because I disagree with her diagnosis of
CRF. I am looking for a new vet because when I brought Kotyo to her last
week, she prescribed oral Metacam for him - 12 drops per day, for 5 days.
She gave us the dog version of Metacam, which is 3 times stronger

Ok, I gather that is bad. Yeah, vet shoppng time.

I want to have a vet that I can trust not to kill my cat if I bring him to
her in an emergency, when I don't have the time or opportunity to
double-check every single drug she gives him.

You should not have to double check the meds. I'd swap vets right now if
you.

I'm sorry about your dog. I hope you get as many good days, weeks, or
months with him as possible.

Oh don't feel sad. Jump in Joy with us as he lives years he may never have
had. He may turn out to be like Roscoe-kitty. Roscoe was a 'failure to
thrive' from a reputable breeder (hey, even they have a few) and I was
warned he'd never see age 5. Age 13, he was chasing and killing live crabs
after knocking the bricks off the cooler with our current catch.

I recon we used up the miracles here with Roscoe but Cash-pup is having good
years. He's snoozilating beside me with Daisy-chan (cat) walking on his
back. Oops, she just ran off. Oops she ran back. Oops they ran off!

Checked, sleeping in sin in the bedroom again. *sigh*.

Although we will feel severe pain when Cash leaves us, every moment we have
now makes it worth it.

If it's ok to add a tag to this: All of you who love animals, should at
least *consider* (finances within your limits) those older or medically
challanged rescue pets.

On Mar 19, 8:12*pm, "cshenk" wrote:
"Nadia N." wrote

cshenk wrote:
Nadia I wish I could answer but the level of detail you need here can
probably only come from a PHD type veterinarian and there arent any here.
Yes, I probably went a little overboard on the details in that post. I

It's ok and i didnt mean to castigate you you anything. *Just explain no one
here can help to that level of detail.

have been reading up on CRF for the last week and a half, trying to

Reading up is always good.

possible care. Having people share their experiences of their cats who
were diagnosed with early CRF would be helpful, and I am also hoping to

I've had some 20 cats over my 50 years, but have no experince sorry, with
that one to share.
(before you freak, multi-cat household normally and this includes
childhood).

I currently have a rescue dog who the vets warn me won't live long. *I
didnt dump the vets over this, to find one that agreed with my desires
that i would otherwise despirately seek. I've learned better.

While you may have a need for a new vet, dont discount the training they
have in general.
I am not looking for a new vet because I disagree with her diagnosis of
CRF. I am looking for a new vet because when I brought Kotyo to her last
week, she prescribed oral Metacam for him - 12 drops per day, for 5 days.
She gave us the dog version of Metacam, which is 3 times stronger

Ok, I gather that is bad. *Yeah, vet shoppng time.

I want to have a vet that I can trust not to kill my cat if I bring him to
her in an emergency, when I don't have the time or opportunity to
double-check every single drug she gives him.

You should not have to double check the meds. *I'd swap vets right now if
you.

I'm sorry about your dog. I hope you get as many good days, weeks, or
months with him as possible.

Oh don't feel sad. *Jump in Joy with us as he lives years he may never have
had. *He may turn out to be like Roscoe-kitty. *Roscoe was a 'failure to
thrive' from a reputable breeder (hey, even they have a few) and I was
warned he'd never see age 5. *Age 13, he was chasing and killing live crabs
after knocking the bricks off the cooler with our current catch.

I recon we used up the miracles here with Roscoe but Cash-pup is having good
years. *He's snoozilating beside me with Daisy-chan (cat) walking on his
back. Oops, she just ran off. Oops she ran back. Oops they ran off!

Checked, sleeping in sin in the bedroom again. **sigh*.

Although we will feel severe pain when Cash leaves us, every moment we have
now makes it worth it.

If it's ok to add a tag to this: *All of you who love animals, should at
least *consider* (finances within your limits) those older or medically
challanged rescue pets.

I don't have anything to add, but I hope Phil sees this soon. Sounds
like you are doing all you can do...

A good and interesting post from both of you.. cshenk and NadiaN...

"Nadia N." wrote in message
...
Kotyo is almost 9 years old. He's a big cat with lots of muscles, weighs
6 kg. He does not show any of the usual symptoms of CRF - he has a great
appetite, his coat is silky and soft, he is playful and perky. Two weeks
ago he showed signs of some pain while eating - he was pawing at his
mouth and chewing weirdly. Took him to the vet, she said we should do a
dental. As he is almost 9, she did a blood test first. The blood test
showed normal BUN of 40 (normal range 30 - 65) but creatinine of 2.11
(normal range 0.5 - 1.5).

Questionable CRF diagnoses are usually the result of elevated BUN with
normal creatinine. BUN isn't a reliable indicator of CRF because several
extrarenal factors can cause it to rise- but its still a useful reference.
BUN is important in Kotyo's case because his BUN is well within the normal
range! If his abnormal creatinine was a result of CRF, I would expect to
see an abnormal elevation in his BUN. IOW, if his GFR was low enough to
raise his creatinine, it would almost definitely raise the BUN.

Also, certain measuring chemistries used in some chemistry analyzers can
artefactually elevate creatinine values.


I'll put the full test results at the bottom
of this post. So, the vet told me he had CRF and wants to put him
immediately on Hill k/d, Fortekor and Ipakitine. The problem is that due
to her prescribing an potentially lethal overdose of Metacam to my
Kotyo, I have absolutely no confidence in this vet. I think she means
well, but she seems to just not have a very clear idea of how to deal
with cats - she's more of a dog vet. So I am looking for a new vet.


If she doesn't have a very clear idea of how to deal with cats, I would
**never, ever** allow her to anesthetize my cat. Anesthesia in cats is
risky enough even for vets who know what they're doing. I'm very afraid
Kotyo would not survive anesthesia in her hands. She almost killed him
once, please don't give her another chance.




But regardless of which vet I end up with, I want to run additional
tests in order to either confirm Kotyo's diagnosis of CRF, or disprove it.

My reasons for thinking the high creatinine might not mean he has CRF
are these:
- as I said, Kotyo is a big cat - 6 kg, all muscle and no fat. I read on
the www.felinecrf.org site that large cats with lots of muscle may
naturally have higher levels of creatinine.
- Kotyo fought savagely to prevent having his blood drawn - he shredded
my hands and the hands of the vet tech trying to hold him. So possibly
this might have lead to a higher level of creatinine in his blood at the
time it was drawn.

Those are my thoughts exactly.



- on his previous blood test, which was done in Canada 4 years ago when
he had a urinary blockage, his creatinine showed as 209 (2.36), with a
normal range of 83-181 (0.94-2.05). At that time his BUN was also normal
(7.7 with a normal range of 5.0 to 12.5). My Canadian vet at the time
never mentioned this elevated creatinine result at all. I only noticed
it last week after I got the results of the new blood test and dug into
Kotyo's records to do a comparison with the last test results. So is it
possible that the vet thought this value was not signifacant? Also, from
this result, his creatinine was actually higher 4 years ago then it is
now. I did show these old test results to the current vet and asked her
if the high creatinine from 4 years ago didn't mean that he normally has
a higher value, but she said it actually supports her current CRF
diagnosis - his kidneys had already been showing signs of damage 4 years
ago.


I would dump her for having a closed mind and not even considering your very
likely possibility even if she didn't almost kill your cat.



So, what tests can I ask for which can help us get a clearer picture of
what is going on with Kotyo's kidneys?


The Heska E.R.D.(Early Renal Disease) HealthScreen. Its a 5 minute test and
requires just a few drops of urine. But since he might have dental disease,
the test result might be skewed.



We are going to schedule an ultrasound for him in the next couple of
weeks, to look at his kidneys. But if there is no visual shrinking or
other damage to the kidneys, that's not going to tell us much.

I have read about measuring the GFR (Glomerular Filtration Rate). I
would like to do this test, but according to the vet it is not available
in Spain. I will be visiting the Veterinary Faculty of the local
university to ask them if it is possible for them to run the test, but
if they say they can't, then there's no way to get this test done.

One test that is available in Spain is the Urine Proteine:Creatinine
Ratio test by Idexx Laboratories. I asked the vet if we should run it
and she said there was no point, because the creatinine was a better
indication of kidney damage. Should I insist on having this test run
anyway? How good is it in confirming a CRF diagnosis for stage 2 CRF?
(according to IRIS a creatinine level of 2.11 means stage 2 CRF)

I know we can also do a urinalysis to measure the urine specific
gravity. However I am not sure how reliable this test will be for Kotyo.
He drinks a lot of water with his wet food, and that will show as low
USG on the test. Since he was blocked in 2006, I have been adding
roughly 45 ml of water to his wet food at each meal, which comes to
about 135 ml of water per day. He is eating wet food exclusively, and he
always finishes all his food and drinks up all the added water. So I am
afraid that him drinking all this water might affect the USG results. At
his last urinalysis in Canada (October 2006), his USG was 1.015. The vet
remarked on this, but when I told her I was giving him extra water she
said that this could explain the low USG. If I were to stop adding water
to his food for a while, and then do a urinalysis, would the USG result
be more reliable? If so, would it be enough to just not give him
additional water for 24 hours before I get the urine sample? I don't
want to stop with the additional water for long because he has the bad
habit of not peeing until his bladder is really really full. So when I
don't give him extra water, he pees only once every 24 hours. With the
water added, I can get him to go twice per 24 hours, sometimes even 3
times. If he only goes once per 24 hours, he gets a cystitis flare-up. I
have been controlling his cystitis with a glucosamine supplement and the
added water - he hasn't had a flare-up in over a year and half.

Should I also have a 2nd blood test run? This time trying to get blood
without Kotyo fighting us, so that doesn't affect the test results?

Are there any other tests I can ask for which will tell us if Kotyo
really has CRF or not?


The only difinitive test is a iohexol clearance study. Do you live near a
vet college?

I'm running a little late- its adoption day. I'll try to go over your post
in more detail tonight.

Best,

Phil


Here are the full results of Kotyo's blood test done March 9, 2010. I've
tried to translate them from Spanish as best as I could - for terms I'm
not sure of I put a question mark next to the word:
urea/BUN 40 mg/100 ml normal 30-65
creatinine 2.11 mg/100 ml normal 0.5-1.5
GOT (AST) (???) 14 U/l normal 10-29
ALT (SGPT) 22 U/l normal 20-67
total Protein 8.5 g/100 ml normal 5.8-8.0
Alkaline Phosphatase 78 U/l normal up to 55
glucose 78 mg/100 ml normal 60-100
Gamma Glutamil Transpeptidasa (GGTP?) 4 U/l normal 0-10
Amylase 669 U/l normal 150-1500
total Bilirubin 0.14 mg/100 ml normal 0.2-0.7
Albumin 3.60 g/100 ml normal 2.5-4
Globulin 4.9 g/100 ml normal 2.8-5.5
Cociente Albumin/Globulin (A/G Ratio?) 0.73 normal 0.6-1.1
LDH 328 U/l normal up to 500
calcium 10.6 mg/100 ml normal 7.2-12.0
Phosphorus 5.61 mg/100 ml normal 4-8
Cholesterol 364 mg/100 ml normal 75-250
Sodium 147 mEq/l normal 145-157
creatin fosfo quinasa (???) 128 U/l normal 150-798
Potassium 4.5 mEq/l normal 3.6-5.5

Hematies (RBC?) 9.20 10^6/ul normal 6*10^6 - 10*10^6
Hemoglobin 15.2 g/dl normal 8-15
Hematocrit 43.9% normal 30-45
VCM (???) 47.7 u3 normal 39-55
HCM (???) 16.5 pg normal 12.5-17.5
CCMH (???) 34.6 g/dl normal 30-36
leucocitos (WBC?) 11.3 10^3/ul normal 5.5*10^3-19.5*10^3
placuqetas (Platelets?) 211 10^3/ul normal 200*10^3-500*10^3
Eosinophils 1% normal 2-10%
Basophils 0% normal 0
cayados (???) 1% normal 0-3%
segmentados (???) 70% normal 35-75%
Lymphocytes 26% normal 20-55%
Monocytes 2% normal 1-4%

Any help with these questions will be greatly appreciated.

Nadia and Kotyo
--
Little Monster pictures: http://picasaweb.google.com/nnakova/Kotyo
Sweety pictures: http://picasaweb.google.com/nnakova/Sweety
Kotyo and Sweety together:
http://picasaweb.google.com/nnakova/KotyoAndSweety