Hello. Lovely to, to, to be with you. Thank you as always, for the invitation to, to come and do a webinar for you.
And my request for the, the request of me was to talk about the management of chronic kidney disease in the cat, which I am very, very happy to do because this is a disease I see all the time. And it really is something that can be very, very well managed in general practise, although I do know that is very reliant on Finances and we all know that finances, and what you can get into the course, but finances are, a real problem. But let's take one intervention of time, but I'm gonna start just by setting the scene a little bit more about, frequency, you know, how prevalent, the skin condition is, but I really want to talk about Iris as well, which I'm sure you do all, know, but you know me, I like to start it with a case.
So we are gonna start and complete with Harvey. So, hang on a thought for him. He's 14.
He's a beautiful domestic long hair, as I think you'll all agree. And he came to me with inappetence, bad breath, and polydipsia. Now we know, particularly in indoor outdoor cats, which you can see Harvey, was, he was now sadly, it can be hard to note polysia because if they're drinking outside and peeing outside, when you're gonna see it.
So by the time an owner notices it within the home, it is usually really quite severe. And then on a physical exam, a poor body condition put him at about a 3 out of 9. He was mildly dehydrated and sadly, he's already at the stage of having, small, irregular firm kidneys, not popcorn kidneys yet, cause I heard one of my colleagues call them, and I thought, that's such a good description.
So they weren't popcorn, but they were kind of like small, knobbly, you know, I don't know what to call them as a, a food group. I'll have to think about that one. Obviously, the diagnostics are gonna be the same diagnostics that you'd always do, but I am going to put my, my standard request, check weight first, and most importantly, write down what the weight is, then look back and see what the weight used to be, because that's really important.
We must calculate the percentage weight change. There's anything more than 5%, it really behoves us to Do something to investigate unless there's been a a a significant reason like the cat's actually on a diet, which Harvey Harvey wasn't. And then really particularly in an elderly cat like this.
Do check blood pressure and or look at the eyes before you take the bloods, please. Unfortunately, it has happened to me, it has happened to other people, that when you take blood from a cat with high blood pressure, then, the raising intracranial blood pressure can result in acute death. And because cats have got an incomplete circle of Willis, that increase in in in cranial blood pressure can't be dissipated very quickly.
Once you know the blood pressure is OK, then, you're gonna be taking, bloods to find out what's wrong. And certainly with a cat that's, PUPD you're gonna be checking urine as well. And here are Harvey's results.
It's he's got a systolic blood pressure of 170, so it's certainly, he is hypertensive, but thankfully very unlikely to have retinal changes at this point and he didn't have any retinal changes. So I feel quite comfortable taking bloods at 170. Although if there was retinal changes, then I wouldn't.
And he's got a mild non-regenerative anaemia. His PCB was at 24. But the the urea creatinine of phosphorus were more exciting, urea of of 30, creatinine of nearly 300, and he's slim.
So, you know, maybe that's a bit higher, really, because he hasn't got much muscle or it would be if he had more muscle set the right way around. His phosphorus looks to be within a standard reference interval. But, of course, we know it really should be lower in a cat with we want to get it lower in a cat with chronic kidney disease.
His USG is just at the top of Ioanuria, so he's 1012. That is really important because cats got those beautiful loops of Henley. So for them to get down to Iosenuria is incredibly Unlikely with just chronic kidney disease.
This is almost always an E. Coli UTI, which is what we did find. So even if he hadn't had an active sediment, I would have been culturing this urine because as far as I'm concerned, he has an E.
Coli, and I just need to prove it. His, UPC was, was 0.6, which is increased.
Kidney disease, we really want it to be less than 0.2, but he has got E. Coli UTI so we can't judge that until we get the, the UTI under control.
So that's us thinking about what we've got. Now we need to decide what to do. Now, we all know about the IRIS guidelines.
You've got iris stage 123, and 4 with one where there's no aotemia, but you've got maybe the SDMA is increased, but more likely you've got a low USG and that's why, you know, that it's I was stage one or you've got a renal stone, something like that. Iris 2 is mild aotemia. You've got the numbers there in front of you.
But at this point, the cat is still not unwell. He is still normally feeling fine at this point. They only start showing, .
A, being clinically well going with the food, etc. By the time you get I stage 3, and you all know that stage 4 is really not where we want to be going. You've got the SDMA values there.
They are particularly important when you've got a little skinny cat like this, because obviously creatinine comes from muscle. If you haven't got muscle, then you are going to, have a creatinine lower than you would expect for that cat. So it's important that you've got a real skinny cat to do an SDMA because that will then tell you what the actual iris stages.
It's really important to check the UPC ratio as we did, and you're aiming for less than 0.2. And the blood pressure is the other part of the, the iris staging, which we've done in this cat.
So we know that chronic kidney disease, it's very common. So I have 1 in 10 of all cats are gonna get it, and particularly when they're older cats, then it's 30%, so it's high. And while you saw the STMA, numbers on the previous slide, I am, I think the easiest way to remember it is that if you've got, The normal careering, but the SDMA is higher than say 14.
Some people would actually have a feeling they've moved it to 18. I'm having a, a, a brain fart so I'm thick with a cold. That would increase you to to RS one.
Whereas if you've got, you know, your, creatinine, it's, it's basically the way to think of it is the SDMA being increased will put you up one IRS number. And so you can see that you can have a a cat that's really very skinny. But it's SDMA is over 38, and that's IRS stage 4, even if the creatinine is normal.
OK, the creatinine can be normal, but if the SDMA is over 38, you've got RSS 4. Obviously this little guy, here is a very, very skinny example. And why is this so important prognosis?
Because you need to be able to tell the owner what you expecting. I just wanted to, to underline the amount of kidney function that is lost at each of these Irish stages. So when we're talking about iris stage one, already 2/3 of the kidney has been lost.
And yet the only thing you're gonna see is a USG that's lower than you'd expect. We use 10:35 cut off, but remember, really importantly, it's all to do with what the cat eats. Because if this cat normally eats dry food, the normal, USG for a cat on dry food is over 1050.
So if you've got a cat that's only eating dry food and its USG is less than 1050, actually. You've got lower USG and you've already got RS stage one. Whereas if there's all wet food then that's where you're expecting more like 10:35, 10:40.
By the time the cat is aotemic, you have lost 75% of kidney function already. 75%, and it's only at this point you're actually gonna pick it up on a blood test. So this is why it is so important with elderly cats to have regular urine samples.
It can be collected at home, so they don't have to stress out the cat, but really important that you monitor the the USG of our older cats. And it's not invasive. The owners like to pee at home, then all you need to do is, you know, a quick USG dipstick sediment.
By the time the cat is actually uremic, so at this point, the cat is feeling unwell, we've lost 90% of kidney function, 90%. And obviously end stage 95%. And this is really why SDMA is so important because it can pick up the fact that we've got renal insufficiency with as little as 25% of kidney damage.
So that is before you pick it up on urine. So that's important. And then there's updates this year, which is the SDMA one just caught me out because I, I'd forgotten it, it's gone up to 19, my apologies.
They've given us a breed specific reference intervals. They've given us healthy bins having higher creatinines, about 20% of cats, vermins have got high creatinine. Now I Published this when I was a resident.
So in the 1990s, that, that the, the Americans have only just picked up on this, I find a little bit frustrating, but there you go. So, Berman cats, and sometimes you'll see it with rag dolls as well. They have a, a higher, SDMA than, sorry, correct me, than you might expect.
Their SDMA is normal. And unlike puppies, healthy kittens should have normal SDMAs, that is different from puppies. And why is knowing about the IS guidelines so important?
It's a very easy go to place, and you've got all the interventions listed there, obviously, that's a busy slide. I'm not going to go through it, just enough to say that you've got a list on stage one, all the things you can look at, we're going to look at those now. And then what you need to add in by the time you've got stage 2, that's particularly looking for low potassium at stage 3, that's phosphorus really kicks in at that point looking for anaemia, etc.
So let's look at our interventions. So, first of all, let's remove potential causes. So let's look for yelonephritis.
It is not that uncommon in cats. And it can result in a normal culture that is really, really annoying when the bugs stay in the kidney and you can't culture them. If you've got a cat that anything tells, you know, this is an acute onset kidney.
Or it's an acute or chronic, and you've got the the USG is lower than it was previously and there's a big step change and you can't culture anything. I would do an antibiotic trial. I would be using amoxicla.
OK. And I would give it for a week. If the USG comes up, it's confirmed, you've got pyelonephritis and keep going for another week.
Leptospirosis, yep, it's a player but but not commonly identified, should we put it that way. Obviously look for nephrotoxins. It's my little old Bengal cat many years ago, picture of her completely ignoring the the toxic lily, above her head, which is kind of fun.
And we're really going to be talking about the palliative treatments because we as yet can't do renal dialysis and I want to talk about things that can be done in general practise. These are all the different interventions that can be done. We're gonna go all the way down to reversing anaemia.
In this talk, I'm not gonna talk about that, but Dawein is the, the treatment of choice. Make sure to give iron as well. And not many people have got the wherewithal to do much about acidosis, so I'm gonna gonna ignore that.
I know, I shouldn't, but I'm going to. It's my talk. Cornerstone though is diet.
Really, really important. Lots of things have been done to these diets. They are made dense in calories.
They've got increased, potassium because cats with kidney disease are likely to drop their potassium. Increase water-soluble vitamins because if you're PUPD you lose them. Lower in salt, increased omega 3, lipids, that's really important along with antioxidants.
We want to, limit the amount of, oxidative damage to the kidney, which will make things worse, and they tend to be a alkalis. The main thing they do, the main, main, main thing is reduced protein and phosphorus. And we now think it's actually phosphorus is the most important thing to do.
And certainly there's lots and lots of papers that show if you feed these diets, you are gonna have fewer uremic crises, and most importantly, you're gonna have clinical improvement and increased lifespan. Lots of studies show that on average, these cats, when they eat these diets, live a year longer than if they didn't. What's important though is the exact requirements are still not known.
And what is required for a 4 year old fit Maine Coon who's been daft enough to go and eat lilies and, get acute, kidney disease compared to a, a 6. 16 year old mog, with very poor muscle at that point, you know, they need different food. And if, when they're still, well muscled, etc.
Always go with early renal. To be honest, I don't end up with, you know, full renal, very often. I, I see cats that that tend to be earlier on the the the spectrum, but not always.
So my, my first step into renal diets is going to be early renal. I love that, that, that those are now available. Wean gradually.
In one study we did, we actually had 100% of owners manage to wean and everybody goes, wow, how did you do that? It was easy. It was a big study.
It was funded by industry. And they were the owners were gonna get 3 years of free food if that cat lived all the way through that plus blood work, etc. And owners worked to make sure those cats ate the diet.
So it can be done, but obviously, it's not always that easy, but the most important thing is wean gradually, because these diets are different from what the cats were eating before. What I'm very keen on is that I, I love that we've got multi-function diets now, and this really plays to the thing about, by the time a cat's got chronic kidney disease, particularly as an older cat, it is likely to have other diseases as well, and we need to factor those in. So one of those very common other diseases is, joint disease.
And so I love that, hills and other, It, food producers as well, make a combination of a mobility diet with a kidney diet. Royal Cannon is the only one I know that does a, a kidney one with a hypoallergenic one, but if I'm wrong, please somebody correct me. And I was just looking at some of the, the hills literature, and now they're adding a prebiotic fibres and beta.
And what these do is they actually trap the uremic toxins in the cat's bowel. And that is really gonna help their gut gonna reduce the amount of uremic toxins in the cat. So that is a really good way, to go.
So diet, really, really important. What about phosphate? Well, this is usually reduced as part of the diet, because getting this down is absolutely of paramount importance.
If you look at the radiograph at the top, the, red arrows show mineralization of the, aortic arch. And of the gastric lining, and these are the most common places to mineralize. You can also see it in the the .
What's one of a bronchi, you can see it kind of outlining the respiratory tree in some cases as well. So it's really important that phosphate is assessed, and then you do have targets from iris to try and get these down. They're not that easy to do, but it is really important.
Start, in most cases, by going to the diet, and the diet should bring the phosphate down. If it doesn't, then add in phosphate binders. But some cats are on a prescription diet for different reasons.
A typical would be a diabetic cat. These are very hard to treat diabetic kidney cats. And what I would do, we know that the diabetic diet is so important for a diabetic cat.
We're gonna start by adding a phosphate binder to that, and then juggle and see where we get to. Why is this so important? Well, look at the different in, in overall likely means survival time.
Again, you're gonna be able to give the cat about a year extra. The most important thing I can tell you about a phosphate binder is they don't work if they're only put in occasional food, you know, so if it's put in, you know, say morning, they put in the morning food. Well, it will reduce the phosphate that's absorbed from the morning food, but it won't reduce it for all the other foods.
So it's got to get into every meal. And obviously, if the cat's on a dry diet, that is more challenging. We've got a number of different types that do all work remarkably well.
And now we have these pure carbon traps and we've got Poros one, which actually traps the uremic toxins and Bel, much like the, the products that fibres and beta that hills are doing. So there's really good work now, pushing towards other ways of binding phosphate, not just a classical phosphate binders. FGF 23 is now being, introduced.
That's already in the states. It's supposed to be here already, but I haven't seen it on the, on the IDEX sheet. I'll have to, have a double check.
And, and this is, a better way to monitor for phosphate, than looking actually at the phosphate level itself, because it's assessing more than just phosphate. There are obviously many, many uremic toxins. It's not, not just phosphate.
But obviously we don't want to overrestrict because that can lead to weakness and anaemia. We don't want to go there. It can also result in high calcium.
And this we've seen a number of times where cats have been over phosphate restricted. And you see the calcium coming up. So if you've got a cat that is on kidney diet, particularly if it is, is on phosphate binders, watch out for calcium increase because you might start worrying that, you've got a hypercalcemia.
Well, you have, and you need to address that before you start getting, calcium oxalate stones in the kidneys, the ureters, etc. And, and you've got a disaster on your hands. Then we look at, potassium, really, really important.
And this is a cause and effect thing. If you get a diet that is low in phosphate, sorry, low in potassium, that can actually, if you feed it for long enough to a cat, cause kidney disease. And obviously, if you've got chronic kidney disease, or chronic renal failure, then that is going to, cause, potassium loss in the urine.
So it, it goes round and round. So we do need that supplement supplemented. Thankfully, we do have options here, although I do agree that the commons, which is usually the easiest way of doing it, thankfully, there are other versions now, these products are quite costly, but they are really important because you do want to keep the potassium, you know, above 4, you want it between 4 and 5.
If you let it get much below 3, then you are gonna have a risk of polymyopathy, generalised weakness, neck ventriflexion, that's the lack of a new cresting cats, and, and, and you're gonna make the kidneys a whole lot worse. So we're putting so much on the diets, what we really need to make sure is that the cats eat them. Lots of reasons why these cats might have reduced appetite.
We've got the uremic gastritis, have mineralization of the, the, the wall, and then you've got the uremic toxins themselves. You may even have GI bleeding, which will put the the Urea. So we really don't want the cats not eating.
That is bad. So cat friendly practise is gonna be your best way of encouraging the cats to eat, certainly within the hospital situation. Hand feeding, warming food.
This is where our nursing staff are just brilliant. The only thing I would say is I really don't like to go into the ward and see like 3 different bowls in front of a cat and the cat facing away, looking at the wall. That's gonna overwhelm the cat.
So don't do that one food at a time. The cat hasn't touched it within half an hour. Take it away.
Give it a little bit of time. Try it again. And feel optimum is a combination of Phila classic, that's facial pheromone, which reduces anxiety, and feelway friends, which is the mammary appeasement pheromone.
And so that is a good thing to have plugged in in your cupboard. There are lots of, kidney diets. There are lots of ways to tempt cats.
And we've got things as well, like the Purina Hydracare, which is a water supplement. If the cats will, will eat this, some cats will take it really readily. Others not keen, but if they will, that could increase the fluid, uptake by as much as like, they say 28%.
So pretty good numbers. And a lot of these soups are actually OK. They are actually lower in In phosphate, etc.
But remember, within the hospital, I'm just gonna be starting them to be fed. I'm not gonna be starting a renal diet in the hospital. I just want the cat to eat.
Appetite stimulants, yeah, we're all using Mirtazapine, particularly, the ear one, just remember to reduce the frequency of dose with chronic kidney disease, otherwise, you can start seeing euphoria and hyper excitation, etc. I also love gabapentin, not just for when they come into the clinic, when they're in the clinic, but at home, if you've got an anxious cat. And we do know it, it's an appetite stimulant because it reduces anxiety.
Oddly, Talmasartan and benazapril are also appetite stimulants. I'll mention more about those later. And the only other one I was going to mention is B12.
If your B12 drops, the first sign of it is poor appetite. So If you haven't, if you're not gonna monitor the level in the cat and obviously it would be nice to know, checking your blood level, then just give it because if you give it too much, they just pee it out, not a problem, it's a water soluble, vitamin. And then we've got ice and Allura.
These are copperrein products. These are, they really can very effectively stimulate appetite, basically the same product, but it has been reformulated, and, aura. We haven't got access to it yet, but it's supposed to be coming soon.
So by the time you hear this, it might well be here. We use this most because it's such a powerful appetite stimulant. We use it in feeding studies when we need the cat to eat, but they are going to be very much, promoted as, for kidney disease too.
But go low, go low on the dose, because the side effects can be quite marked. So, you know, if, I know it's too mixed per ing, but actually I would, I would start it lower than that, if I don't need them to eat, to start eating instantaneously. And the, the biggest problem we've we've had is critically low blood pressure and, and bradycardia.
So just, just be careful. Very effective drugs, but nothing's for free, hey. Neuroppotin is our friend, anti-nausea, if you've got a kidney pain because you've got stones, etc.
That's, that's gonna be great because obviously it's a visceral, . Analgesic as well on Dowsetron in in really severe cases. I don't use the prokinetics very much unless you've got GI stasis in the hospital, in which case I'm going to use a metoclopramide constant rate infusion.
I don't use the H2 antagonists anymore as really indication that we shouldn't really be using them. And tube feeding. If the cat is not eating in the hospital and, they haven't eaten for, for a while, then yes, I'm gonna have to give them some kind of nutrition and I'm gonna have to do it.
If the cat won't eat, I'm gonna have to, to put a tube in. I don't like nasal tubes, but I will use them if it's only for a few days. And if you have to anaesthetize one of these cats for any reason, maybe a dental, something like that, then I'll happily place an O tube so that I can then use that for medication and for food so I can get the cat propped back up again.
What I would say is if it's an older cat, it's really important that the owners don't keep feeding the cat through the tube when the cat's had enough and actually wants to die. So there, there is a balance. It's, it's, acute use, not really long term use.
And then fluid, obviously so important because they're at risk of getting, dehydrated. So we need to make sure they've got instant access to water at all time. I really find lifting bowls up is such a good way of getting cats to drink more.
They're, it's not sore when they, put their necks down to drink. That means they're gonna drink more when they do. And it also means that just put water.
Lifted up in a few places around the house and that's going to stimulate them to to drink. If they're a cat that really likes to drink from the tap, and they can't get up to the tap anymore, it's important to provide running water for them, in which case, water fountains can be very useful. And subcu fluids is absolutely a way to go.
Quite a lot of owners are quite comfortable doing this. Just if you've got owners who are a bit excessive, don't let them get too much because that can cause, overhydration and actually, too high, sodium. I don't like skin buttons or these tubes that go under the, the, the neck.
I haven't found much success with them. But here's Marge Chandler, and she, used to work here, with gorgeous Toby, and she's showing how to give subcue fluids. You can see the, the dirt bag is hung up behind her.
And, Toby's owner is stood with me taking a photograph. And I think everyone can see that he's, completely happy having his subcue fluids. So what about proteinuria?
Well, proteinuria is an independent risk factor for death, whatever the cause. So really important to look for proteinuria. And it is an essential part of the investigation of a cat with chronic chronic kidney disease.
So please don't leave it out. Yes, proteinuria, significant proteinuria is less common and the cat and the dog because they don't get as much disease, but it is really important. Actually I'm gonna skip those two comments and I'm just gonna use this graph.
So go to the top of the graph. You've got, so. This is Kaplan Meyer survival curve at the top, everybody is alive.
And if we look at the yellow line, these are the cats that got a UPC greater than 0.4, and you can see that that they're all dead by just over 1000 days. Whereas if we look at the cats between 0.2 and 0.4, then 5% of them are still alive when all of the cats in the other group have died.
So there's really not much of a difference. And you compare that to less than 0.2, 40% are still alive.
So yeah, it's a no brainer. The the number you should be working to for these cats is 0.2.
I love that little cute cartoon. So we'll change words further up if you haven't noticed it. And this is just some new data that's, that's, that's come in, .
I, I'm not sure if anyone's doing protein leapesis consistently, but this is something that to watch out for, it, it might be useful. But I did want to point out how useless the dipsticks are. So let's look at cats because the cats is what I care about the sensitivity.
Yeah, OK. One study said OK, but one study said only 60%. Sensitive.
Well, it's missing 40%. That's not good. Specificity is absolutely rubbish.
So if you've got a cat that has got a disease where knowing about proteinuria is important, so for example, chronic kidney disease is the most important one, and then hyperthyroidism and diabetes would be the other two, then you really need to do a UPC. And that doesn't need to be on sterile urine. This can be on litter box, urine are not a problem at all.
If you've got very bloody urine, then that is gonna make it wrong. But so long as it's not, as long as it's anything less than reasonably pink, it's gonna be fine. I'm not gonna go all the way through the the RAS system in, in detail.
I don't think you probably want that at this time of the day. But what I just want to remind you of is the drugs that have an intervention here. So we've got angiotensin, cause to angiotensin one.
And then ACE inhibitors block this at this point, as opposed to the angiotensin to receptor blockers. They block at this level because what we're trying to block is the AT1, which causes vasoconstriction. Sodium retention.
Sympathetic nervous system activation, increased inflammation, growth promoting effects, all stuff we do not want in a kidney cat. So we need to block these. What I will point out is ACE escape in lots of tissues.
There are enzymes that will by step this effect, which means that the ACE inhibitors stop working. And that's important when you're looking for a long term effect to reduce protonuria. So what studies have we got?
Well, in cats, we've got lots relating to Benazepril. And what the studies showed, it wasn't quite statistically significant, but there was a reduction in proteinuria and an increase in survival time, which was more significant when the higher the UPC was, particularly in Persian cats. Whereas Telmisartan was compared against Benazepril was shown to be just as effective, and more so the higher the UPC went up.
It's also a liquid, which I find particularly easy to use. And then this study is quite important. This compared protonuria in the Talmosartan treated group and the benazepril treated group.
And what we've got is the effect of ACE escape and overall, But April tends to stop working as a to reduce proteinuria at about 30 days, which is why telmisartan is a better approach. Remember also though, it of course is one of your treatments against high blood pressure. And so if your cat's got normal blood pressure or low normal blood pressure, then occasionally you end up having to switch to Benazepril because that hasn't got such an effect at reducing blood pressure.
It does a little bit, but not as profoundly as Talmasara. Let's think about blood pressure. It is incredibly common in our kidney cats.
And the end effect is it's gonna make the kidneys a whole lot worse. And yes, it could be being caused by the kidneys, but it's gonna make the kidneys a whole lot worse. It can cause heart failure, it can cause cerebrovascular accidents, which can cause dementia.
Or strokes, and then the ocular changes. These are from obviously without amplification, without looking at the back of the eye and where that word came from. And you can see in this one, you can see all the vessels from the, the retina are clearly seen, without, looking deep into the eye.
And the same in this one, and we've got a, a bleed as well. And neither of these eyes is chemically dilated. Both of these cats are blind.
This is a really simple technique. If you're not using it, this is a really good one to master. It's a little bit of a steep learning curve, but once you've nailed it.
I can do a quick medic medicine grade, retinal exam, not ophthalmology grade, which is obviously, you know, looking much, much harder. I can literally do it in a couple of seconds. And if you get quick, then you don't need to use recommide.
But when you start, use trabecumide, give yourself the best chance. You hold the trans eliminator beside your eye, and at your arm's length, you have the, the cat's eye. Obviously you're in a dark room, two of my fabulous nurses are showing how it's done.
The kit, very simple. So standard ophthalmic ophthalmoscope. You, if you haven't got a transilluminator, which will cost you about 100 pounds, you can just use the smallest white circle.
It's just transluminator is a little bit easier to use. And obviously, you always want to use the rear start, start with the lowest light that you can. And then you need a 30, 25 to 30 diopter lens.
This is a glass one I've had since undergraduate days, and it's brilliant. I would be lost without it. Put your head at about the cat's head.
So Suzie's head is a little bit, a little bit high. Try and get yourself on the level. And then shine the light so you can see the torpedal reflection.
When you can see the torpedal reflection, you've got the light in the eye. And then at that point, just drop the lens down in front of your light beam, and then you're gonna see the, the, the retina. Why is it important?
Well, there's all sorts of things that we could be seeing. Obviously, the, the first picture, you, you don't need to be looking at the retina. This is a cat that sadly, she went blind because she's got bilateral glaucoma.
Both of her lenses have, have got very bad cataracts. In fact, they're floating free. One is lying on its side, on the bottom of the globe, and the other one is in the anterior chamber.
A second picture at the top, you've got, complete retinal detachment. And then these ones looking at this level is really important. Let me just see if that black box.
I'm gonna stop using my mouse so the box will disappear. You can see all these little greyish greeny wriggles. Imagine a tablecloth was thrown in the air and then goes back down on the table.
You're gonna have wrinkles of cloth. Sarah Kaney's description is brilliant. And that's what we're seeing.
There's been little areas of retinal detachment. And at the bottom, we've got haemorrhage on top of very tortuous blood vessels. So these are the sort of things you can see, well, very easy to to interpret.
And if you're not sure if you're seeing that something like that partial retinal detachment, the other differentials for that might be, for example, toxin plasmosis. If it's an older cat, that's easy to check for. Well, treat for high blood pressure first if that doesn't make a difference, then check the talk so or if the the detachments or you've got haemorrhage associated with the blood vessels, then that could be FIP if the cat was a younger cat.
So taking blood pressure is so important and I know we've all got blood pressure machines that just live in the cupboard. They only work when you take the, take it out of the cupboard. I much prefer Doppler.
It's absolutely predictable. You know what you're getting. What, what I would say is, I know time is, is precious, so people, prefer the, oymetric methods.
If the blood pressure, sorry, the heart rate written on the machine, as you can see on, this little guy, guy called a boy. And you see that if you've got a heart rate of 150 of 155, and that is what you felt his heart rate was, that it, and you get the same kind of reading, 5 in a row, I'm much happier to believe it. But what I would say is be careful about using these numbers.
These numbers seem to be set in stone, but if you've got a noisy clinic, Then you're very unlikely to get systolic blood pressures at, for example, 140 because the cats are all gonna be rather more stressed. So if you aim for 140, you could end up with hypotension at home, and that is gonna be bad for the kidneys as well. So you need to know what your clinic normals are, and you're only gonna kind of get an idea of those by taking blood pressures regularly in your clinic, and you'll get a, a much better idea of Oh yeah, what's the minimal and the, and the asterisk, yes, it's, it's showing you that the, the risk of target will get damaged if you get below 140 is, is obviously, it's, it's not there at all.
But just don't aim to go too low if you're not getting regular, kind of 140s, 160s in your cats in the clinic. And the thing is that the osciometrics can lead, can read higher than the Doppler ones, or that they can read lower. So we, we're kind of built on sand.
So just be careful. I, my normal, it's maybe be safer if you're not sure when you're first starting out, then aim for maybe 150, 160, rather than going to, to, to 140 and certainly don't go lower than 140. Your treatment options, if you've got a blood pressure higher than, 180, certainly if you've got 200, if you've got any sign of retinal damage, you want to go straight for amlodipine because it is much more, repeatable and it's gonna do the job for you every time.
It's gonna bring the blood pressure down further than, telmisartan or benazepril could. So it is your treatment of choice and we've got little tablets, so it's a good one to go for. We don't have to chop them up like we used to.
Whereas the ACE inhibitors and ARBs, so we've got the two of them and say that they are licenced for the treatment of reducing chronic kidney disease, and reducing blood pressure, protein loss. Sorry, benazepril is not licenced for the reduction of blood pressure. Themisartan is, and their appetite stimulants, which is kind of handy too.
So, Very effective, particularly Talmisartan, which is my liquid, low blood pressure choice of, treatment of choice, unless you've got very high blood pressure, then you've gotta go with amlodipine. But I do have a lot of success using, almsartan, comfortable with it. If you have, a severe case, you may need to combine telmisartan with amlodipine.
But you do not want to start, you can start amlodipine in a dehydrated, unstable cat because if you got a crisis, and you got retinal haemorrhage, don't start these guys until you've got them rehydrated, because it can make things acutely worse, and you don't want to do that. And then UTIs because remember that Harvey's got a UTI. These are common in cats with kidney disease, not just females, although females tend to get them more significantly, and they can significantly make kidney disease worse, particularly if they go up to the kidneys.
And as I said earlier, if you get a step change in, How the cat looks, feels, and blood creatinine. If it's suddenly gone up acutely, that, that you kind of get, that's odd. Why is that so much higher than it was last time?
Suspect a UTI. And if you don't detect it, Particularly if you've got iris 3 or 4, it can be because you've got the, the azotemia is stopping neutrophils actually getting into the kidneys and into the urine, which means you won't see an active sediment. But you should still see bacteria, but it depends on the quality of your, your microscope, of course.
So if at all in doubt, we should be culturing these urines. And to be honest, with kidney cats, I do like to culture them every time. What about That having to have the cat in for cystocentesis work that I haven't published yet, and we want to get more cases to to prove it.
But what we're showing is that if the cat goes onto a clean litter box and well disinfected and then and then rinsed, then either allowed to or pull a couple of pieces of kitchen roll off and then use the ones a bit lower. So you're using clean ones underneath. And you're using the non-absorbent cat litter, which happens to come sterile.
It's not marketed as as it is. You've then got a, basically you've got a sterile system. And most cats do not have on their paws.
So if they just go in. Have a pee and leave. Culture that urine, it is regularly sterile.
If it's not sterile and there's not a UTI, what we will normally see is maybe 2 or 3 different types of bacteria at very low numbers, less than 10 to 2. So if you got urine from brought in from the cat's home and you've got 2 or 3 different bacteria, low level, I'm not at all worried. But if I see just one pure spike, you know, grades from 10 to 5, you know what?
CETI. If I see maybe 3 or 4 different bacteria, 2 are, 2 or 3 are low level, and 1 gives me a really high spike, again, I'm happy that that is a UTI, but if I've got any doubts, that will be the cat that then does need to come in for a system. So this will save the cats.
Lots of cystosis is not benign. We do see vago vagal reflexes where the cats collapse and occasionally die on Cysto and obviously there's bladder tears, occasionally aortic tears, really bad news. Thankfully they don't happen very often.
So don't be worried about. Urine collected from home, as long as it's collected the way I said, disinfect the litter box, then rinse the litter box, either dry or leave it to, to, leave it to dry and use the, non-absorbent litter, then that is a Tantamount to a sterile system and can be a very effective way, much less stressful for the cat. So we're back to my beautiful Harvey.
Remember his numbers, his creatinine was almost 300, so he's definitely over the 250 that would push him into an IS stage 3. His phosphate is at the top of normal, and for iris at stage 3, we should be looking to bring that down to at least 1.6.
And he is hypertensive. At 170 millimetres of mercury. He's got a UTI, which we knew he was gonna have because he had a USG that was isothenuric.
Remember, even Iri 4 cats still have got some function in those beautiful loops of Henley, that it's very unusual for them to go below 1016, 1017. That would be even in an IRS 4, so isotonuria in a cat, very unusual, always presume an E. Coli UTI unless proven otherwise.
And his UPC is up, but he has got this UTI so we need to resolve the UTI and reassess. So think about how you treat him. Treatment?
Well, diet is your mainstay, absolutely, . I did actually start him onto, the, the complete kidney because he was an IS 3. But if I was doing it again, you know what, I would actually go to the early, kidney first, the early kidney diets, and then reassess if I need to, go with more restriction.
But the diet's so important to eat that diet, he should get, on average, a year longer than he would have done otherwise, which is good by anyone's money. And of course, the kidney diet, it's gonna keep our potassium up. It's gonna bring down our phosphate.
It's got that effect just on its own. It's got all those wonderful antioxidants. It's got, all sorts of other things that reduce kidney inflammation as well.
He needs his two weeks of, amoxicillin. That is the first treatment of choice for cats, UTIs, whether it's in the kidney or the bladder. 2 weeks.
Some people might say, well, is that a bit long? I would go 2 weeks, the advice might change, but certainly, we know his kidneys are really poor. And you're gonna get poor blood supply into those kidneys, and I'm presuming that he's got pyelonephritis.
So I really want to get rid of that. I started him on Benazepril because, this was a while ago. Importantly, monitor.
So here we are monitoring and they, these numbers are just the numbers I've I've just talked you through and we put him on diet, antibiotics and I put him on ACE inhibitor. After one month, his UPC has come down beautifully. We're down to 0.1.
I'm very happy with that. And his blood pressure came to 155, which I was happy at, happy in those days, nowadays because our clinic is Quiet where catwa is. I'd like to get that a little lower, ideally to the 140, but, remember, don't over restrict them, because of the worry about going too low.
So don't beat yourself up if you're not getting all the way down to 140 is another way of looking at it. What I probably should have done at this point, I should have checked his USG as well because I should have been looking to make sure that his USG has come up. And for some reason I, I didn't write it down, which was obviously very, very remiss of me.
Then on a 6 month check, it is written down. And he's 1016, and that is much more what I'd expect of a cat. I know you might say, what's 1012 and 1016.
It's a big difference. 1012 is isosuria, the kidney is doing nothing to concentrate the urine. 10:16, the kidney is doing something to concentrate the urine.
So I'm much less worried in a, an RS3. But at this point, what I'm not happy with, for some reason, we were measuring PTHs at this time and I left it in because you can see just how high they can go. But the diet alone wasn't doing it for the phosphate.
You could absolutely argue, I should have looked at the rest of his bloods, and not just his UPC and his blood pressure. I'm sure I did look at the USG, but just failed to write it, idiot me. .
I should have done, full bloods at this point. There were money worries. So that is why I didn't.
I thought, well, let's, he's eating the diet well, let's keep going with the diet. But you can see that when I checked after 6 months, his phosphate now is, is really very high. And remember that that's one, is gonna be making him feel sick.
But 2, the calcium phosphorus product means he was at risk of mineralizing more gastric lining, etc. And that's not gonna help. So I added in phosphate binder at this point, and remember you've got many options now for phosphate binding and that the kidney diets I've actually got things to actually bind the reemic toxins to, which is lovely.
And then after 12 months, you can see that the, the, the iris stage is really very stable. Phosphate is coming down, which is great. That's a nice improvement from 3.2, but remember, we want to get to about 1.9, so we're not, we're not far off 1.9.
0, I'm having a brain fart. Was it 1.6.
Either way, always double check, but it's coming down nicely. What else can we see ISG very stable. You, now, this is interesting because his UPC protein loss is looking great, but he had another UTI.
It was, E. Coli again, and it can do that. It does not necessarily increase the, the UPC.
So just because the UPC is OK does not rule out. A UTI. His blood pressure is now 180, which I'm not at all happy with.
So at this point, I switched the ACE inhibitor to Istin. Likelihood is it probably stopped working at about the month and you know what? I should check that more.
I realised it was still OK here. But it's OK, so this gap, what can we say it ran out ACE inhibitors, the ACE escape occurred after 6 months. It is variable, but on average it's about a month.
So at this point, he's gone back onto antibiotics and he's on Este. And then following Harvey, over the next 2 years, his blood pressure was now normal. It, it worked well on the amlodipine.
It was no longer proteinuric. He did have 2 more go of, an E. Coli UTI and it was really important to therefore monitor his urine frequently and mom could just do that by, .
Urine from a clean litter box, we didn't do that then, we certainly would now. And then 3 years after first diagnosis, his kidneys did progress to IRS 4, and we put him to sleep at this point. But 3 years on an IRS 3, that is really good.
So it shows that by fine tuning, let's go back, by fine tuning what he needed to be treated with. Really elongated his life, which is fabulous. So, diet.
Absolutely essential. And then you add in the other things. Checking blood pressure is an absolutely essential part of it.
And remember about UTIs causing Izosenuria, particularly if they're E. Coli. So to finish monitoring, you can see that's what we were doing, really, really important.
Every time you can check the eyes, get used to doing distant indirect ophthalmoscopy. Be very quick. Measure, the cat, body weight every time, of course.
Write it down, really important. You see, I failed to write things down, in, in this case, the real cases. And percentage weight change.
If there's more than 5%, that's unintentional, you have to do something about it. Blood pressure and or ocular exam before you take bloods so the cat doesn't die on the end of the needle. It really does happen.
And then not just checking, blood results and obviously add SDMA in into that as a, as a standard, then you've got the, urine samples and remember the culture, even if there's a quiet sediment, there can still be infection there and the UPC is an essential part of assessing this. And the FGF 23 will come online for another blood test if it's not already. And then repeat, it depends how bad the cat is.
I would normally repeat every, 3 to 4 months, 6 months if they're really very stable when you've got virus, 1 or 2. It is dependent on, on the cat, the owner, the finances, etc. But remember that you can have urine samples collected at home.
And that will seriously reduce costs and stress of the cat having to come into the clinic. Remember to use gabapentin to get the cats into the clinic. That is gonna make them feel much better.
But if you overdose on GABA, it can bring the blood pressure down, so don't overdo it. So I hope this has been useful for you. So, practical because you know me, I'm a practical person.
Clinical signs can be very variable, and there's gonna be multiple diseases out there. At least they're gonna have arthritis as well, but they may well have other things. And now, thankfully, we've got diets that can accommodate for different interacting, problems.
So a full diagnosis is really important to make sure that the treatment is correct. And then the monitoring is so important. And that, and from the go, you tell the owners, I'm gonna be monitoring all these things because it would change what I do at any particular time.
And so UPC, blood pressure, UTIs. And I mentioned the fact if you're not sure whether you've got pyelonephritis or not, then try an antibiotic trial. We can still do that in this country.
You can't do that in some others. Use amoxiclav as your Antibiotic of choice because it's going to be much more effective. Do not be thinking about using convenia.
It's much less effective because enterococcus is the second most common E. Coli, sorry, after E. Coli.
E. Coli and then enterococcus. So Eococcus is the 2nd most common bacteria causing UTI in cats, and it is naturally resistant to cefervescent, so convenient.
So using that is really a bad way to go. It really does need to be a oxycle. And then Sarah Kaney, who's a good friend, she wrote, this, this little book, caring for a cat with Kidney failure.
If you've got cats who have got owners who are really motivated, want to do everything they can direct them to Sarah's website. There's some good stuff on there, free to download things like how to do subcu fluids, all that sort of thing. But this is the book.
It's only about 10 pounds, and quite a lot of owners are really keen to have something like that that can help them. It's good for vets and nurses too, very practical, very useful. You'll see I co-wrote the lower urinary tract book, and I have to say I gained nothing from, this other than, I love working with Sarah.
I gave her. My bit of writing in that book, I got no . Money from it.
I gave it to her as as a wedding present. So, just so I'm, I'm clear that I'm not trying to promote something that I get a financial gain from. So I hope that has been a useful talk for you.
And you know, if you have questions, etc. You know how to find me, just email me and I'll do everything I can to help. So thank you again.