Hello everyone and welcome to this webinar on the nurse's role in managing feline chronic kidney disease. So first of all, I thought I'd just introduce myself so it makes a little bit more sense as to why I'm talking to you about this topic today. So I spent 7 years working for the Feline Healthy ageing Clinic at the University of Liverpool, which is a research project into how cats get old.
So we would see cats every 6 months from the ages of 7, and we would assess all different aspects of ageing. And obviously, as you can imagine, one of the common things that we came across was chronic kidney disease. So I'm gonna go into detail about kind of a little bit of an overview of chronic kidney disease, and then I'm gonna talk about the veterinary nurses's role.
Obviously that's what one of the the main points of this webinar today. But really delving into kind of what we can do as nurses to help manage these patients, and the involvement of practical monitoring, so what kind of things can we do. Nutritional management as well, as we know, that's a that's a big part of managing chronic kidney disease, so I'll delve into that too.
And then I'll touch on educating the owner, supporting the owner, and a little bit of palliative care as well. And I'm sure you know all about kidney disease and understand the pathophy physiology of kidney disease, but I'll just touch on it briefly, just so we've got that fresh in our mind from the beginning. So we know the main responsibilities for the kidney is to manage fluid balance in the body.
So it's also responsible for managing blood pressure and hydration. The kidneys are responsible for electrolyte balance as well, it's integral to cellular and organ function. It always also they also help acid base balance so they regulate that pH removal of waste, so the ammonia and the urea, and the kidneys are also responsible for excreting some drugs, the production of erythropoietin, and the activation of vitamin D through calcium and phosphorus metabolism.
So the kidneys have a very big job to do in the body. And what exactly happens when the kidneys stop working, what's going on with those kidneys when they start failing? So it begins with a gradual irreversible loss of nephrons, so those filtering units.
And the kidneys then start hyperfiltration by dilating those globular artery arterioles, increasing capillary pressure and renal plasma, but this process of clearing the waste, which is grey, also leads to disruption of capillaries and we get some protein loss. So this increased globular filtration rate increases the clearing of waste, but then we get this pressure which then leads to disruption of capillaries and protein loss. Now this protein is reabsorbed by the epithelial cells, broken down and then re-enters the blood as amino acids.
But this breaking down of the protein releases oxygen free radicals which can stimulate the release of inflammatory cytokines. And then this inflammation then damages the epithelial cells. So this capillary pressure then leads to scarring and occlusion of those capillaries.
And this is what then leads to tu tubular institial fibrosis, which is the hallmark of CKD. So what actually starts as compensatory results in additional renal damage, it's a bit of a nasty cycle. And the progression of chronic kidney disease is driven by this cycle of hyperfiltration, protein urea, inflammation and fibrosis.
And how are we gonna know when these cats are presenting with chronic kidney disease? So clinical signs that we're likely to see in these patients, and again I'm sure this is something that you're very aware of, and we're likely to be seeing weight loss as one of the common factors. In appetences, anorexia, these cats are maybe starting to feel a bit nauseous and going off their food, a little bit more picky with their food.
Vomiting can occur as well. On palpation we might be feeling altered kidney size. Dehydration, so we're we're seeing these cats and they're they're obviously looking dehydrated.
The owner might be reporting that they're drinking more and urinating more. On our full physical exam, when we're carrying out all our diagnostics, we might then get some systemic hypertension. We're probably gonna see a low USG on our chronic kidney disease cats.
We're gonna be getting that low USG which is really that first kind of signal that something's not quite right. We're gonna see muscle loss, especially as the disease progresses, that muscle loss is gonna be quite severe. In severe cases as well, we might get halitosis, so that oral ulceration in the mouth and that that typical kidney disease smell like uremic smell.
And the cats may be lethargic, have poor coat condition, just generally feeling a little bit naff and not quite looking after themselves very well. I'm just taking some data from the feline Healthy ageing clinic. 11% of our cats we diagnosed with chronic kidney disease within the first couple of years, so this was on enrollment of the cats between the ages of 7 and 10.
So quite young. We did diagnose chronic kidney disease in some of those cats, and two of the things that linked the most to it from the owner reported behaviour was sniffing food and walking away and leaving more food behind in the bowl. So these could be the first potential kind of signals that the owner might see that indicates that there's something not quite right there.
So how do we diagnose kidney disease? So we're gonna be thinking about a full history and an exam, we're gonna be taking all the information from the owner and I'll go into more detail about questionnaires and things like that as we go along. Our urinalysis, a USG, a urine protein creatinine ratio.
We've also got our blood tests, so we've got our serum biochemistry, SDMA and electrolytes that we can run our haematology, and we're definitely gonna be once to doing a blood pressure as well to check for systemic hypertension. Now the Iris have, the Irish website has really good CKD staging guidelines for cats and dogs, and there's a QR code there for you just to link you straight to the page. But literally you can just Google Iri kidney staging and it will bring you directly to the website, it's a great resource.
And then we've got our treatment options and obviously as veterinary nurses, we can't actually diagnose chronic kidney disease. We can't create, you know, official treatment plans, that's just not within our remit and that's I'm sure that's something that we could talk about for hours and hours and hours. But I think it's important that we are aware of the whole process of diagnosis treatment, and really having that knowledge so that we can then support those owners the best we can.
And obviously the main thing that really helps slow the progression of CKD is diet and nutrition. So I'll go into that in a bit more detail as we go along. Then we've also got the options for phosphorus binders and potassium supplements too.
Hydration is really, really important, and we'll go into a little bit about owner education in relation to that. And then we can use appetent stimulants and more kind of involved medical management as that CKD progresses. And then we want to be thinking about palliative care as well.
When it's coming to the end and these cats are in that real high stage of kidney disease, palliative care is something that we really need to be talking to our owners about, and again I'll go into a bit more detail with that as we go along. So as a registered veterinary nurse, what are our core principles, what are the main things that we are to be considering when we're taking care of our cats that have been diagnosed with chronic kidney disease? First of all, we need to work on veterinary direction.
As I said, we can't go diagnosing chronic kidney disease, creating treatment plans. So it's really important that we have that relationship with the team in the practise, so that the team are aware of how the nurses manage chronic kidney disease, the vets can have that strong relationship with great communication between staff members so that they can report any findings, monitor. The nurses can monitor and complete the treatment plans with the owners, and just then feed back that information.
So we want to be focusing on monitoring, as I said, not diagnosing. So really our main role is to be tracking those clinical trends. Make sure that we're recording everything accurately and if we see something that we're concerned about or we think that maybe needs to be referred over to a vet, that we do that, we escalate those concerns and we communicate with the team.
And educating and supporting owners is a huge part of this process. And it's all about kind of guiding those owners on diet and nutrition, making sure that they're being compliant with any medication, asking them if there's any issues, giving the owners that opportunity to feel like they can come to the nurse and be really honest and open if they're struggling. Cos we don't want these owners struggling in silence and being unable to carry out the treatment plan.
We want to be able to make sure that they can talk to us and open up to us. So we can give them lots of different guidance, which I'll go into a little bit more detail as we go on. And obviously our main focus as veterinary nurses is always to promote welfare and quality of life in our patients.
We're advocating for that cat, we're recognising when maybe more palliative or supportive care might be appropriate, and we're having those conversations with owners about them too. So there could be a few different ways that our CKD patient has arrived in your nurse clinic and it's time for you to start monitoring that patient. So the chronic kidney disease may have been picked up from a routine health check, or maybe the vet has advised the owner to come and see a nurse for maybe like an ageing check, and encourage the owner to have the cat have some blood tests and some urinalysis, so the nurse can then send the home owner home with some cat core and kind of go through all that process with the owner.
Or they might have been diagnosed with the vets and the vet's referred them over to the nurse for the monitoring and treatment plan, and that's usually the main way this happens, that the vet diagnoses the kidney disease and creates a treatment plan and then hands over to the nurse to monitor and kind of go through that treatment plan with the owner. And clinical monitoring is a big part of that, so we want to be seeing these cats regularly depending on what on what stage of kidney disease they are in. We might be checking on them every 6 months, we might be checking on them every 3 months, or it might even be, you know, a monthly visit.
So depending on what stage that cat is in, clinical monitoring is one of the things that veterinary nurses can really take, take a role in. And the biggest and most important thing I feel with chronic kidney disease is getting a regular weight. Now we can encourage the owner to weigh at home as well more regularly.
We want to be seeing that cat in the clinic and we want to be weighing that cat regularly, but we also want to be encouraging the owner to weigh at home as well, maybe fortnightly or something like that. We're gonna be checking that hydration status, checking those mucous membranes, the capillary real time, checking for any skin tenting, and it can be quite difficult to assess skin tenting, especially in our older cats that have maybe lost that kind of elasticity of their skin, and they've lost muscle, and we tend to get a bit more kind of sagging of the skin, so it, it can be quite tricky as they're getting older. Muscle condition score in 2, I've got another slide about this, in more detail, which I'll go through with you.
Blood pressure, a regular blood pressure check, if we know the cat's got chronic kidney disease, we know that the kidney's ability to maintain that blood pressure is likely to be reduced, so we want to be keeping a good close check on the blood pressure. We want to be getting the owner to regularly bring in urine samples as well, so whenever they've got the appointment, we really want them to have some catcor on board, or we can speak to the vet and ask the the vet come in to do a cystocentesis on that cat, so then we can monitor that urine. And then obviously blood sampling, we're regularly gonna be keeping an eye on the electrolytes, we're gonna be keeping an eye on those parameters, the biochemistry parameters, making sure that they're not anaemic.
So blood sample is something that veterinary nurses can do with discussion with a vet, as long as that vet is happy for you to continue monitoring and continue taking blood samples and feeding that information back, then nurses can do that. And then medical management, which again essentially comes from the vet. The vet makes the plan for the medical management, but we can help support the owner in making sure that they're managing that medication OK, and do they have any problems.
And then finally we've got palliative care as well, and again I'll go into that in more detail with you nearer the end of this presentation. So let's go into each of those aspects of the monitoring in a little bit more detail. So regular weight checks, as I said, are really important.
And if the cat is unhappy and the only thing you're gonna get is one thing that day, focus on getting a weight. And a body condition's gone. There's a little, little, image here taken from a very recently published paper from Christine Pye.
Who was a PhD student at the feline Healthy ageing clinic, who has looked at body condition score and muscle condition score in our cats as they get older, and this is general ageing cats. But you can really see there that the difference in the unhealthy cats, compared to the healthy cats in the orange, lost weight at a faster speed and declined quite dramatically. So it's really important that we're monitoring the weight of these patients, and we want to be calculating the percentage changed as well.
And really anything below 5%, we may be gonna be keeping a close eye on, especially for our cats that are, you know, in those later stages. And this is over a 6 month period, so anything below 5% during a 6 month period, we're gonna be questioning a little bit, keeping an eye on. Anything above 5%, so 5 to 10%, we're gonna be doing a little bit more we're gonna be doing a little bit more finding out what's going on there.
We're gonna be maybe doing some additional diagnostics. We want to be speaking to the vet and feeding that information back to say, look, this cat's losing a lot of weight too quickly, they're on the right food, etc. Etc.
I think we maybe need to do some more investigations. I'm calculating the percentage, it's really, really simple, and I'm just gonna play this little video here for you to just help guide you into how to calculate the percentage of weight change in your cats in the clinic. In this video, I'm going to show you how to calculate the percentage of weight change in your cats.
So we're going to start by taking the cat's current weight. And divide that by their previous weight. And then times it by 100.
We're then going to take this number and we're going to minus 100. To give us a percentage change. Which for the cat is -9.1%.
Anything over a 5% weight loss in six months would have us maybe a little bit concerned, and we will be asking further questions and maybe doing further investigation. And then we've got our muscle condition scoring too, and this is a really, really valuable parameter that we can get from our cats. And again, just another image here from that recently published paper, you can see that the unhealthy cats lost muscle a lot quicker and more dramatically than the healthy cats.
So it's really important that we're monitoring muscle condition. And I found it quite tricky at first to kind of get my head around the muscle conditioning when I first started doing this, and I think it's really useful to start kind of muscle conditioning healthy cats, so when you've got a cat under anaesthetic, so to begin your muscle condition scoring, you're gonna start feeling and then check out the muscles over the shoulder area, areas, then you're gonna start. Out along the spine and have a feel of those muscles around there.
And then also checking out the gluteus muscles as well as the thigh muscle again just to make sure that these to help guide you that WSAVA provide a really good visual and guide you from the WSAVA as well, which helps guide you with doing the muscle condition scoring. So to begin your muscle condition scoring, you're gonna have a feel of the sagittal crest and then check out the muscles over the shoulder area. Then you're gonna scan down along the spine and have a feel of those muscles around there.
And then also checking out the gluteus muscles, as well as the caudal thigh muscles as well, right behind the femur, just to make sure that these muscles are doing OK. WSAVA provide a really good visual on their website to help guide you to. And when we're thinking about muscle loss, there's two different main kinds of muscle loss.
So we have sarcopenia and we have cachexia. So sarcopenia is pretty much the normal part of ageing, it's this skeletal muscle loss, which is age related. The older they get, the more muscle mass loss they're going to have, and it's gonna cause muscle weakness and things like that can reduce quality of life.
It really impacts survival too, so the kind of lower that muscle condition. The less chance of survival that that they have, it's a little bit of a predictor of kind of what's to come. And but it can be minimised with optimal nutrition, so that's sarcopenia, which is that normal part of ageing.
And then we have caexia, which is a complex syndrome where we have muscle and fat loss. And it's often driven by metabolic changes and associated with wasting diseases, and chronic kidney disease is one of those kind of wasting diseases, and as they go into later stages of chronic kidney disease that we can really see that wasting. We quite often get that kind of droop in the body, if that makes sense.
And nutrition can only prevent, it can't minimise, so we've really got to be quite on the ball with nutrition when we're seeing this muscle loss. And these are just a couple more pictures of some muscle loss that we've seen in our patients, and this here is a video. And you can kind of see on that spine there, that lumbar spine area, that there's some really severe muscle loss.
It's really hard to capture on a photo or a video, but on this first picture in particular you can see where we've got quite a lot of muscle loss around this that shoulder area. So then moving on to our blood pressure, I thought I'd just do a little slide with some tips on blood pressure. There's also lots of kind of cat friendly tips and things I could include in this webinar, but it's quite tricky to fit it all in.
So blood pressure, as I mentioned before, is really important. We want to be checking that blood pressure every time we're seeing these cats. We want to make sure we've got plenty of time.
Give ourselves plenty of time for these appointments when you're doing your checkups and your monitoring appointments. Always make sure you've got plenty of time to allow the cat to acclimatise to the room and it's gonna reduce that increased blood pressure that we're gonna be seeing from stress in these cats. Now we use a 2.5 centimetre Hockinson penile cough, which is actually human penile cough.
I think you can get them now actually. I think it's Thames Medical that actually sell them now, but we found that a size 2 cough was way too small, most of the time, but, and a size 3 cough was just too big. So we questioned our results a little bit, so we tried one of these 2.5 centimetre cuffs, and they are perfect for most cats.
So I'd highly encourage you to get yourselves one of these. They've got a really nice kind of velcro on them as well. They're, they're really nice.
Mineral restraint, obviously we don't want to be holding these cats tightly or pinning these cats down when we're taking the blood pressure measurement. We want to be keeping that limb at the level of the heart, whether that's the tail or the forelimb that we're using. Now we completely avoid alcohol.
We don't use surgical spirit, cats hate the smell of it. It's just a very strong poignant smell, and it can really put them off and upset them. So we just use a bit of gel, we wet the paw or the tail with a gel, and then we put a blob of gel on the Doppler and we're pretty, we're pretty successful with that process.
And now we're not using hand wash in that picture, we actually put our ultrasound gel in an empty hand wash bottle. Obviously give it a good clean first, and it just pumps out the perfect amount of gel and it prevents making that kind of horrible squirty noise that it does when you're shaking the bottle in front of the cat and the cat's looking at you thinking, what on earth are you doing? So great little tip there.
We always do at least 5 measurements, and I tend to wait for the blood pressure to start kind of becoming a bit consistent before I take those measurements. Quite often you find that the blood pressure is a little bit higher as the cat's first getting used to the feel of something tightening on their limb and the the cold gel. So I give it a few measurements and then I start, then I take my 5 measurements.
And then I average those measurements out. And always release the cuff in between as well, make sure that between each measurement, you're completely releasing the cuff to allow that complete blood flow to come back. And always record your blood pressure and there's a really nice chart here from ISFM and Siva, that has a little note on it about the position of the cat, why, where did you take the blood pressure, what equipment did you use, the size of the cough, and each kind of there's there's 10 slots there.
For a blood pressure, I tend to do 5, but you can do 5 to 10 and then average out your result, and these can be uploaded onto the computer system and then you've got a really nice visual lens of the next last person that checked the cat. OK, I'm gonna make sure I follow that the last person did, so we've got consistency. So they're a really nice, nice tool to use.
And then obviously we've got our diagnostic sampling, so our kind of monitoring sampling, urinalysis, we can, we can be doing regularly. We can be getting the owners to catch a sample in the litter tray, give lots of advice on cleaning the litter tray, make sure they keep it in the fridge, etc. Etc.
Or we can be asking the vet to come in and support us and carry out a cystocentesis cos it's not something that we can do, it's better to be nurses. So we can do that as well, but getting a urine sample is key to monitoring these patients. We also want to be doing, we want to be doing a dipstick, so we want to be checking for blood and protein.
Our kidney cats, our older cats in general are more prone to in urine infections due to that dehydration, that lack of movement that they probably don't do as much as they're older. It's important to be monitoring for urinary infections as well. Obviously ourSG we want to be monitoring that.
We also want to be checking the sediment, it's something that I tend to do with all the cats is I check the sediment. I'm looking for crystals, any leukocytes or blood in that urine that's maybe gonna give me an indication that there's an infection going on there. And then we've also got granular casts as well, which are pretty common in low numbers, but if we do get a lot of granular casts in and highline casts in our urine sample, which are these here on the left, that little image there on the left, these can indicate renal changes, so it's, it's good to keep a lookout for those.
And obviously checking our urine protein, creatinine ratios. And then we've got our blood tests as well, and again I could go into lots of different tips about taking cat friendly blood tests. We use lots of treats to help take samples from our cats, always make sure that you're not holding the whiskers, keep their feet for, plant 4 ft planted on the table, don't wrap them too tightly.
As I say, I could go in, go into lots more detail about this, but just a few little tips there. And then we're gonna be doing our regular check of biochemistry, electrolytes, haematology. And SDMA is a potential, more of kind of an indicator, but there's been some recent studies, and a review done by Hardy in 2023, there's a link to the Qala code there to that paper.
Didn't find any clear advantage over four studies of SDMA over creatinine. So most data show similar diagnostic performance and some even favour creatinine on specificity. So.
Question mark over SDMA we don't do it in the feline healthy ageing clinic, we just stick to our creatinine, and not electrolytes and obviously all the other monitoring factors. So regular blood tests, regular urinalysis, we want to be included that in our nurse clinics. And we really want to be getting constant feedback from our owners.
So we can use questionnaires. With our owners we can use general questionnaires. There's an example here from Siva, which is a general kind of older cat health check and there's no harm in asking further questions when we're regularly monitoring these patients, cos then we might start finding that we've got some comorbidities, we might have arthritis going on.
There might be a hyperthyroidism involved, diabetes involved, we don't know. So we can still be kind of taking that bigger picture when we're checking over these cats, and we can create our owns, we own questionnaires, we can take them from different resources online, there's lots of different resources out there. But we really want to be thinking about their physical behaviour, any physical changes, any activity changes, so are they maybe not using all the space in the house anymore, are they keeping themselves to themselves, are they not going outside as much?
Eating and drinking habits, and these are really important for our cats with kidney disease, especially if they're showing signs of nausea or anything like that. Are they drinking more, is things changing, is the kidney disease speeding up potentially? Toileting behaviours, we want to be keeping an eye on that litter tray and general behaviour changes as well, so, you know, they're a bit more irritable than normal, do they still want attention from their owner, etc.
Etc. They're really good because they can support that diagnosis and help the owner as well to understand exactly how it's changing their cat and it educates the owner on kind of what's happening and helps them to know what to look for. Quite a lot of our owners would say to us that, oh, I never even considered that this could mean this, but now that I know, after doing the questionnaire, I'm much more on the ball about keeping an eye on it.
So it's a real nice simple way to educate owners too. And it just gives us that nice big holistic view from our owner's point, we've got our clinical monitoring and we're getting a nice big picture. One of the things though I would always say is to provide it before the consult, so give it to the owner before they're due to come in.
We don't want them filling in this questionnaire quickly in the consult room and not thinking about it or when they're in the waiting room and they're feeling harassed cos the cat's upsetting the carrier. Try and get these questionnaires to them before their appointment so they can really think about the questions and make sure that they're answering them completely honestly. So let's start diving into this real management of the kidney disease and.
There's different things that we might need to be managing, we might need to be managing protein urea, we might have some medical management for that, managing the phosphate levels. We might have to manage hypertension as well, we might have some systemic hypertension. Later stages there might be nausea, so we might need to be considering anti-emetics, managing that dehydration, as they're getting to that end stage, do we need to be thinking about them coming in and having some fluid therapy, or educating the owner on some fluid therapy?
And we may even have to be treating anaemia as well, so there's lots of different things going on medically. For the medical management, but diet is the only thing that can slow the progression of CKD so we want to be using therapeutic diets, we want to be adding that dietary supplementation as well, those phosphate binders, that potassium. So we're gonna go into more detail on nutritional management.
So nutritional management has kind of main roles, so we want to be using the dietary management management to decrease that nitrogenous waste, preserve those remaining functional nephrons, and we really want to reduce the rate of further nephron damage. And there's quite a lot of nutrients to consider. We've got a phosphorus, protein, water, energy, sodium, potassium, any supplements, fibre, there's quite a lot involved in the nutritional management of chronic kidney disease.
And one of the big things that's involved in a kidney diet, a renal diet, is to help manage that phosphorus. And phosphorus is normally excreted by the kidneys, but this becomes, this action becomes significantly reduced when our cat's kidneys start to fail. And this then results in this increased serum phosphorus in the blood.
So we want to make sure that they have a diet that's low in phosphorus, so the kidneys don't have to work too hard to excrete that phosphorus. And we want our phosphorus level to be between 0.9 and 1.45.
We don't want it going too low. And obviously we don't want it to be going too high because then it has a cascade of other effects. So really we want to get the owner to use the renal diet which is already low in phosphorus, and some senior diets are also getting better at this too.
But sometimes we might need to use phosphate binders. This might be if the food transition failed, so maybe the cat literally refuses to eat any kind of renal diet, it happens. The owner might be unwilling to change the diet.
They might not have be able to afford the therapeutic diet, or they might have some other reasons why they just don't want to change the cat's diet. We might still be getting a persistently high serum phosphorus as well in our blood results, despite the cat being on a renal diet. So what we want to be doing is adding this to the food, so what it does is traps the phosphorus in the food and prevents it needing to be excreted by the kidneys.
But it is less reliable than the actual diets. So ideally we want the cats to be on the diet, so that when that diet isn't working for the phosphorus, we can then add in those pho phosphate binders too. Now let's talk about protein, so protein gets talked about a lot when it comes to our kidney diets, our renal diets.
And the protein produces this nitrogenous waste when it's broken down during utilisation, which this waste is usually excreted by the kidneys, but obviously we have our impairment in the kidneys. So this nitrogenous waste starts to accumulate and this then exasperates the consequences of this euremic syndrome. But we also have another problem, is that the main source of phosphorus in the diet actually comes from protein.
So what we don't want to be doing is completely restricting protein. We don't want to be taking that real harsh restriction. But a slight restriction could limit waste products forming.
So we want to reduce that intake and make sure that we are giving those cats a high quality and highly digestible protein. It's important that that protein is highly digestible, as we know older cats, their digestion starts to suffer as they get older. So we want to make sure that that protein is nice and highly digestible and also that it's a good high quality so that it's not producing too much waste product.
So that that waste product then hasn't got to be kind of excreted by the kidneys and the kidneys haven't got to work hard. So we can reduce the intake slightly, but as long as that protein is of a high quality and highly digestible, then we're OK. And renal diets automatically have high quality and high, highly digestible protein.
But if our owners are thinking about feeding their cats homemade diets and things like that, it's really important that we get this piece of information over to them about the importance of protein. Then we want to be thinking about our potassium. Now, the potassium is pretty much kind of a result of kidney disease rather than a cause of progression.
So because of this high water turnover, this kind of constant urination, the drinking lots, we get a loss of potassium. And this hyperkalemia can have a knock-on effect and in severe cases can cause muscle weakness, lethargy, this kind of ventral flexion of the neck, and I saw this in a cat years ago. That came in for a senior clinic to see me in a nurse clinic, and I just noticed how kind of heavily drooped its head was.
And on further investigation we found that it actually had severe kidney disease and loss of potassium, and with some supplements and managing the kidney disease, it actually went on to live a good few years. So it does occur sometimes, it's rare, but we do sometimes see it. So what we want to be doing is replacing those ongoing losses again with that correct diet.
It's that correct diet that we're thinking about here, that renal diet, monitoring closely, and we can supplement if we're finding that on those blood results, the potassium level is really, really low, we can add supplements to the diet, but it's not that, it's not needed as often, especially if the cat's on a good renal diet. Then we've got this sodium, which is a link between blood pressure, we have this link between blood pressure and sodium and there's some questions around whether we really need to be thinking about eating a lot or thinking about it a bit more. An increased sodium might further damage those kidneys, so we want to avoid cats having excessive amounts of it, but we don't really need to be reducing that sodium amount.
It's not indicated just yet, but there is a lot more research needed in this area when we're thinking about the sodium in our chronic chronic kidney cats. And now we've decided on the diet, we know that the cat needs to change its diet, and we need to make sure that the owner is well informed about how to encourage the cats to eat that diet. Cats are very aversive and can be quite aversive to new foods and new things.
So there's a really good guide that a colleague of mine, George Woodsley gave me, and I think this is a really great guide to use. If you've got a cat that will eat anything at all, then you can transition that food over that 2 to 3 days. If you've got a cat that's a really good eater, well, you know, eats pretty much, pretty well, you can go to that 7 day period where that cat, there's an image here from Royal Canon which helps guide owners into transitioning that food over a slow period of time.
If the owners are reporting that they can be a little bit fussy, then let's give that longer, let's give them another, you know, 3 or 4 days of that transition period. If we've got a really fussy cat, we're gonna go a bit further, we're gonna give it 2 to 3 weeks instead. And if we have a cat that we know is resistant to any change at all, and they're really funny about new foods, we want to take a long time transitioning that food over a week into it over months if we have to.
But the benefit of that cat being on that renal diet, if it takes us a little bit longer, the benefit outweighs that risk of of waiting and doing that transition slowly. So it's really important that we're getting that transition right. And absolutely always wait into the cat as well and at home.
If you, you know, diagnose chronic kidney disease in a cat that's been hospitalised, for example, whatever you do, don't go trying to give it that renal diet right in that moment. All that cat will do is relate that food and that diet to being in a negative environment. So we need to wait until the cat is feeling better and is at home, so that there's no risk of any kind of aversion to that diet.
And we don't have to go straight in with a renal diet sometimes, depending on what stage that cat is. So diet selection's gonna depend on the parameter results, the urinalysis results, clinical signs as well, how severe is this kidney disease in this cat? The patient preference, so yeah they're gonna like the taste of it.
Are they, they got a good enough appetite to eat this diet? Is it available? Is it available to the owner for affordability?
So lots of different factors, it's gonna kind of depend on which renal diet that you choose. There's loads out there and I'm not gonna give any advice on which one's better because I don't know. But it's something that you can chat with your owners about.
You might have confidence in certain products yourself, which can impact that decision. But what they tend to tend to advise Irish staging of 1 to 2, we can stick with a lower phosphorous diet. So a senior diet or you can get early renal diets that are for those cats that are in that lower staging of kidney disease.
Then as we step up to stage 2 and 3, we really want to be thinking about a therapeutic diet, especially for chronic kidney disease. We want it to have that restricted phosphorus, that moderate, high quality protein. And then when we get to stage 4 plus, this is gonna kind of depend on end of life staging.
We want to be thinking about quality of life rather than slowing progression by this point. Is the diet, is the cat eating the diet? Is the cat actually maintaining its calorie intake, or is it just not into that diet at all?
Now might be the time that we start thinking about letting that cat eat whatever the hell it wants. So it all depends on the staging, all depends on the owner and the individual cat itself. And then we want to be thinking about what kind of things can the owner change at home to encourage the cat to be more comfortable, and one of the big things that we want owners to be thinking about is that fluid intake.
We really need to make sure that our cats diagnosed with kidney disease are getting enough fluid and they're staying well hydrated. And there's lots of different things we can do for our owners and we can give them lots of different information. One of the simple ones is literally just adding a tablespoon of water to their wet food.
Some cats will eat soggy biscuits too, not many, and it doesn't sound very appetising to me, I must say. But so adding water to the wet food tends to be a little bit more successful, but you can try adding water to the dry food as well. We wanna make sure that we've got the correct water bowls for the cat.
Cats are so picky when it comes to their choice of bowl. They don't like their whiskers touching the water or the edges of a bowl. My cat, I've noticed before, he literally puts his paw under his whiskers to stop it touching the water, .
It needs to be wide and flat, can't full to the top, make sure that the water bowls are always nice and full to the top. We want to avoid plastic because they can hold chemical smells and cleaning products, and we want to avoid metal if we can, especially if the cat wears a collar, cos that kind of clinking noise against the metal can be quite off-putting. And some cats can see their reflection as well in the steel, and that puts them off.
So they can be really funny about actually what kind of bowl they're gonna drink the water from. So I would go for a ceramic bowl like in that image there, and this was something that my friend had in her house for her dog. And the water just kind of bubbles up at the bottom and the cats absolutely loved it and I was like, oh, let me take a photo of that.
So that's nice, it's a nice wide bowl. We wanna make sure we've got enough of them as well. Make sure that there's a water bowl upstairs and downstairs.
If you've got a 3 story house, make sure there's one on every single level. It's likely our older cats that are suffering with chronic kidney disease are gonna have other things going on as well, particularly arthritis. So we want to make sure that they're not gonna have to go up and down the stairs to drink the water.
The choice to have water and act on that decision to drink needs to be as easy and as simple as possible for them. And they need to be in the right location as well, and I don't mean on the levels of the house, but I mean in the room itself. When cats are drinking and they're eating, they feel quite vulnerable.
So when they're drinking, they want to be able to see what's going on all around them. And it's very. And very easy for us as owners to just plunk a bowl of water down in a corner of a room or against a wall because it's out of the way and it's easier like that.
But if that cat is going to its water bowl, and all it can see is the wall, and it has no idea what's going on around it, behind it, it's probably gonna avoid drinking from that water source. So I would always say just to make sure that you bring the bowls just a little bit further away from the wall so that they can sit behind the bowl. You can use water fountains as well, water fountains are really useful.
Lots of cats like that running water. Normal water intake as well, we want to kind of be advising our owners on this, that the normal water intake is about 2 to 5 mL per kilogramme per day, per day. And owners should be reporting any changes in that and keeping an eye on that intake.
And this brings me onto a nice tool called Valaqua. This is a water bowl, a nice wide-based water bowl that connects to an app and it tells the owner how much that cat is drinking every day, which can be really, really useful for monitoring that water intake. And something else we can be advising on our owners on is litter trays, because they're gonna be urinating a lot more.
We want to make sure that they've got plenty of litter trays in the house for the cats, so again, on each level, and that it's the correct size. As I again, as I mentioned earlier, it's likely our cats are probably gonna have a bit of arthritis, so we want to make sure that they can get in that litter tray without having to be in pain. Move around in that litter tray and not have to feel all kind of scrunched up and bent over in the litter tray.
We want to make sure that it's a nice big litter tray that they can get in nice and easily. And we wanna make sure we're using the right substrate as well. So you've got these metal metal, wooden pellets, that are quite commonly used, but they're actually quite uncomfortable on the cat's feet, and especially if they've got sore joints, having to balance on these like wooden pellets can be really uncomfortable.
So we want to make sure that we're using a soft substrate and, it's nice and thick, and this is like kind of like a cardboardy mixture of litter, that I use and it's lovely and soft on their feet. We want to try and get owners to move away from using litter liners and deodorizers in litter trays. They make life much easier for owners and reduce the smell, but cats hate them, they're likely to get the lion and caught in their claws.
Cats hate strong smells. We really want to do everything we can to make sure the cat is comfortable using a litter tray, cos if they're not using that litter tray. Then they're likely to get urine infections or start toileting around the house and other areas which we don't want.
And we're gonna need to make sure the owners are aware they're gonna need to increase the hygiene as well when they're cleaning the litter trays for these cats. Making sure that they're on top of that so the cat is happy to consistently use the litter tray. And location is really important again for our cats.
They feel vulnerable when they're going to the toilet. They're in a vulnerable state. So that litter tray needs to be somewhere where they're not gonna be disturbed.
The dog isn't gonna poke its head in on them while they're trying to go to the toilet. The litter tray isn't in the middle of the kitchen and the kids have just come home from school and it's 4 o'clock and it's chaotic. We want to make sure that that litter tray is in a quiet location in a quiet part of the house.
And kind of continuing on with that owner advice and that owner support, there was a really nice paper that I read about how owners feel when their cat is diagnosed with kidney disease. And this is a image taken as a QR code here and there's a a link down there to the paper in that we're talking about here, but you can see how the owners felt when they were, their cat was diagnosed with chronic kidney disease. And there is anxiety there, we can see that they're upset, confused, panicked, quite dramatically increases after diagnosis, feel guilty.
You can see unconcerned is very low, it's unlikely that we're gonna get unconcerned or relief when our owners are getting this diagnosis for their pets, and how that kind of hopeful feeling drops as well from diagnosis. So we know and we can see from this, and we can see from research that. Owners find a diagnosis of kidney disease in their cats a difficult thing to deal with, and veterinary nurses are really well placed to help support those owners through this process.
We can offer phone calls, so we can offer regular check-ins, maybe they've been diagnosed by the vet, they've come to you for a treatment plan, you've helped them with the treatment plan, support that plan, you've sent them on their way. It's always worth giving them a call a couple of weeks later, just to check in to see how they're feeling. Have they got any additional questions now that they've spent some time at home, starting the plan, etc.
Etc. We can just offer a phone call, they don't have to bring their cat in all the time either. Make sure we're providing them with reliable resources that they can spend time looking at themselves.
There's some nice webinars out there. Sarah Caney has a lovely one on the vet Professionals website about how to help owners support their cat. There's lots of, you know, research out there, there's lots of websites and guidance that we can link owners to for them to read in their own time to help digest the information a little bit more.
And we want to be helping and supporting owners when it comes to end of life, and this is something that I'm gonna go into a little bit more detail with because we want to make sure that we're helping and support those owners as much as possible. They're gonna be feeling anticipatory grief. This is this grief that begins when they know that something is coming, they know that their the the time for that cat is coming to an end.
And that grief, that anticipatory grief is something that I experienced lately. With my own cat when I had to say goodbye to my own cat and she spent a few days under palliative care and I had to have all the resources in one place. And the grief I felt in those few days trying to support her, compared to the grief I felt afterwards, it was so much stronger and I never really realised how hard that anticipatory grief is to deal with.
So I think that's something that we really need to support owners with, especially when it comes to palliative care. Is that they're aware that they're, make them aware that it's OK and it's normal to be feeling such a level of grief in this moment. And I think it's really important as well that we touch on quality of life assessments, and I really encourage you to use them in your consults, in your clinics.
They're really, really valuable. They can help monitor different stages of treatment, so we can start our quality of life assessment when we start our treatment plan, encourage the owners to be doing these quality of life assessments regularly. We might start seeing that the quality of life decreases.
OK, we need to change our treatment plan slightly. The quality of life has dropped in this cat. This is what we're here for, we're making sure that the quality of life and the welfare for this patient is important.
Something's changed, let's change our plan. It helps raise awareness as well, it helps raise that awareness to the owner of quality of life and what it means for their cat. I think it's quite hard when owners are saying, you know, oh well he's still eating, so he's absolutely fine.
But let's consider everything else. Is he still emotionally happy? Is he still able to do the things he usually does?
We don't want to just be basing quality of life on whether the cat is still able to eat or not. It's quite hard to change that thought process in owners and quality of life assessments are really good for that to help kind of show the owner that we are monitoring the welfare of your pet here, we're keeping a close eye on the welfare of that patient. And again it just provides that little bit of owner support.
Helps them, especially when it comes to the end of life decision. If they can physically see that the quality of life in their pet has dropped. That helps them and kind of concretes with them that OK, it's coming to that time.
But we've got to be a little bit careful cos they can be quite subjective. Obviously we can't hear what the cat is wanting to tell us, the cats can't tell us how they're actually feeling, this is all subjective. We're basing it around what we know.
And it's really dependent on the owner's knowledge of behaviour as well, and I think this is why it's important that we educate owners on behaviour. And for example, why cats will still eat, even though they are feeling dreadful. They have that drive to eat.
They are opportunistic feeders. If they see food, they will try and eat it just in case they don't get that opportunity again in 10 hours' time and then they become too weak to hunt for their food. So they will take that opportunity and hunt that food and eat that food when it's in front of them.
So that drive to eat, that real strong drive to eat is still naturally in our cats. And it's important that we kind of try and relay this information to our owners to help them understand why their cat behaves in a certain way. Obviously it means the owner has to complete the quality of life tour.
We can't complete them for them, they have to be done by the owner and the compliance can be quite tricky, is getting the owner to complete that and they might be in a little bit of denial as well, maybe they might not want to see those results too. And we've also got to think about the reliability and validity of these tools as well. There's lots of different tools out there.
And especially when it comes to feline quality of life assessment tools, this is a really nice review that was done on quality of life assessment tools for cats that's out in the published literature. 32 tools were assessed, only 26% of them were validated, and there is one specifically for chronic kidney disease. And I can't remember which one it is now, but there is one specific for chronic kidney disease, .
Sorry, that's my cat chatting in the background. But when I say this to only 26 validated, I think it's important to think about how important it is that it's validated. I think if you're carrying out research, validation is really important, but if we're just wanting the owner to think about quality of life and have something to help us assess quality of life, does it have to be a really robust validated tool?
And one of the validated tools that we use at the feline Healthy ageing Clinic, obviously we are research, we are working into evidence-based results, so we want to use something that's reliable, but this is also a fantastic tool that I think can be really well utilised in practise. Now it is a paid subscription, I think still, but it considers multiple chronic diseases as well, so it considers arthritis and kidney disease, etc. Etc.
There's also a vet assessment and an owner assessment. And the vet answers questions on the health of the patient that day, if they've had any diagnosis of any disease, etc. And then the owner answers about 45 questions, I think.
It's very quick. The questions are based on a scale, so how happy is your cat today on a scale of 0 to 5? Is your cat wanting attention today?
0 being not at all, 5 being yes. And it does its fancy algorithm. And it gives us these two really nice graphs.
So the top graph is what we see as professionals, as the veterinary professional. We have it plotted on a nice chart like this, and the owners see the lower one. So on the owners, the owners see, there's a line where 70% of healthy pets sat.
Then we've got the grey bar underneath, which is what they were at previously. And then we've got the coloured bar on top is where they're at now. And that top chart there is of a cat that was put to sleep, not long after that, final quality of life there, checked on, but you can see how it declines, and it's a really nice tool to be using with our owners to help show them and visually allow them to see that their pet's health and welfare is declining.
And then these are just some examples of not necessarily validated tools, but tools that are useful. So you've got the HHH HHMM scale. This is quite a commonly used one.
I do really like this one. It considers a nice holistic view for the patient. Or you can just use a general quality of life scale that's been found on Google.
Sometimes it's just about getting the owners to think about it and see something that gives them a result that kind of reassures them that they're doing the right thing. So, as I say, it doesn't have to be an official validated tool, but just a tool that's useful to help support that owner and help support you as well when you're having those discussions with those owners. And then this moves me on quite nicely to palliative care, so this is where we get kind of a diagnosis of a life limiting illness, and we move from curing to comfort and quality of life, and you could argue that from the very beginning of the diagnosis of chronic kidney disease, we are into this process.
We are into a palliative care process. But it's not something that we really owners quite enjoy talking about, it's quite a tricky conversation to have. So really we want to be thinking about the cats and the owner's physical, emotional and social needs and make sure we're almost protecting that human animal relationship at this stage.
I had what an owner that was having to give their cat lots and lots of medication, and she came in and she just broke down in tears. And I was like, oh gosh, what's happening, you know, tell me all about it. And her, the biggest thing that was upsetting her the most was the fact that her cat is going to hate her in the last few months of its life because she's constantly giving her medication.
And that's gonna leave an emotional kind of, you know, potentially a bit of emotional damage for that owner. So it's allowing those owners to speak up about these situations and making sure that we're considering that human-animal relationship when we're thinking about politics. And as I said, we need to be thinking about the caregiver, we need to be thinking about that owner.
Can they afford all these treatments that we're gonna want them to do? Can they afford the phosphorus binders and the, you know, the medication to manage that protein in your ear? Do they have the time to be regularly given this this medication?
We might have religious beliefs that are factoring in, the owner might have a super busy schedule and is gonna find this medication process and this monitoring process actually really, really stressful. Do we need to change that plan maybe and make it a little bit less stressful for them? But still improving that quality of life for that patient.
They might have had a past experience, you they might be given this diagnosis of chronic kidney disease. And then all of a sudden they're thrown straight back to an awful situation that they had with their their last cat that had chronic kidney disease and it might start really bringing up these emotions. Have they got the physical capability to be given this medication?
Are they an old lady that's got arthritis in her hands and she really can't physically do the medication? Can she see the medication? Can she read the instructions OK?
Maybe there's other members of the family that can help out and support the owner, so it's important that we're asking all these questions because the last thing we want to do is send the owner on their way and that actually they can't physically do the treatment plan. And then we want to be thinking about that particular patient as well. Again, has the cat had past experiences, are they really, really aversive to any kind of medication?
Does the treatment plan suit the cat's lifestyle? Maybe they're out and about for, you know, 15 hours of the day and the owner rarely sees them, but now they're gonna have to keep their cat in to make sure that it's getting its medication and monitoring its urine. Is that OK for the cat?
Or is that gonna impact its emotional health too much? Talk about medication preferences, maybe the owner thinks that tablets will work better, or is there an alternative? Make sure that we're really looking at that bigger picture.
And emotional health is something that we really need to be considering. Are we causing too much stress and damage to that to that cat's emotional health by throwing all this medication at it? We might have a cat that copes absolutely fine with all of that, but then another cat that doesn't.
So we really need to be thinking about these patients individually when we're starting this kind of treatment plan and potentially palliative care. And communicating around this topic can be quite difficult and it can be quite difficult literally from the very beginning when we're talking about that diagnosis with the owner, maybe we're in the consult with the vet and we're there to help support that owner. The communication style is really important.
We want to be minimising that caregiver to stress. And that communication is gonna effectively build that trust between you and the owner. That's gonna increase that client bond and it's gonna allow that owner to be more open and feel more comfortable in the whole process.
We want to make sure that we're talking to them in an appropriate setting when we're telling them information. You know, for example, we may have seen the cat, we've done our bloods, we've done our urinalysis, and we're actually realised that the cat's bumped up a stage in the iris staging, and we need to tell the owner this. We want to be making sure that we're telling them in the right place, not in the waiting room.
We want to be making sure that we've got that consult room, we have that privacy, and we're able to give the owner that information effectively. We don't want to be using all these big words with them, keep things simple, keep the terminology simple. And the owner should always feel listened to as well.
We want to make sure that we're giving the owner that time to respond. And allowing the owners to give their feedback as well. And using signposting language is actually really quite nice for these conversations, allowing the owner to know what's coming next.
So for example, you know, we've talked about diagnosis, we we've give, you know, we've talked about what chronic kidney disease is. Next up we're going to discuss treatment options. Are you happy for me to continue into that stage, or would you like a bit of a bit more information on what we've just discussed?
Allow them to feel like they know what's coming next. Chunk and tech technique is also a really nice technique as well. We can just give the owner a chunk of information and then check that they've understood.
How do that reflective listening, you're making sure that they have took in what we've told them, they understand everything before we move on to the next step. So that kind of sensitive communication is really important when we're talking to our owners, particularly in those stages of the later stages in that palliative care care stage. And we can really as nurses manage these cases really, really successfully and hopefully all this information that I've given to you in this webinar can really help guide you into monitoring our cases.
And there's just some few things that we can do to make sure that our cases are successfully managed. And I think the first thing if you don't already run clinics or run any nurse clinics or run specific kind of renal clinics is to get a good plan. Who's going to run them?
Which nurse is going to run them? Is it gonna be a couple of nurses? Is it gonna be a nurse and a vet that's gonna team up together?
What are we gonna do in these clinics? What kind of clinical monitoring are we going to be doing? Where are we going to do them?
Do we have a branch maybe that works better for them? Or do we use a specific room, and when, what time of the day? We don't want to be doing these clinics when all the admins are coming in in the morning or all the discharges.
Make sure that these clinics are in a suitable time of the day to make sure they work successfully. And having those working relationships is really, really important. Team up with a couple of vets in the practise that are passionate about this kind of thing too.
Sit down together, have a bit of a brainstorm, you know, tell them that you want to be doing these clinics, you want to be having a bit further involvement in monitoring these patients. Let's chat about it, how can we work together? And it can be really, really valuable, really, really useful, and it just brings so much more job satisfaction as well.
I ran a lot of clinics, before I started working in research and I thoroughly enjoyed the clinics. I didn't want to be in theatre, I wanted to be in the clinics supporting the owners, talking to those owners and improving the welfare of the patients in that way. Make sure the whole team know as well about what you're doing.
Make sure that the receptionists know that you can manage these patients, make sure that the other team members know. Make sure that people in the other branches know, because if the whole team are aware of what you're doing, you're more likely to get success. Inform your clients too, tell your clients, advertise it on social media.
Did you know our nurses can monitor your our patients that are struggling with chronic kidney disease? Did you know that our nurses can monitor treatment plans, etc. Etc.
Shout about yourselves, really tell the world that you are a veterinary nurse and you are really excited to be able to run these clinics and to monitor these monitor these patients closely and be there to support your owners because they really can really can bring so much job satisfaction. So I really hope that was useful for you. Please do have a look at our Facebook on our Instagram, the Feline Healthy ageing Clinic.
And if you've got any further questions or you want any more advice or resources or anything at all, please don't hesitate to contact me on the email there. Thank you very much.