The Final Goodbye – When to Put Your Cat to Sleep

Posted on March 3, 2024 by felinepurrspective_u3q4o6

Saying the final good bye to your cat is never easy. Medical care for cats has progressed by leaps and bounds in the past few decades and it is not uncommon for cats to live to be 19 or 20 years old. As age takes its toll and the older cat’s mind and body declines, many cat owners hope that their old friend will slip away in her sleep. Unfortunately, this does not happen often and we need to decide if it is time for euthanasia.

The word “euthanasia” comes from the Greek: “eu” or well, and thanatos, “death”, i.e. – the good death. A “good death” is the last gift we can give our cats.

The decision to put your cat to sleep is not made lightly.

The cost of medical care may be out of your reach financially and you elect euthanasia rather than have your cat suffer untreated.
You may have done all the medical treatments possible and your cat is just not responding. You must say goodbye.

But, what about the cat that clings to survival but is dwindling, still eating but not thriving? When do you say goodbye?

when to say goodbye and put your cat to sleep

In the case of the cat with the “dwindles”, it helps to make a list of what your cat does during her day. Keep an eye on these behaviors and watch for signs of apathy or disinterest.

It can be helpful to keep a calendar of your cat’s daily behavior or events (such as illness or playfulness). Each day can be evaluated as “good”, “bad” or “average”. When the “bad” days outnumber the “good” ones, it may be time to put your cat to sleep. Your veterinarian can help you with assessing your cat’s quality of life.

Last week I said goodbye to Marley, one of “The Feline Purrspective” team. Marley was a gentle, extremely sociable cat who enjoyed head rubs and treats. He was friendly with people and fairly tolerant of other cats. His health was generally good until he was about 16 years old. He will be sorely missed.

Marley’s timeline is summarized in the table below. I have highlighted the concerns that contributed to the decision to euthanize.

AGE	TIMELINE OF LIFE EVENTS
3-14 years	I adopt Marley from the veterinary technician school I attended. Marley is introduced to my 3 cats and becomes part of my household. He learns to go on morning walks and participate in the evening treat and playtime. He becomes quite adept at food puzzles. His health is good although he does seem to lose teeth at his annual dental cleanings.
14-16 years	Marley has two instances of malignant tumors on the bottom side of his tongue, which were successfully removed. His health and demeanor remain good overall: he still goes on daily walks and participates in evening treat and play time.
16-17 years	Marley’s vision and hearing begin to deteriorate. He starts to show signs of Cognitive Dysfunction Syndrome (CDS) and starts a Sam-E supplement. He stops going outside with the other cats on walks. He is still chasing treats at night but does not play with toys.
17-18 years	September, 2023: a firm, fibrous mass is found in front of Marley’s left ear. I decline surgery due to Marley’s progressing CDS. Marley is becoming less active and seems fearful of the other cats at times. He still comes for treats most nights.
18+ years	Marley turns 18 years in early February 2024 The tumor on his head has increased in size and his left eye is starting to close and squint. He spends most of his time in a heated basket, leaving only to use the litter box or to eat. He is no longer grooming himself and has stopped coming for treats at night.

Looking at the highlighted sections in the table above, you can see that going for walks outdoors and the evening treat/play time were key activities in Marley’s daily life. By the time he is 16-17 years old, he has stopped taking the daily walk but still participates in the nightly treat time. In the next year, he stops this activity.

These behaviors defined who Marley was and were indicators of his will to live. In the final months of his life, he lost this will to live. It was time to say goodbye.

the final goodbye

On February 24, 2024, I said a final goodbye to Marley. I gave him some gabapentin before taking him to the clinic for euthanasia. He passed quickly and peacefully in his basket – he was gone before finishing his favorite treat and before all the euthanasia solution was injected.

The decision to euthanize Marley was based not only on the progression of his medical condition, but also on the changes in his behavior. I feel he was not in pain but his life was no longer worth living. From a friendly, outgoing cat, he had become a reclusive, confused creature, going through the motions of surviving. I don’t feel that his last years were mismanaged but I do feel it may have been kinder to let him go a few months earlier.

I have shared my experience in the hopes that it can help other cat owners who are wrestling with this very difficult question: when to put your cat to sleep. I found it helpful to pay attention to Marley’s daily activities, and note how often he participated in them and when he just stopped doing them. Tracking these key behaviors can give you, the cat owner, an idea of your cat’s mental state: is he is still engaged in life or just going through the motions? If he is just going through the motions, is it time to say goodbye?

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Caring for Cats with FeLV or FIV

Posted on February 4, 2024February 4, 2024 by felinepurrspective_u3q4o6

There has been a stray cat hanging around the house. He is friendly and after a few weeks of feeding him and scratching his head, you decide to adopt him. You do the responsible thing and take him to your vet for an exam, vaccines, and FeLV/FIV test.
To your chagrin, he tests positive for one of the viruses. What’s next?

caring for cats with felv or fiv

medical care

Like any other cat, medical care for cats infected with FeLV or FIV virus consists of preventive healthcare and managing clinical illnesses when necessary.

Preventive Health Care

Preventive healthcare centers around veterinary exams, routine parasite prevention, vaccination, and dental care when needed. However, bi-annual exams are recommended for the virus-infected cat and special attention is paid to (Reference 1):

the mouth: cats with FeLV or FIV are more prone to dental disease
the eyes: is there inflammation of the anterior (between the cornea and iris) or posterior (between the iris and the lens) chambers of the eyes?
the size and shape of the lymph nodes
the skin: are there external parasites, fungal infections, indications of cancer?

Other recommendations are similar to those for a healthy cat but compliance is more crucial due to the virus-infected cat’s immunosuppression (Reference 1):

routine deworming
feed complete and balanced diet, avoid raw food (risk of food-borne disease and parasites)
annual screening bloodwork including a Complete Blood Count (CBC): a CBC is recommended every 6 months for FeLV infected cats; every year for FIV positive cats
vaccines must be kept up to date to keep these cats from contracting upper respiratory infections and panleukopenia

Managing Clinical Illness

Like healthy cats, cats with FeLV and FIV can suffer from kidney disease, hyperthyroidism, diabetes, and urinary tract infections. Treatment for these diseases will follow the same protocols as for healthy cats (Reference 1).

Diseases secondary to immunosuppression account for a large portion of the syndromes seen in FeLV-infected cats. Be on the lookout for persistent diarrhea, sneezing, nasal discharge, inflammation of the eyes and recurring skin infections.

In cats with FIV, stomatitis (inflammation of the mucosal membranes of the mouth) is common (Reference 2). Untreated, this is a painful condition that may keep the cat from eating. Removal of most or all of the cat’s teeth may be needed reduce the inflammation and pain.

Cats with FeLV and FIV are prone to developing tumors, primarily lymphomas. FeLV infected cats are 62 x more likely to develop these tumors than healthy cats; FIV cats are 5 x more likely (Reference 2). Be sure to bring any lumps you feel on your cat to your veterinarian’s attention.

managing cats with Felv or fiv in the homE

Cats with FeLV and FIV should be kept indoors if possible. However, if your cat likes to go outdoors, consider leash walks, cat enclosures or yards with cat fencing.
Make sure to provide a home environment that reduces stress and provides enrichment (see What Your Cat Needs to Feel Secure )
Spaying and neutering infected cats reduces the likelihood of fighting and transmission of the virus.
A catio allows a cat access to the outdoors while keeping her safe.

Reducing Transmission of the Virus

CATS WITH FELV

It is BEST to keep the infected cat indoors and separate from other cats in the household. If this is just not going to work, here are some tips to reduce transmission of the virus. (If your infected cat has clinical signs of illness (may be shedding the virus), he must be isolated).

Remember FeLV is spread by saliva. It can be hard to keep cats from grooming each other but you can make sure cats don’t share food bowls by meal-feeding cats separately or using micro-chip feeders.
The FeLV virus is not very hardy and does not live long outside its host. Common disinfectants quickly inactivate both FeLV and FIV viruses.
Scoop litter boxes promptly and clean litter boxes regularly.
VACCINATE uninfected cats even if they are isolated from the infected cat. This provides uninfected cats protection from progressive infection.
Consider separating the infected cat from the others when you cannot supervise him.

Protective immunity takes 2-3 weeks after the primary vaccination – this would be the second dose in the initial series of two shots. Remember, there is no therapeutic value to vaccinating the infected cat for FeLV (Reference 1).

CATS WITH FIV

Mixed households with FIV infected cats have a fairly small risk of uninfected cats acquiring the virus if there is no fighting (cat bites) among cats. It is not recommended to introduce new cats into such a mixed household – fighting may occur during the introductory period, transmitting the virus to an uninfected cat.

Treatments for cats with FELV or fiv

Antiviral drugs used in the treatment of HIV have been shown to increase survival times and improve quality of life for human patients. However, studies have not shown that using such antiviral drugs in cats to be effective.

Zidovudine (AZT) is one of the few antiviral compounds that has been found to be effective in cats with FeLV or FIV: it can reduce viral load and improve symptoms in cats with neurologic signs or stomatitis (Reference 1).

Diagnosis of FeLV or FIV in a cat is not an automatic death sentence. The viruses can be managed through attention to the cat’s overall health, regular checkups, and prompt attention to clinical signs of illness. FeLV cats often suffer clinical illness and have a shorter life expectancy than cats infected with FIV. Cats with FIV often live as long as uninfected cats, dying of causes unrelated to their virus infection.

references

Little S, Levy J, Hartmann K, et al. 2020 AAFP Feline Retrovirus Testing and Management Guidelines. Journal of Feline Medicine and Surgery. 2020;22(1):5-30. doi:10.1177/1098612X19895940
Hartmann K. Clinical aspects of feline retroviruses: a review. Viruses. 2012 Oct 31;4(11):2684-710. doi: 10.3390/v4112684. PMID: 23202500; PMCID: PMC3509668.

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What You Need to Know About Cats With FeLV and FIV

Posted on January 28, 2024 by felinepurrspective_u3q4o6

Gus and Miso were outdoor cats from the same neighborhood. They are FIV+.

Feline Leukemia (FeLV) and Feline Immunodeficiency Virus (FIV) are among the most common causes of infectious diseases in cats. FeLV can lead to cancer, anemia, and immunosuppression. FIV primarily suppresses the cat’s immune system (Reference 1).

Cats with FeLV and FIV have played a role in human medicine. The discovery of FeLV pointed to the role of viruses in causing cancer. FIV has given us insights into its human counterpart, HIV.

what you need to know about cats with Felv and fiv

Feline leukemia virus (felv)

FeLV was discovered in 1964, when attention was drawn to a multi-cat household with multiple cases of lymphoma. The FeLV virus was found in the cats’ tumors. Once testing procedures were developed in the 1970’s, FeLV was found to be a major cause of disease in owned cats (Reference 2).

FeLV is very infectious. It is passed from cat-to-cat by bodily fluids (Reference 1).

Infected mother cats shed the virus in their milk and pass it on to their kittens.
The virus can be found in the saliva, urine and feces of infected cats and can be transmitted by sharing food bowls and litter boxes.
Cats can also be infected by being bitten by an infected cat.

three stages of FeLV infection (Reference 1).

abortive infection

cat on cat tree — Indoor only cats are not likely to have contact with FeLV infected cats.

The cat is able to mount an immune response, killing the virus, and has a lifelong immunity to the virus. These cats will test negative for FeLV but have antibodies to FeLV.

regressive infection

The cat mounts an immune response but does not eliminate the virus. He will become ill with fever, swollen lymph glands, anemia and low white blood cell count. Once recovered, he will be asymptomatic and have antibodies to FeLV but may still have detectable virus in his blood. These cats do not shed the virus in saliva, urine and feces. There is a low chance that the virus may reactivate.

progressive infection

If the cat’s immunity is compromised in some way, her immune response will not be enough to kill the virus. It will spread to the bone marrow and then to the mucous membranes and glandular tissue. The virus is then shed in saliva, urine and feces. Cats with this stage of infection will succumb to cancer or complications of diseases that are usually not fatal.

feline immunodeficieny virus (FIV)

FIV is not as contagious as FeLV. Routes of transmission are (Reference 1):

Bite wounds that introduce saliva with virus and FIV-infected white blood cells into the wound
Transmission from queens to kittens is uncommon
Transmission is uncommon among cats living in households where the cats do not fight
Unlike humans, sexual transmission is unusual

initial infection with FIV

Fighting cats — FIV is transmitted by cat bites often acquired during cat fights.

The cat is ill with fever, swollen lymph glands, and a low white blood cell count.

immune response

The cat’s immune system produces FIV antibodies. The antibodies suppress the amount of circulating virus, lowering the total amount of virus in the infected cat’s blood.

asymptomatic phase

The asymptomatic phase that follows the immune response can last many years, although progressive dysfunction of the immune system can occur. As a result of this deterioration of the immune system,
FIV cats are prone to chronic and recurrent infections.

Cats with FIV are 5 x more likely to get cancer than uninfected cats. However, many FIV+ cats live as long as non-infected cats (Reference 1).

identifying cats with felv and fiv

Identifying and segregating infected cats will help reduce the numbers of cats with FeLV and FIV. The development of Point-of-Care (POC) tests allows the status of cats to be checked when at the veterinary clinic. FeLV vaccines are available to protect uninfected cats.

Screening for FeLV and FIV is recommended (Reference 1) :

when the cat is first acquired
prior to vaccination for FeLV
following exposure to infected cats
when the cat has clinical signs of illness, eg. dental disease

What is the testing like?

Most POC tests require a few drops of blood from the patient. Results are usually available in 10 minutes. Most test kits include tests for both FeLV and FIV.

Test Results (Reference 1)

Negative Results

Negative tests are generally reliable
A retest of a negative result is recommended in 30 days (FeLV) or 60 days (FIV) if there is high risk of recent exposure – for example, a cat bite acquired in a cat fight
Cats with regressive FeLV infection have low levels of antigen which may not be detected by some tests and the cat will test negative

Positive Results

Because a positive result will involve lifestyle changes, repeat testing is recommended at a reference lab to rule out a “false positive”.

FeLV

Cats that initially test positive can transition to a regressive infection pattern within 16 weeks of infection.

FIV

Kittens that nurse on FIV mothers may test positive on a POC test
Most kittens will test negative once they stop nursing and the maternal antibodies have waned
Kittens that test positive after 6 months are likely to be FIV+
Cats vaccinated with FIV vaccines may test positive

vaccines for cats with felv and fiv

FeLV

Vaccines have been developed for FeLV and give cats protection against progressive infections (Reference 1).

Vaccination is particularly recommended for kittens as they are more susceptible to progressive infection than adult cats.

Kittens can receive their first vaccine when they are 8 weeks or older.
This first shot is followed by a second dose 3-4 weeks later.
A booster vaccination is recommended 1 year after the second shot.
The vaccine may be discontinued for adult cats that are not at risk of interacting with an infected cat (eg. indoor-only)

FIV

FIV vaccination has been discontinued in the US and Canada due to the low protective rate of the vaccine. However, FIV vaccines are still available in other countries, such as Japan, Australia and New Zealand. Cats vaccinated with FIV vaccine may test positive on a POC test (Reference 1).

FeLV and FIV are viruses that together affect 9% of the cat population in North America. These viruses suppress the cat’s immune system making him more susceptible to infections, cancer, and other diseases. POC tests are available to identify cats with FeLV and FIV, allowing cat owners to take steps to protect uninfected cats by vaccination or husbandry. The next post will address caring for virus infected cats and giving them the best of their nine lives.

references

Little S, Levy J, Hartmann K, et al. 2020 AAFP Feline Retrovirus Testing and Management Guidelines. Journal of Feline Medicine and Surgery. 2020;22(1):5-30. doi:10.1177/1098612X19895940
Pedersen N, Synopsis of Feline leukemia virus infection and its relationship to feline infectious peritonitis. May 21,2021. https://ccah.vetmed.ucdavis.edu/sites/g/files/dgvnsk4586/files/inline-files/. Viewed January 2024.

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Managing the Diabetic Cat – Home Monitoring and Emergencies

Posted on November 19, 2023March 11, 2024 by felinepurrspective_u3q4o6

A diabetic cat sports a fabric collar over her glucose sensor.

Managing the diabetic cat

Managing the diabetic cat is a balancing act. The goal is to reduce the clinical signs of diabetes while avoiding complications like low blood sugar.

How do you know if the therapy your veterinarian has chosen for your cat is working? Monitoring the clinical signs of diabetes is a start. (Reference 1). Pay attention to:

Your cat’s attitude and activity level
daily thirst and urination
daily food intake
weekly weight and body condition score

Your veterinarian will want to monitor your cat’s blood and urine regularly but these are “snapshots” (values at a particular time on a particular day). What is happening during a diabetic cat’s day?

monitoring Insulin-based therapies

Insulin-based diabetic therapies focus on the level of glucose in the blood.

Blood sugar is highest before giving one of the twice daily injections of insulin.
After giving insulin, the cells start to take up glucose and the level of glucose in the blood starts to drop
Blood sugar levels out somewhere between the morning and evening doses and starts to increase as insulin wears off
The lowest point in the plot is called the “nadir”; the high points in the morning and evening are called “peaks”

If you sample your diabetic cat’s blood every few hours and plot the blood glucose values on a graph, you will get a picture of how the insulin is working.

The Home Glucose Curve

Because cats are prone to stress hyperglycemia, it is best to measure these curves at home. This can be done using (1) a handheld meter and sampling every few hours or (2) a Continuous Glucose Monitoring system, consisting of an electronic sensor applied to the cat and a device to read the output of the sensor.

Blood Glucose Meter

These are like the meters used by human diabetics. Instead of pricking a fingertip, it is typical to prick the area around the vein that runs along the outside of the ear. The strip in the glucose meter soaks up the blood like a sponge and a current is generated. The strength of the signal is proportional to the blood sugar.

Continuous Glucose Monitoring System

A Freestyle sensor on the back of a cat’s neck

The Freestyle Libre is a continuous glucose monitoring system developed for humans that can be used with cats. The electronic sensor is the size of two stacked US quarters; the sensor can be scanned with a smartphone or dedicated reader device. The sensor samples every minute and stores data for 8 hours before starting to overwrite it. It is important to scan the sensor at least every 8 hours.

Sensor life can range from a few days to 2 weeks. The sensor can be placed on the back of the neck, behind the shoulder, or on the flank. A 2″ x 2″ area is clipped and cleaned for sensor application.

A plot of the average of glucose reading recorded during a two week period.

Monitoring glucose allows your veterinarian to adjust the insulin dose or change the type of insulin to best regulate your cat. The goals of insulin therapy are (Reference 1):

Peak Glucose values of 180-250 mg/dL
Nadir Glucose values of 80-144 mg/dL

managing the diabetic cat – emergencies

HYPOGLYCEMIA
Low blood sugar can be life threatening when blood glucose drops to < 40 mg/dL. You may notice your cat is tired, unresponsive, disoriented and anxious.

What triggers hypoglycemia in the managed feline diabetic?

insulin dose is too high relative to food intake
too much insulin is given
your cat is in remission

If your cat’s glucose in the blood is normal, there is no glucose in the urine, and his fructosamine is in normal range, your veterinarian will start to gradually reduce the insulin dose until insulin is discontinued. If blood glucose values remain in the normal range and there is no glucose in the urine for 2- 4 weeks once insulin has been stopped, your cat is in remission!

If you suspect low blood sugar…

measure blood glucose (BG)
BG less than 80 mg/dL – feed the cat or give up to 1 tablespoon corn syrup by mouth (1 tbsp = 15 mls – you don’t need to give this all at once)
recheck BG in 15 minutes
if glucose rises, continue to offer food and check glucose until the value is in a normal range
notify your veterinarian
if your cat is unconscious, rub some syrup on his gums or inside his cheek, measure BG, and go the the ER!

DIABETIC KETOACIDOSIS

Diabetic cats have an abnormal glucose metabolism and their bodies may break down fats for energy, resulting in ketones in the bloodstream. Too high a level of ketones makes the blood acidic, causing cells to function abnormally. This is more likely to happen:

in newly diagnosed diabetics and poorly regulated diabetics
when there are illnesses such as infections, tumors, dental disease (Reference 2)

Watch for…

Loss of appetite
Lethargy and depression
Vomiting/diarrhea
dehydration
difficulty breathing
a sweet smell to the cat’s breath

This is a true emergency – high levels of ketones in the blood and urine combined with the blood and other body fluids becoming acidic can be fatal. Treatment starts with IV fluids to correct dehydration and electrolyte imbalances and administration of insulin to restore glucose as the main source of energy.

Managing the diabetic cat: non-insulin based therapies

Blood glucose curves are part of the recommended monitoring process for cats receiving oral non-insulin therapy but they do not have as important a role as monitoring a cat on insulin. Cats receiving the oral therapies are not prone to low blood sugar and the blood glucose curve will not have the characteristic shape of a cat receiving insulin. Glucose readings are simply averaged. It is more important to monitor ketones as these cats may be more prone to develop DKA.

Ketones can be monitored using “urine dipsticks”. The cat’s urine is collected using non-absorbent litter or a litter tray with a sieve bottom. Urine is collected with a syringe and dropped on the urine test strip (Reference 1). The makers of Senvelgo, a oral liquid non-insulin drug, recommend checking ketones this way every 1-3 days in the first 14 days of therapy.

Urine dipsticks detect acetoacetic acid and are not very sensitive. Hand-held meters that detect levels of beta-hydroxybutyrate in the blood provide a more sensitive measure of ketones. Blood can be collected from the ear vein of the cat and level of ketones measured similar to the blood glucose meters described above. Abott’s Precision Xtra meter has been validated for use in cats (Reference 3). Perhaps, as non-insulin therapies become more common, monitoring of ketones in the blood will become part of managing the diabetic cat at home.

With appropriate treatment, the diabetic cat can have a life expectancy similar to cats without diabetes. The key to managing the diabetic cat is early diagnosis, weight control, regular exams and labwork, and home monitoring of clinical signs, glucose and ketones.

references

ISFM Consensus Guidelines on the Practical Management of Diabetes Mellitus in Cats. Sparkes, A. (chairman), Journal of Feline Medicine and Surgery (2015) 17, 235-250
Rudloff E. Diabetic ketoacidosis in the cat: Recognition and essential treatment. Journal of Feline Medicine and Surgery. 2017;19(11):1167-1174. doi:10.1177/1098612X17735762
Weingart C, Lotz F, Kohn B. Validation of a portable hand-held whole-blood ketone meter for use in cats. Vet Clin Pathol. 2012 Mar;41(1):114-8. doi: 10.1111/j.1939-165X.2011.00389.x. Epub 2012 Jan 17. PMID: 22250845.

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Treating Diabetes in Cats – Insulin and Non-Insulin Therapies

Posted on November 12, 2023March 11, 2024 by felinepurrspective_u3q4o6

Insulin injections can be given under the skin in the loose skin over the shoulders.

Diabetes is a condition where there is persistently high levels of glucose in the blood and urine. In healthy cats, insulin, a hormone produced by the beta cells in the pancreas, signals the cells in the body to take up glucose, reducing the glucose in the blood and urine. Diabetic cats are similar to human Type 2 diabetics – they are insulin resistant and have beta cells that are not functioning normally. What treatments are available for these cats?

treating diabetes in cats

One way to treat diabetes in cats is to supplement the insulin the cat is still producing with twice daily injections of insulin. There is not a commercially available feline insulin. Fortunately, production of anti-insulin antibodies does not appear to be a significant problem in cats and we can turn to the synthetic insulins made for the human market or a product derived from pig insulin, developed for dogs (Reference 1).

Practitioners typically reach for the longer-acting insulins listed below to manage feline diabetics (Reference 1)

Glargine (brands:Lantus, Basaglar) is given twice daily. It is available in a 100 Units (U)/ml solution. It does not need to mixed before use and should be clear, not cloudy.
Protamine Zinc Insulin (PZI) is also given twice daily. It comes in a 40 Units (U)/ml suspension which should be rolled or inverted gently to suspend it before using.

Vetsulin is derived from porcine insulin and has a shorter duration of action compared to glargine and PZI. It is not as well tolerated by cats as glargine and PZI. It should be shaken prior to use and be uniformly white in color. It is available in a 40 Units U/ml suspension.

treating diabetes in cats with insulin

Insulin is given by syringe under the skin (subcutaneously) every 12 hours. It is best to stick to the every 12 hour schedule but if this is not possible, you can administer it within 2 hours before or 2 hours after the 12 hour mark. Skip the dose if you are out of this window (Reference 1).

Insulin Syringes

U-100 syringes are used with Glargine insulin.
U-40 syringes are used with PZI and Vetsulin.
Syringes with 0.5” needles are recommended – shorter needles may not always go far enough through the skin.

Giving Insulin Injections

The injection can be given in the loose skin near the shoulder blade or hip.
Rotate injection sites to avoid build up of scar tissue and for better absorption of the drug.
There are many good videos on giving subcutaneous injections. Take a look at the “Caring for your Diabetic Cat” video on the “Health Topics” page at Cornell Feline Health Center.

Insulin can be given in the loose skin over the shoulders and hips.

Try to make giving injections as pleasant as possible. Establish a routine. It can help to have dedicated place to give treatments, for example, a soft blanket on one side of the sofa. If there is a treat or food your cat likes, be sure to offer this during or after the injection.

Diet and the Diabetic Cat

Insulin resistance has been linked to obesity in cats. If your diabetic cat is obese, losing weight can help manage his diabetes and possibly reduce his insulin dose.

If your cat has lost weight due to diabetes, start insulin therapy before starting a weight loss program. Once your cat is stable and you have established your “diabetic” routine, implement your weight loss plan (Reference 2).

Plan for weight loss

determine how many calories your cat is eating
reduce current calories by 10-20%
monitor weight and body condition score (BCS)

Diets for Diabetic Cats

a high protein, low carbohydrate diet is recommended
canned foods are recommended due to their higher water content and lower carbohydrate content
many obese cats have low BCS in spite of excess body fat and high protein may be needed to maintain lean body mass

There are therapeutic diets targeted at treating diabetes in cats. Purina DM and Hill’s m/d feature high protein and low carbohydrates. If your cat does not care for high protein/low carb diets, consider a high protein, low fat, moderate fiber and moderate carbohydrate diet such as Hill’s w/d food, designed to address glucose balance as well as weight loss and urinary care.

For cats with concurrent diseases, you will have to choose which condition is better treated by diet. For example, if your cat has kidney disease and diabetes, it may be wise to feed a kidney diet and manage the diabetes by adjusting insulin dose or type of insulin.

treating diabetes in cats – “non-insulin” therapies

Recently, the FDA approved two drugs given orally for diabetic cats: Bexacat (12/2022) and Senvelgo (8/2023). Bexacat is a once daily tablet; Senvelgo is a liquid given once daily with food or directly into the cat’s mouth.

Both these drugs (SGLT2 inhibitors) work by blocking the reabsorption of glucose by the kidneys. Instead of being returned to the bloodstream, glucose is excreted in the urine, lowering blood sugar without insulin. High levels of blood glucose have been tied to beta cell dysfunction – SGLT2 inhibitors lower blood sugar and are thought to promote growth of new beta cells (Reference 3).

These drugs work best for treating diabetes in cats who have been recently diagnosed and have NOT had previous insulin treatment. At this time, Bexacat and Senvelgo are NOT recommended for cats…(Reference 4)

13 years or older
with pancreatitis or a history of pancreatitis
with kidney disease or other concurrent disease
having suffered a condition known as ketoacidosis.

Candidates should be healthy, with the exception of being diabetic (Reference 4).

Treating diabetes in cats has traditionally focused on giving insulin injections and feeding a high protein, low carbohydrate diet. Experts recommend using the long-acting insulins for cats. The injections are given twice daily. Recently, new oral therapies have been made available that offer once-a-day dosing and the potential of regenerating pancreatic cells.

In the next post, we will look at how we can monitor insulin and non-insulin therapies to ensure our diabetic cats’ health and safety.

references

ISFM Consensus Guidelines on the Practical Management of Diabetes Mellitus in Cats. Sparkes, A. (chairman), Journal of Feline Medicine and Surgery (2015) 17, 235-250
Clark M, Hoenig M. Feline comorbidities: Pathophysiology and management of the obese diabetic cat. Journal of Feline Medicine and Surgery. 2021;23(7):639-648. doi:10.1177/1098612X211021540
(Nakamura A. Effects of Sodium-Glucose Co-Transporter-2 Inhibitors on Pancreatic β-Cell Mass and Function. International Journal of Molecular Sciences. 2022; 23(9):5104. https://doi.org/10.3390/ijms23095104 )
AAHA publications NEWStat® 2023-1 New oral diabetes medication for cats requires careful case selection Singler, Emily 1/13/23. https://www.aaha.org/publications/newstat/articles/2023-1/new-oral-diabetes-medication-for-cats-requires-careful-case-selection/ viewed 11/23.

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Diabetes in Cats – What is it? How is it diagnosed?

Posted on November 5, 2023March 11, 2024 by felinepurrspective_u3q4o6

This diabetic cat is walking on his ankles. This is called a plantigrade stance.

Diabetes is a condition where there is persistent high glucose (sugar) in the blood and the urine. Like humans, cat can develop diabetes. Which cats are at risk for diabetes? How do you diagnose diabetes in a cat?

Two previous posts addressed diseases that we tend to see in older cats, chronic kidney disease and hyperthyroidism. This post completes the trio by looking at feline diabetes.

diabetes in cats

Why do high levels of glucose occur in the blood and urine? Uptake of glucose by the muscle and fat cells in the body is dependent upon the hormone insulin. Insulin, produced by the “beta” cells in the pancreas, signals these cells to take up glucose. If the beta cells fail to produce enough insulin, these cells will not receive glucose, and, consequently, will not have energy for cellular functions. The glucose in the blood stream is then filtered out into the urine.

clinical signs of diabetes

Clinical signs of diabetes (Reference 1) are similar to those of hyperthyroidism and chronic kidney disease.

increased thirst and urination
weight loss
increased appetite

In some cases of uncontrolled diabetes, a cat will start walking on his ankles, referred to as a “plantigrade stance”. Cats often recover a normal gait after several months of treatment for diabetes. Some practitioners use oral methylcobalamin, a form of vitamin B12, to help speed up recovery (Reference 2).

the feline diabetic

Most feline diabetics are similar to type 2 human diabetics: they have insulin resistance and beta cells that are not functioning normally.

when muscle and fat cells become resistant to insulin, more insulin is needed to maintain glucose uptake.
beta cells in the pancreas respond by producing more insulin.
high levels of insulin trigger the liver to store glucose as glycogen instead of releasing it into the bloodstream (the cat is still able to get glucose from the GI tract).
eventually, the beta cells cannot continue “hyper-secreting” insulin and fail, resulting in high levels of glucose in the blood, not in the cells. (Reference 3)

diabetes in cats – who is at risk?

obese cats
cats over 7 years old
cats that are not very active
male and neutered cats
cats receiving steroids such as prednisolone

Obese cats are 2-4 times more likely to develop diabetes mellitus. Obesity leads to insulin resistance in the muscle and fat cells. However, many overweight cats never develop diabetes. They will have normal blood glucose values as long as the beta cells can produce enough insulin to suppress glucose production in the liver.

diagnosing diabetes in cats

Persistent high glucose levels in the blood (hyperglycemia) and urine (glycosuria) accompanied by one or more of the clinical signs above support a diagnosis of diabetes mellitus. A thorough history needs to be taken and a complete physical examination done. Diagnostic blood work will include routine chemistries, a complete blood count, urinalysis, urine culture or bacterial assay, and T4 measurement.

Why measure T4?
Excess thyroid hormone increases glucose production in the liver. If a cat is hyperthyroid, the hyperthyroidism needs to be managed in order to control the blood sugar.

One of the challenges to diagnosing diabetes in cats in the veterinary clinic is stress hyperglycemia. A cat’s blood glucose values can become falsely elevated due to the stress of the car ride, the exam and other factors. If the blood glucose is high enough, glucose spills over in the urine, also causing a false positive. Options to rule out stress hyperglycemia include (Reference 4):

repeating the lab work on a subsequent visit with the patient on pre-visit sedation
collecting a urine sample at home
measuring blood glucose at home
adding a serum fructosamine to the blood panel

Fructosamine measures the average of the blood glucose over the two weeks preceding the sample collection and consequently should not be affected by stress hyperglycemia. Fructosamine may not be accurate if the cat became diabetic within the past two weeks or if the cat has uncontrolled hyperthyroidism (Reference 1)

Once your cat is diagnosed with diabetes, what happens next?

The next post will address the treatments available to the diabetic cat and how the chosen therapy must be monitored.

references

Sparkes, A (chairman), ISFM Consensus Guidelines on the Practical Management of Diabetes Mellitus in Cats, Journal of Feline Medicine and Surgery (2015) 17, 235-250
Sereno, R. Managing complications in diabetic cats, DVM 360:article 5/1/2011. https://www.dvm360.com/view/managing-complications-diabetic-cats (viewed 11/2023)
Clark M, Hoenig M. Feline comorbidities: Pathophysiology and management of the obese diabetic cat. Journal of Feline Medicine and Surgery. 2021;23(7):639-648. doi:10.1177/1098612X211021540
American Association of Feline Practitioners, Diabetes Educational Toolkit, https://catvets.com/diabetes-toolkit/troubleshooting, viewed 11/2023

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Diets for Managing CKD in Cats

Posted on October 1, 2023March 11, 2024 by felinepurrspective_u3q4o6

Diet is a key therapy for cats with chronic kidney disease (CKD). Diets for managing CKD in cats aim to (Reference 1):

lessen the clinical signs of CKD
slow the progression of the disease
provide adequate nutrition

Diets for managing ckd in cats

The goal of diets for managing CKD in cats is to reduce the amount of uremic waste products while providing adequate nutrition. There are a number of commercially available diets that are formulated to do this. These foods feature (Reference 1):

reduced phosphorus
restricted amounts of high-quality protein
higher calories
reduced sodium
potassium supplementation
B vitamins and fatty acids

Phosphorus

Phosphorus is needed for the growth, maintenance, and repair of all tissues and cells, and for the production of the genetic building blocks, DNA and RNA. Phosphorus is also needed to help balance and use other vitamins and minerals, including vitamin D, iodine, magnesium, and zinc (Reference 2).

As kidney disease progresses, the ability of the kidneys to excrete phosphorus declines. To reduce stress on the kidneys, diets for managing CKD in cats aim to reduce the amount of phosphorus and balance the ratio of calcium to phosphorus. Too much phosphorus and not enough calcium can lead to kidney and bone damage (Reference 1). Commercial kidney diets are formulated to maintain an appropriate ratio of calcium to phosphorus.

protein in diets for managing cats with ckd

Since protein contributes significantly to phosphorus content, kidney diets restrict the amount of protein. Less protein means less uremic waste products. Emphasis is placed on formulating these diets with “high quality” protein. High quality proteins are a “complete package” and provide the cat with all the amino acids he or she needs. Thus, the protein used is highly bioavailable and generates less uremic waste products (Reference 1).

There are concerns that reduced protein diets predispose cats to weight loss and loss of lean muscle mass. Some recent studies suggest that senior cats may require more protein than younger cats to maintain lean body mass (LBM) (Reference 1).

Some practitioners advocate feeding higher protein diets to cats suffering with CKD to maintain the LBM. This may not be the answer to maintain LBM – increased protein in the cat’s diet means more uremic waste, making the cat feel nauseated and not inclined to eat. Ultimately, the cat will be eating less and calorie reduction will lead to muscle wasting as the cat’s body uses his own muscles for nutrition (Reference 3).

More on Lean Body Mass…

A recent study in 2019 (Reference 4) found a correlation between consumption of essential amino acids (essential amino acids must be consumed in the diet) and LBM. Cats with CKD Stages 1 and 2 were fed either a control kidney diet or a higher calorie “test” kidney diet that included higher amounts of essential amino acids and carnitine, an amino acid derivative that plays a role in energy production in the body.

The cats eating the lower calorie control diet lost LBM whereas the other group of cats eating the “test” diet maintained their LBM. Researchers observed that the cats on the control diet did not eat enough food to get adequate amounts of essential amino acids. They found that essential amino acid intake, not total dietary protein, correlated with maintaining LBM.

Although offering reduced protein, most commercial kidney diets make sure that more than sufficient amounts of the essential amino acids are available. The challenge is to get cats with CKD to eat enough of the diets.

Other Supplements

Commercial diets for managing CKD in cats also supplement:

Potassium, an electrolyte essential to the function of muscles and nerves
B vitamins – these water soluble vitamins can be depleted as the cat drinks more water and urinates more
Fatty acids – fatty acids found in fish oils are thought to reduce inflammation and decrease protein in the urine

Starting a kidney Diet

Renal diets are typically recommended for cats in IRIS Stages 2, 3, and 4. Occasionally a reduced protein diet may be prescribed for a Stage 1 cat who has persistent protein in her urine. Many practitioners like to introduce therapeutic diets when the cat is in IRIS Stage 2, because the cat should still be feeling well and more likely to accept the new diet (Reference 3).

The best time to switch to a kidney diet is when your cat is eating her regular cat food well and is feeling well. Wait to introduce the new diet if…

Your cat has just come back from the hospital
You have visitors or are doing home remodeling
Your cat is not eating her regular food well
Your cat is vomiting or having diarrhea

Introduce the new diet gradually, over several weeks (Reference 1)


Week 1	Week 2	Week 3	Week 4
Offer 25% of the new diet and 75% of the current food	Offer 50% of the new diet and 50% of the current food	Offer 75% of new diet and 25% of the current food	Offer 100% of the new diet

Make sure to offer the appropriate amount of calories to your cat – the new renal diet will most likely be more caloric than the your cat’s current food and you will not need to feed as much.

tips for transitioning to a kidney diet

Choose a food similar to the one your cat is eating already – wet or dry? fish or chicken?
Offer the new food in a separate bowl alongside the regular food
Make sure to offer fresh food
Use a “topper” to encourage your cat to try the new food – fish flakes or a favorite treat
Try gently warming wet foods – the stronger smell may make the food more appealing
Meal feed your cat – small, frequent meals gives your cat more chances to try the new food
Avoid mixing medications into the new food – use a small amount of another food or pureed treat to give the medications

If you are struggling with a finicky cat, talk to your vet. If your cat is healthy, ask if you can do a trial of mirataz to stimulate his appetite and facilitate the transition to the new food.

Alternatives to a commercial kidney diet

Use a phosphorus binder in the food your cat will eat. Consult your veterinarian for the appropriate dose.
Home cooked diets are an option but should be formulated by a veterinary nutritionist. Nutritionists affiliated with websites such as balance.it will work with your vet to formulate a recipe for your cat.

Studies have shown that diets for managing CKD in cats can increase longevity, help control uremia and maintain phosphorus concentrations. While some have concerns about the protein restriction in these diets, kidney diets have been shown to maintain LBM providing the cat eats enough food to get sufficient nutrition.

New research is focusing on the connection between the kidneys and the GI tract, particularly the uremic toxins that originate in the gut. Prebiotic and probiotic treatments in CKD cats are being investigated to see if improving the health of the microorganisms living in the gut can reduce blood concentrations of gut-derived uremic toxins. (Reference 5)

references

Quimby, J. and Ross, S., Diets for Cats with Chronic Kidney Disease (CKD) [updated 2022]. http://www.iris-kidney.com/education/protein_restriction_feline_ckd.html [viewed 9/2023]
Phosphorus: Fact Sheet for Health Professionals, https://ods.od.nih.gov/factsheets/Phosphorus-HealthProfessional/, viewed 9/2023.
Cave, N. and Wall, M. Protein restriction for cats with chronic kidney disease, Vet Focus, Issue # 30.1, © 6/25/20
Hall JA, Fritsch DA, Jewell DE, Burris PA, Gross KL. Cats with IRIS stage 1 and 2 chronic kidney disease maintain body weight and lean muscle mass when fed food having increased caloric density, and enhanced concentrations of carnitine and essential amino acids. Vet Rec. 2019 Feb 9;184(6):190. doi: 10.1136/vr.104865. Epub 2018 Dec 4. PMID: 30514741; PMCID: PMC6589452.
Summers, S. and Quimby, J., The feline gut-kidney axis: food for thought, Veterinary Focus, Issue #33.1, 5/31/23, https://vetfocus.royalcanin.com/en/scientific/the-feline-gut-kidney-axis-food-for-thought, viewed 9/2023

Managing the Cat with Chronic Kidney Disease

Posted on September 24, 2023March 11, 2024 by felinepurrspective_u3q4o6

HDO BP cat — A cat relaxes in his basket during a home blood pressure check. Regular blood pressure checks are essential to monitoring chronic kidney disease.

Chronic Kidney Disease (CKD) in cats is progressive and not curable but there are strategies we can undertake to improve the quality of life of our “kidney” cats and possibly give them some more time with us. Here is a checklist for managing the cat with chronic kidney disease:

Keep Kitty hydrated
Feed a diet that will lessen the stress on the kidneys
Maintain appetite
Manage high blood pressure
Treat anemia if necessary
Treat urinary tract infections

Managing the cat with chronic kidney disease

hydration

Kidney failure is tied to the “death” of nephrons that filter the blood. The remaining nephrons compensate by increasing filtration. Dehydration decreases renal blood flow putting more stress on the remaining nephrons. Keeping the “kidney” cat hydrated helps maintain electrolyte concentrations and dilute the waste products the kidneys are struggling to filter out.

Increasing Voluntary Water Intake

Have a variety of water sources and fountains in the home to encourage water intake.
Consider feeding a wet diet – many canned foods contain about 80% water.
Try water from tuna, water used to poach chicken or fish (offer alone, add to the water bowl, or try frozen in an ice cube tray and added to the water bowl).

Hydration supplements like Purina’s Hydra Care are designed to maximize the amount of water cats take in while drinking. Nutrient enriched water is more viscous, clings to the cat’s barbed tongue, and increases the water consumed with each lap of the tongue.

Subcutaneous Fluids

This refers to giving fluids under the skin, not in a vein. It is done using a bag of sterile fluids, an IV line and a needle. This is a strategy often employed in IRIS stages 3 and 4 of kidney disease. This can be done in the veterinary clinic or at home, once you and your cat are comfortable with the process.

Kidney-friendly diets

As the kidneys fail, they are no longer as efficient at filtering the waste products of protein metabolism. Phosphorus in the form of phosphates tends to build up in the body while potassium levels may drop.

Commercial renal diets for kidney cats feature reduced phosphorus and restricted amounts of high-quality protein, an increased calorie density, sodium restriction, potassium supplementation, supplementation with B vitamins, anti oxidants and omega-3 fatty acids (Reference 1). There have been a number of studies done addressing the effectiveness of these diets – the results show that cats suffering from CKD lived longer when fed a renal diet (Reference 2).

Phosphorus Binders

For some cats in advanced stages of CKD, a renal diet may not reduce phosphorus enough; other cats simply refuse to consume a renal diet. For these cats, adding a “binding agent” to the food can help reduce the amount of phosphorus that is available for the cat to metabolize. Supplements that “bind” with the phosphates in the food form a nonabsorbable compound eliminated in the stool. “Phosphorus binders” include (Reference 1):

Aluminum hydroxide
Calcium carbonate
Calcium acetate
Sevalamer (a hydrogel of poly-allylamine, free of aluminum and calcium)

appetite and nausea

A “kidney” cat can suffer from nausea and vomiting due to the buildup of uremic toxins in the bloodstream. The cat consequently doesn’t eat well resulting in dehydration and weight loss. Reduced potassium levels and anemia due to CKD also contribute to a reduced appetite (Reference 1).

Medical Management

Managing the cat with chronic kidney disease also includes managing nausea and vomiting. Drugs that target nausea and vomiting include maropitant (Cerenia) and ondansetron. These are typically available in oral tablets.

There is another drug that is often the first choice of many practitioners. Mirtazapine is an antidepressant drug that not only controls nausea and vomiting, it also stimulates appetite.

available in a transdermal gel (Mirataz) as well as tablets
the transdermal form is FDA approved for use in cats
the transdermal gel is applied once daily and the dose is easily adjusted
side effects are vocalizing and increased activity.

If a cat is too nauseous or unwell to maintain food intake, a feeding tube should be considered.

high blood pressure

Increased filtration rate in the remaining nephrons and activation of the renin-angiotensin system can lead to high blood pressure in cats with CKD. Systolic blood pressures over 160 mm Hg require treatment to prevent damage to the cat’s eyes, heart and kidneys. In particular, the leakage of proteins into the urine (proteinuria) can be reduced once high blood pressure is managed (Reference 1).

Amlodipine is the most commonly used drug to reduce cats’ blood pressure. It is a calcium channel blocker that is available in tablets that can be taken once or twice daily. Amlodipine typically reaches therapeutic levels in 7-10 days. Managing the cat with chronic kidney disease should include a blood pressure check every 3-6 months.

anemia

One of the kidney’s functions is to produce the hormone erythropoietin. Erythropoietin triggers cells in the bone marrow to make more red blood cells. Failing kidneys may not generate enough erythropoietin and anemia (low levels of red blood cells) can result.

Fewer red blood cells means less hemoglobin. Less hemoglobin means less oxygen is getting moved around the body. Anemia can result in weakness and tiredness.

If the fraction of red blood cells in the blood drops below 20%, many practitioners will supplement the cat with a man-made analog of erythropoietin. The most commonly used drug is darbepoetin; it is given as an injection under the skin. Injections of iron supplements often accompany the darbepoetin injections in the initial stages of therapy (Reference 1).

A new treatment (2023) is available for anemia in cats with CKD. Varenzin -CA1 is a once daily oral liquid medication made specifically for cats. Varenzin-CA1 is designed to stimulate the cat’s body to make its own erythropoetin.

Urinary tract infections (UTI)

With increasingly dilute urine seen in cats with CKD, UTI’s are more common. Most of these UTI’s do not have clinical signs such as frequent urination or blood in the urine. Urinalysis should be part of the CKD cat’s checkup. White blood cells found in a centrifuged urine sample are indications for a bacterial culture and treatment. Treatment can be based on sensitivity testing and a kidney friendly antibiotic chosen.

Managing the cat with chronic kidney disease requires attention to multiple factors. Treating dehydration, nausea, high blood pressure and anemia can keep the “kidney” cat comfortable and slow the progression of the disease. A critical part of managing the cat with chronic kidney disease is feeding an appropriate diet. The next post will look at the science behind the commercial renal diets and alternatives to them.

references

Sparkes, A. (panel chair), ISFM Consensus Guidelines on the Diagnosis and Management of Feline Chronic Kidney Disease, Journal of Feline Medicine and Surgery (2016) 18, 219–239.
Quimby, J. and Ross, S., Diets for Cats with Chronic Kidney Disease (CKD) [updated 2022]. http://www.iris-kidney.com/education/protein_restriction_feline_ckd.html [viewed 9/2023]

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Chronic Kidney Disease in Cats

Posted on September 17, 2023March 11, 2024 by felinepurrspective_u3q4o6

Cat on Baby Scale — Weight loss is a symptom of kidney disease.

Chronic kidney disease (CKD) is common in older cats. A 2014 study found that 30-40% of cats over age 10 years had CKD. (Reference 1).

chronic kidney disease in cats

Let’s take a closer look at what the kidneys do for our cats.

regulate fluid volume in the body
maintain the pH and electrolyte composition of the body.
make renin, an enzyme that helps maintain blood pressure
make erythropoietin, a hormone that stimulates production of red blood cells
filter the blood removing waste products

Nephrons are the tubular structures in the kidney that filter the blood and produce urine. A cat’s kidney has about 200,000 nephrons (Reference 2).

Over time, nephrons become damaged and are replaced by scar tissue. Renal failure occurs when less than 25% of the nephrons are functional and the remaining nephrons can’t maintain adequate function. The most common cause is an inflammatory process called tubulointerstital nephritis (Reference 3).

The remaining nephrons compensate by increasing filtration rate. The result of this “hyper filtration” is scarring of the tubes in the nephrons and loss of protein into the urine. The “hyperactive” nephrons also release the enzyme renin. Renin triggers the production of the hormone, angiotensin II, that makes heart beat more forcefully and raises the cat’s blood pressure. (Reference 3).

Diagnosing Chronic Kidney Disease in Cats

Clinical Signs of Chronic Kidney Disease

Some clinical signs are similar to those of other chronic diseases such as hyperthyroidism and diabetes. Like those disorders, these signs are usually not present until later in the disease process.

weight loss
increased thirst and urination
rapid pulse and breathing
unkempt hair coat

In addition the “kidney cat” may have

lethargy
weakness
poor appetite
bad breath or ulcers in the mouth (occasionally)

Diagnosing Chronic Kidney Disease in Cats

CKD is typically diagnosed by measuring creatinine and SDMA in the blood and measuring the urine concentration (Reference 1).

Creatinine

Creatinine is a by-product of energy-producing processes in the muscles. A healthy cat’s kidneys filter out most of the creatinine. As kidney disease progresses, the remaining nephrons filter out less creatinine and values of creatinine in the blood rise.

SDMA

SDMA (symmetric dimethylarginine) is a metabolite of arginine, one of the essential amino acids for cats. SDMA is produced from metabolism of proteins and, like creatinine, is filtered out by the kidneys. Unlike creatinine, SDMA is not influenced by the change in muscle mass. SDMA is more sensitive to the increase in the filtration rate as kidney disease progresses. It will increase earlier than creatinine.

Urine Concentration

As remaining nephrons increase filtration to compensate for the loss of nephrons, the cat drinks more fluid and the urine he produces becomes more dilute. As CKD progresses, urine concentration decreases.

the stages of chronic kidney disease

The International Renal Interest Society (IRIS) has formulated a guide to staging CKD in cats, as well as in other animals. There are 4 stages of CKD. The table below summarizes the values for creatine and SDMA seen for cats in the stages of CKD.

Stage	Creatinine (mg/dL)	SDMA (mcg/dL)	Comments
Stage 1	<1.6	<18	Blood values are normal but urine is dilute or kidneys are abnormal on examination or imaging
Stage 2	1.6 – 2.8	18 – 25	Clinical signs are mild or absent
Stage 3	2.9 – 5.0	26 – 38	Clinical signs are present but vary in severity
Stage 4	>5.0	>38	Risk of uremic crisis

Signs of Uremic crisis (end stage kidney failure):

Refusal to eat, vomiting, lethargy, confusion (possibly pacing and restlessness), withdrawn, uncontrolled urination or defecation, ammonia-like odor to the breath, seizures (from https://www.petmd.com/cat/conditions/urinary/kidney-failure-cats). Emergency treatment is needed.

other signs of chronic kidney disease in cats

Even if creatinine and SDMA are within normal limits, high blood pressure and protein in the urine may indicate that a cat has kidney disease. Recall that as nephrons “die”, the remaining nephrons increase filtration to compensate and blood pressure rises. The higher pressure damages the walls of the tubes in the nephrons and protein can leak out into the urine.

High Blood Pressure

Systolic blood pressures under 140 mm Hg are considered normal; SBP 140- 159 is prehypertensive; over 160 is hypertensive and treatment is recommended. (see “Measuring Your Cat’s Blood Pressure: Why and How”)

Protein in the Urine

Protein in the urine can be associated with disease processes such as urinary tract infection. Persistent protein in the urine warrants a closer look and the veterinarian will often choose to run a test to measure the urine protein creatinine ratio (UPCR). UPCR < 0.2 are normal; ratios of 0.2-0.4 are borderline; ratios over 0.4 support a diagnosis of CKD.

Diagnosis of chronic kidney disease can be challenging. Clinical signs are non specific and shared by other chronic diseases such as hyperthyroidism and diabetes. Because the kidneys have so much reserve capacity and our markers do not detect it until nephron death approaches 70-80%, it can be easy to miss some of the more subtle indicators of kidney dysfunction. It is important for our cats to have regular exams to assess their overall condition, lab work, and blood pressure measurement. Kidney disease is progressive and not curable, however, early intervention can slow down the process. In the next post, we discuss treatment of Stage 1 through Stage 4 of chronic kidney disease in cats.

references

Sparkes, A. et al. ISFM Consensus Guidelines on the Diagnosis and Management of Feline Chronic Kidney Disease, Journal of Feline Medicine and Surgery (2016) 18, 219–239, https://journals.sagepub.com/doi/pdf/10.1177/1098612×16631234
Sadeghinezhad, J. and Nyegaard, J. Cat Kidney Glomeruli and Tubules Evaluated by Design-Based Stereology. The Anatomical Record, Volume 302, Issue 10, 18-46-1854, 14 May 2019, https://doi.org/10.1002/ar.24144
Grauer, Gregory, Feline Chronic Kidney Disease, Today’s Veterinary Practice, February 6, 2015, Issue March/April 2015, https://todaysveterinarypractice.com/urology-renal-medicine/feline-chronic-kidney-disease/

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Diagnosing and Treating Hyperthyroidism in Cats

Posted on September 10, 2023March 11, 2024 by felinepurrspective_u3q4o6

Over 10% of cats over 8 years old will be diagnosed with hyperthyroidism in their lives. Although evidence points to thyroid disrupting chemicals in the cats’ food and environment, we don’t really know why these cats will become hyperthyroid. Prompt diagnosis and treatment will help these cats live long and healthy lives.

Diagnosing and Treating Hyperthyroidism in Cats

Diagnosing

Clinical signs of hyperthyroidism include increased appetite and weight loss. These signs progress slowly and it may be months to years before the cat owner realizes that something is wrong.

Cats are considered seniors at the age of seven. Regular lab work is recommended for senior cats and most senior feline blood panels include a thyroid hormone (T4) measurement. Persistently elevated T4 concentrations coupled with one or more of the classic clinical signs (below) at the same time often confirms the diagnosis of hyperthyroidism. (Reference 1)

weight loss
increased thirst and urination
increased vocalization
hyperactivity
rapid pulse and breathing
vomiting, diarrhea
unkempt hair coat

This list of clinical signs is also shared with other feline diseases, such as diabetes, kidney disease, and GI disorders. These diseases can lower the T4 measurement, so that it is in the reference range, making diagnosis of hyperthyroidism challenging.

a challenging diagnosis

Cats that may have kidney disease as well as hyperthyroidism are particularly challenging to diagnose. Thyroid hormone increases the blood flow through the kidneys, often lowering kidney values to within the reference ranges. At the same time, kidney disease impairs the binding of T4 to proteins, reducing the T4 concentration. One disease masks the other and vice versa (Reference 2).

Cats with borderline T4 values and those suspected of having another chronic disease will need additional testing before a definitive diagnosis of hyperthyroidism is made. The veterinarian may request a more sensitive test called a “free T4 by equilibrium dialysis” in addition to remeasuring total T4. “Free T4” measures a form of T4 that is not bound to proteins in the blood. (Reference 3)

Routine thyroid monitoring in humans and dogs measures levels of TSH or thyroid stimulating hormone. Unfortunately, levels of TSH in hyperthyroid cats are often too low to be detected using canine tests. Zomedica has recently developed a feline TSH assay capable of measuring the low levels of TSH in cats which may aid in diagnosing feline hyperthyroidism. (Reference 3)

treating hyperthyroidism in cats

At the present time, there are 4 treatments available to cats with hyperthyroidism (Reference 1).

radioactive iodine (I-131)
medical management with a drug called methimazole
surgical removal of abnormal thyroid tissue
dietary therapy using iodine-restricted food

1. Radioactive Iodine (I-131)

Treating hyperthyroidism in cats with radiation must be done at a licensed facility. An injection of radioactive iodine is given under the skin, like a vaccine. The cat stays at the facility until radiation levels drop enough to send cat home (about 3-4 days) (Reference 1, 4)

95% cure rate
side effects are rare
small risk of hypothyroidism (too much tissue is destroyed and the cat will need thyroid supplements)
owner must store wastes and soiled litter for 2 weeks
cannot cuddle kitty for extended times for 2 weeks post discharge (e.g. cat cannot sleep on bed)

2. Medical Management with Methimazole (Reference 1)

not a cure and the cat must receive daily medication to manage his hyperthyroidism
methimazole is available in pills and transdermal gel
frequent monitoring of T4 values is necessary
side effects: vomiting, facial itching, liver failure
tumor may continue to grow and become cancerous

3. Surgical Removal of Thyroid Gland (Reference 1)

The abnormal thyroid tissue is removed surgically, leaving the normal tissue alone. It is a procedure most surgeons can perform.

up to 90% cure rate
if not all the abnormal tissue is removed, hyperthyroidism can return
general anesthesia can be risky in cats with cardiac issues and kidney disease
there is a risk of damaging the adjacent parathyroid glands (regulate calcium in the body)
risk of hypothyroidism if too much normal tissue is removed

4. Dietary therapy (Reference 1)

Hills y/d diet reduces the amount of thyroid hormone in the body by decreasing the amount of iodine in the cat’s food.

response is 82% when on the diet
safe for cats with kidney disease
the cat cannot eat other foods
only low-iodine treats and water can be used
the cat will become hyperthyroid if he stops eating the diet

Both I-131 and thyroid surgery offer a cure for hyperthyroidism. However, both have a low risk of too much normal tissue being destroyed and the cat developing “hypothyroidism” as a consequence. The “hypothyroid” cat does not produce enough thyroid hormone and must be supplemented with daily oral medication for the rest of his/her life.

Both I-131 and surgery run the risk of unmasking more advanced kidney disease. Unlike medication or diet which can be adjusted or stopped, I-131 and surgery are permanent. Before recommending I-131 or surgery, some practitioners will conduct a trial with methimazole to assess kidney function when the hyperthyroidism is managed. However, some clinicians will opt to treat with I-131 even in the face of advanced kidney disease – persistent hyperthyroidism will further damage the kidneys if left untreated (Reference 5).

Diagnosing and treating hyperthyroidism in cats can be challenging. The presence of other diseases can mask hyperthyroidism and interfere with testing. I-131 is considered the gold standard for treating hyperthyroidism in cats. It does not carry the risks of surgery, avoids the side effects of methimazole and the difficulties of maintaining a strict prescription diet with a cat. Whichever treatment you choose, you have taken a step toward giving your hyperthyroid cat a healthier and longer life.

references

Carney HC, Ward CR, Bailey SJ, et al. 2016 AAFP Guidelines for the Management of Feline Hyperthyroidism. Journal of Feline Medicine and Surgery. 2016;18(5):400-416. doi:10.1177/1098612X16643252
Geddes R, Aguiar J. Feline Comorbidities: Balancing hyperthyroidism and concurrent chronic kidney disease. Journal of Feline Medicine and Surgery. 2022;24(7):641-650. doi:10.1177/1098612X221090390
Kvitko-White, Heather. Recognizing and confirming feline hyperthyroidism. dvm360 March 2021 Volume 53, Feb 9, 2021. https://www.dvm360.com/view/recognizing-and-confirming-feline-hyperthyroidism (viewed 9/2023)
Brooks, Wendy. Thyroid Treatment Using Radiotherapy for Cats. Veterinary Partner:VIN. Date Published: 01/01/2001
Date Reviewed/Revised: 09/05/2023. https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4951399 (viewed 9/2023)
Vaughan, F. and Wackerbarth, D. “Methimazole Trials: What Are They Good For?”, https://www.felinehtc.com/documents/Methimazole-Trials.pdf (viewed 9/2023)