Renal Failure Cat--need to talk through some things...

[Simkie]

I’ve posted about Juliet in a few other threads, so some of this might not be unfamiliar if you’ve stumbled across those posts, but I’m a little frustrated with the vet I saw today and really need to talk through some things…help me out?

Juliet is a 17 yo cat who’s had elevated BUN and creatitine for 10+ years, but her renal disease has recently progressed and management of it has gotten considerably more involved. She is clinically doing GREAT, but her bloodwork is pretty miserable. Latest values from today, 3/20 number in parenthesis.

BUN: 97 mg/dL (68)
Creatinine: 5.7 mg/mL (5.0)

And actual anemia for the first time on today’s labs:

RBC: 6.15 M/uL (6.42)
HCT: 28.2% (30.3)
HGB: 9.7 g/dL (10.3)
Retic: 2.5 K/uL (8.3)

I asked the vet today what we do about this. He said B12 and iron. We’re already doing B12 and gave Julie IM iron today.

I asked about erythropoetin, and he said “absolutely not–we looked at epo in the 90s and while cats did well for about 3 months, they all totally crashed after that and died.”

This is absolutely not what I’ve read, and I confirmed when I got home. Started here:

http://www.felinecrf.org/esas.htm

Then here:

Darbepoetin alfa: a new therapy for the management of anaemia associated with...

And here:

http://veterinarymedicine.dvm360.com/managing-anemia-patients-with-chronic-kidney-disease?id=&pageID=1&sk=&date=

And here:

The use of darbepoetin to stimulate erythropoiesis in anemia of chronic...

I’m struggling because Juliet is doing SO well at home. She’s seriously packing away food. She’s gained a half pound. She’s active and interacting and jumping and getting into trouble. Her coat looks good. She’s using the litter box and pooping and peeing. I am so terribly concerned about her quality of life and watch her like a hawk for any and all signs that she’s declining and I am just not seeing it.

But what I don’t want is for her to progress into anemia that causes her to feel like crap and have to euthanise because we’re skipping this treatment which has a really good chance of treating the anemia with a small risk (10%!!!) of an antibody reaction in 4-5 months. I am ALL about quality of life.

Am I being totally unreasonable here? Does anyone have experience using darbepoetin or erythropoetin in a renal failure cat? As long as we have quality of life, I’m cool with managing until we see signs that quality is slipping. And I’d rather have a shorter period of good quality then a longer period of okay quality.

I’ve abbreviated some history–can provide if more info is helpful. This is what she’s currently on/eating. Writing this out, it sure sounds like a lot, but she is tolerating it beautifully (she’s never been a tough cat to treat.) It’s one pilling in the am and one in the pm, a syringe of lactulose am/pm, and the fluids.

Food:
Weruva chicken–1 1/2 to 2 cans/day (she’s regularly eating 11 oz day!)

Once daily:
150 mL plasmalyte
12.5 mg zenequin
2.5 mg famotidine
1 mg zofran
500 mcg methylcobalamin

Once daily for five days, then off for two:
4 mg cerenia

Twice daily:
1 cc lactulose

Twice a week:
mirtazipine (transdermal)

[In_The_Gate]

In general, a red blood cell count of 28% is a long way from needing erythropoetin stimulating agents. The red count is practically normal still and may stay that way for a long time. It’s certainly not something that should make her feel sick. Iron and monitoring closely to make sure it doesn’t drop is all you probably need right now. The monitoring closely is key to trying to avoid a crisis and make sure you know if the anemia is getting worse before it’s severe. Your veterinarian is right about Epogen - the incidence of reactions to it such that cats become permanently blood transfusion dependent is fairly high. I’ve seen it happen and it sucks - cats get euthanized for this when it happens because you can’t live on blood transfusions forever. 1/10 is fairly high, especially when you’re giving a drug to an animal that doesn’t really need it right this minute. If the anemia was going to stay stable for six months by itself we’d feel really bad if we gave her something that killed her before that point.

We now use darbepoetin instead which has a much lower incidence of autoimmune reactions but is much more expensive (at our hospital $90/dose with it given weekly initially with the goal to get to once to twice a month). If for some reason the anemia progresses much faster than expected you can give a blood transfusion while you wait for the darbepoetin to kick in (it can take a few weeks even when it works) - so you would not get stuck euthanizing her if the anemia drops suddenly more than expected. If it’s a gradual anemia, most cats won’t reach the point they need transfusions until the Hct is 16-19%.

Obviously, please don’t rely on the advice of internet strangers. I have never met your cat and can’t tell you what is right for her as an individual. If you don’t trust your vet, take your cat for a second opinion ideally with an internal medicine specialist.

[Simkie]

Oh, forgive me…I didn’t really clarify. I understand we’re not to the esa point now. I understand that darbepoetin is the better choice. The links above are largely related to its use.

I’m frustrated because this vet doesn’t even seem to be willing to have the conversation and thinks ALL cats develop PRCA in three months and die horrible, awful deaths because of it…which is not what I’m seeing online. Are the links above wrong? Is the risk of PRCA with darbepoetin really that great, and the death following it that immediate and terrible?

I’m a planner. I want to know how often we need to recheck bloodwork, how to mange the anemia Juliet is developing and if darbepoetin is worth trying. The vets answers today seem to be in direct contradiction to multiple reliable sources online. I want to stay on top of this stuff so we can avoid her getting critical. I am seriously disinclined to hospitalize her for transfusion and would much rather treat early enough so we can correct anemia with an esa agent and maintain quality of life.

Regarding cost, the Tanyas CRF page above gives several ideas on getting darbepoetin at a fairly reasonable cost. Any feedback on that?

[In_The_Gate]

I’ve had only one possible reaction to darbepoetin but in reality I think that cat stopped responding because of cancer causing the bone marrow to not make blood cells anymore. It’s absolutely worth trying if the anemia gets worse before a crisis point if you can afford to use it. Reactions to the darbepoetin are rare but it still does happen. I would still want to see the anemia getting steadily worse before I started darbepoetin.

If cost is an issue and you’re going to use Epogen I’d be much more hesitant to give it until the cat reached a near crisis point and you had no alternatives. I think Walmart hospital pharmacy may order the darbepoetin for you with a prescription but it’s a bit of a PITA and takes a while.

It’s probably worth checking again in 2 weeks, sooner if she seems worse or tired, then monthly for at least a few months if the anemia is stable or more often if it’s gotten lower. If these aren’t things your vet talked to you about you should get a 2nd opinion.

[Pancakes]

I second everything In The Gate is saying, and I’ll echo that we use darbo instead now.

To decide if/when to do it – do a reticulocyte count first, see if the anemia is non-regenerative. If it’s from chronic GI ulcers contributing to elevated BUN count, then you shouldn’t need to do darbo. Just another thought.

[Zu_Zu]

Darbepoetin is looming in the future for my cat ~

No I have not used Darbepoetin yet but it is on the horizon for my cat.

My cat is on Renvela - Enalapril - Citrolith - Ferrous Gluconate and daily subq fluids

Darbepoetin is most likely next …

Another blood check this week .

• the pharmacy in Chicago says they can not supply the Darbepoetin without being concerned * because all this med is flown in to me overnight and

apparently the Dabepoetin is “vibration sensitive” so they recommend that I purchase it locally • as opposed to risk $300.00 on a flight and UPS delivery •

Should * clarify we are under the care of a local vet who is being directed by a renal specialist in Chicago ( personal friend ) who had researched renal failure in dogs / cats for decades … Lectures everywhere !

Thank goodness because the local vet is stymied by my cats ‘numbers’ that have remained HIGH … diagnosis 1/5/15 with big kidney small kidney syndrome .

Please forgive me if I have incorrectly spelled a med or incorrectly labeled the syndrome …

Feline CRF is an emotional roller coaster for the owners ~ exhausting !

My dear Smarty Jones is 11 yo and we cherish each borrowed day we are awarded ~

Jingles & AO for all the CRF ‘treasures’ ~

Life is fragile and precious ~

** I was quoted $300.00 a month, I believe…* a once a week injection to be lowered with time …

Again ``` please don’t flame me on this post … I am sharing the little bit of information I have … I am not medically trained = I know nothing except what I am told by the specialist and my local vet …

I am simply a person who dearly loves a cat named Smarty Jones ~

• Smarty remains WILD & INVOLVED & HUNGRY !!!

[Simkie]

Awww, I’m so sorry to hear you’re dealing with this too, Zu zu. It sucks!

Juliet has thankfully been a relatively straight forward case. Her blood pressure is normal, her phosphorus has been in check and her potassium hasn’t dropped much. Initially we had a high sodium level, but we addressed that by pulling her off of our salt-softened water and using only RO filtered.

We do have a complication of a mass in her belly, which is a huge unknown. The vet was pretty grim when we found it on ultrasound and predicted that she would decline relatively quickly, which has not come to pass. I was prepared to schedule euthansia the week after that diagnosis, but she just keeps getting better…

ITG and Pancakes, thank you for your own experiences with these agents. When would you consider starting darbepoetin if the goal is to head off anemia requiring transfusion? We lost 2% HCT in the last month. Pancakes, the reticulocyte figures are in the OP.

I’m really struggling here with the vet care. We moved in August of last year, and I left my wonderful, brilliant vet in Fort Collins, along with a top notch referral hospital and CSU. I’m at what’s considered one of “the best” clinics around here, and they have a pretty fancy facility with a lot of nice stuff in house, but I feel like I’m pushing every step of the way to get care. People don’t spend a lot of money on their pets around here. Today I saw a vet in the practice that I’d not worked with before.

[Pancakes]

I wouldn’t transfuse until you get to 20% or lower (though numbers don’t tell the whole story). It can take several weeks. I’m not sure when is the perfect timing as things can accelerate quickly too…

Have you looked to see if there is a boarded internist in your area?

[foggybok]

Hello, sorry about kitty.

Just for background, I have experience in research regarding anemia of kidney disease and am quite familiar with the literature as well. I have also worked with some of the top veterinary nephrologists in the country on my project.

It sounds like you are on the right track. Your vet is right to worry about PRCA, but no, it’s not every cat and as you already know, darbepoetin is much better in this regard. That said, eventually they can get antibodies to that as well. I’m hoping a non-biologic can find it’s way into veterinary use, but it will be a few years… that’s the best approach. In the meantime, Epo and darbo are what we have.

I remember a conversation I had with a world expert in the field. He said the best thing about using these agents was people “got their pet back” the animals felt better and ate better (and keeping them eating is the biggest key). At the right stage, the anemia really should be treated. Your kitty isn’t there yet. But when he/she is, I’d find a vet that will help you out. but I’d also be prepared for the consequences.

ZuZu, I’d find another pharmacy, I’ve never had trouble getting in Darbepoetin.

[foggybok]

I just noticed you are in Minnesota? I’d highly suggest taking her to the U and seeing Dr Polzin or one of his residents. He’s a great guy and really know his kitty kidney disease. he’ll get you on the right track

[Zu_Zu]

To qualify my statement ~ they have the product however

The Chicago pharmacy has the Dabepoetin & actually will send it

however they recommended I purchase it locally due to the 'vibration sensitivity ’ of the med

because it would have to be flown in overnight (as are the other meds) and might
suffer the flight as well as the UPS delivery :eek:

the pharmacist voiced concern

which at $300.00 a month’s supply - I appreciated this concern
thus
I will obtain it locally .

The other meds are compounded / flavored in chicken or tuna and arrive in fine form.

This is the pharmacy recommended and used by the Vet Specialty Clinic …

They have helped me and my cat .
I will continue to purchase meds from this pharmacy •

[QUOTE=foggybok;8112448]

ZuZu, I’d find another pharmacy, I’ve never had trouble getting in Darbepoetin.[/QUOTE]

[Simkie]

Pancakes, I have no desire to transfuse Juliet and will likely put her down if we get to the point where that’s required. If the anemia continues to progress, I want to step in with an ESA to avoid the requirement to transfuse…and I want a plan from my vets here on how best to do that (that’s certainly the piece I’m not getting from them!) I don’t have a boarded small animal vet here at all. It’s bizarre to me how advanced human medical care is in this town vs the relatively basic veterinary care.

Foggy, thanks for the recommendation at the U. I’m easily 90 minutes from the cities and I just don’t think it’s fair to have her crated for the better part of a day to get her up there, seen and home. She travels fairly well, but it’s still stressful for her and at this stage in her life I just want to make her feel well with as little stress as possible. When we start talking hospitalization (as for transfusions) or day long car rides…I just get very concerned about that quality of life question.

If I can’t find a vet here willing to talk about using darbepoetin or even erythropoetin, I’m not sure what we’ll do. Will have to give that some thought :-/

[Louise]

Simkie, I don’t have a scrap of useful advice for you, but you have been so helpful to me in the past that I just wanted to chime in and say that I’m thinking of you and your Juliet.

[foggybok]

Can you ask your vet to call Dr Polzin for a consult? Maybe that will make them more open to treating with an ESA. That way kitty doesn’t have to travel, but you get his expertise…

ZuZu, your response makes sense, I misunderstood the situation. Sounds like they’ve given you good service.

[shiloh]

Simkie - I don’t know if this will help but I recently had to have a cat with FIV on fluids because of high fever, vomiting, diarrhea. Kitty’s RBC count went down and vet told me to back off fluids because in her opinion that was what was causing RBC to drop. I’m just throwing it out there.

I wish I could offer more concrete help. I have ridden the renal failure roller coaster many times - I hate it. I am thinking of you and your kitteh. You have helped me in past and I wish I could offer more.

[In_The_Gate]

Simkie - I would not want an anemia to get below around 23-24% as if you let the anemia get below that there is a much higher likelihood you would need to transfuse your cat before the darbepoetin kicks in. If the anemia drops quickly or the cat is not feeling well I may start it before then especially if I have an owner that is going to euthanize over give a transfusion if we waited too long. There’s no magic number though as every situation is different. In your cat I would not decrease the fluids because of the anemia. The fluids are keeping her alive and feeling well and in reality are going to change the Hct minimally. If the anemia gets worse you need to treat the anemia not give less fluids.

[Simkie]

Awesome, ITG–thanks so much for providing some figures on where you’d start looking to treat with darbo. Super helpful. (BTW, I totally want a magic number. And a crystal ball, please.)

Foggy, yeah, I’ll talk about consulting with the vet up north. Excellent resource. I had really top notch care with a variety of boarded specialists in town for so long, it’s been a really tough transition to no longer have those resources.

Thank you ALL so much for your support and kind words and thoughts. I’ve known this time is coming for years, and that I got a lot of time with Juliet that has really been “bonus”…but this still sucks.

My plan for the evening is to craft an email to the vet at this clinic who has otherwise handled the case. Ask about darbepoetin, provide some of the links above, state my desires to stay on top of this and head off severe anemia, along with my extreme reluctance to hospitalize for transfusion, suggest perhaps we can consult with Dr. Polzon and ask about a recheck schedule.

Does anyone have experience ordering from the Walmart Specialty Pharmacy? The data on the Tanya’s CRF page is a little dated, but the price sounds quite reasonable. Given the lead time, I’m wondering if we need to start that process now. Perhaps I should also check with the Mayo pharmacy to see if they’ll sell it to me…don’t have high hopes (they wouldn’t sell me fluids with a script) but good box to check.

Juliet downed a whole can of Weruva today–licked the bowl CLEAN–but did vomit a little pile of undigested food when we got home. Will certainly have to keep an eye on that and if we can’t control her nausea, all of this conversation about anemia might be a totally moot point.

[Simkie]

Heard back from the vet–she’s doing some investigating and hopes to be able to discuss in further detail by the end of the week. The abdominal mass is of concern. Vets, perhaps you’d like to see the report? I did request that a boarded radiologist review the rads and ultrasound on that one, and have those findings.

Julie hoovered her food last night (ate ~90% of the can) and licked the bowl clean today. Hairball last night, which could explain the vomit earlier in the evening. Nothing’s come up since then. She’s a long hair with a LOT of hair. I brush her quite a bit, but she’s still grooming herself (good sign!) and gets the occasional hairball.

Really wish I had that crystal ball…

[Simkie]

Guess who’s got a PCV of 36??

I love good news like that.

My “regular” vet on this case is willing to try the darbepoetin, and I can get it at my local hospital pharmacy, when we need it. We’re on a monthly recheck schedule.

The abdominal mass is growing slowly. Guessing game as to what’s going to become problematic first. Juliet is still bright, eating and gaining weight, so we’ll just keep doing what we’re doing for now.

[Zu_Zu]

Impressive update ~ Be Proud of your work !

[B]
Impressive update !

Be proud of your work !

Good news in all directions !

((hugs)) and Jingles & AO continue for Juliet & Simkie ![/B]