In most cases, I would say yes. Whilst I can't promise
that your cat will pull through a crisis or survive for years, I can tell
you firstly, the numbers do not tell the whole story; and secondly, that not
being proactive is definitely going to reduce his or her chances.
Just as I cannot promise your cat will be a success story, nor can your
vet know for sure that s/he won't be. None of us has a crystal ball
(though if your vet does happen to have one, please find out where I can
get one too because I could really use one).
Vets have some idea of the prognosis based on your cat's test results and
their previous experience,
but there are so many other factors, such as the cat's attitude and
tolerance levels (my Thomas ate like a horse with creatinine over 7 or 650
international), how proactive the vet is, which treatments are used and of
course the caregiver's efforts. The only ones of these which we can
control are the latter two (and possibly which vet you use, though that
also depends upon where you live), so I recommend focusing on these and
then, whatever happens, you know you've done your best.
In
Prolonging the life of the renal failure patient
(2000),
Waltham Focus10 (3), Dr Jonathan Elliott states that
"in a retrospective study, the correlation between plasma creatinine and
survival in cats who presented with signs of stable CKD was very poor,
with only 5% of the variation in survival time being predicted by the
initial plasma creatinine concentration".
In
The laboratory diagnosis of feline kidney disease
(2008) Heine R Veterinary Focus18(2) pp16-22, Dr Heine
states "cats can sometimes, especially in cases of acute
kidney injury secondary to obstructive
FLUTD,
develop creatinine values of 1600-1800 μmol/L
(20.98-23.6 mg/dL) and yet recover."
Survival in cats with naturally occurring chronic
kidney disease (2000-2002) (2008) Boyd LM, Langston C, Thompson
K, Zivin K & Imanishi M Journal of Veterinary Internal Medicine
22(5) pp1111-7 found that "median survival for cats in IRIS
stage IIb at the time of diagnosis was 1151 days (range 2-3107), and was
longer than survival in stage III (median 778, range 22-2100) or stage IV
(median 103, range 1-1920)." But the median is a
halfway point, i.e. 50% of cats lived less than the median, and 50% lived
longer than the median. So sadly 50% of the cats in Stage 4 at diagnosis
lived less than four months, but that means that 50% of Stage 4 cats lived
for longer than four months. What I find interesting is that at least one
cat in Stage 4 lived for 1920 days after diagnosis, or more than five
years!
I would
say that cats who are diagnosed early with
low numbers have the best chance - many of them live for years. Although
it is less common, some cats with high numbers also live for years. The longest surviving
CKD cat I know of lived for
sixteen years after diagnosis, having been diagnosed at six months of age.
The next longest surviving lived for twelve years, having been diagnosed
at three years old. So yes! In many cases there is hope. As the Success Stories
page shows, even some cats with high numbers live for years.
Much depends upon your
particular cat, how sick s/he is at diagnosis, how much s/he wants to
fight, how well s/he copes with being handled, how good the veterinary care is that s/he receives,
and, sadly, to some degree how deep your pockets are (though many
treatments probably cost less than you think, see
Obtaining
Supplies Cheaply). This is not only my opinion:
In
Renal
disease (2006) Dr D Polzin says "With appropriate therapy, cats with stages 2 and 3 CKD commonly survive 1
to
3 years...however, many survive much longer. A host of factors influence prognosis
of
CKD, both favorably and unfavorably. Included among these factors are the
quality of medical care provided to the patient, the degree of interaction
between the veterinarian and pet owner, and the level of owner commitment."
Some vets seem to recommend euthanasia almost immediately, but CKD is not
generally considered to be a painful disease (dehydration feels a bit like
a hangover, uncomfortable but not agonising), so there is no need to rush
into an irrevocable decision.
I do not understand vets who take an arbitrary "if s/he's not better by
tomorrow/within three days/whatever period the vet mentions, you have to
put to sleep" approach. In the vast majority of cases, you need to
treat your cat properly for at least two weeks before you can make an
informed decision. Plus deciding on euthanasia is your decision, not the
vet's, and you have to live with the feelings of guilt and loss which
often follow. So do not be talked into euthanasia on the day of
diagnosis or if your cat's numbers do not improve after a day or two on IV
fluids, because in
many cases there is room for hope; the cat just needs
some time to stabilise with proper treatments tailored to his or her
particular needs.
If
your cat has been diagnosed early and/or is stable, you are fortunate in
many ways because with careful monitoring and a proactive approach, your
cat may stay relatively well for months or years.
For cats who are stable
but who have relatively high bloodwork values, perhaps at the top end of Stage
3, there
is still hope: the values may fall with treatment, but even if they do
not, there is a possibility your cat may remain at this level for some
time (see below).
If your cat is
stable despite having numbers at the top of Stage 3 or in Stage 4), your cat clearly copes well
with CKD, which is usually a good sign, although treatments should still be
begun as soon as possible, including possibly a session on intravenous
fluids.
Cat
in Crisis: Probably Receiving Intravenous Fluids (IV) Back to Page Index
Since
it is so hard to diagnose CKD early (see
What
Happens in CKD? to understand why), your cat may be in crisis at diagnosis.
Please do not be too
despondent if this is the case, particularly if your cat has crashed (see
Symptoms)
and is on a drip, as happened to Thomas. Many cats have horrendous bloodwork at
diagnosis, or may experience a sudden crisis after having CKD for a while,
which is often a reflection of severe dehydration. The
true bloodwork values will not be apparent until your
cat is rehydrated and stabilised, either via sub-Qs for less critical
cases or via IV for more severe ones. If your cat has an
infection,
you need to get it under control before you can tell how severe things
really are; hypertension may also make bloodwork look worse than it will
once the hypertension is under control.
Cats with
severe anaemia (PCV or HCT below 20%) often appear extremely ill, but
usually feel and look dramatically better once the anaemia is under
control.
Some cats with very high numbers
will actually be suffering from
acute kidney
injury (AKI) rather than CKD, and whilst AKI is difficult to treat,
if treatment is successful the cat may actually make a complete recovery.
There are a variety of
possible outcomes for a cat who has crashed and is on IV with extremely
high bloodwork values:
the cat's numbers
improve on IV and the cat looks and acts better, and continues to do
well at home;
the cat's numbers do not
improve on IV, but the cat nevertheless acts better, and the numbers
gradually reduce at home (usually with sub-Q therapy);
the cat's numbers do not
improve on IV or with sub-Qs, but the cat acts better and continues to
do well at home despite the high numbers;
the cat's numbers do not
improve on IV, and the cat continues to act ill once s/he is home, and is put to sleep;
the cat's numbers do or
do not improve on IV, but the cat crashes again once at home.
Obviously I cannot predict to which category your cat
might belong, but it is usually
worth trying treatments, particularly if your cat has a kidney infection,
where the numbers may improve once the infection is under control.
I am growing increasingly concerned recently about the
number of vets who offer just one day on IV, tell the person their cat's
numbers have not improved after that short stint, and recommend
euthanasia. In most cases this is inappropriate in my opinion. Yes, not
every CKD cat can be saved; but euthanasia is an irrevocable decision so
you need to be very sure, and for most people that means giving their cat
every chance. Dr S DiBartola says "Don't pass
judgement on a lethargic dehydrated cat with markedly
abnormal laboratory results. 2 to 3 days of conscientious intravenous fluid therapy can produce
remarkable results."
For a severely
ill cat, one or two days on IV are simply not going to be long enough.
Thomas was on IV for four solid days and nights, and only began to eat a
little on day 3. Also, Thomas's numbers did not improve
at all on IV fluids. He had urea of 89 (BUN: 241) at
diagnosis, and it was the same after four days and nights of
IV. Some cats will actually have numbers which worsen
while on IV fluids. Try not to panic! Your cat did not get this sick
overnight, and s/he won't necessarily get better in only 2-3 days. In
Thomas's case, my vet suspected he would fall into category 5 of my
possible scenarios above, but
in fact he was in the second category. He was acting
a little better by the end of the four
days on IV fluids, and with home treatments over a few weeks we eventually reduced his
numbers to urea 27 (BUN: 76) and creatinine 316 (US: 3.57), where they
stabilised for some months.
So even if you are dealing with category 4, I would
recommend that you make sure that
your cat is given a reasonable stint on IV, and is given a reasonable
chance of success at home, especially if anaemia is present. Being at the vet's is very stressful for most
cats, and they often need a few days at home convalescing before they
begin to act better.
If
we take the analogy of a CKD cat falling over a precipice, what seems to
happen to quite a few CKD cats is that the cat's bloodwork deteriorates in
stages, like moving one step closer to the edge of the precipice; but the cat may remain
stable at
each step for some time. Thomas, for example, was
in IRIS Stage 2 with a creatinine level of 318 (US: 3.57), nearly double what
it should be, for six months; and he then moved a step closer, but still managed a couple of months with creatinine of 627 (USA: over 7) and had a very good quality of life during
this period. Other cats may not show such extreme changes, with gradual
falls that may be a year or more apart.
If your cat
already has high numbers, and these worsen, try not to be too discouraged.
Creatinine is not a linear measurement, so a worsening of creatinine that
is already relatively high is not as sinister as it might first appear.
The
Diagnosis page explains more about this.
So if your cat's bloodwork has
suddenly worsened, don't give up hope - if you review your treatment
programme and add new treatments as appropriate (including a period on IV
if the bloodwork values are high and your vet agrees) and work closely
with your vet, you may well find your cat stabilises once again, albeit at
the higher bloodwork values. If your cat's phosphorus levels worsen, it is
particularly important to get these under control, because
high phosphorus
levels may make the CKD progress faster and also make many cats feel
bad.
If Bloodwork Worsens Suddenly
Please do not
panic if your cat's bloodwork worsens suddenly. Whilst this may indicate
that the CKD is progressing, there are a number of other possible causes.
Infections, particularly
kidney infections,
may cause a spike in bloodwork, as may
kidney
stones. An ultrasound can help determine if these
issues are present.
Many cats with uncontrolled
hypertension
may have worsening bloodwork, which may improve once the hypertension is
brought under control.
If your cat's
phosphorus levels are high, it is
particularly important to get these under control, because they may make the
CKD progress faster and also make many cats feel
bad.
If A Cat with Low
Bloodwork Values Acts Sick
I would expect a cat with low bloodwork values (creatinine
below 3.5, Stages 1, 2 and the lower part of Stage 3 of the IRIS
classification system) not to appear too sick. These cats may have the
occasional bout of vomiting or diarrhoea, and may sometimes not want to
eat, but overall they should be doing quite well as long as they are not
dehydrated and are eating enough.
Therefore if your low numbers cat is consistently off
colour (lethargic and exhibiting general malaise) even after treatment for
obvious problems, I would ask your vet about other possible causes. Many
cats with hypertensionfeel off colour, but improve greatly once their
blood pressure is back to normal. My Ollie had low kidney values (creatinine
of 2.8) but had fairly regular diarrhoea. It turned out this was caused by
hyperthyroidism and it disappeared once the hyperthyroidism was under
control.
Some CKD cats who persistently exhibit general malaise
despite treatment for obvious problems may have some kind of
gastro-intestinal problem.
Pancreatitis is a
common cause in CKD cats; other possible causes include inflammatory bowel disease (IBD) or
cancer (lymphoma). It would probably be worth considering
an abdominal ultrasound in order to rule out such problems.
Treat the Cat, Not the Numbers
Test results matter, but they
are not the whole story. This is why we have a mantra on
Tanya's CRF Support Group: "treat the cat, not the numbers". Of course, it is still
important to do what you can to improve the bloodwork and to treat
whatever issues arise, because this will both make your cat more
comfortable and increase his/her chances of survival. This mantra is
simply a way of pointing out that many cats do astonishingly well despite
their bloodwork results being poor. There are no guarantees and it is a fine line to tread, but it
is usually worth trying treatments, although you must also consider your
cat's temperament when deciding how much to fight the CKD.
Some vets
consider levels in Stage 3 to indicate high numbers and therefore to carry
a very poor prognosis; but on
Tanya's CRF Support Group, these are actually considered to be "medium
numbers", and in fact many list cats have lived three or four years
or longer with Stage 2 levels. Cats with numbers in this range should
really be considered as having renal insufficiency rather than kidney
failure.
Dr Katherine
James has mentioned that most people seem to opt for euthanasia when
creatinine remains consistently in the 660-900 (US: 7.5-10) range, and the
cat is doing badly. However, this is just a rough guide; cats in Stage 3, with
very high numbers despite IV therapy and rehydration, may sometimes respond very well to treatment and enjoy several months of
quality life, particularly if their numbers have worsened gradually
over time, giving their bodies time to adjust to the reduced levels of
kidney function. Even if a cat is in crisis at diagnosis, there may still
be hope:
Vet Info mentions a cat they treated who
lived for eight years with CKD despite initially presenting in crisis
(click on Kidney Failure - Daily Fluid Treatment). The Success
Stories page tells the stories of some CKD cats who have managed to
lead happy and in many cases, lengthy, lives at various stages of the
disease, including one cat, Paris, who survived for over sixteen years.
