This is another
of those questions which virtually everybody asks themselves as soon as
they get the diagnosis.
In most cases,
the answer to this question is yes.
This page tries
to explain the various scenarios you may be facing and how to increase
your cat's chances in each of these varying situations.
Percentage of Function Lost
Many people fear the worst because their vet has said their cat has lost a
massive amount of kidney function so they think there is little hope.
How Bad Is It? explains why it is actually normal not to be able to
diagnose CKD until up to two thirds of kidney function has gone.
Even if your cat has lost over 90% of function, there may still be hope:
Renal dysfunction in small animals
(2016) Brown SA Merck Veterinary Manual says "With
appropriate therapy, animals can survive for long periods with only a
small fraction of functional renal tissue, perhaps 5%-8% in dogs and cats."
So Is
There Any Hope?
In most cases, I would say yes. Whilst I cannot 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, so your vet
cannot know for sure that s/he will not be. None of us has a crystal ball,
so by all means listen to your vet's opinion but do not assume that your
vet's opinion is fact.
Factors Affecting the Prognosis
Vets have some idea of the prognosis based on your cat's test results and
their previous experience, but there are so many factors other than your
cat's blood test results which affect the prognosis, including:
how sick your
cat is at diagnosis
your cat's
attitude and tolerance levels (my Thomas ate like a horse with creatinine
over 7 mg/dl (650 µmol/l international)
how much your
cat wants to
fight
how well your
cat copes with being handled
how good the
veterinary care is which your cat receives, including how proactive
your vet is
whether any
other illnesses are present
which
treatments are used
the caregiver's
efforts
how much you
can afford to spend (though many
treatments probably cost less than you think, see
Obtaining
Supplies Cheaply).
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.
Renal Disease
(2006)
Polzin DJ
Delaware Valley Academy of Veterinary Medicine says "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."
You will notice I don't include age. Old age is not a disease, so try not
to let your cat's age work against him or her.
What Do the
Numbers Mean?
How Bad Is It? provides information on what the various test results
mean and discusses the commonly used IRIS staging system. Let's talk
briefly here about what the numbers seen in bloodwork tend to indicate in
terms of the prognosis.
Some vets
consider levels in Stage 3 (creatinine between 2.9-5.0 mg/dl or 250-440
µmol/L) to indicate high numbers and therefore to carry a very poor
prognosis; but on
Tanya's CKD Support Group,
these are actually considered to be "medium numbers", and in fact many cats
on the group have lived three or four years or longer with levels around 3-4
mg/dl (260-400 µmol/L).
Dr Katherine
James has mentioned that most people seem to opt for euthanasia when
creatinine remains consistently in the 660-900 µmol/l (US: 7.5-10 mg/dl)
range, and the cat is doing badly. I generally consider the prognosis to
be more guarded if a cat's creatinine level is over 7 mg/dl (627 µmol/L)
when stable (I don't worry as much if the creatinine is at this
level in a cat who is recently diagnosed and on intravenous fluids at the
vet's because of dehydration, or if the cat has an infection).
However, this
is just a rough guide; some cats in Stage 4, with very high numbers
despite IV therapy and rehydration, may 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.
If Your Vet Recommends Euthanasia
Some vets seem to recommend euthanasia almost immediately. This may be the
appropriate approach in some cases, but not in all, though if your vet is
negative, this may lead you to think there is no hope when in fact there
might be. For example, I have heard of some vets who recommend immediate
euthanasia for cats whose numbers are barely out of the normal range and
who are acting completely normally! I also hear quite often about vets
who, no matter how bad or otherwise the cat's bloodwork is, impose
arbitrary deadlines along the lines of "if s/he's not better by
tomorrow/within three days/whatever period the vet mentions, you have to
put to sleep." In our house vets like this are known as Dr Doom and Gloom.
Yes, they may be correct in that your cat might be one of the unlucky
ones; but I prefer a vet who says something like "I cannot make any
promises, but I'd like to try x, y and z and see if that helps your cat.
If it doesn't, at least we know we've tried our best."
Your vet's
approach does make a difference.
Renal Disease
(2006)
Polzin DJ
Delaware Valley Academy of Veterinary Medicine
says "The estimate of prognosis often influences the owner's decisions
about treatment options in complying with recommendations for management
of the patient. A comprehensive evaluation of the patient is the
best way to establish a reasonably accurate prognosis."
In fairness to
vets, it can be difficult for them to strike the right balance between
giving you encouragement and raising your hopes, only for them to be
dashed. However, 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. Deciding on euthanasia should always be your
decision, not the vet's, because you have to live with the feelings of
guilt and loss which often follow.
CKD is not generally considered to be a painful disease (dehydration feels
a bit like a hangover, uncomfortable but not agonising), so in most
cases there is no need to rush into an irrevocable decision. Cats who are
severely dehydrated or severely anaemic can look really ill; but treatment
may help.
Dr SP DiBartola has stated "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."
The laboratory diagnosis of feline kidney disease
(2008) Heine R
Veterinary Focus 18(2)
pp16-22 states "cats can
sometimes, especially in cases of acute kidney injury secondary to
obstructive FLUTD,
develop creatinine values of 1600-1800 •mol/L (20.98-23.6 mg/dL) and yet
recover."
Therefore I would suggest that in most cases it is better not to 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.
Scenarios You May Be Facing
Let's take a look at the various scenarios you may be facing when your cat
has CKD. Some of these may occur at initial diagnosis, whilst others may
arise further down the line.
If
your cat has been diagnosed early and 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.
Feline chronic kidney disease (2015) Grauer GF Today's Veterinary Practice5(2)
pp36-41 says "Diagnosis of early CKD, followed by appropriate treatment, may result
in improved survival. There
is solid evidence that dietary treatments, and increasing evidence that
antiproteinuric treatments, can slow the progression of CKD."
For cats who are stable
but who have relatively high bloodwork values, perhaps at the top end of Stage
3 or even higher (creatinine over 5 mg/dl or 440 µmol/L), 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).
Also, If your cat is
stable despite having such numbers, 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: Very High Numbers and/or Receiving Intravenous Fluids (IV)
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
and is on intravenous fluids (a drip) at the vet's, 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.
For cats who are in crisis, there is usually a trigger of some kind, such
as:
All of these can make your cat and the bloodwork look terrible, but once
you get the situation under control, you may well find that your cat's condition
greatly improves and the bloodwork may also improve, sometimes quickly, or
sometimes over a period of several weeks.
Some cats with very high numbers
will actually be suffering from
acute kidney
injury (AKI) rather than CKD, or possibly
acute on chronic kidney
disease. Whilst AKI is difficult to treat,
if treatment is successful the cat may actually make a complete recovery.
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.
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. 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 SP DiBartola has
stated "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 mmol/l (BUN: 241 mg/dl) 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 4 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 mmol/l (BUN: 76 mg/dl) and creatinine 316 µmol/l (US: 3.57
mg/dl), 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.
Prolonging the life of the renal failure patient
(2000) Elliott J
Waltham Focus10(3) pp10-14 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."
The laboratory diagnosis of feline kidney disease
(2008) Heiene R Veterinary Focus18(2) pp16-22 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."
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).
If Bloodwork Worsens Suddenly,
Especially After a Period of Stability
Please do not panic if your cat's bloodwork worsens suddenly.
Firstly, you need to ensure that any possible causes of the problem are
addressed. Common triggers include:
An ultrasound can help determine if urinary tract infections or kidney
stones are present. Once you have addressed the problem, you may
find your cat's bloodwork improves once again.
If
you cannot find a cause, it may be that your cat's CKD is progressing. 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 µmol/l (US: 3.57 mg/dl), 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
µmol/l (USA: over 7 mg/dl) 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.
Reassessment of "normal" values in dogs and cats
with chronic kidney disease Grauer
GF International Renal Interest Society says "Cats may have stable
renal for months to years and be relatively unaffected by the CKD or they
may have slowly progressive disease over several years. Animals may be
stable for a long period of time but then experience an abrupt,
unpredictable decline in renal function."
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.
If your cat's
bloodwork has suddenly worsened, don't give up hope. If you review your
treatment programme and add new treatments as necessary (including a
period on intravenous fluids
if the bloodwork values are high and your vet considers it appropriate) 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 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 mg/dl or 300 µmol/l), 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, 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.
Cats with
anaemia can look and act very sick. Cats with anaemia caused by the
CKD would normally have more advanced CKD, but anaemia may also be caused
by infection or inflammation.
My Ollie had low kidney values (creatinine
of 2.8 mg/dl) 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 CKD 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.
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.
Survival Times
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. A number of cats on Tanya's CKD Support Group have
lived for 5-8 years after diagnosis, including cats who were diagnosed
aged 12-14 who lived to be 19-21 years old. So yes! In many cases there is hope.
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! It should also be noted that
this study looked at cats some fifteen years ago, and treatments have
improved since then.
I would
say (and the above study seems to support this view) 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, as the Success Stories
page shows.
Finding the right balance: medical management of
renal patients (2014) Vaden
SL Eukanuba Veterinary Diets Clinical Symposium, Norway says
"Although most
cases of chronic kidney disease (CKD) are progressive and irreversible,
survival can be relatively long. With appropriate medical management, many
affected animals will die of other causes."
Renal Disease
(2006)
Polzin DJ
Delaware Valley Academy of Veterinary Medicine
says "With appropriate therapy, cats with stages 2 and 3 CKD commonly
survive 1 to 3 years. However, many survive much longer"
Dr D Chew said
in a webinar that I attended that it is not unusual for CKD cats to live
for 3-5 years after diagnosis, and his own CKD cats have survived longer
than that.
TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE
EXTREMELY DANGEROUS.
I have
tried very hard to ensure that the information provided in this website is
accurate, but I am NOT a vet, just an ordinary person who has lived
through CKD with three cats. This website is for educational purposes
only, and is not intended to be used to diagnose or treat any cat. Before
trying any of the treatments described herein, you MUST consult a
qualified veterinarian and obtain professional advice on the correct
regimen for your cat and his or her particular requirements; and you
should only use any treatments described here with the full knowledge and
approval of your vet. No responsibility can be accepted.
If your cat
appears to be in pain or distress, do not waste time on the internet,
contact your vet immediately.
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If you wish to
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