Thursday, October 2, 2014

Feline HCM-Update on Myrna Loy (and Elizabeth Taylor, too)

For whatever reason, Myrna Loy has had a surge of energy since Sunday.  A month ago, she saw the cardiologist for a check-up, had an increase in atenolol due to a higher heart rate, and still had good kidney blood values.  A week later, she struggles to chew, isn't eating much, and sees the vet.  We found that kidney values had increased and combined with not eating, meant that she was low on energy.  She began antibiotics in case she had an inflammation in her mouth and she developed diarrhea due to the antibiotics.  This led to an increase decline of appetite and energy.  I then cut the antibiotic into four  of 1/2ml-from two doses of 1ml-which decreased the severity of the diarrhea.  I also continued the liquid supplement mixture (omega 3, baby food sweet potato, krill oil, etc.) and gave KMR mixed with corn syrup by mouth when she would not eat (this was a form of protein and energy for her.)  Last week, Elizabeth Taylor was hospitalized with a severe bladder inflammation. So, last week was a hectic week with one cat very sick, and another having trouble eating enough on her own and being somewhat run down.

Then suddenly Sunday 9/28/14, Myrna pops up perky, energetic, alert, engaged, playful, and hungry.  She had slowly been eating somewhat better by the end of that week preceding but she has been eating very well on her own since Sunday even though she was still on antibiotics (which thankfully ended 101/1/14.)  She played all day Sunday and barely slept until the early evening. She brought me her potato toy, her mouse, played with the ribbon toy, and played fetch with my husband.  She has played with the mouse almost every day since and has brought it to bed at nap time.  She has been cuddly at night, curled up in my lap for hours.  And last night, 10/1/14, she brought the mouse to bed at bedtime and I tossed it back to her and she jumped for it.  I continued to toss it and she continued to jump up on the bed to try to catch it and often she caught it with both paws-something she's not done in years.  
Myrna and Elizabeth

Elizabeth has finally finished her course of Clavamox antibiotic which has been difficult for her to take. It has caused great foaming of the mouth and much running away.  She really does not want to eat strictly Hills CD as prescribed but we are working on it.  I'm not as concerned about her lack of eating as I am with Myrna.  Why?  Because Elizabeth will eat something per meal, is drinking a lot on her own, and doesn't take heart meds that lead to dehydration and can, for a variety of reasons, damage her kidneys.  She's not starving at all. And she could lose some weight being almost twelve pounds.  Myrna, on the other hand, needs to eat and drink; must keep up her energy, support her kidneys so that they react properly to the heart meds.  And Elizabeth seems to continue to recover, is using her litter box faithfully, and does not seem to be in any pain or discomfort when urinating. 

Tuesday, September 23, 2014

Feline UTI vs. Idiopathic Cystitis-What's the Difference?

There is a difference between a cat urinating frequently due to taking lasix and one that urinates frequently because of an infection or other kidney/bladder health issue. There's also a difference between a cat that drinks a lot due to a kidney/bladder issue and one that is on lasix.  How do we tell the difference?  

A cat on lasix will  drink a lot of water and quite often, which is what we want to see.  The meds drive the cat to drink.  Drinking helps support kidney function; helps hydrate the body as the lasix withdraws fluids-which can lead to severe dehydration, which we want to avoid for numerous other health reasons.  And the frequent drinking combined with the diuresis process from the lasix, will drive the cat to want to urinate often, sometimes large amounts, possibly every 2-4 hours.  The cat will be comfortable using the box. But sometimes they may go out of the box as the urge to go so frequently may overwhelm them. Valium or Buprenex may work to ease their discomfort (search Valium to read why Myrna takes it for this very reason.) 

If the cat's NOT on lasix, then you can assume there's an issue with the kidney/bladder.  You may see the cat drink a lot of water and quite often as the body seeks a way to support kidney function and/or to help flush out any bacteria/crystals/inflammation in the kidney/bladder.  You will see the cat urinate a few times a day if an issue is just beginning or every few minutes with increasingly small amounts of urine when a flare-up is hitting.  Often, blood is in the urine.  The cat may also choose to go out of the box on paper, rugs, cold floors, blankets, etc. as the box may be uncomfortable to use.  You may see the cat sit in the box for a minute or longer trying to expel urine. You may see the cat push urine out, as if straining to excrete urine.   The cat must see the vet or ER vet as soon as possible.  

The typical protocol is for the vet to collect a urine sample by needle withdrawal so that the sample is clean.  They will check for bacteria or crystals, and check the WBC (white blood cell count).  A flare-up can occur if crystals formed in the bladder, irritating the bladder.  Crystals can also lead to a very painful blockage in the urethra.  This blockage is more dangerous for male cats than for female cats.  If your male cat urinates out of the box, it must see the vet or ER vet immediately to see if there is an infection or blockage.  Because a blockage can allow bacteria to enter the kidneys and cause other physical issues, often male cats will die from blockages if treatment is not sought early.   If the WBC count is high, that indicates an infection.  Often with only crystals in the urine, the WBC will be low.  With an UTI or actual bacterial infection, the WBC will be elevated.  The cat may also have a fever and will probably be in a lot of pain.  IV fluids or sub q fluids should be given to help flush out the bladder.  If there is an infection, pain meds and antibiotics such as Clavamox will be prescribed.  Without an infection, usually the vet will give pain meds and suggest that the cat only eat SO or CD wet and dry foods, foods that promote bladder health and fight the formation of crystals and help fight formation of bacteria.  The cat could also take Methigel, a urine acidifier which helps change the pH of the bladder to help prevent crystals and bacteria.  For other kidney/renal/bladder issues, there are other brands of foods for these specific issues. Ask the vet which prescription cat foods might work best.  Other tests that may be needed would be xrays to check for stones and an ultrasound to image the kidneys and bladder to look for other physical causes such as blockages, cancers, and for idiopathic cystitis.   Idiopathic cystitis is caused by a thickened, inflamed, irritated bladder, usually without bacteria or crystals present.  Pain meds to relieve the pain and the swelling and the irritation will be needed and probably a psychotropic to keep the cat calm, not only as it heals but going forward for the rest of its life.  This is what Elizabeth has had since a kitten but hasn't had a flare-up in over two years.  But this is what MSU believes is what she now has and not a UTI. 

We had been told by the ER on Sunday that Elizabeth had a UTI, that bacteria presented in the urine sample and that the WBC was elevated.  Except, it turns out, they captured the sample from the exam table and probably picked up bacteria there.  AND the WBC wasn't that elevated to point to an infection-the WBC should have been much higher had she had this bad of a flare-up due to bacteria.  So, after two days of urinating small bloody samples, and still doing so today, and because her regular vet couldn't see her (nor did they seem too concerned that she wasn't responding-they suggested we come back on Thursday when they do ultrasounds-THURSDAY???!!!), and because the ER didn't (in my estimation) handle this matter fully, I took her to Michigan State Vet Hospital. 

After four doses of Clavamox 62.5mg on Sunday, and more antibiotics Monday, she continued to urinate tiny amounts of bloody urine. It was unusual that she was not responding to meds.  We gave her plenty of Buprenex to relieve the pain and the fever but it didn't seem to help.  We also gave her 12ml of water by mouth every couple of hours.  We had a blanket and some washable rugs on the floor for her to use. When cats have UTIs or any flare-up that makes urinating painful, they will often choose soft fabrics and cold floors which feel more comfortable, which is what she did.  That's why we also kept her isolated in a bedroom and constantly scooped the litter boxes.  

At MSU, they are keeping her overnight for treatment.  They gave pain meds and IV fluids.  They cultured the urine; they did blood work; they did an ultrasound of the bladder.  They reviewed the xrays from the ER and the ER records.  The vet called to say Elizabeth is resting well with pain meds and IV fluids. She doesn't have a UTI. No bacteria in the urine sample they withdrew with a needle. The WBC in that specimen was low, too low for an actual UTI flare-up. Hence, lack of response to antibiotics. They will finish tests tomorrow; try pain meds for home and a psychotropic. They hope she will come home tomorrow if she responds to treatment.


Sunday, September 21, 2014

Cat Issues Abound on a Sunday-Myrna and Elizabeth

Myrna ok today. Not eating well. She sits at the bowl and eats for five minutes but nothing is really gone, just pushed around. She will eat dry food and dry treats. Has diarrhea due to antibiotic. I'm giving her yogurt, Forta Flora to help combat it; cutting out oily supplements; cannot really decrease water due to possible dehydration due to diarrhea; and will need to give water and liquid protein (tuna juice, KMR, corn syrup-just a touch of this) by mouth to support her general nourishment, electrolytes and kidneys and hydration levels.

Elizabeth presented us with a present first thing this morning-going out of the box followed by constant urination of dime size and smaller amounts every few minutes. Luckily, this time, all in a box. I secluded her in the bedroom; gave endless mls of water by mouth, two doses of buprenex of .2ml and then .15ml; and Clavamox 62.5mg pills (which are left over from this summer)-two of those between 9:30 a.m. and 1 p.m. She presented with blood in urine around noon. My husband took her to the ER because you can't wait 24 plus hours before the vet sees a cat that is urinating with blood. An infection can grow and infect the kidneys, not to mention who wants a cat urinating every few minutes around the house? Vet found bacteria and blood; will give us more Clavamox and Buprenex.
Myrna Loy


Elizabeth Taylor

Saturday, September 20, 2014

Myrna Responds to Clindamycin

Update-they gave Clindamycin oral liquid antibiotic to Myrna. I gave it to her last night for the first dose. She will receive it twice a day. She was still very active last night and "high" on Mirtazapine so she ate well in the evening and has, for the last two days while on Mirtazapine, been very aggressive about getting at our food on our plates. She hasn't been this aggressive in about fouryears, ever since she discovered toaster waffles. This morning, she was perky and alert, not at all run down as she has been the last two mornings before taking Mirtazapine. She ate well but is having difficulty chewing. So, perhaps she does have an infection or abscess in the mouth we cannot see and unfortunately will never be able to xray due to anesthesia which she cannot-and most HCM cats cannot-undergo. BUT it's clear the antibiotic is helping. Not sure if it will cause gastro issues as Clavamox has in the past but we'll see. When I pilled her, the roof of her mouth did feel differently, more open. So, perhaps she's not nauseous from poor kidney values. But her kidney values did increase slightly and enough to be concerned. I will give her supplements for kidney support again. Perhaps not eating well enough the last few days did drive up kidney values. We will retest in a couple weeks or so providing she continues to eat. Not sure how long she can be on an antibiotic or if it will be something we do ten days on, ten days or so off, and then wait to see if she returns to not eating and then try them again.

Myrna Develops Difficulty Eating and Has Poor Kidney Values-A Week Ago Values Were Fine

(Thursday, September 18, 2014)  Myrna isn't eating today and looks uncomfortable. She's needed extra 5mg lasix once a day since Monday and last night, we injected .25ml because breathing rate kept increasing. Rate decreased to 8 and seems good this a.m. But still it's something else. She's not eaten well enough all week and has trouble chewing. Have appointment with regular vet this afternoon and might see cardio tomorrow.

(Later in the day)  Myrna at vet today. Took xrays, CBC/chem panel with pancreatitis test, UA, blood pressure (100-102) and heart rate (162.) Both vet and cardio happy with bp and heart rate-sort of low bp but she handles it well and it's due to meds; sort of high heart rate but high due to vet visit and so assumed to be more normal at home and at rest, and it's lower than it was last week at the cardio visit. Cardio believes she's handling the increase in atenolol (now BID) to lower the heart rate. Xrays showed very slight congestion which we knew but no harsh sounds in lungs and no heavy pockets of congestion-good news. Her mouth, teeth, gums all seemed normal. Problem may be due to nausea, stomach acid or stomach upset. She responded well to Cerenia-a stomach calming med late in the afternoon; and ate very well beginning a minute after I gave her 1/8 of Mirtazapine.  Will suspend all unnecessary supplements for a few days. Will know blood and UA results tomorrow.

(Friday, September 19, 2014) The vet called with blood results for Myrna.  It's troubling.  In one week Myrna's BUN up to 41 from about 30 or so-but had been normal; creatinine from 2.7 to 3.2 or more-can't remember exactly. They think decline in kidney function is due to increase in lasix and the shot we gave Wednesday night caused the kidneys to hit their limit which does not bode well for her future ability to take more lasix if needed.  She needed mirtazapine yesterday and today to eat. She may need to take Pepcid. Now taking Cerenia. Concerned with difficulty eating so will give an antibiotic in case she has a tooth abscess that can't be seen . Not eating much last couple days and not eating at all Thursday until late in day after the blood work,  may have also driven up kidney values due to some dehydration-which is why you must give cats liquid food and water by mouth when they are not eating or even eating well enough. Will decrease lasix cautiously.  Currently on 18, 13, 15, 18mg per day; will cut back to 15, 13, 15, 18mg per day.   This puts her between a rock and a very difficult place: the afib in the heart which is a recent development will make it difficult for the heart to beat well enough to handle pumping and blood flow and congestion; a decline in kidney function will make it difficult for kidneys to process the diuretic process demanded of lasix.  The demand on both the heart and the kidneys will increase and yet the function will decrease. 

Tuesday, September 9, 2014

Myrna's Bloodwork Shows Some Improvement-Extra Vitamins and Supplements Might Be Helping

Myrna's blood lab work looks really good.  The high glucose, sodium, and magnesium levels from July have decreased to normal; her BUN has decreased to normal; the creatinine is slightly higher (was 2.2 now 2.7 but was 2.7 in June.)  Her potassium level is up to 5 from around 3.  The vet believes the vitamins and supplements we give is doing a good job so far in assisting the kidney function.  

Myrna receives potassium tablets, sweet potatoes-excellent source of potassium, magnesium, iron, krill oil, COQ10, Vitamin E, iron, B12, and club soda (bicarb), and apple cider vinegar cut with water.  She will need more omega 3 and potassium and magnesium to try to combat the atrial fibrillation that has suddenly developed (blog post 9/8/14.)  And she will need more potassium and magnesium and vinegar to assist kidney function.  We need to determine the additional amounts required.  But it's all a guess, really. There's no research that I've found that says a 10lb cat requires an additional x#of mg/ml. 

Here is the vet's email:

"Her creatinine is mildly elevated at 2.7, but her BUN is normal and her electrolytes are all normal.  Your efforts have been fruitful as her potassium is at the high end of the normal range - this is fantastic.  Her urine is dilute as a result of her high diuretic doses.  Believe it or not, this is an indication the her kidneys are functioning - it requires effort from the kidneys to dilute the urine to a lower-than-normal specific gravity.  These lab results all indicate that is is reasonable to move forward the the increased Lasix dose that we discussed yesterday.  You can start the increased dosing of atenolol tomorrow as long as Myrna is feeling like her normal self.  If she is fatigued, weak, or breathing abnormally, we'll hold off a little longer."

(Lab results are only some of what was tested)

Urine Lab Results:
Color YELLOW
Appearance CLEAR
Specific Gravity 1.012 
pH 6.5  (5.5-7.0)



Blood Lab Results: 
Total Protein 6.7 g/dL  (5.2-8.8)
Albumin 3.7 g/dL  (2.5-3.9)
AST (SGOT) 31 IU/L (10-100)
ALT (SGPT) 78 IU/L  (10-100)
BUN 31 mg/dL (14-36)
Creatinine 2.7 mg/dL ().6-2.4 HIGH)
Phosphorus 4.3 mg/dL  (2.4-8.2)
Glucose 117 mg/dL  (64-170)
Calcium 10.2 mg/dL  (8.2-10.8)
Magnesium 2.5 mEq/L  (1.5-2.5) 
Sodium 153 mEq/L  (145-158)
Potassium 5.4 mEq/L  (3.4-5.6)


Monday, September 8, 2014

Myrna's Heart Develops New Complication-AFib

Myrna had her regular check-up with the cardiologist today. She has developed an arrhythmia due to atrial fibrillation.  This is a new complication that will make management of the disease and congestion difficult. And there's very little we can do.  Yet, while this is a new complication, it comes after almost five years of the disease.  Many cats develop it sooner or die of HCM too soon to develop a fib.  And she continues to battle congestion or Congestive Heart Failure.  The cardio reiterated that Myrna is the only patient she and her practice partner Dr. Brown has ever seen with the heart size of Myrna (2.2) that continues to live as long as she does and do as well as she does with the ongoing CHF.  (Good vitamins and supplements, plenty of meds and correct dosing and adherence to the strict schedule, and vigilance on our part as to changes in her physical condition and reactions, and the best damn cardio team all play their part.)

Myrna Loy
She has been suffering with congestion all summer long.  It comes and goes and we deal with it by determining when she needs extra lasix: usually it is when her breathing is above her "normal" breathing rate of  32 a minute (a cat is usually around 24) or when she is breathing hard, making a hard push through the chest cavity.  When she is breathing steadily at 32 and it is not difficult but has a third "bump" in the chest cavity (in, out, BUMP; in, out, BUMP) then we know she needs the inhaler.  That BUMP shows up near the back, near the end of the ribs as she physically makes an effort to exhale.  There have been times when she is breathing above 8 or hard AND has that third BUMP in the breathing process through the chest cavity.  That's when we not only give extra lasix but give a dose of the inhaler as well. And that is the most effective protocol for us to follow.

There are concerns with the inhaler as it can be contraindicated with atenolol, the beta blocker that slows down the heart rate.  The inhaler is inhaled and absorbed into the bloodstream.  If it builds up, it can increase blood pressure and have a negative interaction with atenolol (a process that involves antagonists, beta 1 or 2 receptors, bronchodilators and constrictors,etc.-a process I do not understand well enough to explain.)  We are to give it in the a.m. and p.m. and only in between as needed, which we have been doing.  But the cardio hopes that with cooler weather, the need for it twice a day may decrease.

The arrhythmia was heard via stethoscope and was confirmed via ECG.  The echo showed atrial fibrillation, a process by which too many electrical impulses disturb the heart rate making it erratic.  The heart cannot pump or contract (systole, diastole) correctly.  This allows blood to flow between chambers but without the heart muscle reacting.  This means the unused heart muscle will over time become potentially weak like any muscle that is unused.  This will create a myriad of complications: will make it difficult to fight congestion; will cause a lack of efficient and sufficient circulation of blood and oxygen; will lead to weakness in her body, etc.   From Pet Place website:

"Atrial fibrillation (AF) is a common electrical disturbance or arrhythmia of the heart, marked by rapid randomized contractions of the atrial heart muscle causing a totally irregular, often rapid , ventricular rate. In this arrhythmia the normally coordinated electrical activity in the upper heart chambers, the right atrium and left atrium, is lost. The muscle of these chambers begins to wiggle like a "bag full of worms." Atrial flutter is similar to AF, but the atrial contractions are rapid but regular. Both rhythms are very abnormal and reduce heart function." 

This weakness is already showing up.  She has lately been lacking an ability to jump up and down and to land well enough depending on the angle of the jump.  I was afraid her rear leg pulses were getting weak but they are now strong at 130.  But that is also due to her heart racing at 150-190 (as it was today in the office.)  No, I don't know how a heart cannot contract sufficiently and yet produce a high heart rate.

Because the heart rate is up, and we need to prevent a racing heart, the cardio prescribed additional daily atenolol and she will begin to take it twice a day or BID-1/4 of a tab BID.  Her lasix medication levels will change as well from 15, 13,15,18 mg to 18, 13,15,18mg a day.  (She receives lasix four times a day.)

She also presented with a touch of pleural effusion-fluid around the heart and lungs-in the pericardial-but not enough to aspirate.  But they gave a lasix injection and additional lasix at home may be warranted. But again, this is a troubling sign and due to the new complication.

"Pericardial effusion, sometimes referred to as "fluid around the heart," is the abnormal build-up of excess fluid that develops between the pericardium, the lining of the heart, and the heart itself."

The blood work comes back tomorrow and I'll know more then how her kidney values are doing and if the supplements I've been giving are helping.

She still has a clot in the heart but nothing has broken off that can be seen.  So far, so good.

Here are the cardio's notes: 

The new complication that myrna is presenting us with is an arrhythmia (irregular heartbeat) called atrial fibrillation.  A fib is a persistently irregular heartbeat that results from severe output (amount of blood circulated to the body.) This can result in a relapse of congestive heart failure, generalized weakness, and/or blood clot development.  I am happy to say that it does not appear as though Myrna has experienced a blood clot [Editor's note: In the rear legs. There is one in the heart.].  There were none of the hallmark abnormalities during her examination today and she had normal blood pressure in both of her hind limbs. (130mmHg on the right and 126mmHg on the left.)  [Editor's note: I had been concerned that her rear legs were weak due to low pulses.]  Rather, it appears that her weakness is a result of the new arrhythmia. Unfortunately, the arrhythmia will persists throughout her life-we cannot eliminate it entirely. However, we can improve control of her heart rate by increasing her dose of atenolol.  She is a good candidate for this adjustment because her heart rate is higher today (190/min on the ECG) and her blood pressure is normal.  There is a small amount of fluid accumulation around her heart and lungs today (pericardial and pleural effusion), indicating that we're not keeping up with her congestive heart failure treatment as well as we would like.  We will need to increase her dose of lasix to better manage her heart failure."