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:
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." 

Jimmy Stewart Has a Follow-Up with Vet Post Dental Surgery

Jimmy is recovering well from dental surgery.  He had blood drawn last Thursday and the vet called Friday to say she doesn't think he's pre-diabetic.  His glucose was normal at 92.  All other values are normal.

When he was at Michigan State on August 20 for surgery, his glucose was 320-but that was after he had been in the car for over an hour and at MSU for over an hour before they drew blood.  So, it could have been elevated due to stress.   But the surgeon was concerned that he was pre-diabetic. The fructosamine test was also high.

The regular vet thought the elevated glucose was due to stress because whenever he's had blood drawn at the regular vet's office-because it's close to home and he has less time to be stressed-the glucose has been normal.

And it has nothing to do with how well the kidneys are or are not functioning (in his case, at this time.) The regular vet said that when glucose gets above 250-280, that the "extra" will spill over into the bloodstream regardless of kidney function.

However, we had also been feeding him a different cat food for the two weeks between surgery and the blood recheck which could have affected the outcome.  The food was Fancy Feast Classic which has no gravy, therefore, fewer carbs.  And we were also feeding Purina Naturals grain free food which supposedly has fewer carbs.   That could have caused the difference.  We will know more when we recheck the fructosamine at the end of the month.

When kidney function has declined, it is possible that sodium, glucose, magnesium, and many other blood values will increase.  If all blood values are normal except glucose, then it is possible that a cat is diabetic.  If there are spikes in glucose, then the cat could be pre-diabetic.  And while the fructosamine test is suppose to be the standard for determining if the cat is diabetic, it acts as a historical aggregate of glucose levels.  So, even when glucose is falsely elevated due to stress, the fructosamine will reflect that history.
Jimmy Stewart

Monday, September 1, 2014

Baby Has Thyroid Condition? Vet Not Really Sure

Baby has had her thyroid values checked twice this summer. I took her to the vet back in the spring because she was acting funny.  Strangely enough, I thought she had a heart condition but she wasn't the one that turned out to have a heart murmur-that was Katharine.  Subsequent echo shows Katharine has a slight normal murmur but no indication of heart disease but will need annual echos.  She is Myrna's sister so could be predisposed to heart disease.  Meanwhile, Baby's thyroid values-T4 was 64, T3 1.1, Free T4 was 45, Free T3 was 3.4.

I have no idea what this means and the vet is unwillingly to put her on any meds yet.  Further testing and scans will be needed, probably at Michigan State Vet Hospital.   Baby has a check-up in November but I'm not sure if we should wait until then. Will need to discuss this soon with the vet. 

Jimmy Stewart to MSU for Dental Surgery-He Might Also Be Diabetic

At MSU for Jimmy Stewarts dental surgery. He was very calm in the car. Nervous being examined but so well behaved.

Despite June's fructosamine test that showed normal glucose-after the regular blood test showed an elevated level; and last weeks glucose was normal-Jimmy's glucose today is high, urine glucose is present and high (shouldn't be present) and fructosamine shows high. They believe he might be pre diabetic. Inflamed teeth could be causing pancreas reaction-it deals with body's inflammatory response; and stress does add to elevation; and internal dehydration-which shows in high albumin level-when that is not related to liver disease-may add to higher glucose. But fructosamine level is key. Once home and healed, need to retest blood and urine but now need to feed a diet low in carbs, high in fiber like humans. Control of spikes of sugar levels is key with diet and control of diabetes in the future.

Four teeth to be removed. Vet says we must brush every day every cat's teeth. If you can decrease gingivitis you can slow effects and resorption when it is active.

From the doctor's notes: "Feline resorptive dental disease...this incurable condition is the result of infection and inflammation at the gumline causing cellular growth that degenerates tooth crowns. Unfortunately, the only therapy is the removal of the affected teeth.  Daily home care and regular dental cleanings...are recommended..."

This is why I go to MSU for dental surgery and this is why it is important to take blood work and take it again.  Yes, we had normal blood values a week prior to dental surgery but MSU wasn't happy with the glucose levels. Had we not retaken both the blood work and the fructosamine tests, we may not have known about the possibility of a pre-diabetic existing condition.  Any other vet would have done the surgery; I would never have had the informative discussions with the dental surgeon about glucose and urinating out of the box (it can be a leading cause because the sugar spikes and makes the bladder feel full and creates an urge to dump the urine/sugar) and how spikes in glucose work and why diet is key. 

Feline Heart Patients-Heart Size Might Matter and Potassium Support in the ER May Be Key

Coopers heart left atrial went from 1.9 in May to 2.3 with Friday's echo. That's a large jump in a short time. In comparison, in March, Myrna's left atrial was 2.2. I do not have any notes on what it was in June although I do know the cardio said it was stable. She sees the cardio again in September and we'll see how things are then.

Coopers potassium level in July was 3.6-low but decent. It was about the same Friday but tanked hours later in the ER to 2.4. Perhaps a lack of potassium support in the ER (doesn't seem to be noted in chart records which I obtained unless I missed it) and not having had his daily doses of potassium pills and sweet potatoes since Thursday is the key to why the kidneys could not function well enough to get rid of congestion on Saturday. Yet he was still urinating large amounts in the ER. But something was causing the fluid to not leave his lungs. Low blood pressure-which is why he was on dopbutamine-is also a clue. I'm not sure I can solve the puzzle. Vets assume the kidneys hit a tolerance to diuretics and can do no more. But potassium support in the ER seems necessary if potassium declines.

Supplements to Use to Improve Feline Kidney Function

We mix krill oil-about 100mg depending on size of oil we buy, COQ10 100mg, vitamin E oil 100IU, (was using vitamin C powder-just a smidge-but concerned about negative interactions with heart meds), and about 1/2 ml of water, and about 1/8 of Gerber Baby's First Foods Sweet Potato into a small bowl.  I syringe it into a 3ml syringe and give it by mouth to Myrna (and was to Cooper.) It did help to improve Cooper's kidney values somewhat. We will see in September if they are improving Myrna's values or not. 
[Editors note: September blood work showed improvement for kidneys to filter out sodium, glucose, magnesium-values that were high in July; BUN dropped slightly from 34 to 31-a normal level, although creatinine rose slightly to 2.7 from 2.2)

 We give almost 1 ml of apple cider vinegar by mouth to combat stomach acid and to help the kidneys by preventing metabolicacidosis. I mix one part vinegar and one part water or more water as needed so that the cat can tolerate it.
 I ordered this from Amazon.
 This was ordered from Amazon.
 Nature Made and Sundown supplements seem to work well for Myrna. I give her 1/2 iron three times a week.  The Sundown Potassium is inexpensive but works well. I give 1/3 of a pill to her four times a day.
 I give 1/2 a B12 twice a week.  I give 1/4 of a magnesium three times a week.