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The Duncan Journal

Introduction

Duncan was recently diagnosed with Chronic Renal Failure and Restrictive Cardiomyopathy. We hope that by writing about our experience with Duncan, we will give newcomers to feline CRF the small comfort of knowing that they are not alone.

March 11, 2007

Duncan

Duncan Lionheart Magickcatte and his litter mate, Joseph Campbell Magickcatte, were born on March 13, 1998. We brought them home in May (Mother’s Day) of that year.

We have always been somewhat concerned that Duncan’s creatinine number during annual blood tests was high normal or even a little beyond high normal at times. Some years we had it re-done and it would then be within normal range. We were never quite comfortable about this.

The First Crisis

In late January, 2007, we began to notice that Duncan, who was always an enthusiastic eater, was turning away from his food bowl. We also noticed a slight increase in urinary output but we couldn't be sure at first which cat might be peeing more. Though Duncan did not appear sick other than sometimes not wanting to eat, we had a blood test done on February 8, 2007.

The next day we were shocked to hear that Duncan’s BUN (98) and creatinine (8.2) numbers were so high. In addition, his phosphorus was far beyond high normal at 11.9. His specific gravity was very low at 1.015.

We knew that he needed IV fluids and we wouldn't leave him at our regular vet’s office with no staff in attendance overnight so we took him to our local emergency and critical care facility where he would be monitored constantly. Both our vet and the ER doc were leaning towards this being an acute renal event. The possibilities were a urinary infection or a kidney stone since his white blood cell count was elevated. A urine culture was done and came back negative. His medications while he was on IV fluids were Pepcid AC, Alternagel and Ampicillin.

We visited Duncan twice a day and each day his BUN and creatinine numbers came down. His creatinine was decreasing by approximately 25% every day. He was not eating well and his liver values were being checked daily since hepatic lipidosis was a very real concern. We were reluctant to give him an appetite stimulant based on our personal experience with Avatar, so the vet techs began assisted feeding instead. Fortunately his liver values remained within normal range.

We felt all along that this was CRF and a few days after Duncan had been on IV fluids, the ER vet we were working with was inclined to agree.

The first few days that we visited Duncan, he seemed happy to see us though obviously stressed. On his third day of IV fluids, Duncan seemed extremely distressed when we visited him. He was holding his head in a strange, rigid way that is hard to describe. He seemed to be much too upset to even notice that we were there with him. We began to seriously consider bringing him home sooner than planned because of his agitated state. We discussed it with the vet.

Our plan was to get him home where he would be more comfortable and we could start administering sub-Q fluids. We had not been aware (or hadn’t remembered) that a cat has to be weaned from IV fluids so we had no choice but to leave him there for a couple more days. His blood pressure continued to be high. He was throwing up everything they fed him.

We had hoped that on the fifth day of Duncan’s hospital visit, he would be able to come home. Each morning, Carol would get a report from his ER vet by telephone and on this morning, Carol was told that Duncan was pulling out his IV and chewing on it. He was still throwing up his food and they started giving him Reglan in addition to Pepcid AC. Carol had noticed the night before that Duncan's respiration rate seemed slightly elevated and that morning the vet told her that Duncan was having some respiratory distress with respiration of 60 at times. Normal respiration is 20 to 30 but no more than 40.

IV fluids were stopped. The vet recommended a chest x-ray and did it immediately. They found fluid build-up in his lungs and his heart looked “a little big” on one of the x-rays. He was transferred from the ER vet to an internist at this point.

The Diagnosis

Fortunately, the internist had a cancellation that day and was able to do an echocardiogram within a short period of time. Though Duncan was in the oxygen cage for five hours, we were told it wasn’t a life-threatening situation. The internist called us in the afternoon with the awful news that Duncan had restrictive cardiomyopathy. Both the right and left atriums of his heart were enlarged. In addition, there was fluid around his heart. During the echocardiogram, the vet also examined Duncan's kidneys and while they both looked somewhat abnormal, the right kidney is smaller than the left. Chronic renal failure was confirmed.

After Duncan had been in the hospital for nearly seven and a half days, we were finally able to bring him home along with his medications, a bag of Ringer's solution, an administration line and a handful of needles. It is about 10 miles from the veterinary clinic to our house and Duncan’s constant meows on the ride home were distressed and even sounded angry. Once we got him home, he immediately went under a bed and there he stayed for hours at a time. His litter mate, Joseph, kept vigil on the floor by the bed. Eventually Duncan would come out for brief periods but still would go back to his safe spot frequently. Over time, he relaxed and ceased to hold his head rigidly at a strange angle.

Now we were faced with several problems. Duncan is one of those cats who panics when he is immobilized. We had to pill him three times a day and administer 100 ml of Ringer's solution subcutaneously once per day. We faced this with some anxiety. Although we have had this web site online for more than ten years and have both assisted with the administration of fluids many times, neither of us had ever done the dreaded 'stick'.

Fluids

When Avatar started getting sub-Q fluids more than 11 years ago, we took him to the vet's office (which was only a couple blocks away) every other day. This time, we were determined to bite the bullet and do the fluid therapy ourselves.

We set up a fluids station on the kitchen counter and prepared for the first session with much trepidation. It was decided that David would do the stick and Carol would assist by holding Duncan. For the first few sessions, we had the assistance and support of our friend and website colleague, Sandy Carr.

With two people holding him in place, Duncan wanted badly to get away. As we said before, he panics when he feels trapped. To make matters worse, even though he has lost some weight, it is very hard to raise a tent of skin on his back. Making that first stick was extremely hard. Somehow we got through the first session and were physically and emotionally drained by the experience.

The second day was worse than the first and we were beginning to wonder if we would ever get better at it. There were several days when he got less than 100 ml, but we didn't give up.

We noticed that, although Duncan was struggling when being held down, he was tolerating the fluids themselves quite well. He didn't seem to mind the stick and when the sessions ended, he walked over to his food bowl as if nothing very bad had happened.

We began to use less forceful restriction. Carol now places a hand on Duncan's rear-end and another on his head. Instead of holding him down, she is just keeping in contact. Duncan no longer panics and the job is getting easier for all involved.

We even survived our first instance of bleeding from the injection site. You should know that it happens occasionally. So far it has only happened to us once and while it proved to be inconsequential, we'd prefer that it not happen again. Click here to read the full story of how we went from nervous newbies to proficient caregivers.

Food

Duncan never ate canned food in the entire eight years of his life. After he got home from the hospital, he showed no interest in the upper-scale dry food we had fed him before. Though we brought some canned Hill’s k/d with chicken home we assumed that he would not eat it. And he didn’t... until Carol assist-fed some and got him jump-started. Since then he has been eating it every day along with Hill’s dry k/d and other dry foods. He has absolutely no interest in the dry food that he ate for so many years.

While his appetite is not what it used to be, he is eating without too much coaxing.

Attitude

Four or five days after he got home from his IV fluids, we began to see signs of the old Duncan. He was obviously much more relaxed and began to behave as he always had, snuggling with Mom, playing with his brother and stretching out for naps in the sun.

We had been told that he should not have much exercise owing to his heart condition and that he should not jump or play with his brother or exert himself. We feel that the only way to stop him from doing those things would be to put him in a cage. We want him to be a cat and enjoy his life so we watch him carefully but we may not be as strict as we should be.

Shortly after Duncan’s cardiomyopathy diagnosis, a friend sent us a beautiful blue (to match his eyes) set of carpeted stairs. He and Joseph both use the steps now to get to the bed rather than jumping from the floor.

Follow up

On March 6, 2007, we took Duncan for a re-check and his BUN was 33 and creatinine was 3.6. His blood pressure was high and we are in the process of acquiring a stethoscope to monitor his heart rate which was also high. In addition, we have purchased a baby scale to keep track of his weight. Since all other numbers were in normal range, the only medication we give him now is a half (.5 mg) of a Pepcid AC per day. He continues to eat Hill’s k/d and miscellaneous dry foods.

The Future

We will be taking Duncan in for follow-up echocardiograms and blood tests on a regular basis. His most recent echocardiogram looked fairly normal, the doctor said.

We plan to add to Duncan's Journal from time to time. We will take you along as we ride this emotional roller coaster.

Update - July, 2007

Since March, Duncan has been faring amazingly well. Many people have asked us how he is doing, so we felt an update was called for even though there have been no new clinical developments. 

July 24, 2007

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In March, 2007, Duncan was down to 14 lbs. from his highest weight of 16 lbs. Now, he is heading back up to 16 lbs. again. It is usually a wonderful thing for a CRF cat to gain weight, however we are concerned that it will have a negative impact on his heart condition.

While Duncan will sometimes eat Hill's k/d and Purina NF, it is not what he prefers. He shunned his regular Iams immediately after his hospital visit but he gradually began eating it again and he has now regained much of the weight he lost.

Once Duncan recuperated from his traumatic hospital visit of eight days in February, he became more active and playful than ever before. Though he has always been a very happy cat, his weight did prevent him from doing some of the more acrobatic moves his brother Joey so gracefully performs. In April and May, before Duncan started to regain his weight, he often took the lead in kitty games. We have begun calling him ‘Kitten’.

Duncan is still getting 100 ml of sub-Q fluids daily. We have all settled into the routine and Duncan often purrs during fluids; sometimes he will wash his paw or playfully bite at Carol's nose as she tells him what a handsome and good patient he is.

We have refrained from having frequent blood tests done since he is obviously doing so well; we will have blood tests done when we next take both boys in for their regularly scheduled checkups. Though Duncan vomits occasionally, it is something he has always done even as a kitten. We have reduced his daily medication to a quarter of a Pepcid AC.

All in all, Duncan is a happy cat and he obviously does not feel sick. We attribute his continued well-being to his daily fluids.

We know this idyllic state of affairs can’t last forever and we are grateful for every day we have with our precious boy.

Update - January, 2008

We have gotten many requests for an update on Duncan's condition. There has been no change in the clinical picture but we felt that an update was appropriate.

January 5, 2008

 

 

 

 

It was a year ago this month when Duncan was diagnosed with CRF and cardiomyopathy and he is doing well.

We are still giving Duncan 100 ml of sub-Q fluids (also known around here as "kitten juice") once daily. He is a perfect patient now. This experience has become so routine that he will sometimes casually wash a paw, nearly always purrs, and frequently gives Carol love bites on the nose while David handles the “stick”.  Fluids administration has become so easy that David can do it alone when Carol is out of town.

Duncan is still getting a quarter of a Pepcid AC daily. Here, too, he has become far more cooperative than he was a year ago. Pilling him is extremely easy.

His appetite is very good (mostly Iams Digestive Care). In fact, his weight continues to rise. This causes us some concern as it is bad for his heart condition.

Duncan 's last echocardiogram was on August 30th and his internist advised that his cardiac disease appeared stable at that time. His BUN was 34 and creatinine was 2.3.

Duncan is a delightful boy. All one has to do is look at him or walk by and he starts purring. He is very happy right now and we are very pleased with his progress over the last year. The photo, above, was taken at Christmas, 2007.

Update - March, 2009

There have been no CRF-specific changes in Duncan's case, but he has had a few other problems recently.

March 31 , 2009

 

 

 

Duncan’s latest labwork (this month) indicates that his chronic renal failure is still being managed very well. Creatinine is slightly above high normal and all other numbers are within normal limits. He has been having some problems of a different nature in the past couple of months. What started as bloody diarrhea has now evolved into chronic constipation. Once his diarrhea was under control, he began to lose weight as he wasn’t eating well and bowel movements were few and far between. He has had x-rays, ultrasounds and several enemas done over the past few weeks. He stayed overnight twice at the veterinary clinic, one time was on his 11th birthday. He has had to take an appetite stimulant (cyproheptadine) along with lactulose and cisapride.

Though he is now eating again and has gained back some of the weight he lost in the last six weeks, we are still giving him the liquid meds (in gelcaps because he really hates taking liquids from a syringe) and hope he will eventually get back to normal. There is no diagnosis other than chronic constipation and possible inflammatory bowel disease. Because of his issues with CRF and cardiomyopathy it is not recommended that we do an endoscopy/colonoscopy on him.

Update - November 4, 2010

 

We lost our dear boy today. He fought with dignity and unfailing good nature all of the following conditions for nearly four years: chronic renal failure, restrictive cardiomyopathy, chronic constipation issues and an (unable to be diagnosed) ailment similar to mild seizures. In the last week his kidneys shut down completely and there was no hope that he would be able to bounce back this time. He had been doing so well for so long.

On October 24, 2010 we took him to his internist for what we thought was another bout of constipation. He stayed overnight and was treated with enemas. On October 28th we rushed him to the vet because he was straining in the litter box and could not urinate. We were worried that he was blocked. He was not blocked but was obviously in some difficulty. Though he did begin to urinate, it was not as much as normal. The urinalysis showed some blood in his urine but no bacteria and his white blood cell count was normal. He was not eating well but maintained his good nature and still purred and interacted with us.

On November 3rd, he began licking his lips and shaking his head. He was becoming lethargic and not drinking or eating. We were now extremely concerned and spent a very frustrating day trying to get an appointment immediately somewhere for him with no success. That night we took him to an ER facility that is a referral specialist vet practice during the day time hours. His bloodwork showed a BUN of 130, creatinine of 13.6, phosphorus of 16.1, potassium 7.0. In a futile effort, hoping against hope, he was put on mild IV fluids overnight. However, in the morning his BUN was 260, creatinine was 27.2 and phosphorus was 32.2. There was fluid in his lungs and his heart was extremely enlarged. The lip licking and head shaking were due to mouth ulcers, a result of end stage renal failure. It is possible that he also had a kidney stone and would not have survived the surgery to remove it.

There was no question or discussion over what should be done. There was no choice because nothing any vet could do would save his life but we could save him from the suffering and pain that would ultimately overcome him. Though we miss him terribly, there is some comfort in knowing that he did not suffer and peacefully went to sleep in Carol's arms.

Photography © Carol Statton DiFiori

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