I'm not sure if my cat has CKD or some other underlying problems  

By the way, I forgot to mention that the proteinuria the vet told me 1+ was after I asked him. Before this, he told me the protein in the urine was +100, and I had no idea, so I asked him, and he told me it was like 100 micrograms... and yesterday I used a test strip to test, it was negative, although I don't know the sensitivity of this. Anyways, I hope all these makes sense, and looking forward to seeing the reply. 

Thanks in advance,

Nicole Chu

By the way, I forgot to mention that the proteinuria the vet told me 1+ was after I asked him. Before this, he told me the protein in the urine was +100, and I had no idea, so I asked him, and he told me it was like 100 micrograms... and yesterday I used a test strip to test, it was negative, although I don't know the sensitivity of this. Anyway, I hope all this makes sense and await your reply. 

Thanks in advance,

Nicole Chu

@nicole Thanks for the added context. Dr. Vanderhoof should answer you soon! In the meantime, I'm pulling in one of our other vets so she can share some insights as well.

Hi Nicole, 

I’m sorry that you’ve been going through this with your cat, I’m glad that he seems to be improving. 

From what you’ve described and the blood results, it appears that your cat was in acute kidney failure/acute kidney injury and has responded well to fluid therapy so far. With acute kidney injury it can be hard to tell if there was any pre-existing kidney disease (acute on chronic), what the cause of the acute injury was and if the kidneys have been damaged/are functioning less after an acute injury. 

I would usually recommend further investigations like X-rays and an ultrasound to assess what the kidneys look like (e.g. is there signs of damage to the kidneys, are there any kidney stones etc.). This might also help to try and find out why this happened, is it possible that your cat ate any toxins or was exposed to poisonous plants? 

Along with monitoring urea, creatinine and potassium along with the usual blood panels, I would also recommend checking SDMA which is an additional marker for kidney disease. It’s important to recheck the urine specific gravity also. 1.018 is quite low but it was during fluid therapy so it wouldn’t be a reliable result. If his urine specific gravity began to increase and his urine became more concentrated (>1.035) that would be a positive sign. I would also recommend to check his blood pressure and UPC. 

This will help you to assess the damage to his kidneys (hopefully minimal) and stage any kidney disease that he may have. Although his kidney levels have returned to normal, most cats that have had an acute kidney injury are likely to have some stage of kidney disease, even an early stage 1, but more tests would confirm if this is the case. There’s more information on this here; 

http://www.iris-kidney.com/education/differentiation_acute_kidney_injury_chronic_kidney_disease.html#text=In%20most%20cases%2C%20differentiation%20between,diarrhea%2C%20inappetence%2C%20and%20lethargy.

In terms of metabolic acidosis, it is quite common with kidney disease and the most likely cause of this in your cat’s case as the kidneys wouldn’t have excreting acid like they used to before. This may have normalised now as you’ve been treating it and the uremia has resolved with fluids. However I would recommend rechecking these bloods again and a recheck with your vet considering that your cat has diarrhoea and increased breathing rate which can be signs of this. 

The diarrhoea may be a consequence of multiple things (e.g. the kidney injury or acidosis) but as you say he has also been on antibiotics so some probiotics would be a good idea along with any treatment that your vet may prescribe for your cats tummy. 

To summarise, it’s great news that your cats kidney levels have returned to normal and that he is getting back to himself. In order to assess if CKD (and what stage IRIS) is present he would need some repeat blood and urine testing along with SDMA. X-rays and ultrasound would be helpful in addressing any underlying causes. 

I hope this helps and feel free to ask anymore questions, 

Aisling 

@mcrustawildernesscat-com Thank you for doing this. I really appreciated it. 

@aisling 

Hi Aisling,

Thank you for your generous help, it means a lot to me.

Besides all the info we’ve talked about, I’d like to mention several more things. The first day we went to the vet, after the CREA and BUN result, the vet told me that my cat got to stage 3 CKD. As you mentioned, we need to do the SDMA and UPC. But here is unable to perform all that. I mentioned UPC to the vet, he seemed doesn’t know in the first place, then I said in Chinese, and he said they don’t do that. It made me doubt him even further. After several days of treatment, my cat seems better, so we did the ultrasound. The vet told me that his kidney has a bit poor corticomedullary differentiation, also hyperechoic. The Vet said even more than the spleen. But as he said, the size of the kidney was around 4.1, if I didn’t remember wrong. I didn’t get the report so I can’t be sure all that was correct. I think I need to redo the ultrasound.

Regarding the acidosis, I gotta say that he was normal when we went to the vet. The only thing not correct was BEecf, which is around -5. Along with ultrasound, we did blood tests as well. Then the result turns abnormal as I mentioned before after the treatment vet gave to him.

We also checked his bp, which was above 160 as far as I can remember, a bit high. But that was when he felt super stressed and nervous. After that, the vet just told me to buy telmisartan to control his proteinuria and along with other meds and SubQ to give him lifelong treatments. 

His diarrhea and breath rate became normal and regulated after the probiotics, anti-diarrhea meds and sodium bicarbonate I gave him. His appetite seems quite good lately. Indeed he seems to have polydipsia. And I’ve been recording how many times he pees in a day. Usually will be 4-5 times around and sometimes exceed like 6. I’m afraid that he will get dehydrated again, so I was thinking to give him subQ with Ringer's lactate solution that the vet mentioned before. But Idk if it’s correct.

In conclusion, is it possible to get to know which stage of CKD my cat has without doing the UPC and SDMA? How many times of blood tests, urine tests (only gravity and protein), and ultrasound need to perform to confirm which stage of CKD he is in? Become I was planning to take him to the vet after 3 months as right now he is feeling better, besides he is really scared of people (a lot). I don’t know if this is the right way to ask, bcoz here they said I’m a bit over-worried(coz I usually ask them a lot), but I really need to possess some knowledge of this due to the place where I live don’t have many vets and not being that much reliable. I really appreciate your help.

Thank you in advance,

Nicole

@aisling 

Hi, 

I just got some of his ultrasound reports, I just uploaded some due to the file size limitation. 

Could you help me to have a look either? 

Thank you in advance, 

Nicole

Hi Nicole,

I’m glad to hear that your kitty is feeling better. Here are my thoughts.

One, I agree that some kind of acute kidney injury may have taken place as Dr. O’Keefe suggested. If the WBC count was high and antibiotics may have assisted with your cat’s recovery, a kidney infection (pyelonephritis) could certainly be higher on the list, but a toxin could be possible as well. Some cats can have a quiet, subclinical pyelonephritis that can become more critical and cause kidney injury. Cats with pre-existing kidney disease may also develop a urinary tract infection that is not noticed because the cat is already urinating more because of early CKD and then it gets up into the kidneys, causing pyelonephritis. 

When a pyelonephritis is treated, it would be expected in many cases for the cat’s condition to improve a lot with fluids and antibiotics, but some kidney injury usually remains. If your cat has improved a lot, this would make the most sense to me. 

Creatinine values that are increased at 3-4 may normalize with enough IV fluid therapy. Checking bloodwork right after fluids will show the immediate effects, but I feel it is very important to recheck these values a couple of days later if possible, because it’s important to see how the kidneys are fairing on their own without all of the fluid support. If you’re continuing to do some fluids under the skin at home, you can also see how effective this is at the current amount or frequency with recheck bloodwork. 

You can find IRIS CKD staging guidelines here: http://www.iris-kidney.com/guidelines/staging.html  

IRIS staging of CKD is based most often on the creatinine level from stages 2-4. Stage 1 is when the creatinine is still normal and is based entirely on the SDMA with a dilute urine concentration (less than 1.035). 

Rechecking the urine concentration would be important, since I would also expect it to be dilute after 4-5 days of IV fluids. If it is still less than 1.035 a day or two after IV fluids have finished, then CKD would still be present.

Beyond the basic IRIS staging, a cat’s CKD may be further substaged using UPC and BP.

It would not sound like your cat is likely to be truly hypertensive with a BP of 160, but if there is proteinuria present, it can be appropriate to consider the telmisartan. A UPC can be helpful to better quantify the generic 1+, 2+, etc. protein reading, since general protein readings in the urine can be caused by many things, but the UPC represents more accurately protein loss through the kidneys. The IRIS staging guidelines specifically use UPC values for substaging.

I had a look at the ultrasound images you attached. I do a fair amount of ultrasound in my practice. I cannot tell for sure which kidney is which as they do not appear to be labeled, but it looks like there are three images for each one. Generally, the corticomedullary distinction is reduced, consistent with CKD. The kidney in the second set of images appears like it may have a 5mm or so cortical cyst present towards the caudal pole, which can be found incidentally in cats with CKD. The kidney in the second set of images appears more hyperechoic, but I suspect this may be an imaging artifact vs. a true difference.

Ultrasound findings do not contribute to IRIS staging, but can help support the diagnosis and look for other causes of disease.

I hope that information is helpful and that your kitty continues to feel better. Best of luck.

@chris-vanderhoof 

Hi Dr. Vanderhoof, 

Thank you for your patient reply. The information you provided is really helpful. I appreciate that. 

Have a nice weekend,

Nicole