My cat may have been misdiagnosed. Time to find a new vet?
November 27, 2012 12:43 PM   Subscribe

Back in July, my 11 year old cat was tentatively diagnosed with possible early renal failure. This past Saturday, however, she had another round of bloodwork and urinalysis...the results of which indicated her kidneys are probably fine! Needless to say, I'm very happy about this. But the more I think about it, the more it seems like the clinic folks jumped to conclusions way too quickly based on too little information. Am I off-base here, or is it perhaps really time to explore other local veterinary options?

This past July, the vet informed me (following one of Nikki's "senior wellness" appointments) that her urine was very dilute, and that in combination with BUN and creatinine at the higher end of the normal range, this indicated compromised kidney function.

The working assumption going forward was that Nikki was in the early stages of feline chronic kidney disease (which basically always progresses to renal failure over the long term). She was prescribed aluminum hydroxide powder (a phosphorus binder) which I duly mixed into her food. Meanwhile, I was told about future possible treatment options: ACE inhibitors, appetite stimulants, and ultimately subcutaneous fluids.

Fast forward to last week. After several days of observing Nikki repeatedly refuse food, I got worried that either she had a dental issue of some sort or was experiencing a sudden progression of her assumed kidney disease. So I made an appointment to get things checked out.

(I should probably note that Nikki does have a history of gastrointestinal issues, including frequent vomiting, constipation, random bouts of poor appetite, etc. She is also an extremely picky eater. This all "fits" with CKD, but obviously it fits a bunch of other conditions too, including plain old hairball trouble, etc.)

Of course, being a cat, Nikki managed to magically regain her appetite the day before her appointment...but since it was still such close temporal proximity to one of her "DO NOT WANT ANY OF THE FOODS" episodes, and since I figured it was about time to check the status of her renal functioning, I kept the appointment.

And this is about where things started getting weird.

During Saturday's exam, the vet made several comments that had me going, "huh?", most notably one about "possibly starting subcutaneous fluids sooner [within the next few months, most likely] rather than later". I am, of course, fine with learning to administer sub-qs if any of my cats end up really needing them...but it was alarming to hear it being suggested as a near-term thing in response to my merely noting that sometimes Nikki got constipated.

Bloodwork was performed, and I spent a full two days bracing myself for bad news. What I got, however, was news so good I momentarily wondered if I was dreaming when I heard it!

Basically, said Ms. Vet., Nikki's urine was "perfectly concentrated", and her kidney values looked wonderful. Apparently her prior results (with the dilute urine, etc.) were most likely a fluke. Of course I was thrilled to hear this!

That said, I was told to keep giving the phosphorus binders. Which I now don't understand at all given I looked at her July results again and her phosphorus was normal!

This means my cat was prescribed a treatment and given a probable diagnosis of a chronic disease based on what looks to me like way too little information.

I feel very stupid for not realizing this back in July, but I was all wrapped up in trying to "avoid being in denial" and "not second-guess people who know better than I do". At this point I'd have to say I'm pretty concerned about continuing to take my cats somewhere that jumps to a rather serious conclusion due to a single test, and then tells me to keep treating her as if she has this condition even though they themselves acknowledge that "her kidneys are apparently working well". I'd at least think they'd want to do a differential diagnosis to rule out something like, say, pancreatitis, but they haven't mentioned anything of the sort.

Anyhow...I know that when it comes to doctors, whether for self or for one's companion animals, it is beyond okay to shop around and try different clinics for ANY reason, even if it's something as silly as "I don't like the decor in the waiting room".

But I really wanted to ask this question for the sake of determining whether what I'm seeing with this clinic is typical of most clinics, or whether I have real reason for concern. Maybe I'm expecting too much attention to detail?

I am not a vet, but if I were a vet, and one of my patients came back with weird urinalysis results, the first thing I'd do would be to schedule a second urinalysis, perhaps this time with specific instructions re. whether the cat should eat or drink beforehand, etc. I would certainly not prescribe any medication until I was more sure of what we were dealing with. The fact that none of this (basic?) investigation was performed or even mentioned makes me nervous. And I just want to get a sense of whether that nervousness is justified before I uproot my cats from this clinic and go elsewhere.
posted by aecorwin to Pets & Animals (9 answers total) 1 user marked this as a favorite
Best answer: Actually, the treatments you were doing may indeed have done the trick. Zach was also diagnosed with those same symptoms (dilute urine, elevated BUN levels), and my vet had me switch his food and give him a dietary supplement every day; she also prescribed the sub-q stuff, but Zach was so fiesty I gave that up after about a week (I figured if he was fighting me THAT hard he probably wasn't as sick as we thought).

After three months of just the food and the supplement, his tests came back improved, and after another year on just the food and the supplement, when he finally did pass (from something totally unrelated), his final bloodwork and urinalysis was normal.

If you're uneasy about side effects from the phosphrus binders, I'd call another vet and ask a second opinion; but it is indeed possible that there really was early-stage renal failure going on and the treatment could have been that miraculous a correction.
posted by EmpressCallipygos at 12:51 PM on November 27, 2012 [2 favorites]

I would probably look for another veterinarian. We have a cat with a similar history. He had hyperthyroid, is a picky eater, frequent vomiter and has a very sensitive digestive tract. He does produce truly prodigious amounts of urine, and has had liver issues in the past.

In our most recent episode of "Pookie's sick again" it took us a while but we finally figured out he is sensitive/allergic to salmon. That makes selecting food for him such a joy. The printing on cat food labels is really tiny.

Throughout all of his issues we have had excellent support from our veterinarian who even called just to see how he was doing. She has always given us all the options and possible prognoses and helped us make the best decisions for our cat and our budget.
posted by Altomentis at 12:59 PM on November 27, 2012

Best answer: OMG, what a gorgeous kitty!

If you like your vet as a person, perhaps you can make an appointment without Nikki, just to discuss your questions. Your vet should be open to this, and should make you feel comfortable with what she tells you. If she's resistant, or dismisses you, then time to find a new vet.
posted by Ruthless Bunny at 1:07 PM on November 27, 2012

Best answer: Chances are that the phosphorus binder was doing its job, hence the improved urinalysis. Your cat may have been slightly dehydrated at the Saturday visit due to not eating and that led to the mention of sub-q fluids (I am presuming that you are feeding canned food to help your very-likely-to-still-have-CKD cat). Please, whenever your cat goes without eating for more than 24 hours, forcefeed her to avoid the chance of hepatic lipidosis.

Secondly -- and I only know this because one of my cats has CKD -- talk to your vet or look for a vet who has experience with the use of calcitriol in the management of CKD. If your cat is a candidate, I hope you pursue it. My cat is symptom-free on it, and my vet says that she's not seeing cats die from renal failure since she's been prescribing it.

Thirdly, and simultaneously seconding Ruthless Bunny, ask your vet for a consult to help you understand the diagnosis and treatment options for CKD. Yes, you are your cat's best advocate, and the information will help you with that. The only thing that your vet has said, done or prescribed that give me pause is that the initial diagnostic results were "a fluke." That seems unlikely to me.

Finally, Tanya's Guide to Feline Kidney Disease is a great resource. Site overview, the importance of phosphorus control, working with your vet. There are also Yahoo groups if you want to run test results etc. past other people.
posted by vers at 4:44 PM on November 27, 2012 [1 favorite]

I once cured (or bought him a lot of time) my male kitty of kidney failure (bilirubin levels were off the chart) by brushing him vigorously several times each day.
I did it just to relieve his tension as he was hospitalized at the time for this condition but, surprisingly, his levels improved tremendously. I used to play classical music and put him on my lap. I had a good sturdy brush and brushed, well, with vigor but not overly so. Just right.
I would keep it up for a long time - like half an hour or so at a time.
He loved it and, it was explained to me, that the skin and the kidneys are closely related so stimulating the skin helped the kidneys, too.
It worked and he was able to live at a good quality of life for several years. He was about 8 or so at the time.
Good luck to you and your kitty.
posted by Tullyogallaghan at 5:32 PM on November 27, 2012

Elevated bilrubin is associated with liver failure or hepatic lipidosis, not kidney disease or renal failure.

If you have information that explains the connection between vigorous brushing and feline chronic kidney disease, I am all ears/eyes. But I think you were talking about liver disease above.
posted by vers at 5:46 PM on November 27, 2012

Response by poster: Hey, thanks for the responses so far! I won't do the "respond to every post like this is a blog or something" thing, as I know that's bad form around here, but just to address some concerns vers noted:

- Yes, Nikki gets canned food primarily. She's very very very VERY picky but there are currently 2 flavors of Fancy Feast she will usually eat, as well as 1 flavor of Purina Pro Plan Senior (all pate-style foods). Vet prefers her to eat the senior stuff and Nikki likes it as much as she likes anything, so that's what she gets most of the time. With phosphorus binder, along with extra water that I mix in.

- I am well aware of the dangers of hepatic lipidosis and Nikki never goes 24 hours without any food. If she won't eat, she gets syringe-fed. Luckily she tolerates this very well and always seems to feel better afterward even if she's annoyed at me for a while!

- I actually just joined the mailing list associated with Tanya's Guide to Feline Kidney Disease, and part of the reason I ended up asking this question here was because (after I posted Nikki's specific lab values) several folks there noted that her numbers didn't look especially CKDish and that it sounded much more likely she should be checked for pancreatitis. I know those people aren't vets, but still, I figure they at least know this territory better than I do...
posted by aecorwin at 6:29 PM on November 27, 2012

Best answer: When I was in Minneapolis, the general sense was that you take your pet to a local veterinarian for run of the mill stuff, but for anything beyond that you went to the University of Minnesota's Veterinary School. There were all sorts of horror stories of misdiagnoses, lab mix ups, etc., at neighborhood veterinarians, perhaps because they had to be generalists while the U of M could specialize. It might be useful thinking of your current vet as somebody to go to for heartworm medication or the like, but, if something seems more serious, know a vet who is less generalized. Ask around. People may have recommendations.
posted by Bunny Ultramod at 7:54 PM on November 27, 2012

Response by poster: Figured I'd follow up on this since I was thinking about it: I did get a second opinion (same clinic, but different vet) and following a fairly extensive round of further testing, it was determined that Nikki's kidneys are indeed fine, but that she has Inflammatory Bowel Disease. The most useful test in figuring all this out turned out to be an abdominal ultrasound. Her intestines were actually pretty badly inflamed, and her IBD was described as "severe".

She was subsequently put on a strict limited-ingredient diet (venison or rabbit protein wet food, supplemented with hydrolised protein dry food), a low-dose daily steroid (prednisolone), and subcutaneous B12 injections. The difference once she started this regimen was dramatic. She eats the new food eagerly, despite previously not having wanted to touch anything not Purina. Her litterbox habits are normal, she doesn't shed half her fur every time she's picked up, and she has the energy of a cat half her age. She has not vomited even once since starting the new meds, which is astounding.

In short, I can pretty emphatically say that I am REALLY glad I had them run the ultrasound and perform further testing. There WAS something wrong with my cat, it just wasn't the thing initially suspected, and now with proper treatment she is doing wonderfully.
posted by aecorwin at 8:00 AM on October 9, 2013

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