Rowdy has weak hind legs due to CRF, what to do to help?

[Barbara Boehmer]

I currently have two cats with CRF and anemia (one non-regenerative and one highly regenerative). One of them, Rowdy, is having extreme weakness in her hind legs, that I am told is caused by the CRF, and I am wondering if there is anything else that I can do to help her with that problem.

Rowdy is 21 years old, which is comparable to a 100-year-old human, according to the chart at the vet's office. I have had her since October 15, 1985, when she was not quite full-grown. She was a healthy cat up until a few months ago. She started to get skinny and seemed to be having some slight difficulty with her hind legs at that time. I took her to the vet in late August, where they took blood and urine samples and found that she is hyperthyroid, but did not have any other major problems, such as kidney failure or anemia, at that time. She does have some dental issues and some sort of lump in her abdomen, but she is too old to risk sedation to deal with those things. She was started on tapazole brand of methimazole twice daily for her hyperthyroidism and returned 4 weeks later to be retested. The retesting showed that she was at the correct tapazole dosage for the thyroid problem and I was told to continue that, but she now had some slight kidney failure and non-regenerative anemia. She was then started on science diet k/d and daily lactated ringers solution subcutaneously. She developed an upper respiratory infection and was given a course of Clavamox antibiotic, which caused some gastrointestinal bleeding, as evidenced by the dark leathery stools containing dried blood, and was vomiting frequently. She was then put on sucralfate to help heal the gastrointestinal bleeding, reglan anti-nausea syrup, and pepcid antacid, all twice daily, which got her back to eating normally with only occasional vomiting. She has been getting her packed cell volume (pcv) retested about once a month to determine when to start epogen for the anemia. On December 11th it was 22 and I have been told that we need to start epogen when it reaches 16. We also know her blood type, in case she needs a transfusion.

It was originally explained to me that hyperthyroidism frequently masks kidney failure because the hyperthyroidism causes more blood flow to the kidneys, which helps with that problem. Once the hyperthyroidism is under control, then the kidney failure emerges. Once her hyperthyroidism emerged, I asked whether it might not be better to reduce the tapazole dosage, but was told no, because the risk of heart attack, if not given tapazole, outweighed the risks due to the CRF and subsequent anemia, caused by the CRF. As the CRF got worse, the vet declared that it appeared we are about to lose her from CRF, and said to stop the tapazole completely. That was a week ago. I am still giving her the sucralfate, reglan, pepcid, subcutaneous fluids, and science diet k/d. She only nibbles at a little of the Science Diet k/d twice per day and eats the dry Iam's and canned Iam's and canned Nutro MaxCat senior, and canned Fancy Feast that the others eat during the rest of the day. She won't eat the Royal Canin Mature 27 dry cat food.

Although she is eating, drinking, pooping, and peeing, with only occasional vomiting, her hind legs have become extremely weak. Sometimes she walks or sidesteps a few wobbly steps, then falls to one side or the other, rests a bit, then resumes. Sometimes she just drags her hind legs. I have carpeted ramps for her to get up and down off the couch, which she uses. She was getting her claws stuck in them, so I trimmed her claws and that solved that problem. She has two litterboxes with shallow entranceways, but still has some trouble getting in and out sometimes. I have begun picking her up and carrying her to the litterbox, food, and water, at frequent intervals, to make sure that she gets to each often enough. I don't think a cart would be appropriate or that I could get or make an appropriate one in time for her to get any use out of it. I have been massaging her hind legs, and that seems to help. She doesn't seem to be in any pain. She just acts as if her hind legs, especially the right one, have gone numb or something. She also has more difficulty when she needs to poop or pee, and walks better afterwards. I was just wondering if anybody has found anything that helps with whatever it is about the CRF that causes the problem. I gather, from what I have read, that it is due to some sort of imbalance of potassium or calcium or some such thing, due to the lack of kidney function. It appears that she could succumb to kidney failure or heart attack any day now, so I am just trying to make her as comfortable as possible. She still gets around somewhat and purrs when I groom her and pet her and when the other cats lick her. She curls up next to me every night and curls up with the other cats on the couch during the day.

My vet just went on vacation until January 15th, so if I have to take her to the vet again, she would be seeing somebody new. With her in such delicate condition, I worry about a trip to the vet, which she hates, triggering a heart attack, so I am just trying to pick up prescription refills as needed, and make her comfortable at home.

I hope somebody out there has had some success with treating the hind leg problems due to CRF or had some success with dealing with the combination of hyperthyroidism and CRF and non-regenerative anemia and has some useful advice.

[CarolC]

Hi Barbara,

I rearranged parts of your message to put related things together. I just want you to know that while I don't really have any answers for any of this, I do at least understand everything you wrote, about the interplay of age, kidney disease, heart disease, and thyroid problems.

She was then put on sucralfate to help heal the gastrointestinal bleeding, reglan anti-nausea syrup, and pepcid antacid, all twice daily, which got her back to eating normally with only occasional vomiting.
*snip*
I am still giving her the sucralfate, reglan, pepcid, subcutaneous fluids, and science diet k/d.

Since the sucralfate and pepcid were given for the tummy upset from Clavamox, you may want to ask if she needs to continue sucralfate and pepcid. I do not know the ingredients. I cannot guess if they contain salts or minerals she would be better not to have, or if they hinder absorption of something she might need. If you would like someone to try to look this up and try to guess, since you are in the middle of it and may not be able to concentrate, I would be glad to try and give you any links I found.

If she is in a delicate state and begins vomiting, it can cause a seizure (I know this from experience), so keeping the reglan on schedule is important. You can also give injectable reglan, and your vet may switch the prescription for you without an appointment, if you think that would be easier for her.

I asked whether it might not be better to reduce the tapazole dosage, but was told no, because the risk of heart attack, if not given tapazole, outweighed the risks due to the CRF and subsequent anemia, caused by the CRF. As the CRF got worse, the vet declared that it appeared we are about to lose her from CRF, and said to stop the tapazole completely.
*snip*
With her in such delicate condition, I worry about a trip to the vet, which she hates, triggering a heart attack,

Being hyperthroid can cause a high heart rate. Do you have a stethoscope? They are about $10 at Walgreens. You could listen to her heart rate. You do not have to count it, just compare it to how one of your other cats sounds.

My thyroid cat needed a heart med before he had the iodine treatment. He was put on a combo pill of benazpril/atenolol. Benazapril is (or was at the time) the only heart med that was reasonable to use with a CRF cat. Following iodine treatment his cardiomyopathy resolved.

I do not know if it would make any difference for your cat, but here I divide the fluids in two doses for my very senior CRF cat. She gets 75 ml twice a day. I feel I have less worry of a fluid load triggering congestive heart failure, or if it does at least there would be less fluids in her system to deal with. I tend to worry about everything, this may be an unfounded worry.

I gather, from what I have read, that it is due to some sort of imbalance of potassium or calcium or some such thing, due to the lack of kidney function.

My vet just automatically put my two cats on Tumil-K potassium supplement for kidney failure. It comes in a clear gel that does not make a sticky mess if you drip it. You have to give the cat quite a mouthful of it, and the cat will not hate it but will not like it either. Hind leg weakness can be potassium deficiency (but also other things, I am not a vet.)

It appears that she could succumb to kidney failure or heart attack any day now, so I am just trying to make her as comfortable as possible.

I hope that when the time comes, she will go as peacefully as your Tuffy did, but I have had two with similar problems who both went following brief seizures. It is my experience that after they have the seizure, they are no longer aware of anything and pass within 20 to 30 minutes. Even though it is hard to watch, from the cat's point of view it is as quick as a heart attack.

She still gets around somewhat and purrs when I groom her and pet her and when the other cats lick her. She curls up next to me every night and curls up with the other cats on the couch during the day.

When she is gone, you can remind yourself of this snapshot of where she is right now, still happy. You might note every day her contented state of mind, to comfort you later.

[Barbara Boehmer]

I read on the internet that it may take 6 to 8 weeks of being on sucralfate to completely heal an ulcer and that it should not be stopped prematurely once the bleeding has stopped, so I am keeping her on that for a while longer. Her stools are just gradually beginning to be slightly lighter in color and less leathery. The dark leathery stools are indicative of dried blood in the stool.

The kidney failure tends to result in stomach acidity, which results in vomiting and not eating, so the pepcid is needed. She was actually on pepcid before the Clavamox. The pepcid dosage was increased after the problem due to the Clavamox. I have found out from another webiste that amoxycilin might not have caused the same stomach problems as Clavamox. I also have another cat who began vomiting and stopped eating due to Clavamox, then went back to normal after the Clavamox was discontinued. In the future, I will probably request the liquid amoxyclin. Even though the Clavamox is more convenient, does not require refrigeration, and it is easier to ensure they get the full dose, it is not worth the side-effects.

I don't have a stethescope, but I can tell that the heart rate is elevated on both of my CRF cats. I asked the vet about this. She said that she does not currently have equipment to monitor blood pressure on cats that are not sedated, and is trying to get such equipment. She has not suggested any heart medications.

I have given fluids twice per day in the past to other cats. This vet recommends once daily. If I give it to her in the morning, she is less likely to pee on my bed in the middle of the night. I also only have to stick her with the needle once per day.

Somebody on the Yahoo CRF group suggested that her symptoms sound like gait ataxia and she might benefit from a phosphate binder. I may call and ask about that on Tuesday when the vet reopens.

She is doing better this evening. She has not vomited in the last 24 hours and I watched as she, using a combination of walking and dragging, got down the ramp, ate some canned food, drank some water, got in the litter box, peed, got out of the litter box, and went back up the ramp to the couch, all by herself.

[critters]

I'm afraid my CRF experience is quite limited, but you might try reposting at CIC and see what Victoria thinks; she's excellent, and she's been down this road a number of times.

[Christine]

Dear Barbara and CarolC,

I am in absolute awe of the dedication to your babies and am so thankful that you are sharing that information with the rest of us.

Barbara, the fact that Rowdy is 21 years old speaks volumes. I can offer you nothing more that healing prayers and support in this difficult time, but I am sending many to your Rowdy.

[CarolC]

Hi Barbara,

Going through the whole story here because it is easier to keep the facts straight. Going by a combination of medical records, old messages, and memory, memory being far less than perfect these days.

When my cat was diagnosed with hyperthyroidism, his heart rate was over 200. Tapazole would have brought that down, but we decided to do iodine treatment as soon as possible (he was half the age of your kitty) and they have to be off the tapazole for 2 weeks before iodine treatment. So I had a cat who could not be given tapazole, like your kitty only for a different reason. I was worried he'd have a heart attack before his treatment and the vet wanted to get the heart rate under control before the sedation required for iodine treatment. That is why they put him on the combo pill of atenolol/benazapril. It was compounded in a flavored chewable pill, and after the first pill or two, my cat didn't like it and I had to pill him with it, and it is very hard to pill a chewable because it big and soft and it sticks in the pill popper, especially as soon as saliva gets on it. The reason it had to be compounded is that the meds were such a low dose, you could not buy pills that size, or even pills that you could divide correctly to get the right dose. He was also on spironolactone. Even now I'm not entirely clear how these 3 work together. My vet has Himalayans and they are prone to cardiomyopathy, and he was using the same combination on one of his cats. I do not know if his cat was CRF, mine was early CRF and they were afraid that following iodine treatment he might turn out to have more significant CRF, but my cat lucked out on that. He still has CRF, but is currently being treated only with diet.

I was told that after the iodine treatment, he would be able to get off the atenolol (it was for the elevated heart rate) but might need to stay on the benazapril (which is a vasodilator that improves blood flow to the kidneys). They were not sure if the cardiomyopathy was completely due to hyperthyroidism, or if it was also related to the fact that he was a Maine Coon. Fortunately, the walls of the heart returned to normal thickness following iodine treatment, so it was not related to breed, it was just caused by the hyperthyroidism.

Anyway, here is some information on benazapril from the CRF website.

http://www.felinecrf.org/treatments.htm#ACEI

On the Clavamox vs amoxicillin, I guess the only way to find out if your cat does better is to try it (hopefully no more antibiotics will be needed). I wonder what is better about Clavamox? A year ago I posted a thread entitled "Vomiting amoxicillin" because my cat was vomiting it, and learned that it wasn't just my cat, 2 of Jean's cats also vomit amoxicillin. Here is her message.

http://handicappedpets.com/help/viewtop ... 018&t=4252

I may use pepcid as you are doing next time I have a cat that gets to end stage renal failure. It was not recommended to me last time, we just did the reglan. Since then I've learned so many other things we might have done.

[critters]

Clavamox has amoxi and clavulanic acid. http://www.pfizerah.com/product_overvie ... species=FL

[CarolC]

Yeah, that's what it said in my book, too, but I'm not clear on why the additional ingredient makes it easier on the tum-tum. It looks like it just makes it kill a broader range of germs...?

[critters]

Yup--broader range.

[Barbara Boehmer]

The addition of the acid to the amoxycillin in Clavamox causes it to kill a broader spectrum of bacteria and the pill form does not require refrigeration and for some of us pills are easier to give than liquid. However, the acid in Clavamox also makes it harder on the stomach than just plain amoxycillin. Amoxycillin is a sort of penicyllin and cats can be allergic to it just like people. I have had cats that have vomited Clavamox, amoxycillin, Baytril, flavored lysine, and various other things. In some cases, I have done better with making my own mixtures as directed by the vet. For example, I have used both premixed sucralfate liquid and my own mixture made with crushed sucralfate pills and water. The premixed liquid tended to separate and half of it tended to settle in the bottom of the bottle, resulting in inconsistent dosage and waste. The pills are horse-sized oval tablets with a single score in the middle that makes them easy to break in half. They disolve easily, so you do not have to even crush them. I put half a pill in a cat food can with 5 cc of water, then administer 1 cc twice daily, as per the vet's instructions. It is much easier to stir it up and put it in the syringe than to get the separated liquid out of the bottom of a little plastic bottle.

She has eaten, drank, pooped, and peed today, and sat in the sun in the outdoor enclosure for a while. She vomited some fluid once this morning.

I am planning to call the vet's office Tuesday morning and speak to the other vet that is there while my regular one is on vacation and see what she thinks about a phosphorus binder, which I can apparetly obtain cheaply and quickly without a prescription. My biggest concern about the phosphorus binder is the possibility of causing constipation, which she already has a slight case of. For all I know, the hind leg problem could be caused by the constipation and giving a phosphorus binder might make it worse. She does walk better after she poops. Constipation can be fatal.

[Barbara Boehmer]

I have been trying to watch for patterns and figure out what causes her to vomit and what causes her to walk better or worse.

I have noticed that she usually vomits half an hour to an hour after I give her the sucralfate and it looks like the sucralfate that she is vomiting. She has been on the sucralfate for about 5-1/2 weeks, so I think it has done its job and she may not need it anymore. If she is vomiting it, then it isn't helping anyhow. So, I am going to try discontinuing the sucralfate, which she vomited again this morning. If she does not vomit this evening, then I will know that was the problem.

I am still trying to figure out why she walks better or worse sometimes than others. If she walks more slowly, she looks steadier. If she tries to move more quickly, then her hips swing to one side or the other and fall over and she starts dragging her hind legs. She seems to walk better after she poops. She also seems to walk better after she has been up for a while. When she first wakes up, she seems to have more problems, kind of like an arthritis kind of thing. It kind of reminds me of a problem that I have, that I haven't figured out either. Frequently when I wake up, my left shoulder and left upper arm ache and I cannot move my left shoulder, although I can move my left elbow, wrist, and hand, and other body parts. Eventually, I am able to move it with some pain and after a few hours the pain goes away and I can move it easily. It does not matter which side I sleep on and it is only the left shoulder, never the right, and it is not every morning. The way she can sometimes move her legs and sometimes not reminds me of how I can sometimes move my shoulder and sometimes not. In the mornings, although the toilet paper roll is to the left of the toilet, I have to reach across with my right hand because I cannot lift my left arm at all first thing in the morning.

[Barbara Boehmer]

I did not give Rowdy any sucralfate last night or this morning and she did not vomit last night or this morning. She seems to be gradually eating more and walking slightly better. I can't tell if I am seeing the effects of no sucralfate or the effects of having been off of tapazole for a while now or both or what. I tried to call the vet to get an opinion on whether or not to try a phosphorus binder or what to help Rowdy with her hind legs and to ask about another cat as well. The phone rang endlessly. I let it ring about 30 times each of a few calls. I am guessing that either they took an extra unannounced day off after the holiday or, with the main vet on vacation, did not have a vet, and are closed for the day, and forgot to set their automated recording, or maybe they are just having another problem with their phone system in the wind, as before. So, I will have to wait until tomorrow to ask. Right now, since she seems to be doing slightly better, I am just going to continue what I a doing and wait and see.

[Barbara Boehmer]

I found out today that the reason I could not get through to the vet on the phone yesterday was because they were having an electrical problem that affected their phones. I called the vet this morning to ask if aluminum hydroxide would be appropriate for Rowdy, but she was too busy to return my call. When I went in person after 2 pm this afternoon, to pick up some reglan refills, she was still busy and hadn't even been to lunch. I got copies of Rowdy's last blood panel results on November 17th, that indicated, amongst other things (normal ranges in parentheses on right):

kidney failure:
BUN 65 (15-34)
CREATININE 3.7 (0.8-2.3)

non-regenerative anemia:
RBC 4.73 (6-10)
HCT 22.1 (29-45)
RETICULOCYTE COUNT 0.1 (0-1)
ABSOLUTE RETICULOYCTE 4,730 (0-50,000)

infection:
WBC 30.4 (4.2-15.6)
she also had nasal discharge; the Clavamox seems to have cleared
up the infection, but caused the gastrointestinal bleeding,
which is why she was given sucralfate

and:
PHOSPHORUS 10.5 (3-7)

So, it looks like Jim Hayes from the Yahoo CRF group was right about the phosphorus and that is known to cause leg problems like she is having. After reading the test results, I asked the receptionist if I could get some aluminum hydroxide phosphorus binder there. She asked a vet tech, who asked the vet, and the receptionist returned with a slip of paper that said amphojel and I was told I could get it at a pharmacy, but I never got a chance to ask the vet if it was appropriate for Rowdy; She just responded to a third-hand request as to whether they had it. I went to Walgreen's, but they didn't have any amphojel or anything with aluminum hydroxide that didn't have magnesium and other stuff mixed with it for people. So, I ordered some aluminum hydroxide gel through the internet from vetmeddirect. I ordered next day shipping, but after I ordered, I saw that they process orders within 48 hours. So, if they process it by Friday and deliver next day, I might not have it till Saturday or Monday if they don't deliver Saturday. I see that I must also be present to sign for it, but there is no tracking, so I can't tell exactly when to be home and may miss it, but I'm sure I will get it eventually. If I'm not home when they try to deliver, they usually leave a note with the next time they will try to deliver or an address where I can pick it up.

I have enough trouble getting her to eat stuff. So, I figure it will be easier to put some gel in her mouth, rather than try to mix powder with her food and coax her to eat it. I hope it comes with dosage instructions. I am still worried about constipation, so I plan to start with a real low dose and see how she does.

[CarolC]

I'm a bit confused because I know nothing about phosphate binders for cats. In humans, they make fancy phosphate binders, but plain calcium works if taken with the meal. In humans, calcium citrate has less of the GI side-effects (gas or constipation) that you get with calcium carbonate.

You're saying that aluminum hydroxide binds phosphorus, or maybe I totally misunderstood? That is the active ingredient in sucralfate...but maybe sucralfate has other ingredients (magnesium and so forth) in it you don't want? I have a book where I think I could look up the inactive ingredients in Sucralfate, but right now I am a "lap" and can't move.

http://www.marvistavet.com/html/sucralfate.html

Lactulose syrup is wonderful for constipation, and you don't have to give a lot, and my cat doesn't mind it at all.

[Barbara Boehmer]

Aluminum hydroxide binds phosphorus and is recommended on the Yahoo CRF group as the most effective phosphorus binder. Magnesium, which sucralfate has, is bad because it can cause stones and urinary problems. Calcium citrate and calcium carbonate can result in too much calcium. The pharmacist at Walgreen's explained to me that a lot of the products for people contain both aluminum hydroxide, which tends to cause constipation, and magnesium, which tends to cause diarrhea, so that the two balance out. But the magnesium is particularly bad for CRF cats.

The Science Diet k/d and Royal Canin Mature 27 are lower in phosphorus, but Rowdy won't eat much of those, so she eats more of the Iam's and Fancy Feast. She is skinny enough that I need to give her whatever she will eat. She has been eating more of the Iam's hairball formula high fiber dry cat food, so that should help with constipation. She has had some slight constipation, probably from the sucralfate. Tonight I added some psyllium to the canned Iam's and Fancy Feast that most of them eat the most of and nobody seemed to notice. I have capsules of finely ground pure psyllium powder from GNC. It has a much finer texture than Metamucil and no mint-flavoring or anything for people that cats don't like. I emptied the powder from one capsule, mixed it with a little water, to avoid any dry lumps, mixed that with some Fancy Feast, then mixed that with some Iam's, and served it. That should be good for Rowdy and shouldn't hurt anybody else. I have one cat that has had some slightly too soft stools lately, so it should be good for him too. The nice thing about using fiber is that it works for either problem and balances things out. I think I will continue to add one capsule to the main feeding each morning and each evening.

If you read the ingredients on a lot of cat foods, they already contain calcium carbonate, so she is already getting some of that. I am hoping that the aluminum hydroxide arrives soon and, if not, wondering what might be a good substitute in the meanwhile. I don't know if the benefits of the aluminum hydroxide in the sucralfate would outweigh the bad effects of the magnesium or if the way it is bound to the sucrose already it would not be useful as a binder. Since she vomits it, it is pretty much useless anyhow. I hope she does not vomit the plain aluminum hydroxide.

According to the folks on the Yahoo CRF group, Rowdy's problems with her hind legs are typical of too much phosphorus in CRF cats. They predicted the high phosphorus before I posted the test results, so that is why I am focusig on this. It would improve her quality of life greatly if she did not have to drag her hind end around. It was explained to me that the high phosphate levels interfere with the neural pathways, resulting in gait ataxia, lack of proprioception of the hind limbs, and lower-motor-neuron disease. This is what I am trying to fix.