RIP Milo: 28th November 2008

Milo sadly lost his battle with CRF on 18th October, 2008. My ex and I went together and let him go to the Rainbow Bridge. It was done beautifully, the Cat Clinic in Prahan are wonderful (Thank you Richard and Amy). We cried and cried and cried. He was so beautiful. 

The good news is that for all but a couple of weeks during the year, I know he was happy and feeling ok. 6 weeks before he left us, we took him to the vet as we could see he was declining. We were still doing the full treatment with alumium hydroxide and the SQ Fluids of 100mls every 2 days. The vet said he was in end stage CRF and to leave him there for a few days on a constant drip of fluids to see if that would help, though chances were low. We decided to take him home so he could live his last days with his family - he hated staying at the vets. So with the vet's guidance we upped his aluminium hydroxide to over 1500 mls a day and his fluids to 300mls a day in bi-daily doses of 150mls. This got him ok again, though we knew we were running out time.  Eventually the time came and we had to make that dreaded decision. My ex drove the car and I sat in the back scritching him.

Meridith, I am so sorry about your beautiful baby. He is still here and never belive a diagnosis of a certain time. Milo was diagnosed in January with 2 weeks to 2 months to live and he lived until mid October. Others have lived for 5+ years, even when diagnosed at 12 years or older. This is a fact. Go to the yahoo groups. Find them and they will help you.  As for the holiday, many would disagree with me but I think you should go. Get a treatment plan going and find someone to look after things for you. There are pet sitters available. Find them using google, ask your vet. Know where the 24 hour vet is (They are amazing clinics), know how to get there and always have money with you for it. I send you hugs.

Jessica, when they stop eating, try everything. Milo had red meat most of the time. When he would stop eating I got a syringe and fed him watered down whiskers - squirting it directly down his throat. After 2 days he would be fine again. Without nutrition they have no stength. I did this three times over the year and each time it pulled him through.  Try everything. If you are giving aluminium hydroxide try lightly poaching chicken and chopping it into little peices. We used to give Milo alot of fillet steak cut thinkly. It got to the point he would not eat from his plate and only when we dropped little stacks of meat on the kitchen floor (lots of papertowels came in handy to help clean the floor.  The things we do for our sick cats! But we wouldn;t have it any other way. The important thing to remember is that we do our best and we have to accept that one day they will go to the rainbow bridge and we have to let them go and not suffer, but until then, that we give them love and smiles.

Here is my post on the cat forum the next day;

My beautiful aby Milo is now and angel at the Rainbow Bridge. He was the most sweetest boy and I loved him with all my heart and always will. He lived only 5 years and 9 months, and I know that every day was an absolute joy for him. Everybody loved him. Cats, dogs and people. He had the sweetest voice, just like an angel would and he talked and played and snuggled. I loved how when he was in deep sleep his head would turn upside down between his front paws. 

I looked a long time for Milo, traveled about a thousand miles by car to different places. At that time I had a feeling about the cat I wanted to bring home. he was at a cattery in the beautiful Yarra Valley where there are lots of vineyards. I chose him by how he felt against my heart when I held this gorgeous kitten. In January when he was diagnosed with CRF it broke my heart so badly. I cried a thousand tears think I would lose him so soon. Thank you so much to all of you for your support during this year, your posts of links and information were great. The yahoo groups were amazing too. No-one I know uses the formula I put together to help Milo. Using your advice I got a lot of help too and found Richard Gown and Amy who run The Cat Clinic in Prahan (Melbourne). Richard was the only vet in my state who had experience with kidney transplants. When he saw Milo he knew what he was doing. He was familiar with all the terms I had, all the mediations and possibilities I flagged. He was amazed at the knowledge I had gained in just 4 days since Milo's diagnosis with our local vet - how could I not learn everything I could?

My ex and I took Milo to the vet because he gotten so weak we did not want to wait for a vet to come out. I made his carrier really soft for his bony frame and doused it in catnip spray. And he was content all the way there. My ex drive the car and I sat in the back seat with the carrier, with the door of the carried open so I could scritch him all the way there. Both Richard and Amy came and said goodbye to Milo and both said was a wonderful boy he was, and what an absolute pleasure he was for them to get to know. They also said we the most amazing and dedicated cat parents. These guys called us frequently, they gave me repeated scripts for his mediation and liaised with the pharmeceutical company about the dose and strength of the aluminium hydroxide. They gave me different syringe sized for feeding him when he would not eat and were constantly a source of support. During the year we used aluminium hydroxide, SQ Fuids, appetite enhancers, antacids and more. If anyone wants what I know about how treated Milo...especially how you can give your CRF Cat protein, let me know.

Milo was at home there at The Cat Clinic and they laid him on a towel and they sat with us, and gave us lots of time alone with our baby, and then when we said we were ready...Milo was relaxed and laying on the towel, they helped him to the Rainbow Bridge. It was not stressful at all for him and we know the time was right. It broke our hearts and we were just in pieces. Life will never the same again. I love you baby, I always will. Come visit me lots. 

3rd September 2008

Milo is not doing well. He took a turn for the worst a week or so ago. He has lost weight and is very skinny. On the weekend I didn't think he would make it the night and had the emergency vet on standby, directions, number...everything ready and I called them. He wasn;t eating Friday or Saturday. But Sunday evening he got better. We decided to get a vet to do a home visit. We tried to arrange it for Monday night because we don;t want him to suffer. With my two previous CRF cats many years ago, one I always wondered if I let go too soon, and then next year with the other one I waited too long and one morning he had the most terrible convulsions, so I hed him through that and then took him to vet and let him go to be with his brother.

Since Monday he has continued to eat, though I have sit on the floor and basically hand feed him. He is on appetite enhancers and antacids. I still use aluminium hydroxide and we are up to 300mls of fluid a day. So tragically he doesn't have many days left but he is still hanging in there. I will remain so grateful for the extra months...nearly a year he got after his diagnosis in January that he had 2 weeks to 2 months to live.

Milo continues on a good path. Stable and happy. The aluminium hydroxide and the fluids continue. He has the AH before eating and he east whiskers meat sachets and a handful of sliced lamb or beef twice a day. I feel sorry for cats who live out their days on stupid renal failure food that tastes like cardbaord. It is not necessary in my opinion. I'm glad I did my research and found a way around it. His appetite is enormous so I'm lucky.

Milo's result still need to be emailed to me, but all levels are improved. The creatine is still high. It should be under 200. It was 550 when we took him in the first time, after 4 days at the clinic on fluids it went down to 350. Now its at 310, so its not great but its fabulous because its lower. The vet said he was looking great and the results are really good. His next checkup is now in 3 months - Woo Hoo! Having Milo for many Christmas's is now a very real possibility. I think, I don't know, but I think the aluminium hydroxide must be making all the difference. The 100mls of fluids every second day intravenously is helping alot too.

Milo went in on Thursday for full check up. Full blood tests were ordered and we are just waiting on those results. Stephen took Milo in because I was at work. The vet said Milo looked really good and agreed that he had put on weight. His weight goes from 100gms to 400grams increase so its not much but I guess it in a 5kg cat that is very sick. His weight is very important to us these days. They said his urine looked concentrated so they are also going to check that for cystals. He is still bouncing around and very happy so I am really REALLY hoping his blood test don't show any decline in health. Realistically though there might be a decrease in health shown by the blood tests because his kidneys are failing and there is no getting around that. All we can do is hold off the decline for as long as we can. Well, the good news is that I wondered if he would be around for Easter and its Easter tomorrow so he made it! Yay! Now I hope for my Christmas, if may be so bold :) Its looking promising from where I sit! Sure he may not be around for my 50th birthday in 8 years but I think Christmas or maybe a few is do-able.

Well Milo is still going steady. His weight is stable, he has a great appetite, he is happy and active. We still do the 100mls of intravenous fluids every second day and this only takes 5 -7 minutes. And he still has 0.5mls of Aluminium Hydroxide liquid twice a day right before food. We have a syringe and just squirt it into his mouth. He doesn't like it at all, but is very good about it and since he gets food right away after that he quickly forgets about it.

Sorry for the lack of updates. And thank you for the messages - Elizabeth and Carlton especially. Milo has been steady, really steady - no weight loss and doing ok. So we got more supplies from the vet and kept up the SQ Fluids. We have not been anxious to get blood tests since he has been doing ok, and since we are doing everything, absolutely everything we can. Milo is happy and relaxed. Yes he is relatively skinny looking but its not getting worse and I think that is pretty good. Thank you for the support - it means alot. It really does.

Milo remains stable, happy, relaxed. He pretty much refuses to eat the renal food. I know we could force him but he seriously starves if we only offer that. Then he loses weight rapidly and his tummy gets really sunk in and he looks weak and very unhappy - within a day or two. So we do our best. I so love that I had more than 2 weeks with him..... and that he might live past Christmas - why not? He seems to be very stable and doing ok, happy, living life, not declining.

Milo is doing ok, but I now smell his breath more, which is the smell of the kidneys not working properly. I think this would reflect in his urea blood levels. His weight is back to 5.11kg which is what it was at the vets. His healthy weight is 6.5kg. I guess the good news is that he not declining as rapidly as it was thought he might. We won't know for sure how is tracking until we get more blood work done. He seems happy enough, but is not quite as playful as he was... not recently anyway. On the whole he seems relatively stable. We continue to give him the SQ IV FLuids 100mls every second day, 0.5mls aluminium hydroxide twice a day before food (We syringe it into his mouth) and food. I sit on the floor with him to try to get him to eat.

He does have an appetite, but he does not like the renal wet food, and very rarely eats dry food. He is getting smarter at not eating the renal food. Its in little pale brown soft pellets that look just fine. I put in a bit of whiskers gravy to get him to eat, but now he just licks the gravy off the pellets. So I got some whiskers mince wet food which is 8% protein, not ideal, but he needs to eat so its balancing act. I mix that in with the renal but he has learnt to eat the whiskers around the renal, lick the gravy of the renal and I bet he thinks he is outsmarting me. He is right. But we can not let him starve. He also gets some fatty lamb - he prefers that to fatty beef, and the purpose of that is to get him some calories from the fat.

Milo is still doing well, by observation (we have not had another blood test yet). He is not losing more weight, in fact at times he has put on up to 400grams, but it goes up and down, but never lower than he was when we brought him home from the vet 5.11kg. He has gone up to 5.5kg whihc were really happy with. We have not weighed him in the last few though. He is active, happy, eating (though this is a challenge) and having his aluminium hydroxide twice a day and his IV fluids 100mls twice a day. His breath is not worse, and this I think bodes well as it indicates his urea levels are not getting worse.

Milo is doing ok.

Milo has been doing well. He has put on a little bit of weight and has not deteriorated in any way that I can tell. He is happy and playful, sleeping well.
We continue to do the IV SQ Fluids. Now we do 100mls every second night instead of 50mls every night. Milo does not like it, but we do it the same time, in the same place in the same way every time. So he knows what is coming and he tries to be very good. Sometimes he tries to run away before he should but I manage to keep him steady each time.

He eats the Royal Canin Wet, but does not like it. He will not eat it straight and I have to sit with him and put in some whiskers wet food on the Royal Canin one to get him to eat. In reality he is eating 50% renal food and 50% regular supermarket crap food which is 8% protein. I sit on the floor with him and spoon in bits of food and toss it around a bit and keep him eating as long as I can. I do this as often as I can. Sometimes when he starts to walk away, I just pull him back and he eats some more. He does not like the dry Royal Canin Renal, though Bailey loves it. But Milo was never really much into dry food. Sometimes Steve put in tuna water over the renal biscuits and he has eaten them that way.

Milo is also getting 0.5mls of Aluminium Hydroxide in liquid form twice a day before food. He absolutely hates it but he knows its coming and that food follows, so he allows it. We have not made a day or time to get his blood work checked, but expect to do so in the next week or so.

He loves his new yellow bed :)

Milo is not eating as much, but behaviourly seems ok, no difference. Slept with me again. Last night he got 100mls of fluids. he does not like going through it, but he is very good. So the reasoning was if we give him 100mls, then he only goes through the process once every two days rather than every day. its more liquid though and must feel weird. If only cats could talk.

Milo is doing good. He does not seem to be deteriorating at all. Yesterday after work I sat in the garden with him and watched him play with Ellie and Jindi. He is quite happy and playful, though I think he knows he is sick. He is very patient with the SQ's - we are so lucky he is such a calm cat. We could never deal with Bailey like this. he is eating a pouch of Royal Canin wet food, and I stay there with him each day and dribble bits of whiskers gravy on it to keep him eating. he gets the aluminium hydroxide twice a day and the SQ fluids once a day (50mls). He sleeps with me and sits with me and seems pretty good.

We gave Milo the first SQ Fluids intravenously tonight. Stephen did it. Not bad for a person who has a needle phobia. I'll do it another night. We put him in his new bed and he was nice and comfy but the sides are too high and the needle either did not go in, or went in and then fell out. Milo was very unimpressed with all the water over his back. We dried him off and did it again. he did a big flunch and nearly jumped, but settled. It only took roughly 5 minutes. He jumpd to the top of the couch and nearly lost his balance. He had a little hump of water in his back. It must feel very strange. We were advised to do 100ml every second day or 50mls daily. So we prick him with a needle every day or he gets a whopping amount of water in him every second day. We elected for the 50ml daily for now. My idea is that when he is used to what must be a very strange feeling of having water injected under your skin, then we can do it every second day.

Bailey is still being mean. I do not understand how he is so hateful to Milo. He must know it is Milo and yet he acts as if Milo is a stranger. I hope this hostile behaviour from Bailey towards Milo is very temporary. At least it is not as bad as the first day. That was something!

Milo follows me (or another member of the family) alot, and he comes and sits and snuggles into my lap. This is all new. He must know he is sick, or perhaps just the feeling of being unwell makes him want to be near me. He also sleeps close by with one of us each night.

Milo is eating quite well. He eats the Royal Canine, and I sit with him and spoon some whiskers gravy on that when he stops eating. That gets him going again, and he eats more. He is eating a pouch a day so that is good. We also have some fatty beef and we put the aluminium hydroxide phospherous binder on that. So, all things considered, Milo is going well.

Milo's latest bed

Isn't this great? It is deep and luxurious. And the top can be untied to make it into a thick blanket or just for washing. He loves it too!

Milo is back home: Saturday Afternoon.

Went to the vet, were there for 2 hours.
The biopsy did not show lymphoma. There was a low level of useable cells in the biopsy. The cells that were able to be tested showed they were normal. So we are left with high chance it is amyloidosis. There are no more tests to tell if it is anything else, except the full biopsy. The full biopsy is highly risky for a cat, and though it can tell if it is amyloidosis, it serves no purpose because it is not treatable. All it would do is confirm there is very little time left. Therefore there is no point in putting Milo through that biopsy.

Amy (Richards partner) showed us how to do the SQ’s. We are going to be very strict with his food, renal food plus some animal fat on tiny bits of protein so that he eats and gets enough calories.

We will do 50mls of SQ a day. It takes around 7 minutes. After 2-3 weeks we will get his blood tested. If the levels have come down, we will just manage Milo like that and if that takes forever, then that is fine.

If the levels don’t come down, then we will just make his life full of fun and the things he enjoys until its not fun anymore.

I had been trying to feed Milo Hills Sience K/D which comes in a tine and has a mashed consistency. He does not like it. I mixed it with Evo to get him to eat, and gave him chicken breast. For the two nights he was at the vets, they gave him Hills Science with some whiskers food gravy over it to get him started. Well we bought some Hills and some Royal Canin wet food. Turns out Milo loves the Royal Canin. It is much nicer looking and is even presented as little sumptuous wet morsels. Compared to the Hills food which looks like regurgitated vomit, Royal Canin gets my vote too. I will see if the vet will let us return the Hills Science and swap it for the Royal Canin.

So we have Milo, and his new little donut bed, plus a new bottle of catnip spray and …. A bag of needles, drip, water…. And I found the cutest cat bed! It was only $35 and its is adorable. Its like a big fluffy upside down shower cap. I’ll take a photo.

Let me say this, as we walked out of the vet surgery they told me to look at the sign on the outside of the door. So I said thank you for everything, goodbye and as I walked out, there was a sign that said “Beware of the crazy cat lady”.

He is snuggled up in his donut bed next to me right now. It is so good to have him home. I can’t quite describe how much the house changed without him here for two nights. He is the most active, vocal well rounded cat that kind of holds the entire family together. I’m going to try not to grieve for him right now. I know it doesn’t look good, but we will just hold on to possibilities until we get his blood tested again in 3 weeks.

I will post photos in the next few days I hope.

Sat 9.55am

The biopsy results are still not in.
But the creatine went down to 300, which is lower, but still 100 too high. So the fluids are helping, but it indicates a chronic renal problem rather than a reversible actue oneIt also looks strongly like amyloidosis.
So if the biopsy comes back with lymphoma, we can consider chemo
If it comes back with nothing, its amyloidosis and with the fluids Milo may live a couple of months instead of weeks.
We are going in at 1pm to be taught to do the SQ's (IV Fluids)
Its nothing short of heartwrenching

Update Milo 3.38pm Friday

Vet called. Bill so far is $735. Paid $385 last Saturday to local vet. Total $1100. But it includes many blood tests, consults, ultrasound, biopsy and of course ther new donut bed and catnip spray :)

Vet just emailed and said Milo was very happy in his new donut bed with catnip spray and has been kneading it all afternoon. I feel so much better now. I feel so sorry for him being away from home. He has never been away from home overnight before.

Creatinine (From wikipedia http://en.wikipedia.org/wiki/Creatinine)
Creatinine is a break-down product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body (depending on muscle mass).
Creatinine is mainly filtered by the kidney, though a small amount is actively secreted. There is little-to-no tubular reabsorption of creatinine. If the filtering of the kidney is deficient, blood levels rise. As a result, creatinine levels in blood and urine may be used to calculate creatinine clearance (ClCr), which reflects the glomerular filtration rate (GFR). The GFR is clinically important because it is a measurement of renal function. However, in cases of severe renal dysfunction, the creatinine clearance rate will be overestimated because the active secretion of creatinine will account for a larger fraction of the total creatinine cleared.
A more complete estimation of renal function can be made when interpreting the blood (plasma) concentration of creatinine along with that of urea. In the USA, urea concentration is given as blood urea nitrogen (BUN), in mg/dL. In other countries, including those of Europe, urea concentration is measured and quoted in mmol/L.
The ratio of urea to creatinine can indicate other problems besides those intrinsic to the kidney. For example, a urea level raised out of proportion to the creatinine may indicate a pre-renal problem such as dehydration.

Update on Milo 12 Noon Friday

Milo had his small needle biopsy first thing this morning and a blood test. We may have biopsy results by end of day. the good news is that Milo's creatinine levels went back to the levels they were on Jan 6th 370 from 550 yesterday just with one night on fluids, which they are very surprised about. So they are keeping him there for another night. If tomorrow morning the creatinine levels are even lower again, we have a potentially reversible acute problem on our hands. We are picking up the gel aliminuim hydroxide today and dropping that off to the vet. We have asked the to give Milo a donut bed I saw on their shelf and to spray the catnip spray they also had on their shelf on it, and just add it to the bill. Tomorrow when we pick him up they will show us how to do the SQ's (Fluids by IV)

So hears to hoping the biopsy does not show lymphoma and that the creatinine levels tomorrow morning are lower that 370.

Update on Milo 1.26pm

We have found aluminium hydroxide in gel form. Richard did not know it was available. We will be letting him know where to get it as we found through a pharmacist who the wholesaler is. Richard can then help other cats who could use it. The gel is easier to administer for the cat. We will have that tomorrow.

In the morning the vet will check the blood to see if the creatinine levels have fallen from 550. if it does, it means the fluids helped that. This would be a good thing.

Update on Milo 10.30am

Amy from the Cat Clinic Called
Blood tests overnight showed creatinine levels have gone up a lot from 370 to 550 which is very concerning
Urea has gone up a bit from 21.6 to 25.3 – not as concerning
The ultrasound was done, Milo was so good they did not have to sedate him at all
Kidneys are small – consistent with Amyloidosis
Kidney architecture is normal, no cysts or similar
The Cortex and Medulla were distinct, there are some subtle changes there but not significant
The is no visible obstruction, like a stone or anything

They feel very strongly this is Amyloidosis.

They have him on fluids, and want to keep him overnight
Depending on how he goes they may do the small needle biopsy overnight, or first thing in the morning.
They want his kidneys in the best condition for it
Only the full biopsy can confirm Amyloidosis
The small needle biopsy can confirm lymphoma

They will call back later and advise if they are doing the small needle biopsy this evening or tomorrow morning.
He can be picked up most likely tomorrow morning
The biopsy results will be available between 12 and 24 hours.

If lymphoma is not the result of the biopsy, I am not putting him through the full biopsy. It serves no purpose.
We will help him to the Rainbow Bridge when life is no fun for him anymore.
If lymphoma is the result, I will need to find out what it is like for cats to go through chemo and how long they have to endure it before making a decision on putting him through chemo.

I can not believe this is happening

Update from later in the evening:
The Acute Renal Failure is the same as Chronic Renal Failure, just at a worse level. Amyliodosis is a rare disorder of protein metabolism in which abnormal deposits of protein called amyloid is deposited in the kidneys http://www.petplace.com/cats/renal-kidney-amyloidosis-in-cats/page1.aspx. Abyssinians are apparently prone to it. See half way down the page here http://www.abyssinianbc.org/newsletters/bcnl5_99.htm

Milo is home with us. Richard said to feed him fatty protein such as fatty beef.
Milo is in good spirits, but I think he knows he is not well, or knows he needs me. A few nights ago he came and just sat on my lap. Though he an affectionate cat, he is not usually a lap cat.

Richard was able to tell the difference between ipakitine and aluminium hydroxide, to tell me about calcitriol, everything I knew and everything I wondered about just rolled off his tongue. I was feeling relief that I had found him, so I did not have to drag Milo vet after vet to get 3rd and 4th opinions.

Specialist Vet

Richard Gowan is a wonderful man. He seems to know everything about CRF. He talks fast and clearly. But the news is very sad and I am so devastated. Richard looked at Milo and did an examination. Milo is an Abyssinian and they tend to get Amylydosis. If that is the case he will live only a couple of weeks most likely. and he says with Milo there is more than a good chance that he has this. He is in Acute Renal Failure, stage 3 or 4 of 4 stages. He said it was rapid, moving fast in Milo. And he is right. Milo's breathe was fine a week ago. I checked that because I knew of the breath thing, and only today it is suddenly really bad. Last night he slept with me and it was fine. Today it is so different. If it is not amylydosis it might be cancer or maybe something else. But either way he is in acute renal faiure and there is very little to be done. There is the renal transplant option but it is in another city 3 hours flight away, I'd have to take in the donor cat and I already have 5 pets and rent, it will be $10, 000 - $12000 and it would have to be done now, success has not been good, risks are high and the longest a cat has lived after it is only 3 years. Those factors are not ones I would go for.

Tomorrow Milo is going in for an ultrasound, and probably a small fine needle biopsy. That will tell us as much as possible as to be known, and Richard said it might not tell us much. He said SQ's (the fluids) should be started and the aluminium hydroxide phospherous binder is really good. He said ipakitine is popular but it does a general job. With Milo, no way go ipakitine, go aluminium hydroxide and possibly calcitriol. But he said don't worry about the calcitriol because with Milo it will make very little difference right now. He said not giving phospherous binders until the phospherous levels got high is not right. He explained you need to keep them low.

He talked about renal failure having so many potential causes. It was not a simple thing, very complex. And as anyone who has researched it knows, treatment and progress varies with each cat deopnding on age, severity, causes (which is often unknown) and the individual cat, plus genes too. A nice thing was that he was pretty impressed with the knowledge I had in such a short time. But I can not belive my baby will not make Christmas. I always had this feeling Milo would be with me for 20 years. I nicknamed him the Perfect Cat because he is gorgeous, wonderful, loved by cats, dogs, people...everything and he loves everything, he is affectionate, active, intelligent. I am so devastated. My little man is dying right before my eyes. I can not explain how that feels.

Rob called from the local vet

Rob, the young vet from the local vet called today.

I still have the appiontment with the special Cat vet this afternoon. He not specialist aside from the fact his clinic only treats cats and no other animals, but he has experience with CRF and renal transplants. Another vet caroline Webb keeps getting recmomended to me, even by people at work. So its great I have three sources of vets.

Summary;
He asked how Milo was. I said good, eating but skinny
He asked how much he weighs, I said I would tell him tomorrow
I said why does the cat lose weight – I can not remember his answer, but I think it is because the kidney can not process nutrients properly
I expressed a high degree of concern over Milo eating but being skinny
He said Thyroid and glucose were good
A growth on the kidney can cause it, but highly unlikely and especially with a 5 year old.
He said to find out a biopsy is needed, very risky
He said urine was negative – no bacteria
Protein in urine was normal – good (I think this means protein is not being wasted)
Electrolytes are good
We need to keep phosphorous levels down
We need to watch calcium and potassium, if they get too low we give supplements
We need to check blood pressure when he goes in each visit

He does not know enough about phosphorous binders: Rob said he would not use them unless the phosphorous levels go up high. This is the same as Matt (the senior vet said last Wednesday)
He said he did research on a lot of vet sites and they advise against them. They say the they are hard pills to swallow and they also cause vomiting and are not pleasant for the cat, besides being unnecessary if phosphorous levels were ok.

I said Ipaktine is not a pill, it’s a powder. I told him about that it also contains an adsorbent called chitosan, which is a polysaccharide similar to cellulose. That when protein is eaten and digested, an amino acid in the food called tryptophan is converted into indoxyl, which in turn is converted by the body into indoxyl sulphate, a type of uraemic toxin. Chitosan is said to bind with the indoxyl, so it cannot be converted to indoxyl sulphate, thus reducing toxin levels, which helps the cat to feel better. Chitosan is also said by the manufacturer to help reduce BUN/urea levels, and indirectly to reduce creatinine levels (I was reading from this blog as I spoke to him)

He did not know all of that and said he would look into it. He mentioned calcitriol as a drug available in the U.S and would see if that could help Milo. I told him Matt said he would do that for me last Wednesday.

More vets recommended

I am so relieved that I now have two more really highly recommended vets from a wonderful Australian Cat Forum. I will list them here so that I have one place to find them at.

1. Have you tried Carole Webb? She is on Burwood Rd in Hawthorn. Others in here recommended her to me, and I will drive up to Melb from Geelong to see her (or her son). Both have been great, and only deal with cats. From discussions with her, she seems to be really up to date with things.

2. Lotus has nursed several cats with CRF - I think she goes to Carol Webb - who is the Cat Protection Society Vet - Burwood Road Hawthorn - phone 9819 1468 and another that a lot of us go too who is really on the ball with research and cats is Ros Fleay - Chirnside Park Vet clinic - 9737 6366. Ros is not a cat only vet but many breeders travel from all over Victoria to visit with her and she is very knowledgeful and right on the ball with her treatments.

Good News!

I have an appointment with Dr Richard Gowan, at The Cat Clinic. Wednesday. I feel so much better knowing he will be across Milo. Also, I have not said anything about my thoughts or ideas, and this way I will be able to tell how good he is on the day. I offered to send through Milos results, but the vet nurse said to just bring them on the day. So I have 30 minutes for that. Woo Hoo! Oh and he stocks Ipakitine! I'll be leaving work at 4pm that day to get Milo there in time. I have to leave the city, get home, pick up Milo and head to the clinic.

I also heard from a lady via email who has had great success in keeping BUN and Creatinine down. Creatine was actually 1 point lower. She uses 1/9 tps. daily of each - Pet-Adophilus - a probiotic, and Inulin - a prebiotic. Mixes this with a dropper of Pediolite (unflavored, for babies), and the contents of 1 500 mcg Vit. B-12 capsule - in methylcobalimin form. All of these can be purchased at a health food store, except for the Pediolite which you can get at a grocery store. She included her research papers and so I am look into this as well.

Calcitriol

Yay, Just found this info: Calcitriol as the active form of Vitamin D. The ingredients to make the calcitriol must first make their way through the liver and then migrate to the kidneys which if healthy do the final step of making the calcitriol. Calcitriol helps your pet's body absorb calcium and phosphate from food and put it in growing bones, where extra calcium and phosphate is stored. A molecule called parathyroid hormone (PTH) works with calcitriol at bone to release calcium to blood. When too high, PTH becomes a serious health problem and we wish to lower it which we can do by giving calcitriol. If your pet's kidneys are failing and no longer doing their job of making enough calcitriol the parathyroid glands (around the thyroid gland in the throat area) produce more PTH in an attempt to normalize calcium and phosphate in the blood. The PTH is not too damaging until it reaches about 3 times the upper limit of its normal level in the blood as this is when toxicity due to the PTH first appears. This is usually happening about when your pet first appears to be ill. The PTH increase is worsened by the failure of the sick kidneys to eliminate phosphorus from blood which then gets too high a level. This both slows calcitriol formation and also prevents calcitriol from working at the parathyroid gland to block the PTH excess. When at very high levels late in kidney failure the phosphorus combines with blood calcium to precipitate into soft tissues damaging them. Although very injurious, this only happens at late stages of disease and use of calcitriol should prevent getting to such stages nearly as soon as would happen in pets not given calcitriol. The high levels of PTH directly damage kidney cells long before the mineral precipitation phase of renal injury. See http://members.verizon.net/~vze2r6qt/calcitriol/calcitriol2.htm

This just occurred to me

OK, question just occured to me and I admit that I am feeling a little stupid over it. If Milo is losing weight, I take him to the vet, he gets tested and he is diagnosed Chronic Renal Failure - how come no-one explains to me how this causes the weightloss?

Might be a stupid question, but shouldn't the vet have explained to me HOW this kidney problem CAUSES the weight loss?
And since they told me to feed him the Hills Science diet, which is low in everything ... then how does that address his weightloss? How will Milo put on weight if he is eating some skinny-food diet?

2nd Post. Day 8. One Week Since Diagnosis.

Well today was Sunday and I had a good sleep in. For the first time a what feels like a long while I feel adequately rested. If anyone reads this had posted or emailed me from a forum, yahoo group or elsewhere to help with Milo, thank you so much *hugs* Here is where I (try to) keep my thoughts and ideas together.

I will be making a time to see Richard Gowan at The Cat Clinic in Prahan, Melbourne, I am not in a panic as I have done more research, and Milo is eating some of the renal food. So as long I see him soon, I will be happy.

QUESTIONS
Weightloss
How does having CRF cause weightloss in a cat that is eating? I don't question that it occurs, but I want to understand how it has happens.

Phospherous Binder or Calcitriol?
Milo with CRF has normal calcium and phosphate levels.
He has high Urea 21.6 mmol/L (normal 5 - 15) and Creatinine 0.37 (normal 0.08 - 0.21 mmol/L)
I am feeding him 50% Hills Prescription Diet k/d and Innova Evo wet, plus Royal Canin Dry 'Renal'. Some days he gets chicken or turkey or beef, Raw,
Question: With that in mind, do I use a phosphorus binder or calcitriol, or neither. I understand both can not be used.

Which phosphorus binder: Ipakitine or aluminium hydroxide?
If the answer is to use a phosphorus binder, do I get ipakitine or use Aluminium hydroxide. Ipakitine uses lactose and calcium carbates, and the aluminium hydroxide has no calcium (to be double checked).
***[Answer is debatable: One argument is Ipakitine because Ipakitine is partly a phosphorus binder, containing calcium carbonate. However, the key for Milo is that it also contains an adsorbent called chitosan, which is said to help with uraemic toxins. Chitosan is a polysaccharide similar to cellulose and is obtained from the shells of crustaceans. When protein is eaten and digested, an amino acid in the food called tryptophan is converted into indoxyl, which in turn is converted by the body into indoxyl sulphate, a type of uraemic toxin. Chitosan is said to bind with the indoxyl, so it cannot be converted to indoxyl sulphate, thus reducing toxin levels, which helps the cat to feel better. Chitosan is also said by the manufacturer to help reduce BUN/urea levels, and indirectly to reduce creatinine levels. This is based on human research but it still applies potentially to cats. Ipakitine seems to be effective for its phosphorus-binding effects and for its toxin-binding effects (since higher levels of protein in the diet may cause increased BUN/urea levels). The writer of this article says "My own vet in the UK has seen falls in creatinine and urea in some cats when using Ipakitine and no other treatments. I would be happy to try it myself in a CRF cat who did not have very high phosphorus levels.

The other argument is Aluminium Hydroxide because it has more effective calcium binders. aluminium Hydroxide is definitely the choice for cats with high phosphate levels, but Milo's are fine. If calcitriol can be administered with aluminuim hydroxide, and that combination is better that ipakitine, then its worth looking into. But it seems to me that Ipakitine is the way to go.

Ref http://felinecrf.org/treatments.htm#ipakitine

Thyroid
*Milo's T4 is 43 nmol/L (Normal 10 - 48). This is the high end of 'normal' - does that mean we have to watch it? Does that have anything to do with his weightloss?

Diet-Diet-Diet
This is a more difficult than I ever thought.
Traditionally, CRF cats must eat CRF food only - a special renal diet low in all things to keep the load off the kidneys (Calcium, Phosphate and Protein - I think). Once diagnosed with CRF, it is my understnding a kidney is already likely to be 70% or more gone, so we need to look after the rest. Milo's life depends on it. Problem is that the traditional renal diet is low in protein and there is a debate on a low protien diet being more harmful than good on the cat as a whole (I think). So I need to work out what diet I will feed him. I have an interim plan, but that may change as I learn more.

What I learned
* BUN is sometimes just referred to as Urea Nitrogen or just Urea.
* America does not use the international standard of test results/measures called SI, therefore to get assistance from those who can help in America I need to convert Milo's test results from SI to US.I put the converiosn in link my list of links to the right.
* Glucose results reflect diabetes: Milo is normal
* Thyroid problems can cause weightloss. Tetralodothyronine (or T4, which is the indicator for the thyroid). Milo's T4 is 43 nmol/L (Normal 10 - 48)
* Hypertrophic cardiomyopathy - heart muscle getting thick resulting in heart needing to work harder

First Post. Day 1 through to Day 6 after diagnosis of CRF

A Brief History:
I searched high and low for Milo. I was looking for something, only my heart would know when I found it. I found Milo in Melbourne's Yarra Valley. He is an active affectionate and intelligent cat who gets on with everyone, whether they be human or furry, though I never tried him with a fish or reptile. Being a good hunter, birds, moths and small animals are not so fond of him.

Milo went from 6.2kg (13.6 pounds) to 5.2kg (11.4lbs. That is a loss of 1kg or 2.2kg in what I estimate to be 3 - 8 weeks. At first we thought it might be worms, treated him for worms on a Sunday and made an appointment with the vet for the following Saturday just in case there was no improvement.

Last Saturday the vet said Milo looked great, but said we would do some tests because there was definite weightloss. I pointed out the sucked-in tummy and that usually it was well rounded. I insisted on full tests, so he did blood and urine tests. The next day over the phone I was told Milo had CRF. I was shocked and stunned and many tears were shed. My Tigger died a few months after CRF diagnosis in about 1999 at age 8, and a year later his half brother Bindy had the same fate also at age 8. It broke my heart and was very traumatic. At the time I was not on the Internet at home and I had a one man vet clinic and now I know he knew very little of CRF.

Current status:
On Sunday I got the diagnosis and was told to go in and pick up renal food, and that they were going to run more tests on the blood that was already at the lab. On Wed I rang and spoke to the senior vet.

Here is an exert from The River Lounge that I wrote on Wednesday, 3 days ago
"Today I called the vets office and asked to speak to Matt, the man who used to own the surgery. He used to be the principal vet for our Zeus. Matt spent alot of time with me on the phone. He listened while I told him I loved them there but if there was a specialist I wanted to know. I told him I wanted to know if he felt he has enough experience to manage Milo well as only the best was good enough for my baby. I explained Rob was great but young and lacked experience. I told him about the food concerns I had, about my understanding of the electrolytes, and what I knew of phosphorus. I spoke about the fluids and the SQ stuff and all I thought about that and my ideas of when I would know I needed to do that and I told him what I learned about phosphorus binders and what I thought about diet, about how Milo is so young and hopefully we got it early and that I wanted his help to get Milo to live another 10 years at least, about how I am so overwhelmed and that CRF treatment is different for each cat and that what I read covers cats at all different stages of the disease and what my take was on Milo's, and I spoke about, and that I wanted a copy of every test for ever more and I wanted him to explain all the levels and help me understand what was normal and was to be expected, and which levels to watch out for and that my first concern was food because I did not want to put a strain on his kidneys but I did think there was something to the high quality protein debate and I told him about the back legs getting weak due to low protein diets theory.....and I told him about all of you ...... and oh boy he was good"

He assured me they were experienced enough and would get back to me with the next steps and that he would email me the test results right away. I expected an email right away and a call on Thursday, but I think I expected too much. I did not hear from the vet by Friday 11th Jan and so at 5pm Friday I called. All vets were in with patients and so I asked the vet nurse to take down my email address again and check with the vets to see if they had tried to send the test results by email as they promised on Wednesday. I explained I was waiting to find out more about the additional tests that were mentioned on Sunday by the vet to me, and me to another vet during my enquiry on Wednesday. I said I was really quite anxious about getting Milo the treament and management plan and could she make sure they contacted me.

So about 30 minutes later I get an email with the test results attached saying to contact either of them if I had any questions. I also get email later on Friday from the vet I spoke to on Wedneday, and he says he is looking into the phospherous binders I mentioned on Wednesday and also into calcitriol and that we should get Milos blood pressure check soon. Thats it. No mention of the further tests...maybe they forgot?!

I would have expected all of this to be done MUCH sooner than now. OK, its only a week, but for me every single day without a treatment plan is an opportunity to help Milo wasted.

On Wednesday when he was talking to me, he sounded like he knew a lot about CRF... but he does little betwen then and now, and there is no treatment plan right as yet. I honestly expected him to call on Thursday and say something like "Please bring Milo in at 10am on Sat. We have more test results, we have a treatment plan we would like to discuss with you, we need to check his blood pressure and start him on some meds. We also think it would be good for you to spend time with us so we can answer the questions and concerns you have right now which will out you in the best position to help Milo". I would have expected some version of that - but no!

Where I am getting help from
My first point of call was The River Lounge. This is a wonderful online community that a few friedns and I have together. We met years ago a huge American cat site, then we went to Purrpals which was started by Amy. Purrpals turned into The Catnip Lounge, and The River Lounge is where the peaceful friendly members ended up as it is invite only. The people there are mostly cat lovers, though not all of them are, and are wonderful. I also am a proud member of cat-world.com.au, the best Australian cat forum owned by the awesome Julia.
With help I found a CRF Yahoo Group Caring for CRF Felines

A yahoo group where Vets share knowledge and experience of other veterinary professionals, and non vets are welcome petvetcafe

I found, thank to Elizabeth at Catworld a specialist Cat Clinic in Melbourne http://www.catdoctor.com.au/index.lasso where the vets seem highly poassionate. Richard spent 5 years at the only hospital that does renal transplants on cats in Brisbane, so I will be contacting him.

I also found, in my quest for Ipakitine/Epakitine the Melbourne Veterinary Specialist Referral Centre which is Caroline O Brien, Melbourne's only feline specialist works from (except right now she is doing her PHD).
I have a link thanks to Jeannette on how to read food labels
The questions I have at this time
Is Milo's weightloss due to the CRF. How does CRF cause weightloss? Should I be checking Milo's thyroid as suggested by Gabby at the Yahho CRF group (I am reading if a young cat has weightloss it is not necessaily the CRF, and this has not been mentioned by my vet - need to discuss with my vet)
Is BUN in the test results I have? (asking my vet)
What is the best diet for Milo (a work in progress, so far thinking 50% renal food and 50% high quality food with Ipakitine when I find it)
Is there a nutritional difference between raw and cooked chicken or turkey?
What is Calcitriol? (Wikipedia says 'It increases blood calcium levels by increasing the absorption of calcium and phosphate from the gastrointestinal tract, increasing calcium and phosphate reabsorption in the kidneys and inhibiting the release of PTH." but I don't understand it.

I'll post more tomorrow. This has been the best way I can put the mountains of stuff I have in my head down here.