Sunday, March 4, 2012

An odyssey into feline kidney failure

(Note:  I haven't finished this post yet.  I wanted to include the reports from each weekly chemo visit.  And to try to fix up whatever went wrong that put those stupid white highlights on all this stuff.  But, I can't do it right now.  I'm having a very hard time even coming here - the other day, someone asked for information that I knew was in this blog, and it was really a struggle to even look it up.  I don't seem to be healing from Sruffy's leaving, and until something magically fixes that........  Anyway.)

I can't get straight in my head ( or heart) how less than two months ago, I thought everything was fine and dandy with Scruffy.  I was at the vet with another cat, and on the spur of the moment, decided to make an appointment for him to have bloodwork and a dental. And while that unthinking impulse led to the detection of lymphoma and CRD/F  - finding diseases (other than the diabetes and glaucoma)was the furthest thing from my mind.  I even said to the vet, after he'd taken the blood to analyze it on his machine, "I'm not really much worried.  He's never had anything worrisome show up on bloodwork."  Little did I know.  (I also said, "Scruffy never not eats," which turned out to be the day  before he decided he didn't want to eat. )

Here's the official evidence of what has happened in such a short time, as well assorted comments and whining,  raging against the Universe, I guess.

1/6/2012  Bloodwork done at vet's office, on his machine.  (I did once ask how often that machine is calibrated, which was apparently an offensive thing to say.....)

Abnormal results:

AST  (SGOT)    106  (HIGH)  ref. 10-100
ALT  (SGPT)     154  (HIGH)  ref 10-100
Calcium   12.8  (HIGH)  ref   8.2 - 10.8
Amylase 1407 (HIGH)  ref 100 - 1200
Neutrophils   9225  (HIGH)  75%  ref  2500 - 8500

Normal results:

Urea Nitrogen  35  ref 14 - 36
Creatinine   2.3    ref  0.6 - 2.4
BUN/CR ratio   15     ref  4 - 33
Phosphorus  5.5    ref 2.4 - 8.2
Potassium  4.1   ref 3.4 - 5.6
Total T4   1.3   ref  0.8 - 4.0

WBC   12.3     ref 3.5 - 16.0
RBC    6.95     ref 5.92 - 9.93
Hemoglobin   11.7   ref 9.3 - 15.9
Hematocrit    33.7     % ref 28 - 48

and glucose - not that it matters - 90.

Here began the nightmare.  Although I didn't understand any of it at the time, my vet expressed concern about the HIGH Total Calcium level.  And said that maybe it was just a one-off result, that electrolytes aren't necessarily always exact, etc.  And I should wait two weeks and have the bloodwork repeated.  Of course, by the time I got home and started reading a little bit about elevated calcium, I was in such a panic that there was no way I could have waited two weeks.  So.......

1/13/2012   Bloodwork done at vet's office and sent to Antech.  Reported 1/14/2012

Abnormal results:

AST (SGOT)  115  ref 10 - 100
ALT (SGPT)  151   ref 10 - 100
Urea Nitrogen   41 (HIGH)  ref 14 - 36
Creatinine   2.8  (HIGH)  ref  0.6 - 2.4
Glucose  51 (LOW)  lol
Calcium  14.5   (HIGH)   ref  8.2 - 10.8
Amylase   1226  (HIGH)  ref  100 - 1200
fPLI  14

Normal results:

Phosphorus  5.5     ref 2.4 - 8.2
Potassium  3.8    ref 3.4 - 5.6
T4   1.2   ref - 0.8 - 4.0

WBC   9.5     ref 3.5 - 16.0
RBC    6.23   ref  5.92 - 9.93
HGB  10.7     ref 9.3 - 15.9
HCT   31.8      %   19 - 48
Absolute Neutrophils  6650  ref  2500 - 8500

So, further panic ensued.  I was instructed to do fluids at home.  My vet recommended getting an appointment for an ultrasound as soon as possible.  Less than two weeks, was his suggestion. When I called, I was originally told that there was nothing available for two weeks, but then, an appointment was available in three days.  I took it.

1/20/2012   Scruffy weighed 10 pounds, 2 oz, by the way.  Down more than a half pound from what he had been in December, 2011.

"Xrays indicated:  possible cardiomegaly; decreased detail within the cranial abdomen suggestive of mild effusion or inflammation.  Hepatomegaly was noted as well.

Ultrasound abdominal:  On the spleen there were multiple large, hypoechoic, heterogenous masses up to ~80mm to the right of the midline.  On the liver there was a single 27x20mm mass similar in appearance to the liver mass.  The peritoneal cavity had mild/trace effusion.  Single small mass between stomach and liver of questionable origin.

Ultrasound-guided aspirate:  consistent with large cell lymphoma

Istat Chem 8:

Glucose  184
BUN 67
Creatinine 3.9
Potassium  4.4
Chloride  131
iCA (ionized calcium)  1.84

Urinalysis  SG:  1.014, remaining values WNL

T-bili:  0.2  ref 0.0 - 0.5

Scruffy was hospitalized immediately after the ultrasound was completed, and was given a first treatment of vincristine for the lymphoma.  Official diagnosis:  large cell lymphoma of liver and spleen; kidney failure, history of diabetes mellitis, history of urethral obstruction.  I didn't even get to say good-bye to him; they had told me to go home and they would call me to come back and pick him up; didn't happen......

I might also add, even though the fPLI was VERY elevated - 14! - the IM specialist who did the ultrasound said that they had had multiple experiences where the fPLI was not considered accurate after ultrasound testing was done, and that they didn't regard it as a very useful test at this time.  There isn't any further information about pancreatitis on any of the papers, though.  I never did have the feeling that Scruffy had pancreatitis when all this began.  And maybe once the lymphoma was confirmed, there really wasn't any pancreatitis....

1/21/2012  Bloodwork done during hospitalization:

Istat Chem 8:

Glucose    184
BUN   76
Creatinine    3.5
iCA    1.48
Cl    131

He was started on IV fluids, with dexamethasone added, hence the 184 glucose level.  He also had what they felt was a urinary blockage overnight; when the oncologist called around 10 AM, they still hadn't done anything to FIX it.  They  did catheterize him eventually and remove a very large amount of urine, and the catheter remained in place until he was released from the hospital on 1/23/12.  He had not eaten anything since the evening of 1/19/12, because he was to be fasted prior to the ultrasound, and he had refused all food in the hospital.  I came to visit him in the afternoon of 1/21, and brought his favorite food, some lactose-free milk (yeah, I know - phosphorus and calcium and vitamin D - but I didn't about any of that then), his kitty pi, some paper plates to feed him on; he actually ate about a half can of Gourmet Chicken FF while I was there.  I also brought his glaucoma drops and prozac pills.

1/22/2012   (in hospital )

Istat Chem 8  

Glucose  210

BUN 67
Creatinine   3.1
iCa  1.38
HCT 23
HGB 7.8  
remaining values WNL

1/23/12   Istat Chem 8  (in hospital)

Glucose  251
BUN 63
Creatinine  3.3
iCA 1.34 
remaining values WNL 

He was released from the hospital on 1/23, late in the afternoon, with an appointment to return for a second chemotherapy treatment on 1/26/12.  He looked horrible and smelled even worse. We were so glad to have him home.  He settled right in, ate like a horse, and seemed like maybe this was going to be okay.

1/26/12   second chemotherapy treatment.  He was given cytoxan for the first time, with lasix to keep it from remaining in the bladder any longer than necessary.

CBC was "pending" - their lab's machine was broken or something.
Chem 8:

Glucose  213  HIGH  ref 60-130
BUN  90  HIGH  15-34
Creatinine  3.8  HIGH  1 - 2.2
iCA 1.50 HIGH  1.2 - 1.32
Potassium    4.6  HIGH  2.9 - 4.2

PCV (Hematocrit)  36 (on separate machine)   24 - 30
Hemoglobin   9.9  8 - 13

He was started on prednisone when he was released from the hospital.  Although the glucose was elevated today, it wasn't nearly as awful as I had expected.  He weighed 10 pounds, 3 ounces.   While his weight hasn't changed much, it seems to be rearranging itself - his abdomen feels kind of squishy, and his head is so bony.  He loves to have his ears rubbed, the area in front of the actual ear, and now there's no flesh there, to speak of; just boney projections that make it hard to do. His little face has become even littler...  :(

This was also the first time there was a mention of a heart murmur:  "Auscultation of the heart reveals grade II/III/VI systolic murmur."  There has never been any indication of heart murmur before this.  It was suggested that, since we're giving fluids at home and he's getting fluids with the chemo, having a cardiologist check things might be a good idea.

The oncologist's comment after this treatment:  "Today we gave a second chemotherapy treatment since Scruffy has been showing some clinical improvement at home.  His bloodwork shows persisten elevation in kidney values and also the calcium as we discussed.  This likely indicates lymphoma is not in remission yet, but this is not unusual as it typically takes several weeks for cats to respond fully.  We are going to continue going forward with treatment one week ata time as long as he is having good quality of life at home."

And, I had noticed that he had something (which turned out to be an ulcer) on his left eye.  They arranged that Dr. B, the ophthalmologist, come down and look at it while Scruffy was waiting for treatment.  Which was nice of them.  Eye stuff really hurts.  A follow-up ophthalmology appointment was scheduled. 

 He didn't have much of a reaction to the IV cytoxan.  He was a little lethargic the second day, but ate normally and was normally active.  (Well, that's relative with a sick cat, but he was up and around, he was alert, he used the litter box, etc.)  I keep saying, if you didn't know he was dying, you'd never know he was dying.  So much of the time, he has been absolutely himself, despite all the horrors that were going on inside his little body.

Feb. 26, 2012

This is about all I can stand of this right now.  I realize it's kind of obscure, and no one but me would be interested - but I keep seeing places where I would give anything if I'd understood more about what was going on, or if I had realized that there were actually things that I could have been doing that might have helped.  By the time Choy-Foong came along and offered information and support and Aluminum Hydroxide and azodyl, maybe too much time had already gone by,  and too much damage had already occurred.  (Yes, now I'm fixated on azodyl doing some miraculous healing and making The Puffer feel a zillion times better.  I have to have my illusions, or I don't know if I can go on with this.)   I have been sproinging from despair and hopelessness to thinking maybe things aren't as awful as they seem to knowing that yes, they are that awful.  The essence of it all is, once the kidneys are so significantly damaged, they're not going to recover.  Period.  I read lots of letters from people whose CRF cats had been hanging around for 5 years, or 9 years, or whatever, but most those cats seemed to have a very slow onset that their owners were able to treat effectively from the beginning.  Also I didn't see anyone mention simultaneous lymphoma, come to think of it.  And now, I'm sproinging from is he going to die horribly here at home in a matter of hours, do I need to find someone to euthanize him (significant annoyance with my regular vet), to amazement at the fact that he has already eaten a significant amount of food THREE times this morning, he woke me up at 7AM to rub his ears and then we napped with Busy and Milk and Burble for an hour.........  All so normal and non-deathlike, I guess.

I have an appointment to have him euthanized - I can't say "put to sleep" - they're not asleep, they're DEAD - tomorrow afternoon.  I told the vet when he called yesterday - another long story, but I think I'm going to be looking for a new vet - that Scruffy has never really fallen off the Quality of Life Scale.  There are times when he seems weaker, times when he doesn't eat as enthusiastically, times when he looks so pitiful it makes me cry, yes.  But, there are even more times when he's just Scruffy - the same scraggly little brown cat he always was.  And yes, I want desperately to spare him pain and whatever awfulness comes with dying of kidney failure, but right now, I don't SEE any pain, I just see him living like he always has, only eating stuff he's not crazy about.  This is a horrible responsibility.  I don't want to do "it" too soon, or too late.  Crap.  All I do is cry at the drop of a hat any more.

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