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A Feline Expert Shares Her Dos and Don'ts for Caring for Cats With Kidney Disease

March 06, 2018

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Story at-a-glance

  • Today’s Cat Week guest is veterinarian Dr. Lisa Pierson, creator of the superb CatInfo.org website
  • Chronic kidney disease (CKD) is the no. 1 medical condition in cats today. It could be linked to the FVRCP vaccine, which is why it’s so important not to over-vaccinate
  • Dr. Lisa wants to send the message that protein is NOT the enemy of cat kidneys, and that low-protein diets are NOT species-appropriate for felines
  • She has had great success treating CKD cats with carb-free homemade diets that are about 40 percent protein calories and 60 percent fat calories, plus appropriate supplements, especially fish oil
  • If your cat has CKD, it’s important not to force pills or fluids or other treatments on her. Instead, honor her wishes and focus not on her illness, but on the time you have left with her

By Dr. Karen Shaw Becker

My guest for Tuesday of Cat Week is feline expert Dr. Lisa Pierson, founder of the fabulous website CatInfo.org. Dr. Lisa graduated from the University of California, Davis veterinary school in 1984. For the last 15 years, she has focused almost exclusively on feline nutrition and feline medicine. Her passion is trying to help prevent some of the diseases we see in kitties today (e.g., diabetes and urethral obstructions) by feeding them properly.

"My biggest goal, as you well know," says Dr. Lisa, "is to get people to stop feeding dry food to cats due to the water depletion, which can lead to urethral obstruction, and the carbohydrates, which make cats more susceptible to diabetes."

Feline Kidney Disease May Be Linked to a Particular Vaccine

The no. 1 problem veterinarians see in cats today is kidney disease, and so I wanted to talk with Dr. Lisa about the best way to feed kitties with kidney disease. When I was in veterinary school 20 years ago, I was told 3 out of 4 cats will die of kidney disease. No reason was given. We were told, "There's nothing you can do. Cats are predisposed to die of kidney failure." We were taught how to identify the problem, but not what causes it. I asked Dr. Lisa for her thoughts on what's behind the epidemic of kidney disease in cats.

"That's a fabulous question I wish I had the answer to," she replied. "We do know that a well-respected researcher, Dr. Michael Lappin at Colorado State University, has established a possible link between feline kidney disease and the feline viral rhinotracheitis, calicivirus and panleukopenia (FVRCP) vaccine, which is grown in feline kidney cell cultures."

"We really want to be very careful not to over-vaccinate cats," Dr. Pierson continued, "because they can possibly set up an autoimmune type of reaction to their own kidney cells. Having said that, my own cats still developed kidney disease.

I assure you they were not over-vaccinated. They got vaccinated as kittens. They passed away between 18 and 20 years of age. They were never vaccinated again after their kitten shots, yet they still got kidney disease. They were not on dry food. They were on a water-rich diet. So the short answer to your question is, 'I don't know, but I wish I did.'"

An important point to make here is that as Dr. Lisa's situation demonstrates, we can do everything right and our cats may still acquire a debilitating disease, including kidney disease. Many parents of sick cats say, "I don't know what I've done wrong." Often, they've done nothing wrong. Even in optimal environments, cats can and do get sick.

How Many Vaccines Do Indoor-Only Cats Require?

I usually recommend, for people with indoor-only cats, that they skip all vaccines. If you know your cat will never step foot outside and no other cats will be brought into the home, there's virtually no risk of exposure to the diseases we vaccinate against. I asked Dr. Lisa what she thinks about not vaccinating indoor-only cats at all.

"While I'm definitely against over-vaccinating, I always give at least one vaccine when the kitten is at least 16 weeks of age," Dr. Lisa says. "I've seen enough cats die from panleukopenia to make me uncomfortable with the thought of no vaccines at all.

We do take these cats to veterinary clinics and many people do wear shoes in their homes so there is not zero exposure. I would at least vaccinate once. I differ with you on this issue. I'd be worried about leaving them completely unvaccinated for panleukopenia.

I had five cats two years ago. I lost four out of my five cats in the last two years. They were between 18 and 20 years of age. They received [two] FVRCP vaccines as kittens with the last dose administered when they were at least 16 weeks of age. A couple of them may have received another FVRCP vaccine a year later but no FVRCP vaccine was administered after that. None had been vaccinated since they were kittens or maybe a year old.

On their last day with me, I ran panleukopenia titers to measure the antibody levels in their bloodstream. Antibodies aren't the only things that fight disease, of course, but for all intents and purposes, all the cats' titers indicated they were protected against panleukopenia.

My mom's cat is 20 years old. I don't think I vaccinated him after age 5. I ran a couple of panleukopenia titers on him when he was 18 and again just recently and the titers were at a level that immunologists feel is a protective level against this disease.

My own cats are 100 percent indoor-only. They get vaccinated with FVRCP when they're kittens, with the last vaccine at about 16 weeks of age when the maternal antibodies should be gone. I do not administer the FVRCP vaccine again."

So Dr. Lisa does vaccinate her indoor-only cats, but minimally. Historically my indoor cats also received one vaccine at 16 weeks. But I think if I get another kitten who will live strictly indoors, I'll probably not vaccinate at all. I'll probably do none, since his or her exposure will be none, in my opinion.

'Protein Is NOT the Enemy of the Cat Kidney!'

Next I asked Dr. Lisa for her thoughts on what cat parents can do early on in their pet's life to try to prevent kidney disease.

"I really don't know anything concrete," she explained. "Some people believe a water-depleted diet of dry food can harm the kidneys, but I don't know if there's any research to support that theory."

Often, cats fed exclusively dry food have super-concentrated urine because their kidneys are trying to preserve water for the body. "Does that cause or lend itself to kidney disease?" asks Dr. Lisa. "I really don't know."

"I feed a water-rich diet. I feed a species-appropriate highprotein/moderate fat/zero carb diet. With regard to how protein affects the kidneys, it's important to understand protein is not the enemy of the cat kidney. Protein doesn't cause kidney disease. It doesn't exacerbate kidney disease. It is not the enemy of the kidney.

If there's one take-home message I want to get across, it's 'Please stop vilifying protein!' I would not feed any of the protein-restricted, so-called 'prescription' diets to any cat in my care. There are always better options."

The Problem With Protein-Restricted Diets for Cats

Back in 1994, Dr. Delmar Finco proved cats will die of hypoproteinemia (insufficient protein) long before they die of kidney disease. I can't figure out why, if we've had research available for over two decades, there's still this pervasive idea in veterinary medicine that we should restrict protein. I asked Dr. Lisa why she thinks veterinarians still have not recognized that limiting protein is a really bad idea.

"We have to ask why this idea of protein-restricted diets came to be in the first place," she replied. "Why did our profession glom onto the idea that protein is the bad guy? When we eat protein, our bodies break it down. We use what we need and our bodies produce BUN (blood urea nitrogen, or urea), which is a waste product of protein metabolism.

The more protein we eat, the higher the BUN load. If the kidneys are efficient and healthy, they filter the BUN out into the urine. When the kidneys become less efficient filtration organs, the BUN rises in the bloodstream. So the powers that be decided, 'BUN comes from dietary protein. Let's just minimize dietary protein.'

I do not have a problem with cutting back a little bit (say, from 60 or 70 percent to 40 percent) but I do not agree with feeding cats only 20 percent of their calories from protein."

My thought is that if you're feeding a poor-quality, rendered, dehydrated protein that conceivably consists of indigestible animal parts such as hooves and nails, it may negatively affect the kidneys long term. High-quality, human-grade, bioavailable protein — which is what cats in the wild eat — should have little to no negative impact on organ systems. If it did, felines wouldn't have survived as a species.

However, we've preached the low-protein thing for so long, to switch viewpoints now could dramatically impact the billion-dollar pet food industry. I fear it's possible we've gone too far to turn back.

"I'm still hopeful," says Dr. Lisa. "I spoke with a colleague the other day. She had just attended a seminar at which someone said, 'We've got to stop protein-starving these cats.' And I thought to myself, 'Hallelujah!' I've been preaching this for 15 years, as have you."

What Amount of Protein in a Cat's Diet Is the Right Amount?

"I want to give your listeners some numbers to chew on," says Dr. Lisa. "If you look at metabolizable energy, meaning the calories from protein, fat and carbs, they have to add up to 100 percent. Hill's k/d, Purina NF, Royal Canin are prescription diets that restrict protein to a level between 20 [to] 27 percent of calories. A cat's natural diet is about 60 to 70 percent.

When I formulate recipes for my chronic kidney disease (CKD) cats, or I recommend over-the-counter diets, using my proteins, fats, carbs, phosphorus chart at CatInfo.org, I recommend a nice happy medium of 40 percent calories from protein. I don't think cats truly need the 60 to 70 percent they find in the wild. All you are doing is adding to the BUN load. I don't think it's necessary.

I've had fabulous results over the last 15 years feeding thousands of CKD cats right around 40 percent protein, and less than 10 percent carbs. My homemade diets have zero carbs. That means they have 60 percent fat, because it has to add up to 100 percent.

So those are some numbers I want to share with your listeners. In the vast majority of patients, I find that 40 percent protein calories will support muscle mass and the immune system without unnecessarily overloading the BUN bucket that the kidney then has to deal with.

Of course, more BUN is generated with a 40 percent protein diet than one with 20 percent protein. That is obvious. However, all disease processes are a trade-off and one has to remember a very basic equation: 6 ounces of a 20 percent protein diet = 3 ounces of a 40 percent protein diet in terms of grams of protein ingested — assuming the same caloric and water density.

Sure, a cat can meet their protein requirements on a diet that has only 20 percent of the calories from protein, IF they eat enough of it. But what happens when a cat on a protein-restricted diets starts to eat less? The answer is they will become protein malnourished and the diet needs to be more protein dense to make up for the decrease in volume intake."

When You Lower the Protein in a Cat's Diet, You Should Raise the Fat Content, Not the Carbohydrate Content

Interestingly, Dr. Lisa's 60 percent fat figure lines up with the recommended fat intake in ketogenic diets. I think we need to educate pet parents that fat is an excellent source of energy, and it's also dogs' and cats' evolutionary source of energy.

"In the wild, cats eat about 60 to 70 percent protein, 0 to 2 percent carbs, and then 10 to 30 or 40 percent fat," says Dr. Lisa. "So the 60 percent fat for a CKD diet can end up being double what their natural diet is if we want to hold back on the protein a bit and NOT overload them with carbohydrates.

Research on fat content in cat diets indicates that some cats with GI problems such as chronic vomiting, chronic diarrhea, inflammatory bowel disease, and pancreatitis don't do well on a 60 percent fat diet, but it's rare.

Felines are obligate carnivores. They're designed to eat protein, fat and no carbs. When pet food producers formulate prescription diets, k/d for example, with lower protein, they have to raise the percentage of either fat or carbs to get to 100 percent. Hill's raises the carbohydrates, which makes the diet even more species-inappropriate.

Royal Canin actually chooses to raise the fat and keep the carbs down a bit. That's much more species-appropriate. If you're going to lower protein at all, don't raise the carbohydrates. Raise the fat. Cats deal with fat more efficiently than carbohydrates."

A Brilliant Tip for Monitoring Your Cat's Kidney Function at Home

In my experience, many people with CKD cats are frustrated that the condition wasn't discovered earlier. That's why I like to be proactive and perform annual bloodwork to identify subtle changes that can occur in cats' bodies long before they start showing symptoms of kidney dysfunction. I asked Dr. Lisa what she feels is the best age to start doing annual bloodwork on cats.

"That's a great question, but I'm going to turn it around," she replied. "What I check, because it's usually the first thing to head south with respect to kidney disease, is urine specific gravity. I have a spoon sitting next to all my litterboxes — the boxes are uncovered because I'm not a fan of covered or hooded litterboxes — and a little syringe.

For around $50 to $70, you can buy a refractometer — this information is actually on my urinary tract diseases page towards the bottom under the video showing how to obtain a free-catch urine sample at home. There's a link there to a refractometer. I put a couple of drops of urine from the syringe on it and look at urine specific gravity, which is a measure of the concentrating ability of the kidneys.

All my cats go in for annual bloodwork anyway, no matter their age. Of course, if they're sick, I'll take them in more frequently. Bottom line is, I do annual bloodwork, but I'm checking their urine specific gravity frequently ([four to six] times a year) when they get to be 10 years of age or if I notice them drinking more than usual. My cats are very used to spoons stuck under their butt!

The SDMA test — which is the proprietary IDEXX urine test that is supposedly better than creatinine levels in detecting early kidney disease — can also be run. However, measuring urine specific gravity can be done at home for no cost other than a refractometer and it may be even better than the SDMA, in some cases, to help us recognize kidney disease earlier.

Urine specific gravity parameters:1.040 and above shows a normal urine concentrating ability of the kidneys; 1.012 is rock bottom. When you start getting 1.030, 1.025, 1.020, you may want to take your cat in to check the BUN, the creatinine, the phosphorus and the potassium."

That's really great advice. Cheap, easy, and you're not stressing out your cat. Just follow kitty with your spoon when he goes into his litterbox, stick spoon under butt, collect a bit of urine, pull it into your syringe and put a couple drops in your refractometer. You can start when he's a kitten, or as soon as you bring a new adult cat home. You can continue to do it proactively throughout their lives. It's a brilliant tip!

The Kidney Disease Staging System (IRIS) Has Serious Flaws

"I also suggest setting up an Excel spreadsheet for all the BUN, creatinine, phosphorus, potassium and urine specific gravity results," Dr. Lisa continues. "Those are my big five: BUN, creatinine, phosphorus, potassium and urine specific gravity. I've charted all my cats, which brings me to the IRIS staging system.

The IRIS staging system — IRIS stands for International Renal Interest Society — establishes parameters for judging the severity of kidney disease. When the creatinine is over X, they're stage one. When it's over Y, they're stage two. There are four stages.

I personally strongly dislike this system. I think it's far too strict. Creatinine over 1.6 is deemed a problem. I disagree with that. My own cat, Robbie, has had a creatinine in the low [2s] for the past 10 years.

He's 17 years of age, and his kidneys are still fine. I think the IRIS staging system alarms people unnecessarily, and too early. I think it's too strict. I just want readers and your listeners to understand that when your vet says stage 1 kidney failure it's a case of maybe, or maybe not."

This is very true. There's a whole lot of doom and gloom around IRIS staging. I think it can actually lead to premature euthanasia, when the fact is there is much that can be done for these cats, sometimes for years to come.

"The cats are put on a prescription renal diet, which I strongly dislike," says Dr. Lisa. "It's also one of the reasons I have a problem with the SDMA test, because these cats are being put on protein-restricted diets even earlier. I think to myself, 'Great. We've got an early marker, but now these 6-, 7-, 8-year-old cats are being put on protein-restricted diets, which makes me cringe.'"

Why Supplementing With Fish Oil/Omega-3s Is so Important

So let's say we have a cat for which we regularly check urine specific gravity, and all is well until kitty turns 9 or 10 and his number dips to, say, 1.025. We take him in for an SDMA test, and the vet determines he's in the beginning stages of renal disease. I asked Dr. Lisa how she would proceed at that point.

"First of all, let's hope the cat has been off of dry food all his life, or at least as soon as his owner learned dry food is not a very healthy diet for a cat," she says. "So let's hope he's on a water-rich diet.

Regarding urine specific gravity: Picture a sieve in your kitchen, and the holes of that sieve are getting bigger and bigger and bigger. When urine specific gravity drops, it means the kidneys are leaking more and more water. They're unable to save water for the body.

There's nothing that frustrates me more than to see cat owners leave their vet's office with a bag of fluids under one arm and a bag of dry food under the other arm. They've been told to feed a water-depleted diet and then stick a needle in their cat's back to put water into him. That's pretty nonsensical

The sensible approach? Step one, provide a water-rich diet. Step two, the diet should be low in phosphorus. Step three, supplement with omega-3 fatty acids— fish oil, fish oil, fish oil. When we do post-mortems on these cats, we see nephritis. 'Neph-' means kidney, '-itis' means inflammation.

We know that fish oil and omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA), are anti-inflammatory. There was a meta-data study done that looked back at all the individual CKD studies that were done, and the researchers discovered that cats getting high amounts of fish oil seemed to live the longest.

Now, I'm not that bright, but two plus two might equal four in this case, where we have an inflammatory process. Fish oil happens to have anti-inflammatory properties, so it stands to reason that fish oil may slow the progression of kidney disease.

Here's my goal: one capsule per cat per day. One regular strength capsule should have about 300 milligrams of combined EPA plus DHA. They've done safety studies to show that 600 milligrams of combined EPA plus DHA per cat per day is safe.

Fish oil can cause bleeding problems in some patients, which is why if you've gone in for surgery in recent years you've probably been told to stop taking aspirin and also fish oil ahead of time because they have anti-clotting properties. But 300 milligrams of combined EPA plus DHA is safe."

"We also treat with potassium as needed," explains Dr. Lisa, "because sometimes these cats get very hypokalemic, meaning they have low blood potassium levels.

One of the reasons I don't like the prescription renal diets is because toward the end stage, CKD cats can get hyperkalemic, meaning they have too much potassium in the blood. All the renal diets are fortified with potassium, so they end up compounding the problem of hyperkalemia and are detrimental to the patient."

Switching a Dry Food-Addicted Cat to a Moisture-Rich Diet

"I really love homemade diets," says Dr. Lisa. "I'm a big fan. The recipes I formulate mimic the prescription diets in that they include plenty of B vitamins and antioxidants, plenty of fish oil, and I can adjust the potassium as needed based on the patient's blood levels.

They're low in phosphorus. They contain a moderate amount of high-quality proteins versus the prescription diets, [which] are more protein-restricted and often have very [poor-quality] (low biological value) sources of protein (e.g., [Brewers'] rice). My patients thrive on these homemade diets."

I'm of course a huge proponent of homemade diets as well. The number one complaint I get from clients, though, is their cat won't it eat.

"First of all, there is no need to make diet 'all or nothing,'" says Dr. Lisa. "Many cats will not eat a diet of 100 percent homemade and always need a bit of commercial canned food mixed in to make it more flavorful. It's fine to mix commercial with homemade. Some homemade is better than nothing.

That said, I find that people give up far too easily when trying to get their cats to eat a new diet. People shouldn't get discouraged as quickly as they do. They have to roll up their sleeves, work at it, and be patient. Also, the key issue is change the diet before your cat is really sick. No sick cat wants to try something new.

And use your cat's hunger as your friend. Don't put the food down, watch them walk away from it, and just give up by putting their old food back down. Make them go 12 hours without food. Make them go 18 hours without food. Get a little tough.

Look at my tips for transitioning a dry food addict. It's applicable when you need to change any diet. Hunger is your friend, number one. Take the diet they like, 90 percent of it. Mix in 10 percent homemade, then go 80-20 or 70-30. Or do the opposite, take 90 percent of the homemade, start slipping in a little Fancy Feast or Sheba, or whatever you want to feed.

But be patient. Don't give up. You can actually out-stubborn your cat, but people give up far too easily. It took me three months to get my cats off 100 percent dry food. Some of them had never seen canned food in their entire lives, including my 10-year-old. It took me three months to get them from dry food to canned food.

And then it took me a little bit longer to get them from the canned to the homemade, because the canned tends to be gamier-smelling, and probably a little bit more flavorful.

I love FortiFlora, which is a Purina probiotic. I use it as a flavor enhancer, not as a probiotic. If I were to put that powder on cardboard my cats would eat it! I just use it like salt and pepper, just sprinkle it on their meals. It's a liver digest. If you're going to pick something that a cat likes, most cats love liver.

Or you can buy something like Fancy Feast Chicken and Liver or Turkey and Liver, the classic feast, which is kind of my go-to enticement. I try to stay away from fish. I don't want to create a fish addict. There are other problems with fish. But when you're trying to transition a cat away from dry food, I don't mind giving them a little bit of fish, but you'll have to wean them off it."

A Word About Fish Versus Fish Oil

For those of you confused as to why we're recommending fish oil but not fish, I should clarify that our issue with fish as a protein source is that not only are many types of fish contaminated, they are also high in iodine, which can cause hyperthyroidism. Good-quality fish oil supplements don't contain iodine and are tested for purity and potency, which means they're screened for heavy metals and PCBs.

Fish oil also doesn't cause food sensitivities, unlike fish fed as a protein source. Bottom line, fish oil is really in an entirely different category from fish fed as a protein source. It's protein versus fat, as Dr. Lisa points out. Fish oil is safe and a good source of omega-3 essential fatty acids. However, feeding fish to cats is not recommended.

If Your Cat Has Kidney Disease, Ask Your Vet About Calcitriol

I asked Dr. Lisa what else she would suggest cat parents do to help enhance their kitty's quality of life, longevity and kidney function.

"You might want to ask your veterinarian about calcitriol," she answered. "Calcitriol is the active form of vitamin D. One of the jobs of the kidneys is to take the inactive form of vitamin D and activate it. In other words, it makes calcitriol.

The parathyroid gland, not the thyroid gland, but the parathyroid gland, is very intimately involved with calcium and phosphorus balance. It secretes parathyroid hormones (PTH), which can be toxic to the kidneys if it gets too elevated. The off switch for PTH production is calcitriol.

If we don't have enough calcitriol in our body, there's nothing to tell the parathyroid gland, 'Shut up. Be quiet. Stop making so much PTH.' The research on cats is scant and a little iffy. But calcitriol proved to be beneficial in a study of dogs.

There are some feline specialists who are big proponents of calcitriol for cats, and I personally think it's a 'can't hurt, may help' issue. Your viewers should ask their vets about administering calcitriol to their CKD cats. It's recommended early in the disease. If the dosage is adhered to properly, I think it's a can't-hurt-may-help.

When we first tried the calcitriol we got some hypercalcemia early on because we were giving it every day and at higher doses than we currently use. We now give it twice a week instead. And for the record, I don't recheck CKD patients to death. I feed a high[-]quality, low-phosphorus diet with plenty of antioxidants and anti-inflammatories. I use calcitriol and call it a day. Beyond that, the chips are going to fall where they may.

I find that most of my clients get frantic, asking 'What can I do, what can I do, what can I do?' The truth is, not much. Cats' kidney disease will progress as it's going to progress. So again, don't over-vaccinate. Feed a water-rich diet. Sit back and relax with your cat. Don't keep fretting about it because the kidneys are going to do what they're going to do on their own timetable. There's really nothing we can do about it beyond the basics I've just discussed."

If Your Cat Is Diagnosed With Kidney Disease, There's No Need to Panic

I am always impressed with how resilient cats' bodies are. Even in a state of decompensation (organ failure) they keep going and going and going. Often the BUN is very high and they're still eating and physically look fine. If we're chasing a number or making decisions based on a lab result, I think it's easy to become so overwhelmed that it takes away from our quality of life. It's possible to fret so much about the future that we don't enjoy the time we have left with our pet.

"I'm glad you brought that up," says Dr. Lisa. "I find that subcutaneous fluids are used far too early in the disease process. I'm also not a fan of Azodyl. I don't feel it works. I don't feel there's any benefit. I don't want to see cats being pilled with these humongous capsules.

You know me, I'm typically not much of a supplement person. I'm a 'Give them good food, give them fresh water, love them and don't keep poking a needle in their back until it's really time' sort of person."

Dr. Lisa brings up a great point. I love Azodyl, but I do not believe we should be shoving anything down a cat's throat. I think if your kitties will eat supplements like Azodyl or probiotics on their own, awesome. But the last thing you want to do is chase a cat, especially a sick cat around the house and have her hide under the bed and fear you.

This is completely disruptive to your relationship with your kitty, and even more important, it significantly increases her stress response, which will end her life sooner than anything else. There's no reason we should be cramming anything down a cat's throat. If they take supplements voluntarily, great. If they don't, don't force it.

"Absolutely," says Dr. Lisa. "I have an article on pilling cats on my website. I hate pilling cats. I may be a real weeny about it, but I just hate it. And again, be careful about starting fluids too early. Cats can live a long time with CKD.

My cats got kidney disease at 14 and 16. They both died four years later, but not from kidney disease. They died from cancer. And I want to also mention that just because your cat has a low urine specific gravity, it isn't the kiss of death. Cats whose kidneys have stopped fully concentrating the urine can live three, four, five years and longer and quite often die from something else. If your cat starts to get a low urine specific gravity number, there's no reason to panic."

Honoring Your Sick Cat's Wishes

All of Dr. Lisa's suggestions today have been common sense and very respectful of the feline body and spirit. But I think, most importantly, they should provide peace of mind for those of you watching or reading who are worried about your cat and kidney disease.

Sometimes the more information we gather — even though we want to understand everything we can so we can make good decisions — can create profound stress. It can also cause vets to give their clients with CKD cats long lists of tasks to perform that can be daunting. Often, we're making decisions not on how the cat looks or seems to feel, but on a theoretical disease progression that may or may not occur. We end up creating stress for everyone in the family, including the cat, and it doesn't have to be that way.

"Exactly," Dr. Lisa says. "When I go on VIN (the Veterinary Information Network), colleagues are asking each other questions like, 'When do you start fluids?' The answer more often than not is something like, 'When the creatinine is 3,' which is a very arbitrary approach to a procedure that is stressful for both the cat and the owner.

Instead, you need to look at the patient. Are they eating a water-rich diet? Are they eating plenty of it? Do they have any vomiting or diarrhea? Are they bright and alert? You don't just start fluids arbitrarily at a number. You look at the patient.

It's also important to understand that plain water (no sodium, chloride, etc.) taken in orally is healthier for a body then the fluids that are administered subcutaneously. Therefore, we should do whatever we can to increase oral water intake before starting sub Q fluids. This means feeding no dry food and adding some extra water to canned food or a homemade diet."

I think if an animal is saying, "Don't do that to me," we need to not do it to them. That's one of the hardest things to convince clients of, that "This will be a really nice approach IF our patient participates." But if we have a cat who chooses not to participate, we need to respect that. I think we need to encourage our clients to be more respectful and push less. "I agree 100 percent," says Dr. Lisa. "My Toby, I thought he'd be very easy to give fluids to. I tried it, and he hated it, so I didn't force him to accept the procedure."

Sometimes we end up making decisions to not treat the patient, because they have decided they don't want to be treated. That's called honoring our patients' wishes.

"Quality over quantity," Dr. Lisa agrees. "Because let's face it, we want everybody, human and animal, to live forever. There's a selfish component to it, because you don't want to lose them. But don't be selfish with your cats. Listen to them."

I very much appreciate Dr. Lisa Pierson making time for me today and sharing her tips, tricks, ideas, thoughts and amazing information with us. Be sure to visit her website, CatInfo.org, which provides a wealth of extremely helpful and practical information about your cat's health.

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