Saturday, November 15, 2014

Listen To Your Client! Zippy's Polycystic Kidney Disease

This is Zippy's story.

Zippy is 6 year old indoor only male neutered cat. He arrived calmly and quietly cuddled up stoically next to his mom. Zippy is one cat who lives a life worthy of his majestic ancestry. He is a loved integral part of his family. At every examination his family escorts him. They sit worried and concerned with his health and they invest every ounce of effort into maintaining his health for as long as humanly possible. Few are as lucky as Zippy is.

How I wish all of my patients were this relaxed.
Zippy came to see me because his family was concerned that he "was not acting like himself and losing weight. They believed he was eating and drinking normally, but had bad breath, and was licking a lot."

One of the most important lessons to learn as you attempt to master veterinary medicine is to listen to your clients. One of the biggest mistakes that I see consistently with new graduates is that they want to diagnose (you quickly learn to accept that there is not always the luxury of this), before they listen and look. Neophytes read the notes of the computer scheduler, confer with the tech after they put an appointment in an examination room and seek out a book of 'differential diagnosis' before they greet and meet their patient. In the real world the 'common things happen commonly' and your best diagnostic tools are your ears, your hands, and your brain.

I listened closely to Zippy's family. They were great help in understanding Zippy. He did after all look perfectly normal sitting on the silver examination table all confidence and Cheshire cat pose; secretly studying his surroundings and his potential white coat threat. He was serenely in command, (as every cat is), and I know to let them always believe what they rely on as truth. A cat is always in charge, the rest of us simply wish coercion in their direction.

After a discussion of subtle and self-doubting recollections I was left with a few strong impressions; 
  • These people truly loved Zippy. Listen to those people! 
  • This cat was king. His vibe was one of complete command. Listen to those cats! Even if your expert eyes tell you that this cat looks fine, Listen to the true experts, his family.

The technician had gathered her preliminary data. His family was concerned about weight loss but the scale reported the exact same weight as the last time we had seen him. We say it often; "the numbers don't lie." A question mark followed her notes in the chart. Was this yet another client reporting a wrongly perceived problem? Zippy did live in a mulit-cat household and they were not monitoring food intake for each cat closely. This happens pretty frequently. It is one of the reasons I like wet food for cats. Portion control AND patient monitoring. Your cat won't be able to tell me their last decent meal, I rely on you for that.

I calmly and slowly said my "Hello," to Zippy. He barely opened his narrow gaze, his breathing pattern stayed quiet, and he ignored me as insignificant. Mom stayed very close to protect and calm him. He had his family and me quickly accommodating him. He just had that presence that made you think it was appropriate. 

My examination always always proceed in the same manner. I start at the tip of the nose and work backward. (A helpful tip from a professor in vet school). It has served me very well. If you pinpoint a targeted area you will forget something, or worse yet, you will miss another important clue. Always proceed in the same manner. Zippy's front half of his exam was all very normal. 

Onward I proceeded to explore the back half. My hands knew instantly that we had a problem. Zippy had a very large mass in his abdomen. It was so large that it resembled a water balloon and it encompassed his whole abdomen. I was unable to identify any normal structures around it. 
An x-ray was the next stop. 

Zippy appeared to have bilateral (both sides) large soft tissue structures from the ribs to the pelvis. A small empty stomach is visible and a colon, intestines are pushed ventrally (down).

I remind people often that x-rays are best suited for bones. For soft tissue structures an ultrasound is far better at displaying the internal architecture and features of organs. Ultrasound was scheduled next. Thankfully, we have an ultrasound and a very skilled veterinarian who can read and diagnose much of the disorders we suspect through this modality. 

Even upside down Zippy proves himself to be one cool cat.

Through the use of an ultrasound we were able to confirm our suspicion. Zippy's kidneys are both significantly enlarged and the functional integrity of the renal infrastructure is compromised by cysts. Zippy has polycystitic kidney disease.

Instead of the normal soft tissue structured  cortex and medulla which are responsible for filtering the blood to remove unneeded waste and recycle water and maintain correct fluid levels in the body, the kidneys are gradually replaced by large bubbly air/fluid filled pockets that are non-functional and compress . Instead of being a few inches long they are about ten times the normal size.

He is also showing the classic signs of renal failure;

  • Excessive drinking and urination (they had not yet recognized this until I asked about the size of the urine clumps in the litter box), 
  • Bad breath (build up of the toxins that the kidneys aren't excreting through the urine.
  • Muscle wasting and weight loss. (His kidneys were getting larger with fluid but Zippy is losing muscle mass)
  • Lethargy, or reluctance to play, jump, interact.

Polycystic kidney disease is the most common inherited kidney disease of cats. It is most commonly seen in purebred cats like Persians, Himalayans, etc.

It is a slow progressive disease where the elaborate internal architecture of the kidneys becomes full of non-functional cysts. As the disease progresses the kidneys start to show signs of failure. All slow progressive kidney failure causes the typical clinical signs of kidney disease to become apparent. For the astute clients they will notice an increase in thirst. As the cat consumes more water they will also start to produce more urine. We call this polydipsia (drink more) and polyuria (pee more). At about 66% kidney loss pets will drink and pee more. At about 75% kidney loss they will reflect kidney impairment in their blood work. Therefore, there is some period of time between 66% and 75% kidney loss that you know before I know.

Zippy will be monitored very closely at home. We instructed his family on a better kidney friendly diet, providing subq fluids to help flush out the toxins the kidneys cannot, and supplements to help bind and remove the excessive phosphorus. But most importantly we will help Zippy stay eating and happy. Polycystitic kidney disease is a congenital disease. It is not treatable outside of kidney transplant. 

Life is never about quantity it is always about quality. Few cats are as loved and cared for as Zippy is. I wish him many happy years ahead, but I know that even if fate isn't as generous to him as this, that he lived a loved life in spite of the cards he was dealt.

If you have a pet question of any sort you can reach me at Or find me at the clinic, Jarrettsville Vet, or on  Twitter @FreePetAdvice.

1 comment:

  1. Listening to clients - so important. There is nothing more frustrating than when vets don't do that. And we had plenty of those.