[00:00:02] Introduction: Welcome to All Cats Considered, a podcast from the Feline Veterinary Medical Association.
Here we interview professionals from across the veterinary world and take deep dives into the latest evidence-based research, developments, studies and guidelines that improve feline health and well-being.
We are the home for veterinary professionals seeking to enhance the care of cats through high standards of practice, continuing education and evidence-based medicine. In each episode you'll hear interviews with a variety of experts in our field covering a wide range of topics and the latest developments in feline health. We'll share the key points you need to know to improve your patients care.
Let's dive in and listen to this week's experts.
[00:00:44] St. Denis: I am Dr. Kelly St. Denis, co-editor of the Journal of Feline Medicine and Surgery and Journal of Feline Medicine and Surgery Open Reports.
We are here today talking about our latest Clinical Spotlight article, Feline Comorbidities: Cardiovascular and Kidney Diseases. I am joined by doctors Amanda Coleman and Bianca Lourenço from the University of Georgia College of Veterinary Medicine. Welcome to the two of you.
[00:01:11] Lourenço: Thank you.
[00:01:12] Coleman: Hi, nice to see you.
[00:01:14] St. Denis: I'm really glad to have you guys here and I just want to take a moment to say thank you for your hard work and putting this article together. It is just an amazing piece of work. I hope we're going to be able to talk about it today in a little bit detail and get people interested so they'll go and have a look at it because it really is going to be a nice reference for them to have in their practice getting started. I always like to ask our interviewees a little bit about themselves. So I don't know if you guys want to take turns just telling us about yourself, what you do and anything interesting about your research or how you got into what you do.
[00:01:49] Lourenço: My name is Bianca Lourenço. I'm currently an Assistant professor of Internal Medicine at the University of Georgia. I've been at Georgia for a while, but I actually you can hear it in my accent. I'm from Porto in Portugal. I did vet school there.
After graduating I worked as a General practitioner in Newmarket in England for a few months. Almost a year before I went down the route of internships and specialization.
I did a first internship at the University of Cambridge in England. That was really awesome.
Really enjoyed my time there. Then I got very lucky and matched at NC State for another rotating internship. That was so formative. Learned a lot and interestingly during my internship at NC State I had an intern mate that had been at Georgia for her dvm. She kept telling me that Georgia was excellent. Best place on earth. I decided to Drive down and visit and I really loved it. I was again very lucky to match here for my residency. In my residency, Baby Bianca was invited by Dr. Coleman to join a study that was a prospective randomized clinical trial looking at treatment of proteinurian dogs with kidney disease. I joined that study.
That turned into me completing a master's which then I switched and turned into a PhD again under medical mentorship.
I think organically develop this love for the kidneys because as is common, the more you learn about something, the more fascinated you are for it.
After my PhD was invited to stay as a faculty member here at Georgia and I've been here ever since.
It's been really fun to be here because I continue to work with Dr. Coleman and some of my other previous collaborators and we've built this very collaborate renal research group that we still do studies with really big focus on chronic kidney disease overall, but other aspects of kidney diseases as well are interesting to us.
[00:03:50] St. Denis: Right. Sounds like a great place to work, Dr. Coleman.
[00:03:55] Coleman: My background's a little less exotic. I was actually born here in Athens, Georgia, so this is a big. Been a big full circle for me to come back here as a faculty member.
I grew up in Florida though, and went to the University of Florida for both undergraduate and vet school.
And during that time I thought I wanted to be a dairy vet. That was sort of my plan all along. I wanted to work on farms and be outside and all these things and then just really got taken by the physiology of the heart. I had some amazing professors at UF, Dr. Estrada and Aiden, who just made it so fascinating for me. And so I sort of switched gears late in my vet school career and did an internship, internship at North Carolina State, just like Dr. Lorenzo and as she said, was extremely formative there. And during that time I thought maybe, maybe internal medicine is for me. So I always had a little bit of an interest in non cardio things as well, but ultimately decided to do a cardio residency and did that at NC State too, and then came to Georgia for a relationship, you know, these things.
So my husband was a resident at Georgia and so kind of followed him down with the idea. We'll see how this goes for a little while. And then I've been here since, so been here since 2011. I am so happy to be here and I'm so proud of the group that we've built for our research group, Dr. Lourenço and Dr. Kadschmidt, among others. It's just been a great ride here at Georgia. My interest sort of got PIQUED both innately, but also because I was lucky enough to be taken under the wing of Dr. Scott Brown, who. People who know the kidney in cats know Dr. Brown. He's an amazing human. Not only an amazing researcher, but also an amazing person. And so he kind of took me under his wing and helped foster a love for cats and kidneys and hypertension and all those things. I'm a professor here at Georgia.
[00:05:50] St. Denis: And so you've come around full circle back home. That's pretty cool.
[00:05:53] Coleman: Come back, came back home.
[00:05:55] St. Denis: And the two of you make the perfect team for putting this article together, by the sounds of it, and based on the article itself.
So thank you for sharing both your stories. I really love hearing these things because they're really for anyone who's working through their career and not knowing where they are. It's always interesting how things go pathways you don't always expect.
[00:06:15] Coleman: Absolutely.
[00:06:16] Lourenço: It's interesting because I'm hearing Mandy talk about her background and I too wanted to be a dairy veterinarian in vet school.
[00:06:23] St. Denis: So actually if you.
Yes, I wanted to do dairy repro. So we're all in that same boat, isn't it? And I am a cat specialist, so isn't it funny?
[00:06:33] Lourenço: I also kind of like was then very excited about exploring deep physiology and was a little bit easier in small animals, and so that's why I pivoted. But I actually very much enjoyed working with dairy cattle. So this is very interesting.
[00:06:48] St. Denis: I guess we have to get back and talk about the article.
Given this intimate relationship that you guys discussed between the kidneys and the heart, the vasculature, you introduced this concept of the cardiorenal access early on in the article. And I wondered if you guys could tell us a little bit about what that concept is in terms of definition. You don't necessarily have to cite it out, but just specific pathways also of interaction between the heart and the kidneys.
[00:07:15] Coleman: Thinking about the cardiorenal axis is sort of maybe just most useful as a framework for reminding ourselves of this intimate relationship between these two organs and the fact that there's tons of cross talk in both directions.
They also share sort of, you know, the vascular side of things. And so I think it's just useful for us to think about this as maybe a conglomerate that talks back and forth, both in health, but also more importantly, probably for us as clinicians in disease. And it reminds us to think about, okay, if we're treating an animal or cat with heart disease or failure, how might our treatments or even the disease itself impact the kidneys and vice versa. And that sort of leads into this concept of the cardiorenal syndromes, which we introduce a bit in the article as well.
[00:07:56] St. Denis: Yeah, and that's a really great pathway to lead into everything that gets discussed. And you have a really intricate figure there on those interactions, the specific pathways. And there's a real highlight that you guys have noted in increasing in sympathetic nervous system RAAS and systemic arterial hypertension.
And I really like that figure that you guys have presented to sort of really show that link between cardiovascular and kidney injury and dysfunction. Do you guys have any comments or anything or thoughts about that aspect of that cardiorenal access that you've presented?
[00:08:30] Lourenço: Yeah, we had so much fun putting that figure together. I can tell you that historically, probably the better known and explored link between the two would be systemic arterial hypertension as a way to connect those two and physiologically regulation of blood pressure.
That is certainly a very important part of this story, but it's not all of it. So we took some time to think about some other pathways or some other methods for connecting the two, some of which do play into hypertension, such as sympathetic nervous system stimulation and the renal density aldosterone system.
But also thinking about other molecular pathways, including the roles of inflammation, inflammatory cytokines that are expected to be released in response to either substantial heart or kidney disease, for example, mineral and bone disorders that accompany kidney disease, and how those could lead, for example, to dystrophic mineralization and have an impact on cardiovascular structures.
And think about it as a more global level.
Certainly blood pressure is the easiest one to measure clinically and to see effects on the heart, for example, echocardiographically. But we know that there's this cytokine milieu that is occurring with both diseases and probably causing damage to the other system when one is affected.
[00:09:58] St. Denis: Right. That systemic arterial hypertension is really a point of focus even just in that diagram, because as you said, sympathetic nervous system in rats also impact systemic arterial hypertension.
We know that this is on the topic of systemic arterial hypertension, we don't see a lot of clinicians measuring blood pressure. I was lecturing on the weekend and asked a room of about 300 people if they used. And I think I saw three or four hands when it comes to this. What are your thoughts about measuring for hypertension in cats? I know sometimes in cardiology there's this question about the accuracy of what we do in the practice.
And just getting a little bit off track here. What are your thoughts on who should be tested for blood pressure. And what are maybe some of the best approaches?
[00:10:45] Coleman: Like you, I'm always, I don't know, dismayed maybe, at the number of folks that are regularly measuring blood pressure. Understanding that I live in this cardiovascular world, so obviously I'm going to focus on it. But I think there's a couple of scenarios as cardiologists where we really encourage the measurement of blood pressure. One important point to point out is that there's a common misconception that heart disease can cause hypertension. And in general, that's not really the case. And in fact, it's systemic arterial hypertension has effects on the heart as a target organ. And so that's important to keep in mind. It's also important to keep in mind that echocardiographic changes are really common in cats that have systemic hypertension. There's been a couple of studies. There's about four different studies that have looked at small groups of cats, granted, but they've shown that anywhere up to from 49 to, I think, 85% of cats with systemic hypertension have echocardiographic changes. So they're common. And so I think that when we start to think about measuring blood pressure, one is if we have a patient who has echocardiographic evidence of possible hypertensive cardiomyopathy. So kind of the typical phenotypic change for a systemically hypertensive cat is going to be left ventricular concentric hypertrophy. And anybody who treats cats knows that there's lots of different reasons why that might happen, and r hypertension being only one of those. So if we have a cat with left ventricular concentric hypertrophy who is over the age of maybe five or six years, they're automatically going to get a blood pressure measurement. And that's just because of the prevalence in that age group is much higher than in younger cats. Or if we know that they have a known history of acute or chronic kidney disease and changes on their cardiogram. And then the other kind of group that we routinely measure blood pressure on are cats that have advanced heart disease and heart failure. We always measure blood pressure in these cases. One, because we want to identify hypertension, obviously, because if you superimpose that on underlying disease, you can make things worse. But we forget the hypotension part, too. You know, we don't often talk about hypotension and identifying that. And a lot of these cases are animals that are on diuretics or a blocker of the renin angiotensin aldosterone system. And so we want to be sure that we're monitoring for both hypotension and hypertension in those. In those cases. So I think as cardiologists, those are the two big groups that we think about measuring blood pressure in.
[00:13:09] St. Denis: Yeah. And I certainly encourage people in clinical practice to get handy with, you know, understanding their machine and getting readings even from younger cats, so that cats can kind of get used to it. I can honestly say in a practice, I don't know if I've ever seen hypotension in an awake cat, simply because most of them are healthy and nervous in the clinic, as opposed to having a low blood pressure.
[00:13:32] Lourenço: As a kidney interested person, I think of measuring blood pressure a lot as well.
And I also start these conversations with empathy. This is one of the many instances in which having worked as a general practitioner for a while is helpful because I can very honestly and embarrassingly say that I can't remember measuring blood pressure in a conscious animal.
Once when I was a gp, we did have a blood pressure measuring device that lived in the anesthesia suite and was used for anesthesia, which I'm already pretty proud of. And that was it. Right. So every time. Because similarly, I have asked people, when I'm in lectures and not a lot of hands go up when we talk about blood pressure measurement. I will say, and maybe this is wishful thinking, but I ask the students year after year if they've been measuring blood pressures and conditions that I'll chat about in a minute, and I see more and more hands going up. So I hope that all of the education that all of us have been trying to spread about the relevance of blood pressure is making a difference.
It is difficult because on one hand, we all know that it is time consuming.
It takes away at least one person that is now dedicated to get blood pressure in that cat.
And some patients, like you were mentioning, we often get values that are not hypo. In fact, very commonly we have situational increases in blood pressure and then we're faced with the decision, what do I do with this value? Right. And so that is typical, too.
I love the suggestion you just made of occasionally getting blood pressure earlier in life to even have an understanding of the type of blood pressure readings that cat might have in the hospital environment.
We get a lot of questions about, for example, the potential influence of gabapentin or other things on blood pressure. And Mandy Coleman and I did a really fun, very small but really fun, a study a while ago in which we explored this in healthy cats that had devices implanted that would allow us to measure direct arterial blood pressure in real time. And we subjected these cats to very fun and very gentle simulated veterinary visits. So we put them in their little carriers and we brought them to the teaching hospital.
And regardless of whether those cats. And again, it was a small study, we only had five or six cats.
But regardless of whether cats had a placebo capsule or gabapentin, every single cat had a higher blood pressure in hospital.
That makes it difficult because we know that we might potentially have a cat that has situational hypertension. Noted.
Again, having a preexisting value is helpful. And then interpreting our results in light of whether we think this cat is already coming from a population at risk for hypertension.
So certainly older cats. We know from longitudinal data that blood pressure increases with age in all cats, particularly those with CKD. Right. So animals with chronic kidney disease are predisposed to hypertension. So paying special attention to the cats that have a predisposing cause, whether that's chronic kidney disease or hyperthyroidism, to name some, that are particularly common and with a very well established link to hypertension.
Doing a fundic examination.
[00:17:02] St. Denis: Exactly.
[00:17:04] Lourenço: Some of our findings and probably looking at trends and repeated values. Right. Because one single hypertensive reading might not tell you the whole story. Right.
[00:17:17] St. Denis: Usually can't draw any meaningful conclusions from one reading.
[00:17:20] Lourenço: Exactly, exactly. Look at that over time and see if that is truly believable.
But then address hypertension when it is believable. There's been a number of cats in some clinical studies we've done recently for whom just doing a fundic examination, for example. Very quickly answer the question, is this a believable finding? Because those cats had subclinical changes to their retina.
And so it was immediately very easy for me to say that they were in fact hypertensive or lucky enough to have Mandy Coleman echo them and tell me that, yes, they have consistent changes to their heart. So I think not only getting a value, but in absence of overt target organ damage, see if there's occult target organ damage, but see if it's repeatable.
[00:18:10] St. Denis: Right.
[00:18:10] Lourenço: And yes, intervene or not.
[00:18:14] St. Denis: Yes, I do. That's. Those are really great points. And I try to make sure when I'm talking about blood pressure that we're making it a routine part of the visit. So it's one of the first things I do. I have the blood pressure machine out all the time and. And I always look at the retinas as well, because if you talk to people about this. The more you do these things, the better you get at seeing abnormals. So. Or identifying problems with individual cats. So thank you for that.
[00:18:39] Lourenço: The other fun thing about measuring blood pressure is that it's so relatable.
Owners completely understand what you're doing.
[00:18:47] St. Denis: Yeah.
[00:18:47] Lourenço: And they have appreciation for values. Right. Like if you say the blood pressure is 170, so many people are used to having their own blood pressure monitored. They can understand that that's probably high. Now, obviously we need to have some education about what we consider normal for our readings. Right. And telling them that up to 140 is currently considered normal tensive for a cat, for example. But still, these values mean something to people. And again, it makes it easier to then institute therapeutics when people have been a part of the screening as well.
[00:19:24] St. Denis: Not to mention they're also always impressed by the little tiny cuffs.
Where are you going to put that? Wow, that's so cool.
That's such an important part of this conversation because there's such an important link between the two for you guys. In terms of what we know about heart and kidney disease, how common is it for us to have concurrent conditions? So cats with both kidney and heart disease, would you say? And how do we know that? How do we figure these things out?
[00:19:54] Coleman: For the most common cause of heart disease and failure in cats, we're usually talking about hypertrophic cardiomyopathy. And if you look at large studies, the percentages that usually come out are somewhere around 16%, which is kind of cool. It's been very consistent across studies of asymptomatic cats walking around have HCM. And the prevalence of that increases with increasing age. Bianca can say better than me the prevalence of chronic kidney disease in cats, but I think everybody who treats cats knows that it's age dependent and massively prevalent condition. So it stands to reason that these two things would coexist, particularly in older cats. It's a little difficult to know. Right. Because disease in one can cause disease another and the other. And some of the sort of treatment that we give for one can mimic disease in the other. For example, cats and heart failure on diuretics. It's very common for us to see acute increases in serum creatinine. And we don't know is that because we have. I'm going to use the word pre renal. I know I'm in the on the talk with some internists, but sort of is this a pre renal thing or is this intrinsic disease? And so I think a couple of Studies we have looked at cats that present to emergency departments with acute congestive heart failure and trying to suss out like is the incident or the prevalence rather of azotemia at the time of presentation before being treated with diuretics and things like that. And probably the largest study that we have looked at about 119 cats, and it showed that 44% of those cats that presented with acute congestive heart failure were azotemic.
And the median age of that group is of note, it was 10 years. So it's a little difficult to know, you know, what, what caused, or is that just concurrent CKD, for example? But that's sort of the best guess that we have. And I think if you're thinking about an older cat who has got substantial heart disease or heart failure, it's probably safest to just assume when they're, when they're older cats that they probably have, we say a titch of the ckd. But I think that it's kind of hard to know the true, you know, because of this crosstalk and the difficulty with diagnosing early ckd. Like that's really difficult. How do we identify those iris stage ones without additional diagnostics, imaging and things like that? So prevalent? We think
[00:22:15] St. Denis: so. I noticed that in the conversation in the article, you talk about how when you have cats with chronic kidney disease, you guys have specific plans for evaluating the heart. So is that something in general practice? Should practitioners be thinking, oh, I've got a cat with chronic kidney disease, what should I be looking for to make sure that we don't also have concurrent cardiomyopathies or cardiac disease?
[00:22:38] Lourenço: Like Mandy was saying, the prevalence of cardiomyopathies in asymptomatic cats is 16%. So I think it would be very reasonable to echo many of these cats. It's just not very practical because it's a costly test. Right.
At our institution, we pay special attention to cats that already have something else signaling that we might be concerned, or sometimes those that we are already predicting that we might be using a more aggressive fluid plan to restore bulimia and hydration for the former. Certainly cats that have arrhythmias, gallop sounds, louder murmurs, recognizing again that that would still miss probably an important portion of cats that have neither of these and still have heart disease.
We sometimes explore NT-proBNPs, for example, but again, those can be hard to interpret because they're renally excreted. Right. So you can still not have a lot of confidence, but maybe you could trust a normal for example, acknowledging that no test is perfect, but those would be candidates. Occasionally we have cats for whom for example, we have placed nasogastric tubes for their food feeding support and again detected something on thoracic radiography that made us concerned. And I think more and more our interns and residents and I think anybody who has access to ultrasound, they've started doing point of care ultrasounds for a subjective non cardiology assessment of the heart. Right?
And many people are confident getting left atrium to aortic root ratio. That is at least within their capability to say, hey, I'm already concerned or not. All of those would be really great candidates for the investment of an echocardiogram. Again, recognizing that if finances are not an obstacle, then probably almost all, particularly those that are going to get an aggressive fluid plan, should be echoed.
[00:24:52] Coleman: I think another thing important point that I wanted to make is that really the point of doing echocardiography, which I think it's important to know that echo is currently the gold standard, the most sensitive and specific tool that we have to detect underlying cardio cardiac changes. The point of screening these cases is to identify cats that have more advanced stages of disease so that you can identify those as cases that might have cardiovascular complications. Like is this a cat that's more likely to become volume overloaded and to go into congestive heart failure with aggressive fluid therapy, for example. And so one useful thing that I think folks can do in practice if they don't have access to an echo sonographer or cardiologist is kind of use the combination of thoracic radiographs and NT-proBNP. And I think that that's gonna miss some cases, right? Like you're gonna get some false positives and false negatives with that approach. But the likelihood that you miss a cat that has moderate or severe heart disease, if you have normal thoracic radiographs and a normal NT-proBNP that's relatively low, I would say so I think that's a reasonable like starting point. So if you had a case that you, you know, had one of these physical examination findings, I think Dr. Lourenço hit it on the head. Like we know that certain physical exam findings are going to be, are going to tell us that a cat is more likely to have heart disease, a gallop arrhythmia, a murmur of grade four or greater. If you had a case like that and you were worried, or you had a cat with known heart disease just doing a thoracic radiograph and an NT-proBNP and using the combination of those, I would say is a useful screening approach, understanding that you are going to miss, you're going to miss cases that have heart disease, but you're likely to pick up those cases that are more severely affected. It's important to note too that NT-proBNP is mainly excreted. And so if you have an animal with CKD and it has a high value, then that could be a false positive.
Just wanted to add that as well.
[00:26:55] St. Denis: That's important. So I guess if you can add, as Dr. Lourenço pointed out, if you're good with point of care and can get some of those basic heart measurements too, that probably increases your opportunity for finding things if you don't have access to echo.
Yeah.
[00:27:10] Lourenço: And it's important to acknowledge that there's immediately actionable information on the other side of these tests. Right. So if you have a cat that you are already concerned that is in advanced stages of heart disease, your fluid plan should be altered. Right. You're going to, you are dealing again with hypovolemia or dehydration, for example.
You are probably going to be slower in your correction. You're more likely or should at least consider lower sodium containing fluids.
At our institution, when we are concerned, we will commonly place a nasogastric tube so that we could actually provide fluid support enterally using that is virtually sodium free and less likely to overload the cat. So there's meaningful information in addition to discussion with the owner. Right. I think it opens the communication. I don't mean this as in we're condemning the cat, but already important discussion. Right. This is the current health status of your cat. These are our goals.
Challenges might be balancing the fluid needs of one with the fluid needs of the other because they're often at odds. Right. I also think, particularly in recent years, we have come a long way for treatment of kidney diseases in general and really have moved away from the flushing the kidneys. I'm doing air quotes for the listener. Flushing the kidneys or diuresing. Because even in cats without heart disease, we know that that is promoting potentially over hydration, which has implications.
So overhydration can be associated with a myriad of negative consequences, including renal edema, which then might decrease glomerular filtration rate.
So we're more and more cognizant of just keeping the animal normally hydrated, normally voluntary, and no more than that.
And we'll be even more careful. Right. If we know that there's substantial heart disease. So there's many meaningful information to get with that can be helpful and helps us tailor our plans.
[00:29:23] St. Denis: Yeah, that is cool. And you know, as you're talking about this, I'm just wanting to draw attention to our listeners that there is a whole section in your article on maintaining optimal body fluid balance where you present numerous different scenarios and what you might want to consider based on those particular situations. So that's, that's a really helpful section in that, that article. So anyone wants to look at that. It's again, I always say that it's just so nice to have these articles in your practice when you're in general practice. They're there, you've read them, but then you can go back and refer to them because there's so much valuable information.
One of the other things I wanted to touch on a little bit today that you guys really cover well, is just the common drug. So we use specific drugs to treat certain things with heart, like congestive heart failure, furosemide being one that we all often use. And then for cardia, our heart disease, kidney disease story, we have some medications that we might use that those drugs may impact the heart or the kidney, vice versa. And I wondered if the two of you wanted to just take a minute on addressing the impact cardiac medications on the kidney and vice versa.
[00:30:29] Coleman: Absolutely. I think that one of the things to say is that as cardiologists, we, we have selfish reasons. Right? Selfish things that we think about. Right. Like, no, no, we need to clear this edema. The kidneys be darned. So there's that. And obviously we'll talk about that. But I think we also have some altruism as well. And so I think a lot of us think about, we really worry about acute exacerbation of azotemia like AKIs in our cases, particularly ones that are on diuretics and blockers of the renin-angiotensin-aldosterone system, chronic worsening over time. Like if we are making these animals chronically hypovolemic.
And then in addition, with these drugs, we're impacting renal autoregulation and tubular feedback. All the things that the words that Bianca can describe and define better than I. But I think that one thing to keep in mind is that we're all kind of aware of this impact of being overly aggressive with these medications and how that can impact renal blood flow. But maybe taking a moment to also remember that these effects are worse if you have a cat who already has a decreased circulating blood volume. So what I mean by this is we have cats that are maybe being treated for heart failure. And they're stable, they have chronic kidney disease, and then they develop vomiting or diarrhea for some reason and continue to get their diuretics and continue to get their ACE inhibitors. And it is in those settings when animals are already hypovolemic and becoming more hypovolemic, that this is the most dangerous. So I think that the two drug classes that we kind of worry the most about overshooting are necessary, you know, particularly diuretics and keeping these animals out of heart failure. But we are very mindful.
If we get into a situation where an owner has been monitoring sleeping respiratory rates in a patient that is in heart failure, and then that cat develops a reason to have increased losses or decreased intake, and we tell them, skip a dose or two, give us a call, and we can kind of work things out from there.
I'm sure Dr. Lourenço will bring this up. We know that cats with cardiomyopathy are very sensitive to changes in blood volume. And so I think we start to get a little selfish when we think about treating chronic and acute kidney injury and chronic kidney disease with parenteral fluids, the effects of anemia and the drugs used to treat that, or transfusions.
Dr. Lourenço can talk a little bit more about that. But these animals are very sensitive, both the kidneys and the heart, to changes in blood volume. And I think that's why we focus so much of our energy in this article on trying to describe these scenarios. Like, how do you balance this, you know, this blood volume situation in an animal who might not have normal. One or both of these are abnormal.
[00:33:10] St. Denis: The very delicate balancing game, Dr. Lourenço.
[00:33:14] Lourenço: starting from a place of empathy, this, this is hard, right? And we don't always do it perfectly or rarely. Right. So I think a few themes for veterinarians to keep in mind would be the needs of the system that is at the present moment more severely impacting the animal's quality of life or risking their life itself, needs to be prioritized, right? So if the animal is symptomatic for pulmonary edema, certainly we're going to have to address that and put the needs of the kidney, in that sense, a little bit in the back burner. But concurrent with that, probably trying the lowest level of intervention that is going to match what you need, probably avoiding interventions that, again, are too aggressive in animals that have diseases of both the cardiovascular and the kidney, prioritizing the most important needs at the moment, but also trying to find the lowest level of intervention. I like to tell our residents that good monitoring forgives A lot of sins because we make wrong fluid plans all the time. Again, even in cats that don't have heart disease, but we overshoot or undershoot. So as long as you are keeping a close eye on body weight, markers of hydration, you know, pcv, turtle solids, things that are fairly basic, your physical examination findings. Right. Again, if you have access to ultrasound periodically doing point of care ultrasounds looking for effusions, but do that consistently to track changes so that you can alter your fluid glands is very important for some cats, for example, that have concurrent disease and at the moment what's keeping them in the hospital is worsening azotemia that is manifesting in clinical findings of uremia.
Sometimes all we do, for example, is take away their furosemide and see if that resolves the issue and maybe then we can reintroduce it later at a lower dose or treat up to it. Also understand what was the inciting event.
Sometimes the cats with concurrent heart and kidney disease were doing just fine, but just had a period of GI disease or something else that just took them over the edge. And so if we can support them through this more acute period, maybe we can slowly reintroduce certain drugs. That's a common theme here.
[00:35:50] St. Denis: I like that and I think this has been a really good conversation that might be a really good note to end on is just that delicate balance and then also in really acute situations, prioritizing the condition that's causing the most risk at the time. But that monitoring, I love that. Thank you so much to both of you for spending this time with me today. I've really enjoyed speaking with you and highlighting the importance of this article that you've written.
So again, thanks again for joining us and all the best.
[00:36:19] Coleman: Thank you so much for having us.
[00:36:21] Conclusion: Thank you for listening to this episode of All Cats Considered. We hope you enjoyed this interview. For more information on the topics discussed in this episode, please head over to catvets.com podcasts and explore the links in the show notes. Don't forget to subscribe to this podcast on your platform of choice so you won't miss any episodes as we release them. Have thoughts or ideas about the interview you heard today? Share them with us by leaving a comment on our Facebook page or shoot us an email:
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