TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

 

METABOLIC ACIDOSIS

 

ON THIS PAGE:


What is Metabolic Acidosis?


Symptoms


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Home > Key Issues > Metabolic Acidosis

 


Overview


  • Metabolic acidosis means that the levels of acid in the cat's body are too high.

  • It is extremely common in CKD cats, usually cats in Stage IV.

  • Symptoms include weight loss, muscle loss, a bony spine and mouth ulcers. All of these symptoms may have other causes too.

  • Fortunately it is relatively easy to treat.


What is Metabolic Acidosis?                                                                               Back to Page Index


 

Metabolic acidosis is a very complex subject which tends to make my eyes glaze over. However, it is thought to occur in 65-75% of cats with kidney failure, so it is important to check for it and treat it if it is present. Fortunately, you don't really need to know too much about it, you simply need to know the basics, i.e. what it is, what symptoms a cat might exhibit, how it is diagnosed, and most importantly, how it is treated.

Essentially, metabolic acidosis means that levels of acid in the cat's body are too high. Acid is produced in the body as a result of diet. In healthy cats, the kidneys help to balance acid levels in the body in two ways:

  1. Bicarbonate ions (which are alkaline) in the kidneys help protect against acid build-up in the body;

  2. Any excess acids that do arise are flushed from the body by the kidneys.

Unfortunately the excessive urine flow of CKD washes the protective bicarbonate ions out of the kidneys. The damaged kidneys may also not flush the acids from the body properly. As a result of these damaged mechanisms, acidity levels in the blood rise (i.e. the body’s pH becomes too low). This is known as acidosis, and can cause muscle wasting and weight loss, particularly lean muscle loss, partly because acidosis prevents the cat's body from using protein properly.

 

"Metabolic" means that the acidosis is caused by kidney failure. This is to differentiate it from another type of acidosis known as respiratory acidosis, which is caused by the lungs not expelling carbon dioxide properly.

 

I know a lot of people get confused by the word "acidosis" and think it is the same thing as excess stomach acid, but that is not the case. Excess stomach acid is a separate problem with different causes and treatments, so please be sure you are dealing with the correct condition. It is possible for a CKD cat to have either excess stomach acid or metabolic acidosis, or both at the same time.

 

One study, Assessment of acid-base status of cats with naturally occurring chronic renal failure (2003) Elliott J, Syme HM, Reubens E & Markwell PJ Journal of Small Animal Practice 44(2) pp65-70, found that metabolic acidosis generally does not occur until the CKD is relatively advanced, i.e. creatinine over 400 international or 5 US. However, some cats on Tanya's CKD Support Group have had metabolic acidosis even with pretty low creatinine levels, and this was also the case with one cat in another study, Acid-base balance of cats with chronic renal failure: effect of deterioration in renal function (2003) Elliott J, Syme HM, Markwell PJ Journal of Small Animal Practice 44(6) pp261-8.

 

Current concepts for the management of chronic renal failure in the dog and cat - early diagnosis and supportive care (2005), a presentation by Dr S Sanderson to the World Small Animal Veterinary Association 30th World Congress, explains more about metabolic acidosis.

 


Symptoms                                                                                                             Back to Page Index


 

Symptoms include:

  • weight loss

  • lean muscle loss

  • a bony spine

  • weakness

  • vomiting

  • twitching

  • mouth ulcers

  • breathlessness. Breathlessness caused by metabolic acidosis is known as Kussmaul breathing.

  • in severe cases you may see seizures (or absences, spacing or zoning out)

All of these symptoms may have other causes, please see the Index of Symptoms and Treatments for more information.

 

Metabolic acidosis can also cause potassium imbalances, bone loss and if severe, heart disturbances. In Renal disease (2006), Dr D Polzin mentions that metabolic acidosis may increase the risk of pulmonary oedema in cats on fluid therapy. In Chronic Renal Failure (2001), he states that "potassium depletion and metabolic acidosis may promote potentially fatal reductions in plasma taurine concentrations in cats."


Diagnosis                                                                                                                 Back to Page Index


 

Despite the many risks and side effects of metabolic acidosis, unfortunately few vets bother to diagnose or treat it - in Current concepts for the management of chronic renal failure in the dog and cat - early diagnosis and supportive care (2005),  a presentation to the World Small Animal Veterinary Association 30th World Congress, Dr S Sanderson states that "at least in veterinary medicine, it appears that metabolic acidosis tends to be undertreated in patients with CKD."

 

This may be because metabolic acidosis can be difficult to measure accurately. Below are the usual tests used to diagnose metabolic acidosis.

 

If a cat has metabolic acidosis, the cat's potassium levels may appear high or normal in blood tests, but may subsequently fall after the metabolic acidosis is treated. You should ensure that your cat's potassium levels are monitored, because Dr D Polzin mentions in Chronic Renal Failure (2001) that "potassium depletion and metabolic acidosis may promote potentially fatal reductions in plasma taurine concentrations in cats."

 

Arterial Blood Gas Analysis


This is the most accurate way of testing for metabolic acidosis, but it can be difficult to find a laboratory where this test can be done, and it requires sedation. It is therefore usually only done at specialist vet schools.

 

Global RPh explains how to interpret arterial blood gas tests.

 

TCO2


TCO2 or total carbon dioxide in the blood is a way of measuring levels of bicarbonate in the body. If TCO2 is low, it can be a sign that the blood's protective bicarbonate levels are depleted from too much acid.

 

TCO2 has to be measured on a special blood gas machine, which not many vets and not all laboratories have. It is also easy to make mistakes in taking the measurement because if the sample is exposed to air, the dissolved gas escapes and makes the reading look lower than it really is. Since it is a tricky test to run, some laboratories, such as Antech in the USA, may only measure it on request (with Antech, you need to ask for Test No. T115).

 

The usual range for TCO2 is about 17 to 23. In Renal disease (2006) Dr D Polzin recommends treating for metabolic acidosis  when tests show the level is below 15 mmol/l on more than one occasion. The Merck Veterinary Manual states that treatment "may be indicated if the animal is severely acidotic (plasma bicarbonate <15 mEq/L) or remains acidotic 2-3 wk after diet change."

 

If your vet or his/her laboratory cannot measure TCO2 at all, ask your vet if it is possible to test for carbon dioxide (CO2) levels instead - if they are low, they may also indicate metabolic acidosis. 

 

Anion Gap


This is the difference between measured concentrations of cations (pronounced "cat-eye-ons") and anions (pronounced "an-eye-ons") in the blood. It is calculated as follows:

 

AG = [Na+ + K+] - [Cl- + HCO3]

 

which in English means:

 

anion gap = [sodium + potassium] – [chloride + bicarbonate].

 

Med Calc will calculate it for you if you input the appropriate values from your cat’s bloodwork. 

 

The normal range for cats is around 10-27, though it does vary greatly from lab to lab. If the anion gap is increased in a CKD cat, it may indicate metabolic acidosis, so if your vet is unable to test TCO2 or CO2, but has checked the anion gap, this may be an indicator (although you need to be aware that there are other causes of metabolic acidosis too which may not be reflected in the anion gap). 

 

Cornell University College of Veterinary Medicine has detailed information on metabolic acidosis and the anion gap.

 

Urine pH


Some vets diagnose metabolic acidosis from the pH levels of the urine but in Renal disease (2006) Dr D Polzin states: "Because urine pH is often insensitive as a means of assessing the need for or response to treatment, it is not recommended for this purpose."

 


Treatment of Metabolic Acidosis                                                                        Back to Page Index


 

Diet


The first step for mild metabolic acidosis is to try to feed a prescription diet. Most renal diets are pH neutral or even slightly alkalinising. If your cat will not eat prescription food, at least try to avoid foods for urinary tract health, which are acidified and therefore not suitable for CKD cats generally and cats with metabolic acidosis in particular.

 

Fluid Therapy


Subcutaneous fluids are used to help cats who are unable to remain hydrated without them. It is therefore not appropriate to give sub-Qs purely in order to control metabolic acidosis. However, if you are already giving subcutaneous fluids,  using Lactated Ringers Solution (LRS) (which is the most commonly used sub-Q fluid for CKD cats) may be sufficient to correct mild acidosis, because the lactate is metabolised by the liver where it is converted to bicarbonate, which helps correct the acidosis.

 

Potassium Citrate


Cats with both low potassium and metabolic acidosis can be given potassium citrate. In fact, Dr D Polzin says in Renal disease (2006) that other treatments for metabolic acidosis in cats who also have low potassium may only be of limited use. Potassium citrate is an effective treatment for both problems but you may need to watch for crystals forming in your cat's urine.

 

If you are using potassium citrate, you should give it at least two hours apart from any phosphorus binders containing aluminium, because citrate may increase the absorption of aluminium.

 

Potassium citrate should also not be used or its usage should be stopped for cats with high potassium levels. 

 

Bicarbonate of Soda


Bicarbonate of soda or baking soda (sodium bicarbonate) may be used to treat metabolic acidosis. It works by replenishing the bicarbonate lost from the body. It is available in powder form in the baking section of most supermarkets. In the USA, you can also buy it in pill form, in which case you would probably have to crush it before use.

 

Dosage


Dr Katherine James of the Veterinary Information Network suggests an initial dose of 5-10mg per kg of body weight every twelve hours. A kg is 2.2 lbs, so a 10 lb cat weighs 4.55 kg. A cat of this weight would be given 22.75 - 45mg of bicarbonate of soda every twelve hours.

 

In Renal disease (2006) Dr D Polzin suggests a similar but slightly higher initial dose of 8 to 12 mg/kg body weight every 8 to 12 hours. A 10lb (4.55kg) cat would thus receive 36 - 55 mg of bicarbonate of soda every 8 to 12 hours.

 

You can either dissolve the bicarbonate of soda in a small amount of water and syringe it into your cat's mouth several times a day, or you can give it in a gelcap.

 

When Thomas was first diagnosed, he had metabolic acidosis and my vet recommended giving him the following to drink:

  • 10 fluid ounces (0.3l) of water

  • 2 tbsps powdered glucose (available from pharmacies)

  • 1 pinch of salt 

  • 1 pinch of bicarbonate of soda

Not every cat will drink this but it may be worth trying so ask your vet about it. The cat does not have to drink the entire amount each day. You should not allow cats without metabolic acidosis to drink this, so if you have more than one cat, it might be better to give it to your cat separately (see above). If your cat's metabolic acidosis is severe, it would probably be safer to give more accurate dosages as outlined above. Be guided by your vet.

 

Bicarbonate supplementation slows progression of CKD and improves nutritional status (2009) de Brito-Ashurst I, Varagunam M, Raftery MJ & Yaqoob MM Journal of the American Society of Nephrology 20(9) pp2075-2084 found that " bicarbonate supplementation slows the rate of progression of renal failure to ESRD and improves nutritional status among patients with CKD." This was a study with human patients.

Sodium bicarbonate to slow the progression of chronic kidney disease (2011) Rossier A, Bullani R, Burnier M & Teta D Revue médicale suisse 7(284) pp478-82 reports that three trials with CKD indicated that sodium bicarbonate may slow the progression of CKD in humans.

 

It is not clear whether treating the metabolic acidosis generally or the use of bicarbonate of soda specifically helped in these studies. Never give your cat bicarbonate of soda without your vet's knowledge and approval, since too much can cause the opposite problem of excess alkalinity, which can be very dangerous. 

 

Drugs has some information about bicarbonate of soda.

 


Links                                                                                                                         Back to Page Index


 

Acid-base balance: an overview (2007) Morse H, Webb JL & LeRoy BE is a paper from the University of Georgia College of Veterinary Medicine.

Cornell University College of Veterinary Medicine - lots of detailed information on metabolic acidosis and the anion gap.

Veterinary Information Network - Dr Katherine James’ teaching notes on acid base disturbances.

Acid-base, electrolytes and renal failure (1999) Polzin DJ, Osbourne CA, James K Supplement to Compendium on Continuing Education for the Practising Veterinarian 21 11(K)) has information on metabolic acidosis and CKD.

 

Back to Page Index

This page last updated: 25 October 2011

Links on this page last checked: 16 April 2012

 

 

The group is hosted on yahoo!groups, part of yahoo. It has its own address separate from Tanya's website. You can either click here or copy and paste this link into your browser:

 

http://pets.groups.yahoo.com/group/tanyas-ckd-support/

 

If you are already familiar with yahoo!groups, just click on the link and apply to join (and don't forget to complete the short questionnaire you'll be sent), but if you'd like to know more about how the group works, read on.

 

I own and run the group, but I am ably assisted by two moderators, Anne V and Anne A. They help with membership queries, approve messages, and do lots of boring admin stuff behind the scenes to help the group run smoothly for the members.

 

The group has various sections, including a photos section and a realtime chat function but for most people the most important part of the group is its message section. Basically, a member who wants support, vet recommendations, or to hear how others are coping with a particular problem, sends a message to the rest of the group. Other members then respond if they can. All messages sent to the group are stored in a message archive which members can search if they wish.

 

The group is private, i.e. messages sent to it are only visible to members, so people are not posting to the internet at large. The names of group members are also private, so nobody will know you are a member unless you choose to send messages to the group.

 


Joining the Group                                                                                                                        Back to Page Index


 

There are two ways to join the group, via the group's website or via e-mail:

 

How to Join the Group via E-mail


Just send an e-mail to

tanyas-ckd-support-subscribe@yahoogroups.com

You should then receive an e-mail in response asking you to confirm that you definitely want to join the group. Just click Reply and send.

 

If you join the group via e-mail, you will be able to send and receive e-mails to the group, but you will not be able to access the group website and read the message archives or look at the photos. If you wish to do that, you will need to set up a yahoo! ID by visiting the group website.

 

How to Join the Group via the Web


You can visit the group's homepage and follow the instructions. If you do this, yahoo!groups will help you set up your yahoo! ID, which gives you access to the group message archive etc. A yahoo! ID is not the same thing as an e-mail address.

 

Here are the steps to follow. Don't worry, this all sounds far worse than it is! You should find that in practice it all works more smoothly than it sounds when you're trying to explain it in writing:

 

Existing yahoo! ID

  1. Go to the group website: http://pets.groups.yahoo.com/group/tanyas-ckd-support/

  2. Click on the Join this Group button and you'll be taken to a Sign In to Yahoo! page.

  3. Sign in and link Tanya's Support Group to your existing account.

  4. Choose the e-mail address you wish to use for the group (see below).

  5. There is a little box for you to tell me why you would like to join the group. You don't need to be inventive or fancy, it's not a competition, it's just an extra check by yahoo!groups to keep spammers out.

  6. Choose your message delivery options (see below).

  7. Scroll down and click on the blue Join button at the bottom right of the page.

New yahoo! ID

  1. Go to the group website: http://pets.groups.yahoo.com/group/tanyas-ckd-support/

  2. Click on the Join this Group button and you'll be taken to a Sign In to Yahoo! page.

  3. Scroll down a little and click on the Create New Account button.

  4. On the next page you can create your new account. Some people are somewhat inventive in their responses, but in such cases it is important to remember what responses have been given in case the information is needed later to access the account. I can't see any of this stuff, it's entirely private between you and yahoo!groups, so I cannot help in case of later queries. 

  5. Once the account is successfully set up, you'll be taken to a Congratulations! page.

  6. Before you click on the Continue button on the Congratulations! page, untick the box that makes yahoo! your homepage (unless that is what you want).

  7. Also click on the Edit Marketing Preferences link below the Continue button. This takes you to another page where they helpfully opt you in to everything, so go through and set it as you wish.

  8. Then on the same separate page click on Account Info at the top of the page. You will be asked for your password again and taken to the Account Info page. Click on Profile and opt out of the various choices as you wish. The key thing is, you do have choices here, you can make things as public or private as you wish.

  9. Now click on the Continue button on the original page. You will be taken back to the group page to choose your membership settings.

  10. Choose the e-mail address you wish to use for the group (see below).

  11. There is a little box for you to tell me why you would like to join the group. You don't need to be inventive or fancy, it's not a competition, it's just an extra check by yahoo!groups to keep spammers out.

  12. Choose your message delivery options (see below).

  13. Scroll down and click on the blue Join button at the bottom right of the page.


Membership Settings                                                                                          Back to Page Index


 

There are various choices you need to make regarding your membership of the group. The most important are which e-mail address to use, and which way you read messages sent to the group by group members.

 

Membership Settings: Your E-mail Address


You need to decide which e-mail address you wish to use for the group. If you have created a yahoo! ID, yahoo!groups will normally have also set up a free yahoo! e-mail account for you based on your new yahoo ID. You can use this e-mail address to access the group if you wish, but it's not essential, you can use any e-mail address you wish. Since yahoo! is now scanning messages for advertising purposes (similar to gmail), I would recommend not using yahoo! e-mail if possible (though it would probably be better than using your work address for private stuff).

 

If you do not want to use your free yahoo! e-mail address, click on Add e-mail address to add a different one. Be aware, if you don't add a new address here, yahoo! will use the yahoo! e-mail address as a default address. So if you don't receive the membership questionnaire, it may well be because it's gone to your new yahoo! e-mail address.

 

If you ever wish to change the e-mail address you are using for the group, you can do that here:

http://pets.groups.yahoo.com/group/tanyas-ckd-support/join

 

Membership Settings: Message Delivery


This sets up how you will access messages that are sent to the group.

 

This is a pretty active group. If you're looking after your CKD cat, you want support but you probably don't want a full inbox all the time. To help you manage this issue, you have three options for messages, and you can switch between them all as you wish:

  1. Individual E-mails

  2. Daily Digest

  3. Web Only (No e-mail)

Individual E-mails


This is the default setting. If you apply to join the group via e-mail, you will end up with this setting. If you apply to join the group via the group's webpage, if you don't choose one of the other settings, this is the one you will end up with.

 

This setting means that as soon as somebody sends a message to the group, it is sent directly to your inbox. It's a good choice if you might want to know immediately if somebody has responded to you, or if you would like to store some of the group messages for your reference. It's also good for being able to quickly delete messages which don't interest you.

 

The downside is that this is a busy group, averaging 50-100 group messages each day, so your inbox can quickly get full. One solution is to create a folder to use for group messages. All messages sent to the group have a tag in the subject line [tanya-crf] so you can filter all messages from the group to a new folder using this tag if you wish.

 

With both individual e-mail and message digest options, you can also choose the format of messages sent to you (Display Format), either Fully Featured (html, pretty colours etc.) or Traditional (plain text).

 

Message Digest


This means that you receive e-mails from the group, but yahoo!groups waits until there are about 25 messages available and sends them to you all in one go. With this option, you would therefore only receive 2-4 e-mails a day from the group, but it means you have to wait for responses (though you can still check on the group website for messages) and it can be more difficult to find what you are looking for within each digest.

 

With both individual e-mail and message digest options, you can also choose the format of messages sent to you (Display Format), either Fully Featured (html, pretty colours etc.) or Traditional (plain text).

 

Web Only (No Mail)


This means that you receive no messages at all from the group. This is a wise choice if you are using a work e-mail address, or if you cannot cope with the group's message volume. With this system you simply go to the group's website and read the messages that interest you there. Even if this is not your usual choice, it can be helpful to use this option if you are going on holiday.

 

So make your choices, then click the Join button at the bottom right of the page.

 


Important: Membership Questionnaire                                                           Back to Page Index


OK, so you've successfully applied to join the group. However, there is one more thing you need to do in order to join. I want to protect the group members from spammers, so whichever way you apply to join the group, you will receive a short questionnaire asking:

  1. Your first name

  2. The country where you live

  3. Your CKD cat's name and age

You need to respond to this before your membership will be approved.

 

Please don't worry about saying "the right thing." This is not a test to see if you are "good enough" for the group, everybody is welcome here, whoever they are or wherever they come from, as long as they want to help their cat. This questionnaire is basically just to reassure us that you are a real person applying to join rather than somebody trying to sell stuff and spam the group, but it also enables us to tailor our responses to your group messages e.g. if we moderators know where you live, we will not suggest treatments not available there.

 

Please note, only the two Annes and I can see your responses to these questions. The group will not know anything about you unless you choose to introduce yourself.

 

Once you respond to the questionnaire, your membership application should be approved very quickly (most people are approved within two hours or less).

 

Occasionally the questionnaire goes missing. You think we haven't sent it, and we think you haven't responded! If we haven't heard from you five days after you apply to join, we will send you a reminder. Unfortunately, we can only use the address you've used to sign up for the group, so if you've accidentally used your new yahoo e-mail address without realising it (see above), you won't see either the questionnaire or our reminder. If you don't hear from us, please simply write to us at tanyas-ckd-support-owner@yahoogroups.com and let us know. Please respond to the three questions in your response and we will either approve you (if your membership is pending) or send you a personal invitation to join the group (if your membership application has disappeared into a black hole).

 


Messages                                                                                                                                          Back to Page Index


 

Message Options: Sending Messages


You don't have to post, you can just lurk if you prefer.

 

If you wish to change the name that appears on messages you send to the group, Yahoo! explains how you can do that.

 

Starting a Thread


  1. You can simply send an e-mail to ask your question by sending it to tanyas-ckd-support@yahoogroups.com.

  2. You can go to the group website, click on Post Message in the sidebar on the left, and then write your message there.

Replying to an Existing Message


Messages sent in response to another message on the group also go directly to the group, not to the individual to whom you are replying. Therefore if you wish to respond to a message somebody else has sent, you can simply click reply on your e-mail programme. If you reply via the group website, you can click on the message in the group archives, then click reply which is top left above the message.

 

If you're changing the subject, or replying to a Digest (which have the subject line of Digest No. xxx), please change the subject line appropriately to something more meaningful. And please remove everything except that to which you are replying.

 

If you wish to reply privately to somebody, you will need to press reply, then delete the group e-mail address and paste their personal e-mail address into the To: line if you are using e-mail. If you are replying via the group website, you will see a little envelope over on the right under the person's name. If you click on that, your message will go to that person.

 

Message Content


You are welcome to discuss anything relating to care of your CKD cat. We do have a few guidelines we ask people to follow though:

  1. Please do not refer to vets or vet clinics by name for legal reasons. Just say "my vet" or "Dr J".

  2. Please do not ask for money or other donations.

  3. Since this is a very busy group, we ask that condolences are sent privately to the bereaved group member. Certain other messages should also be sent privately e.g. short "me too" messages, off topic posts etc.

  4. Please trim your posts.

Moderation of Messages


When you first join the group, your messages will be moderated for a short while. This means that they will not reach the group immediately, but will first be read and approved by one of the moderators. We do this to ensure that:

  1. you are not a spammer;

  2. you are keeping to other group guidelines (e.g. not naming your vet publicly);

  3. you are trimming your messages appropriately.

If you comply with the group guidelines sent to you when you join the group, you will be taken off moderation quickly. The main reason people stay on moderation is because they do not trim their posts. So please read up on this in the group guidelines. If you get stuck, just ask for help.

 


Leaving the Group                                                                                                Back to Page Index


 

Some people decide to leave the group. Their cat may have died, or they may find the message volume is too much, or they simply decide it's not the place for them. Leaving is fine, but if you're thinking of leaving simply because you cannot cope with message volume, please consider changing your message options first, such as by going no mail. This means your inbox will not be full, but you can still reach out for support quickly when you need it.

 

If you are leaving because your cat has died, please consider joining our sister group, Tanya's Feline Loss Support:

http://pets.groups.yahoo.com/group/tanyas-feline-loss/

 


Conclusion                                                                                                            Back to Page Index


I do hope you've decided to join Tanya's CKD Support Group! It can give you support, it can give you hope. It can make you smile too - where else would people share your thrill at hearing that your constipated cat has pooped? (Believe me, when you've been dealing with CKD for a while, things like this are real triumphs which can absolutely make your day).

 

I personally read every message sent to the group. I don't respond to every post (my priority is running this website) but I do keep an eye on things and post occasionally if I can add to what has already been said.

 


Group Quick Links                                                                                               Back to Page Index


Some of these only work if you are already a member of the group.

 

Weblinks


Group homepage:                                                 http://pets.groups.yahoo.com/group/tanyas-ckd-support/

Managing your membership options:                  http://pets.groups.yahoo.com/group/tanyas-ckd-support/join

Messages archive                                                 http://pets.groups.yahoo.com/group/tanyas-ckd-support/messages

 

E-mail Addresses


Sending a message to the group via e-mail:        tanyas-ckd-support@yahoogroups.com

Group owner e-mail address:                                 tanyas-ckd-support-owner@yahoogroups.com

Joining the group via e-mail:                                   tanyas-ckd-support-subscribe@yahoogroups.com

Leaving the group via e-mail:                                  tanyas-ckd-support-unsubscribe@yahoogroups.com