Common behaviors seen include:

1. rippling or rolling of skin and muscles over the back, ears, head, or tail;
2. excessive staring at their tail, then attacking their tail or sides;
3. biting at the base of their tail, front legs, and paws;
4. running around while meowing in a distressed manner;
5. aggression towards people or other cats. Some cats may show an increase in affectionate behavior;
6. big, dark, round (dilated) pupils.

To diagnose FHS, other conditions related to the skin and nervous system must be ruled out first. These include:

1. dermatologic causes: flea, food, environmental, or seasonal allergies; skin infections or parasites, auto-immune diseases, anal sac disease;
2. neurological conditions such as seizures or neuromas (painful nerve bundle) which may form in cats after declaws or tail injuries;
3. pain: frostbite and orthopedic conditions such as arthritis, injury to the tail, hips, or back;
4. compulsive disorders: may be a primary behavior problem starting from one of the above conditions, then worsening over time;
5. toxins: Pyrethrin/pyrethroid, Organophosphate/carbamate toxicosis;
6. gastrointestinal diseases that are accompanied by changes to appetite, vomiting or diarrhea, flatulence or constipation;
7. urinary conditions, particularly in male cats with a urinary blockage.

To rule out underlying medical causes, expect your veterinarian to do a full physical, orthopedic, and neurological exam to determine the cause. Diagnostics may include radiographs, blood work or urinalysis, skin swabs or skin scrapes.

Treatment for FHS depends on the cause. Your veterinarian may recommend medications, supplements, weight loss or rehabilitation. Treatment of skin conditions may require antibiotics, medications for itch and inflammation or diet change.

If a physical cause cannot be found, antidepressant and anti-anxiety medications may be prescribed.

In addition to medications, there are some treatments that apply to all cats with clinical signs of FHS such as:

1. avoid known situations that cause the behavior in your cat, such as petting;
2. avoid punishing the behavior verbally or physically. This causes conflict and is not likely to stop the behavior;
3. provide a calm, predictable environment for your cat;
4. provide different types of enrichment;
   •    vertical spaces and areas to hide;
   •    offer toys to chase;
   •    encourage hunting with food dispensing and puzzle toys;
   •    train with positive reinforcement techniques.

Its layers act as both a barrier and gateway, plus it must have muscle strength for tone and motion. Proper function depends in part on normal thickness of all the delicate layers.

Diseases of Infiltration

Disease can lead to an influx of inappropriate cells into the layers of the intestine. This infiltration of the bowel by abnormal cells creates thickening and puffiness, which hampers function. The thick intestine does not contract properly, which leads to food pooling and sludging. Pooling and sludging leads to the sensation of nausea and malaise. The thick intestine also cannot absorb nutrients properly, which leads to weight loss and diarrhea. Frequently there is ulceration and bleeding as the membranes become unhealthy.

Dysbiosis

Bacterial populations become altered when the nutrients available to them changes in composition.  In other words, what sort of bacteria live in the bowel depends on what nutrients are in abundance around them. Different nutrients promote different bacterial populations for better or worse. Abnormal nutrient absorption can lead to an overgrowth of bacteria or at least an alteration in the proportions of different populations of bacteria, creating a bad neighborhood in the bowel. Toxic bacterial products can be produced. Bacteria can over-power natural barriers, allowing them to crawl up the pancreatic duct or bile duct where they create inflammation in organs that are normally sterile (pancreas and liver).

Obviously, none of this is a good thing.

Fixing it Depends on Knowing the Nature of the Infiltration

There are two common diseases that involve infiltration: intestinal lymphoma and inflammatory bowel disease (IBD). Both diseases involve lymphocytes infiltrating the delicate bowel. In lymphoma, these are malignant cancerous lymphocytes. In the case of IBD, they are active lymphocytes reacting inappropriately to an immunological trigger (such as a food or bacterial waste product).  A biopsy is necessary to distinguish these two diseases and distinguishing the two conditions allows for the most effective treatment.

Treating Lymphoma

There are two forms of lymphoma: small cell and large cell. The small cell form is associated with a rapid and sustained response to therapy with remissions of one year or longer being common. The large cell form is nearly untreatable with remissions being unreliable or short in duration. A biopsy will determine which type a cat has. Confirmation of lymphoma also allows for a more tailored protocol so as to maximize the quality of remission.

Treating Inflammatory Bowel Disease

IBD is an immune-mediated disease and treatment centers on suppressing the inappropriate immunological response so that the bowel can recover. Specific diets may be employed to minimize inappropriate reactions to food in long-term management. It is theoretically possible, eventually, to recover from this disease completely, though most patients need long-term medications to control the inflammation.

The possibly good news here is that because both conditions involve lymphocyte infiltration, there is a great deal of overlap in therapy so it is possible to make up a treatment plan that will cover both possibilities with a reasonable chance of success. This is not optimal but provides a route to inexpensive therapy.

Diagnostics: Start with an Ultrasound

That said, there are some caveats to the use of ultrasound as the final diagnostic.  For example, there is a great deal of overlap in bowel thickness between what normal patients have, what IBD patients have, and what lymphoma patients have. Normal patients will not have abnormal layering but sick patients can have completely normal layering. More severe disruptions in layering are more typical of lymphoma, especially when they occur in separate segments, but less severe wall thickness change is not very specific. 

Diagnostic Considerations with Abdominal Ultrasound

1. Severe bowel layer distortion implies (but does not confirm) malignancy.
   
2. Milder bowel layer changes could be from either IBD or lymphoma.
   
3. If any lymph nodes are enlarged, they may be aspirated with guidance from ultrasound. If lymphoma is found, the diagnosis is made. If the node is immunologically reactive only, this does not rule out lymphoma but implies benign disease.
   
4. If no lymph nodes are enlarged, the liver may be aspirated. If lymphoma is found, the diagnosis is made. If lymphoma is not found in the liver, it is not ruled out in the intestine.
   
5. Growths or masses may be discovered that are best managed with surgical removal.
   
6. Disease in other organs may be discovered.

Biopsy by Endoscopy or Surgery 

If ultrasound findings are not specific and the diagnosis remains ambiguous, in a perfect world, referral for endoscopy or even surgery follows, biopsy samples are taken, and a tailored therapy can initiate or at least informed decisions can be made. Not every patient is stable for anesthesia, however, and not every owner is financially able to pursue a specialized procedure. 

There is controversy about whether full-thickness biopsy samples (which can only be obtained through surgery) are worth the invasiveness of surgical exploration. Endoscopy allows the surface of the bowel to be viewed from the inside of the intestine so that a biopsy sample can be taken from a specific site. Endoscopy is vastly less invasive and the American College of Veterinary Internal Medicine has indicated that endoscopy is the preferred method of sampling. 

As with ultrasound, there is a great deal of overlap in findings between lymphoma and inflammatory bowel disease as both conditions involve lymphocyte infiltration. PCR testing and Immunohistochemistry can be used to distinguish the two conditions once a tissue sample is obtained. (Cancer cells by definition stem from one cell gone cancerous and thus the entire group of lymphocytes involved in the disease will share genetic markers while inflammatory infiltrates come from a group of cells and will show much more genetic variability.) 

Having a confirmed diagnosis allows for accuracy in prognosis and precision in treatment and may be well worth the expense of this extra step. 

Treatment When we Are not sure which Condition We’re Treating

Because there is a great deal of overlap between the treatment for IBD and the treatment for lymphoma, a therapy plan can be designed that covers both possibilities reasonably well. Typically this involves some kind of corticosteroid; possibly some kind of immunosuppressive medication; and possibly a special diet, probiotics, and nutritional supplements.  Response to medication is generally rapid (within a week) for IBD though it can take up to two weeks, and a common lymphoma statistic is that 75% will achieve remission within three weeks regardless of protocol.  Longer remissions can be obtained with more tailored protocols but this way a reasonably priced therapy is possible.

If your clinic does not have endoscopy equipment, your veterinarian can refer you.

The condition has not been reported in dogs.

The cause is not known. However, the condition is frequently associated with gastrointestinal (GI) inflammatory disorders. The elevation of the third eyelid may be due to a change in the way nerves are supplied to the third eyelid.

A cat’s vision is normal with this condition, but may be functionally decreased simply because the elevated third eyelids are blocking the cat’s vision. Affected cats may have watery diarrhea that began before the onset of elevation. 

Diagnosis

Diagnosis is primarily made on finding classic clinical signs and eliminating other diseases with a thorough ophthalmic and physical examination. The main sign is a protrusion of both third eyelids. Thankfully, the eyes are not painful.

Your veterinarian may do a phenylephrine challenge. Phenylephrine eye drops are applied to the eyeballs to see if the third eyelids return to their normal position within 20 minutes; If they do, then Haws can be confirmed. 

Treatment

This condition is usually self-limiting, so no specific treatment is necessary.

Any diarrhea a cat has should be treated as that may be a contributing factor.

Monitoring and Prognosis

The prognosis is good because the condition is often self-limiting. In one report about cats, the average time for the third eyelids to return to normal was 47 days; however, the number of cases evaluated was limited. In a separate report, 17 out of 45 cats had a third eyelid protrusion that persisted for more than 4 weeks. If the condition persists, your veterinarian may suggest further diagnostic tests, especially if your cat has GI signs.

The “Horse’s Tail”

The spinal cord does not extend down to the tail (it typically ends at the level of the fifth lumbar vertebra), which means that tail injuries do not damage the spinal cord. Unfortunately, injuries to the tail can still cause serious nerve damage.

Because the spinal cord ends so high up, nerves exiting the cord to provide control and sensation to the tail, hind legs, urinary bladder, large intestine, and anus must extend long branches to reach their destinations.  When you look down at these nerves (an aerial view if you will), these nerves are said to look like a horse’s tail, and thus anatomists call this area the cauda equina (which literally means horse’s tail).

What Might be Noticeable at Home After a Tail Pull Injury

Cats with a tail pull injury might show any of these symptoms:

1. A tail that drags or is never held high.
2. Involuntary dribbling of urine.
3. A dilated, flaccid anal sphincter with or without diarrhea or fecal incontinence.
4. Incoordination of the rear legs.

Any of these symptoms might lead the cat into the vet’s office for an evaluation. Some additional findings the veterinarian might notice include:

1. A distended bladder that is relatively easy to express manually (in other words, the bladder is full but can be emptied with careful squeezing.)
2. Bloody urine (if the tail trauma is recent).
3. Painful tail head.
4. Loss of sensation in the tail.

Group One: Cats With Painful Tail Heads as their Only Sign
These individuals are minimally affected and, while they may or may not have a chronically sensitive tail head, they are expected to otherwise have a full recovery.

Group Two: Cats With Lack of Tail Mobility and Sensation as Their Only Sign
These cats are expected to recover tail function completely and have an excellent prognosis.

Group Three: Cats With Lack of Tail Mobility and Sensation Plus Urine Retention as Their Only Signs
Most cats will have a complete recovery.

Group Four: Cats With Lack of Tail Mobility and Sensation and Diminished Anal Tone
This group of cats has about a 75% recovery rate, meaning 75% of the cats that fit this description should recover.

Group Five: Cats With Lack of Tail Mobility and Sensation Plus a Dilated/Flaccid Anus (i.e., Zero Anal Tone)
This group of cats has about a 50% recovery rate, meaning about half of the cats with this description will eventually recover.

If it is not clear whether a cat has partial anal sphincter tone or not, it may be possible to have a test called an electromyogram. The muscles of the anal sphincter and tail can be tested to see if they are receiving any nerve input at all. If they are, there is reasonable potential for recovery. The EMG test is highly specialized and not readily available except at practices with a neurology specialty. Referral will probably be necessary.

In a more recent study (Nov 2009, Journal of Small Animal Practice) researchers found that an excellent predictor of bladder function return is pain detection at the tail head. In the 21 cats with sacrocaudal fracture/dislocation, all 11 cats that had pain sensation at the tail head on the first day after the injury had regained bladder function within 3 days. Absence of pain sensation in this area on the first day did not necessarily mean that bladder control would not return; 60% of cats without tail head sensation on the first day had recovered bladder control by 30 days after the injury.

Should the Tail be Amputated?

If the tail is not expected to recover mobility or sensation, there are some reasons to consider amputation. If the cat cannot lift his tail, he may soil it regularly, creating an infection issue or simply an odor issue. Further, the weight of the tail dragging may further stretch the cauda equina nerves. Whether or not tail amputation is helpful or speeds recovery is controversial but certainly amputation could solve a soiling problem.

Bladder Management

It is important not to allow the bladder to over-stretch. The fine muscles of the bladder can become so stretched out that even if the nerves recover, the bladder may still remain unable to empty fully. This means the cat’s bladder must be gently squeezed three or four times daily to keep it from over-distending. Medications can also be used to assist the bladder’s own ability to contract (bethanechol chloride) or to relax the urinary sphincter (prazosin or phenoxybenzamine).  Since urine retention tends to promote infection, patients will periodically require some sort of monitoring urine tests. If constipation is a problem, periodic enemas or stool softening medications can be given regularly.

Recovery Time

Nerves heal notoriously slowly. It has been said that a good six months must pass before one can say the maximum recovery has occurred and no more positive progress can be expected. Most cats who are going to recover function do so in a one-week period, and most cats who do not recover urinary control after a month probably will remain incontinent. Tail function and sensation tends to take longer.

Tooth resorptions are usually found on the outside of the tooth where the gingiva (gum) meets the dental hard tissue. The lower jaw premolars are mostly affected, however tooth resorption can be found on any tooth. 

The cause is unknown, but theories supporting an autoimmune response, calicivirus, and metabolic imbalances relating to calcium regulation have been proposed.  The resorption generally starts at the cemento enamel junction (gum line) and progresses inward, eroding sensitive dentin. Once the resorption is exposed to the oral cavity, bacteria invade causing pain and jaw spasms. Increased salivation, oral bleeding, or difficulty eating are other signs. Unfortunately, most times there are no outward signs. It is up to the veterinarian or astute owner to diagnose tooth resorption.

Intraoral radiographs (X-rays) are essential to evaluate all the teeth to determine the best course of therapy. Depending on what is seen on the visual patient exam and the intraoral X-rays (tooth resorption type 1, 2, 3), treatment involves following the resorption until it is exposed to the oral cavity, extraction of the entire tooth and roots, or a partial tooth extraction.  In cats affected by stage 5 without inflammation, treatment is not necessary.

Symptoms

Chronic (i.e. long term), voluminous, watery diarrhea is the most common symptom. Diarrhea can come and go so that the cat seems fine sometimes, which can help delay a diagnosis. Cats can also experience excess gas, going more often, foul odor to the stool (we mean more than usual!), and/or trouble defecating.

In general, cats infected with T. blagburni are otherwise normal, have a healthy weight and appetite, and are well hydrated. Sometimes, cats can become dehydrated or develop a poor appetite if the diarrhea is severe or excessive.

What to Expect at a Veterinary Visit

If you suspect your cat has tritrichomoniasis, bring some fresh feces to the veterinary appointment with you. Sandwich-sized plastic zippered bags are great for carrying the diarrhea sample.

Your veterinarian will start with a thorough physical examination, and then check for signs of dehydration and tummy pain. There will likely be an examination of your cat’s feces for intestinal parasites or increased levels of bacteria by looking at the feces under a microscope. Some cats are infected with multiple types of parasites at one time, so it is important that all issues be diagnosed and treated properly.

Unfortunately, T. blagburni is difficult to identify just by looking at the feces. Laboratory tests may be needed and/or blood tests to get an accurate diagnosis. Occasionally, a biopsy may be needed, but this is not common.

Treatment

Medications are available to treat tritrichomoniasis, but they are not always effective.  In some cats, especially in those less than one year of age, infections will improve without specific treatment. However, this can take several months.

Supportive care is important to keep your cat healthy during the infection. Feline diets high in fiber can help firm up the stools. Probiotics may also be useful to improve and maintain normal gut/GI flora. Any additional intestinal parasitic diseases need to be treated appropriately as well.

Control and Prevention

Keep your cat’s environment clean and free of feces. Minimize stress where possible by providing plenty of exercise and individual resting spaces. Scoop litterboxes daily and disinfect them regularly. All cats in the household should be tested for tritrichomoniasis because some cats may be infected without showing symptoms. Uninfected cats can be separated from the infected ones to prevent the disease from spreading, although that’s difficult in a home setting.

Pancreatitis is inflammation of the pancreas, an organ in charge of producing enzymes to help break down food in the intestinal tract. It can come on suddenly, known as acute pancreatitis, or it can be a long-term, chronic problem. Cholangitis is inflammation of the gallbladder and bile ducts. It is sometimes termed cholangiohepatitis when the liver is also inflamed. The gallbladder makes bile, which helps break down fatty foods in the intestinal tract. The ducts or passageways for the pancreas and gallbladder open into the intestines in the same place, so when that area of the intestines is inflamed, infected, or diseased, the pancreas and gallbladder have a higher chance of being injured as well.

IBD is a chronic condition of the intestines in which inflammation leads to a poorly functioning GI tract. Causes are numerous and include overactivity by the immune system, food allergies, abnormal bacteria in the gut, and genetics  ̶  often occurring in some combination together.

How is Triaditis Diagnosed?

In cats with triaditis, the most common sign is vomiting or throwing up. Decreased activity level, diarrhea or loose stool, poor appetite, and weight loss are also frequently seen. Occasionally, fever, tummy pain, a yellow tinge to the skin (known as icterus),and swelling of the belly may occur.

Your veterinarian will want to do a thorough physical examination to assess for other causes of these signs. They will also run tests on the cat’s blood, such as a complete blood count (CBC), chemistry panel, and pancreatic lipase immunoreactivity test. X-rays and an abdominal ultrasound may also be needed. If a bacterial infection is suspected, a culture and sensitivity may be run on fluid or tissues from the affected organs. All of these tests will help point the veterinarian in the right direction for diagnosing triaditis.

However, to get an official diagnosis, a biopsy of the pancreas, intestines, and gallbladder or surrounding liver is needed. While this sounds like a lot of tests, keep in mind that triaditis is really three different diseases happening at the same time, so it can be difficult to get the diagnosis right. Thank goodness kitties are so tough!

Treating Triaditis

In order to treat triaditis effectively, all three diseases will need to be managed together. Pancreatitis treatment may include pain medication, treatment for nausea, and hospitalization and fluid therapy for dehydration. Triaditis treatment is similar, although liver and gallbladder protective medications such as ursodiol, samE, or Denamarin may be used to help encourage healing. Antibiotics may be given if a bacterial infection is occurring. IBD treatment includes managing the cause of GI disease. This management can mean a special diet, medications to suppress the immune system, and vitamin B supplementation when needed.

Additional treatments needed will depend on the complications or effects of triaditis on the pet. Bleeding disorders, gall stones (known as choleliths), severe infections such as abscesses or septicemia, calcium deficiencies, and electrolyte imbalances are some of the complications that may occur, especially if treatment is delayed. For cats that won’t eat, sometimes feeding tubes are necessary.

Triaditis is a complex disease, but your veterinarian will be able to give you a good idea of what is needed for your cat and help you get them back to health. The prognosis can vary depending on the severity of disease.  Luckily, many cats with triaditis recover well with treatment.

(Urinary protein loss due to kidney inflammation)

When a patient, human or non-human, is said to have kidney failure, renal insufficiency, or even chronic renal failure, what most people are talking about is a toxin build up when the kidney cannot adequately remove the body’s harmful wastes. This toxic state is called uremia and is associated with nausea, appetite loss, weight loss, listlessness, and other unpleasant issues.  It is also not the kind of kidney disease we are going discuss here. 

Glomerular disease is a completely different kind of kidney disease and may not involve any toxin build up at all. Glomerular disease is one of protein loss. 

What is a Glomerulus Anyway?

Consider for a moment what an important resource protein is to your body. Your blood, for example, is full of necessary circulating proteins handling clotting, fluid balance, transporting other chemicals etc. Your body went to a lot of trouble to build those proteins and you can’t afford to waste them. If you were to lose them, your body would have to break down muscle in order to recreate them because that is how important they are.

The illustration to the right shows the nephron, which is the functional unit of the kidney. There are millions of these making urine every moment of every day. Only about 30 percent of them must be working in order to maintain normal kidney function. The rest form a back up system so that we will have plenty of extra nephrons should some of them get plugged with debris, damaged by scarring or infection, or starved for oxygen during a traumatic event.

The glomerulus, which in a way looks like a little dandelion tuft, is where our interest lies today. Blood flows through an afferent arteriole into the glomerulus. Inside the glomerular tuft, the blood vessel narrows into a complicated spiral of tiny capillaries, so small that the blood cells pass through single file. The capillaries are gripped by cells called podocytes. Like hands, the podocytes have tiny fingers (ironically called foot processes) that encase the capillaries. Fluid and small molecules can flow in between the fingers while cells and large molecules like proteins cannot pass through.

The cells and large molecules/proteins exit the glomerulus through an efferent arteriole and return to normal circulation. This first step in filtration is driven both by blood pressure as well as by the protein content of the blood.

There are many possible sources of chronic inflammation that could be generating antigen: antibody complexes. Chronic ear or skin infections could be the cause. Long-standing dental disease could do it. A latent, more internal infection might be the cause (such as heartworm, Lyme disease, prostate infection, or Ehrlichiosis). Even a tumor might generate enough of the immune system’s attention to lead to this sort of reaction.

If it is at all possible to identify and resolve the underlying cause of inflammation, this should be done as other therapy is unlikely to fully resolve the protein loss.

How is the Diagnosis Made?

There are several common scenarios that might lead to the diagnosis but they all boil down to one or both of two findings: excess urine protein found on a routine urinalysis and/or low albumin found on a blood test.

Let’s start with excess urine protein found on a routine urinalysis.

A urinalysis examines a urine sample for some of its chemical contents and properties. Protein content is one of the parameters that is checked and reported as a small, medium or large amount. On a urinalysis report this will be designated as “+,” “++,” or “+++.”

This seems like it would be easy enough to interpret but unfortunately there is more to the story. A small amount of protein in a well-concentrated sample may be  normal while the same amount of protein in a dilute sample would be highly significant. How dilute or concentrated the urine is depends on the patient’s water consumption, and we need a method to examine urine protein that is independent of the water consumption.

Further, we need to determine if any protein in the urine is truly coming from the kidneys; after all, a bladder infection or other bladder condition might generate urine protein. To help distinguish renal protein loss, the rest of the urinalysis will be helpful. When your veterinarian is confident that other issues with the urinary tract have been excluded, it is time for a urine protein:creatinine ratio (we will come back to this).

Low Blood Albumin Level found on a Blood Panel

Albumin is one of those proteins that the body really wants to conserve and here’s why. There are plenty of substances the body needs to circulate that simply are not water soluble. How do we circulate these things if they won’t dissolve in water? We bind them to a carrier protein that will circulate and carry them as if they were commuters on a city bus. The albumin molecule is that city bus, carrying important biochemicals around your body.

There’s more. Albumin also is important in keeping water in the bloodstream. This sounds odd but blood is basically a liquid and without enough water, it sludges and clots abnormally. Furthermore, if water is not held in the vasculature, it leaks into other body cavities such as the chest and abdomen, filling these cavities with liquid.

Your body prioritizes the maintenance of its albumin levels and will not allow them to drop. When the albumin levels are down, a serious protein loss is afoot. It could be intestinal or liver-related, but glomerular protein loss is going to be one of the first conditions to rule out. If there is no protein in the urine, the focus shifts to other organs but if there is protein in the urine, it must be quantified and that means there is a urine protein:creatinine ratio.

Interpretation of the Urine Protein: Creatinine ratio

The urine protein:creatinine ratio compares the amount of protein in the urine to the amount of creatinine, one of the metabolic wastes filtered by the kidneys. By using this ratio, it does not matter how dilute the urine is or how concentrated it is. The ratio allows for protein loss to be quantified and then we can tell how significant the protein loss actually is. If the urine protein: creatinine ratio is found to be abnormal, ideally it is repeated in 2 to 4 weeks to be sure that the protein loss is persistent, but this depends on how high the ratio is and whether or not there is a known inflammatory condition that would be expected to damage the glomeruli.

Determining how serious a patient’s protein loss is depends on overall kidney function as well. In other words, a protein-losing kidney that is effectively removing the daily load of toxins and wastes is in less trouble than a protein-losing kidney that is failing.

The International Renal Interest Society (IRIS) considers a urine protein:creatinine ratio of greater than 0.5 for dogs or 0.4 for cats to be abnormal, and if it is persistent, then further diagnostics and treatment are recommended.

Depending on how your pet responds to the therapies above, a biopsy may be recommended. Biopsy is most commonly recommended for patients with UPC ratios more than 3.5 or with significant proteinuria combined with low albumin levels or high blood pressure.

The goal of treatment is to reduce the UPC ratio to below 0.5 or to reduce it by at least 50%. Higher reductions are sought for cats (see later).

Ratios greater than 3.5 are particularly concerning and require more aggressive treatment and more extensive diagnostics. These patients have an increased risk of abnormal blood clotting and generally have more extensive kidney damage.

The urine protein: creatinine ratio varies by up to 30% above or below baseline as a matter of course. A significant change in the ratio caused by disease progression (up) or response to therapy (down) must be greater than 30%.

If Intervention is Recommended what Does that Mean?

Adding omega 3 fatty acids to the regimen appears to improve the protein loss situation and supplementation is recommended. Most renal diets are already fortified with these anti-inflammatory fats but additional use is felt to be beneficial.

Low Protein, Low Sodium Diet

Most commercial renal diets would fit in this category. It seems paradoxical that a disease that causes body protein to be lost would be treated with a protein-restricted diet but, in fact, supplementing protein causes albumin to drop faster.

ACE Inhibitor

These medications have been shown to reduce renal protein loss. Typically enalapril is recommended for dogs and benazepril is recommended for cats. These medications inherently reduce blood flow to the kidneys so care must be taken in patients with elevated creatinine ratios to be sure the uremia does not worsen. Lower doses are used and monitoring becomes more important.

Omega 3 Fatty Acid Supplementation

Most commercial renal diets are fortified with omega 3 fatty acids. These anti-inflammatory fats have been shown to improve survival of dogs with renal disease. It is still unclear how helpful they are for cats but studies are ongoing.

Angiotensin II Receptor Blockers (ARBs)

Angiotensin II receptor blockers are becoming more popular in human medicine and their use is trickling down to manage canine glomerular disease. These medications work with ACE inhibitors to further help reduce urinary protein loss though they can also be used alone. Like the ACE inhibitors, they not only reduce urine protein loss but also lower blood pressure as well and seem to have some effect on reducing the clotting tendency. They are new to veterinary medicine and protocols are still being worked out. The two commonly used medications are losartan and telmisartan.

Spironolactone

Aldosterone is the hormone that acts on the kidney to retain sodium and water and get rid of potassium. Spironolactone is an antagonist of this hormone, which means it increases urine production, retains potassium and removes sodium. In humans, it has been found to reduce urine protein loss by 34 percent, which makes it an attractive medication for this situation especially in patients with nephrotic syndrome (see below). In dogs it might be used when ACE inhibitors or ARBs have not controlled the proteinuria. It is not a medication for cats.

The goal in managing urine protein loss is a 50% reduction in urine protein:creatinine ratio for dogs and a 90% reduction in urine protein:creatinine ratio for cats. A combination of the above medications is likely to be prescribed, and urine and blood test monitoring will be periodically (at least quarterly) recommended in hope of achieving and finally maintaining these results.

Nephrotic Syndrome

In severe cases, a complication called nephrotic syndrome can result due to the extreme urinary protein loss. Nephrotic syndrome is defined as the combination of: 1) significant protein loss in urine; 2) low serum albumin; 3) edema or other abnormal fluid accumulation; or 4) elevated blood cholesterol level. This is a severe complication of glomerular disease and suggests a poor prognosis, especially if creatinine levels are elevated in the blood. 

High blood pressure is a common complication of nephrotic syndrome. Patients also tend to form inappropriate blood clots (embolism) that can lodge in small blood vessels, causing loss of circulation to entire organs or sections of organs. Nephrotic syndrome is an advanced state of urinary protein loss and must be treated aggressively.

Biopsy the Kidney?

There are pros and cons to this relatively invasive test. The kidney receives 25 percent of the blood supply at any given time, which means it is highly vascularized and can bleed in an extreme way. Blood transfusion is needed for 10 percent of dogs and 17 percent of cats having this procedure, and a three percent mortality rate has been reported. So why take the chance on this procedure? The main reason is to obtain information on prognosis.

There are different types of glomerular disease and glomerular inflammation, all of which may have different associated expectations. There is a type of glomerular disease called amyloidosis that involves abnormal protein (called amyloid) infiltrating the kidneys and has a much more progressive and damaging course. Approximately 50 percent of glomerular disease patients have diseases that can benefit from immune-suppressive therapy but the only way to identify these patients is with a biopsy. 

Conclusion

When the kidney cannot retain blood proteins, the body loses its ability to carry out normal blood functions. In an attempt to replace these proteins, muscle is broken down and the patient becomes debilitated. Maintaining proper nutrition and using medication to reduce the protein loss are crucial to managing this form of kidney disease. It is important for the pet owner to keep up the monitoring schedule and to stay in contact with the veterinarian as to the pet’s progress and response to therapy. 

In Summary

1. Glomerular disease is one broad type of kidney disease in which the primary problem is loss of renal proteinuria. Glomerulonephritis is one broad classification of kidney inflammation. It usually results in protein loss in urine. There are subtypes that can be determined by specialist pathologists based on renal biopsy.
2. It is not typical Glomerular disease differs somewhat from “classic” kidney failure renal disease, although it glomerular disease can lead to chronic kidney disease if undetected.
3. In the kidney, there are a million nephrons that make urine every minute of the day and send that urine to the bladder and out of the body through a filtration system. A body only needs approximately 30% of those nephrons working correctly for normal kidney function, at least as far as veterinarians could detect with typical lab tests. The rest are a backup system called the functional reserve.
4. Inflammatory cells punch small holes along the filtration route. Those holes are big enough for proteins to pass through.
5. Sources of chronic inflammation are believed to cause the problem, possibly stemming from issues such as chronic ear or skin infections, dental disease, heartworm disease, vector-borne diseases like Lyme disease, or feline immunodeficiency.
6. Diagnosis is suspected by excess urine protein found in urine, and/or low albumin found on a blood test. Definitive diagnosis of glomerulonephritis and its specific type requires a kidney biopsy.
7. When the kidney cannot retain blood proteins, the body cannot carry out normal blood functions. In an attempt to replace these proteins, muscle is broken down and the patient becomes debilitated.
8. The urine protein:creatinine ratio (UPC) found in a urine test compares the amount of protein in the urine to the amount of creatinine, a metabolic waste filtered by the kidneys. The ratio tells what the magnitude of the protein loss actually is. A persisting, reproducible urine protein:creatinine ratio of greater than 0.5 for dogs or 0.4 for cats is too high. Mild elevations can be due to causes other than glomerulonephritis.
9. Determining how serious the protein loss also depends on overall kidney function. A protein-losing kidney that is still effectively removing the daily load of toxins and wastes is in less trouble than one that is failing. Once the urine protein:creatinine reaches a certain ratio, a biopsy may be recommended. Ratios greater than 3.5 (typical US units) are particularly concerning.
10. The best treatment is when a specific cause is found, such as a systemic infectious disease, and that disease can be successfully treated. However, sometimes despite extensive searching with imaging and blood tests, no underlying cause can be found.
11. One goal is to reduce the urine protein:creatinine ratio to below 0.5 or to reduce it by at least 50% in dogs and 90% in cats.
12. Potential interventions expected to help specifically with proteinuria include: omega-3 fatty acid supplementation; a controlled protein, low sodium diet; and RAAS inhibition (with drugs called ARBs or ACEIs). Accompanying hypertension, when present, may require additional treatment.
13. In severe cases, a complication called nephrotic syndrome can result due to extreme urinary protein loss. The prognosis for this complication is comparatively poor, although it does depend on whether the problem developed acutely or chronically.
14. A kidney biopsy can be informative about a prognosis and suggest whether additional treatments are expected to help. Since immunosuppressive treatments can also do harm, biopsy is usually recommended to justify trying that type of medication. Biopsy can be expensive and requires pre-planning to make it safe. For sample evaluation to be truly valuable, the specimens are analyzed by a specialist veterinary nephropathologist.
15. It is important for you to keep up the monitoring schedule and stay in contact with your veterinarian.

So, if a cat is throwing up or regurgitating hairballs, there is more going on than most owners realize.

Grooming

Grooming allows cats to keep themselves clean. They remove old hair, surface dirt, and foreign bodies when they groom themselves and other cats.

But if a cat is long-haired, he has more hair to remove. (Mother Nature designed felines with short hair. Life is easier for wild cats when they have short hair.) So, long-haired cats who have to do all the grooming themselves — who aren’t being groomed (brushed) by their owners — are ingesting more hair than Mother Nature planned. The elimination of the extra hair may be too much for a healthy long-haired cat’s digestive system.

Over-grooming can also occur in cats experiencing pain. They may lick and groom the painful area to try to make it “feel better” and/or to reduce the stress. Urinary tract pain, musculoskeletal pain, and abdominal pain may cause over-grooming by the unhappy cat.

But hairballs also occur in animals who aren’t “putting too much hair” into their digestive tracts.

What Are Other Potential Causes?

1. Intestinal motility problems
2. Stress and stereotypic behaviors
3. Skin diseases
4. Abdominal problems
5. Urinary tract problems
6. Musculoskeletal problems

If the stomach and small intestine don’t allow the ingested hair to move through normally, the cat will produce hairballs.

If the cat has inflammatory bowel disease, hair – and food – won’t pass through it at a normal speed, or at all. The stomach and intestinal tissue is damaged and doesn’t provide normal motility. It also doesn’t produce the normal digestive enzymes or lubricants that allow the intestinal contents to move along.

The same is true of gastrointestinal cancer. The contents of the tract (hair and food) don’t move along the way they should.

To find the more specific causes of hairballs, your veterinarian may need to explore various body systems and consider conditions that may lead to hairballs. This may include megaesophagus, diaphragmatic hernia, gastrointestinal neoplasia, ileus, intestinal parasites, inflammatory bowel disease, pancreatitis, gallbladder disease, cystitis, bladder stones, kidney stones, arthritis, boredom, frustration, skin parasites, fungal skin diseases, and more.

This is not quite as simple as the problem the client discussed.

Diagnostic Tests

Your veterinarian may recommend tests to look for causes of hairballs including a complete blood count, blood chemical analysis, fecal examination, urinalysis, ultrasonography, radiography, contrast radiography, skin cytology, histopathology, behavior evaluation, etc.

Finding and treating the primary problem is always preferable to just treating the symptom (hairballs). The cat and the client will be happier if everything can be put back to normal. In addition to treating the inciting problem, the veterinarian may recommend diet changes, more brushing by the owner, more play time with the owner, etc.

With diagnostic skills and a little luck, the veterinarian can make the owner happier and the cat healthier and more content.

Hepatic encephalopathy is a neurological condition that can occur in pets, more commonly in dogs, that already have liver disease. Neurological conditions affect the nervous system, which includes the brain, nerves, and spinal cord. The condition is potentially life threatening.

The liver normally filters out certain substances that are toxic to the body’s nervous system, such as ammonia. When the liver isn’t working properly, it can lead to a buildup of these substances in the blood stream. The most common liver disease that causes hepatic encephalopathy is a portosystemic shunt, a condition in which certain blood vessels bypass the liver’s filtration system. Hepatic lipidosis, a build-up of fat within liver cells, is another common cause of hepatic encephalopathy, especially among cats.

Signs

Signs of hepatic encephalopathy include unusual behavior, trouble or wobbliness when walking, seizures, drooling, vocalizing (i.e. whimpering, whining, crying, and other unusual noises), blindness, weakness, and/or coma. Signs of liver disease may also be noted, which include poor appetite, weight loss, yellow skin, gums, and eyes, enlarged belly, drinking and urinating often, throwing up, and/or loose stool. Any or all of these signs may be worse after eating. That is because the gastrointestinal (GI) tract is one of the main organs from which ammonia is filtered, so eating potentially causes an influx of this toxin into the blood stream.

Diagnosis

To diagnose the condition, your veterinarian will give the pet a physical examination looking for signs of neurologic or liver disease. Bloodwork will assess the body’s immune system and check for evidence of inflammation or infection (e.g. complete blood count/CBC) and determine how well the major organ systems are working (e.g. serum biochemistry profile).

Common findings with liver disease include anemia, low red blood cell percentage; elevated liver enzymes e.g. ALT, alkaline phosphatase, and bilirubin; and decreased blood glucose. Sometimes with liver disease, pets are at increased risk for bleeding. Coagulation tests, which can determine how well the blood is clotting, may be run if bleeding tendencies are suspected.

Bile acid tests and ammonia measurements, also known as ammonia tolerance tests, can help confirm liver disease and hepatic encephalopathy, especially when combined with signs and laboratory findings. Occasionally, such tests do not provide a full diagnosis.

Additional tests may be needed to figure out what caused the liver disease, such as X-rays and an abdominal ultrasound. Treatment may be started before all tests are finished if most signs point to liver disease and hepatic encephalopathy. This speed allows veterinarians to help the patient as quickly as possible and prevent the disease from getting worse.

Treatment

Hepatic encephalopathy can be life-threatening, so treating symptoms quickly is important. Hospitalization may be required. In some cases, brain swelling can occur, which is treated with intravenous (IV) medications. Patients with brain swelling need to be monitored very closely. Many such patients are admitted to veterinary ER hospitals for round-the-clock care. Seizures are treated with anti-epileptic medications such as diazepam, levetiracetam, or phenobarbital.

Additional medications may include antibiotics and/or certain types of enemas to minimize ammonia-producing bacteria; lactulose, which helps prevent ammonia from being absorbed from the GI tract; and/or liver protective medications, such as SAM-e or Denamarin®, which combines silymarin with SAMe. Other treatments will depend on the symptoms and bloodwork of the pet, such as IV fluids, therapy for bleeding, etc.

In some cases, feeding a lower protein diet may be helpful to minimize the volume of ammonia produced in the GI tract, but this is not always needed and will depend on the veterinarian’s recommendations. Once the cause of liver disease is determined, treating it will help stop hepatic encephalopathy from worsening or returning after treatment. Such treatments will depend on the type and cause of liver disease.

Will My Pet Recover?

If signs are mild and treated quickly, most pets recover. Treating the liver disease is important to prevent hepatic encephalopathy from recurring, although this is not always possible. Unfortunately, severely affected pets can die, even with treatment. This is why it is important to seek treatment as soon as you notice your pet is showing unusual symptoms. Call your veterinarian for an appointment as soon as possible if you think your pet is experiencing liver disease or hepatic encephalopathy.