The first thirty days

What should I do in the first month after a CKD diagnosis?

You've come home with a diagnosis, a bag of things, and a strong urge to do all of it tonight. Please don't.

The single most common mistake in the first week isn't doing too little. It's doing everything at once, to a cat who feels unwell, until she hides from you and you're exhausted and neither of you knows which change caused what.

This is a month, not an evening. Here's the order I'd do it in.

The first thirty days, one week at a time

Every item here is from the four weeks written out below. Tick as you go. It stays on your own phone and nothing is sent anywhere.

1. 1 Week one: water, one medication, and the appointment

   • More water into her: wet food where she will take it, more bowls in more rooms, wide and shallow rather than deep.
   • Ask whether to start her medicines together or a few days apart. Never hold back an antibiotic or a blood pressure medicine.
   • Book the recheck, and ask for her interval specifically rather than the standard one.
   • Buy a cheap digital kitchen scale, a notebook, two or three extra water bowls, and something that hides a tablet.

2. 2 Week two: the food, slowly

   • Mix a spoonful of the new food into her usual food. Sit at that ratio for a few days before increasing it.
   • If she refuses, drop back to the last ratio she accepted and stay there longer. There is no prize for finishing early.
   • Never introduce the new food on a day she feels rough.
   • If she simply will not have it, say so at the recheck rather than quietly giving up.

3. 3 Week three: learn the home routine

   • If fluids were prescribed, get properly comfortable with them. Ask a technician to watch you do one if it is going badly.
   • Put a paper chart on the fridge with the times you actually give medications, and tick as you go.
   • Start writing four things down: weight weekly, ate normally, vomited, litter box normal.
   • Watch the small signals rather than the dramatic ones: lip licking, coming to the bowl and turning away, in and out of the box, sleeping somewhere cold and hard.

4. 4 Week four: the recheck, and what to ask for

   • Weight, against the weight on the day she was diagnosed.
   • Creatinine, phosphorus, potassium, written down with the date.
   • A UPC, if she has never had one. Ask for it by name.
   • Blood pressure, if the practice has the equipment. If not, ask what to watch for at home.
   • A urine culture collected by cystocentesis, if her numbers moved the wrong way without an explanation.

Week one: water, one medication, and the appointment

Three jobs. That's the whole week.

Get more water into her. Wet food instead of dry wherever she'll accept it, more bowls in more rooms, wide shallow bowls rather than deep narrow ones, and a fountain if she's the sort of cat who likes moving water. This is the highest-value thing you'll do all month and it costs nothing.

Ask how to start her medicines. If she's been sent home with several things, ask your vet whether to start them all together or spread them over a few days. Staggering the ones that can wait makes it easier to tell which one upset her stomach. Some can't wait, though. Never hold back an antibiotic or a blood pressure medicine to do it, and when in doubt, start everything the way your vet wrote it.

Book the recheck. Do it now, while you're thinking about it. Ask specifically when she should be back, because the interval genuinely differs. A stable early-stage cat might be three months out. A stage 4 cat, or a cat just started on fluids, a blood pressure drug or an ACE inhibitor, often needs to be seen inside a week or two.

What can wait: the food change, the supplements, the internet, and the survival statistics. All of it still works next week.

Week two: the food, slowly

Now the diet, and slowly is the whole trick.

A kidney diet is lower in phosphorus, and lowering phosphorus is the intervention with the best evidence behind it in this disease. It buys time. Which is exactly why it's worth taking three weeks to introduce properly rather than three days and failing.

Mix a spoonful of the new food into her usual food. Sit at that ratio for a few days. Increase it a little. If she refuses, drop back to the last ratio she accepted and stay there longer. There's no prize for finishing early.

Two rules that save people weeks of trouble:

• Don't introduce the new food on a day she's feeling rough. Cats attach nausea to whatever they last ate, and you can burn the kidney diet permanently in one bad meal.
• Don't let her go hungry to force the change. A cat eating an ordinary food beats a cat refusing the correct one, every time.

If she simply won't have it, say so at the recheck rather than quietly giving up. Keep whatever share of kidney diet she'll accept in the mix, and ask about a phosphorus binder stirred into the food she does like. That gets back part of the benefit, though a binder can't do everything the diet does. There's more on all of this on the kidney diets page.

Week three: learn the home routine

By now the medications are in and she's eating something. This is the week to add the skills.

If fluids have been prescribed, this is the week to get properly comfortable with them. The first one takes twenty minutes and you'll shake. The fourth takes four minutes. If it's going badly, ask a technician to watch you do one in the clinic. It's usually one small mechanical thing making it hard, and they would much rather spend ten minutes on that than have you give up at home. The full walkthrough is on the subcutaneous fluids page.

Set the medications up so you can't get them wrong. A paper chart on the refrigerator with the times you actually give them, not the times you intended to. Tick it as you go. Two people in a house both dosing the same cat at dinnertime happens more often than you would think, and a chart is how it stops.

Start writing four things down. Weight weekly, ate normally yes or no, vomited yes or no, litter box normal yes or no. Nothing more elaborate. More detail than that and you'll stop doing it by week six.

Watch for the small signals rather than the dramatic ones: she's licking her lips a lot, she comes to the bowl and turns away, she's in and out of the litter box, she's picked a new place to sleep that's cold and hard. Those are worth a phone call, and they're the things owners talk themselves out of mentioning.

Ballpoint, some days missed, a coffee ring on it. That's what a real month looks like, and it works better than any app you'll stop opening by week three.

Week four: the recheck, and what to ask for

You'll be told what she needs. It's still worth knowing what a complete recheck looks like, because some of it gets skipped routinely. This first recheck also starts to show whether her kidney numbers are holding steady or still climbing, which tells your vet more about her outlook than the first result did.

• Weight, compared with the diagnosis weight. This is the scoreboard.
• Creatinine, phosphorus, potassium. Write the three numbers down with the date, every time.
• A UPC, urine protein to creatinine ratio, if she's never had one. Protein loss speeds the disease along and it's treatable with a specific drug your vet won't prescribe without the number.
• Blood pressure, if your vet has the equipment. At least one in five kidney cats is hypertensive, some studies have found far more, and it usually causes no symptom at all until it causes a permanent one, most often blindness. A lot of practices don't own a machine, and mine is one of them. That's workable. If yours doesn't, ask what they'd rather you watched for at home.
• A urine culture collected by cystocentesis, if her numbers have moved in the wrong direction without an explanation. A kidney infection can be silent, it's one of the more common reasons a cat suddenly gets worse, and it's often treatable with antibiotics. It's worth asking about by name because it's easy to miss.

Take your notebook. Take your weights. Ask what her recheck interval is now, since it may have changed.

There's a fuller breakdown of the values themselves on the bloodwork page.

Day thirty

Here's what I'd like the end of the month to look like. The medications happen without you thinking about them. The notebook has four weeks of weights in it. You know what her normal is well enough to notice when it changes. And the whole thing has become fairly boring.

Boring is the goal. Boring is what a well-managed chronic illness looks like from the inside.

Somewhere around day eight or ten, most people hit a low patch, once the urgency of the diagnosis has worn off and the routine hasn't set in yet. If you're in that stretch right now, it isn't a sign this won't work. It's the normal shape of the first month, and it lifts.