Vol. 22, No.
10 October 2000
CE Refereed Peer Review
FOCAL POINT
★ Cats with hepatic lipidosis (HL)
require aggressive nutritional
support; careful monitoring is
needed because life-threatening
complications may arise within
72 hours of initiation of
nutritional therapy.
KEY FACTS
■ In contrast to the usual dietary
recommendations for small
animals with liver disease, most
cats with HL should be fed high-
protein diets.
■ Virtually all cats with HL require
enteral nutritional support via a
feeding tube.
■ Icteric cats with severe HL
must be considered to be in
critical condition at the time
of presentation.
■ Life-threatening hypokalemia
and hypophosphatemia may
occur after initiating nutritional
therapy in cats with HL.
■ Hypokalemia and
hypophosphatemia may
worsen despite adequate
supplementation.
Feline Hepatic
Lipidosis: Treatment
Recommendations*
Auburn University
Brenda Griffin, DVM, MS
ABSTRACT: Aggressive nutritional support is the mainstay of treatment for feline hepatic lipi-
dosis. The ideal diet would fulfill all basic protein and nutrient requirements, provide a positive
energy balance, promote liver regeneration, and facilitate recovery from the metabolic de-
rangements and clinical signs associated with the syndrome. For most cats, a high-protein
diet is indicated. Patients should be monitored closely during the initial 72 hours of nutritional
therapy, the period during which most serious complications occur.
F
eline hepatic lipidosis (HL), a syndrome in which hepatocellular lipid ac-
cumulation leads to intrahepatic cholestasis and liver dysfunction, is a
common hepatobiliary disease in domesticated cats. All cats with HL need
thorough systematic evaluation to rule out primary diseases that may be under-
lying their condition.
Therapy for HL is aimed at reversing fat and protein catabolism, managing
electrolyte abnormalities, and treating the clinical signs of hepatic disease as well
as any underlying or concurrent conditions. Aggressive nutritional support is the
cornerstone of treatment and is the only known effective therapy for cats with
HL. The mortality rate associated with HL ranges from 10% to 40% in cats
treated with aggressive nutritional therapy and is as high as 90% in cats not
treated aggressively.1–3 Recurrence is rare.4
DIET
The ideal diet for treatment of HL is unknown. The best clinical results are
obtained with high-protein diets containing adequate calories and nutrients to
meet known requirements.5 The need for increased dietary protein in patients
with HL is in contrast to dietary recommendations in many other liver diseases
in which increased protein may precipitate hepatoencephalopathy. In one study
in which HL was induced by feeding 25% of maintenance energy requirements,
cats fed calories as protein developed less lipid accumulation than did cats fed
carbohydrate or fat,6 suggesting that protein improves mobilization of fat from
hepatocytes.
*A companion article entitled “Feline Hepatic Lipidosis: Pathophysiology, Clinical Signs,
and Diagnosis” appeared in the September 2000 (Vol. 22, No. 9) issue of Compendium.
Compendium October 2000 Small Animal/Exotics

TABLE I
Commercially Available Diets Used in the Treatment of Feline Hepatic Lipidosis
For Cats without Clinical Signs For Cats with
Manufacturer of Hepatoencephalopathy Hepatoencephalopathy
Abbott Laboratories Clinicare®—Feline Liquid Dieta Clinicare® RF—Specialized Feline
(Abbott Park, IL) Liquid Dieta
Hill’s Pet Nutrition Prescription Diet® Feline p/d®b,c; Prescription Diet® Feline l/d™b,e
(Topeka, KS) Prescription Diet® Canine/Feline a/d™b,d
The IAMS Company Maximum-Calorie™/Felinea,f None
(Dayton, OH)
Ralston Purina Company CNM CV-Formula®b,c CNM NF-Formula®b,c
(St. Louis, MO)
Waltham (Vernon, CA) Waltham® Veterinary Diet Waltham® Veterinary Diet
Feline Selected Proteinb,c,g Feline Low Proteinb,c
a
Recommended for use with nasoesophageal and jejunostomy tubes.
bRecommended for use with esophagostomy and gastrostomy tubes.
cMust be blenderized with water to make a gruel.
d May be fed undiluted using an 18-Fr or larger tube.
eMay be fed undiluted using a 20-Fr or larger tube.
f May be fed undiluted using an 8-Fr or larger tube.
g Contains novel protein and carbohydrate sources (venison and rice) and may be useful in cats with concurrent inflammatory bowel

disease.

When selecting a diet, one should consider that cats
are true carnivores.7 Their physiology and metabolism
require diets high in protein and fat and low in carbo-
hydrate. Cats do not have the ability to synthesize such
essential nutrients as taurine, arginine, vitamin A, nia-
cin, and arachidonic acid that would be present in prey.
Commercially prepared feline diets should be used to
avoid nutritionally incomplete rations (Table I). Diets
formulated for humans or other species require the ad-
dition of such supplements as the essential amino acid
arginine, which is required for ammonia detoxification
in cats.
Cats have much higher protein requirements than do
humans and dogs. Protein should provide at least 20%
of a diet’s calories.7 Because protein is required to sup-
port a positive nitrogen balance and liver regeneration
and because protein supplementation is known to re-
duce hepatic lipid accumulation during rapid weight
loss in obese cats, cats with HL should receive the high-
est level of protein they can tolerate as soon as possi-
ble.6,7 Feline renal diets provide approximately 22% of
calories as protein.7 Most cats with liver disease can tol-
erate higher dietary protein levels (up to 35% to 45%,
which is typical of most commercial cat foods).7
Cats with overt signs of hepatoencephalopathy (se-
vere depression and ptyalism), however, should be fed a
reduced-protein diet, such as one designed to manage
renal failure. Before feeding, diagnosis should be con-
firmed with a fasting ammonia concentration. Admin-
istration of oral lactulose (0.67-mg/ml solution, 0.5 to
1 ml/4.5 kg, three times daily) is often helpful because
it lowers colonic pH, trapping ammonia as ammonium
and thereby decreasing its absorption into portal circu-
lation. In addition, oral metronidazole (7.5 to 15
mg/kg twice daily), oral neomycin (20 mg/kg three to
four times daily), or oral amoxicillin (22 mg/kg two to
three times daily) may be used to reduce intestinal bac-
terial flora, thereby decreasing ammonia synthesis in
the intestinal tract.
ENTERAL SUPPORT
Virtually all cats with HL require enteral support via
a feeding tube. Nasogastric, esophagostomy, gastrosto-
my, or jejunostomy tubes may be used (Figure 1). Icter-
ic cats with severe HL must be considered to be in criti-
cal condition at the time of presentation. Because most
cats that die of HL do so within the first few days of
therapy, treatment—including nutritional support—
needs to be initially provided in noninvasive and non-
stressful ways. Treatment for severe HL should be di-
vided into an initial stabilization phase followed by a
long-term phase.2 Investigators using this approach re-
port lower mortality rates and recovery rates of 90%.1,2
During the initial stabilization phase (usually the first
few days of therapy), dehydration and electrolyte imbal-
ances should be corrected and monitored. Cats often look

SELECTING A DIET ■ PROTEIN REQUIREMENTS ■ INITIAL STABILIZATION

Small Animal/Exotics Compendium October 2000

worse clinically (weaker, more may occur secondary to inflam-

depressed) during the first few matory bowel disease or gas-
days of treatment than when trointestinal lymphosarcoma,
initially presented. Daily serum conditions that cannot be
biochemistries and hematocrits definitively excluded based on
are strongly recommended. Di- clinical signs, laboratory find-
agnosis should be based on his- ings, and diagnostic imaging
tory, physical examination, clini- alone. Esophagostomy tubes
cal pathology, radiography, have become increasingly pop-
abdominal ultrasonography, and ular because their placement re-
cytology of fine-needle aspirates quires minimal technical skill
of the liver. Invasive procedures, Figure 1—Common feeding tubes and sizes used in and no specialized equipment
such as exploratory laparotomy cats (left to right): 5-Fr infant feeding tube, 14-Fr red and may be performed in less
and liver biopsy, should not be rubber feeding tube (catheter), 22-Fr gastrostomy than 10 minutes.9,10
tube, and 8-Fr adult/pediatric feeding tube. The 5-
performed. The least invasive and 8-Fr sizes may be used for both nasoesophageal Esophagostomy and gastros-
method of nutritional support and jejunostomy tubes, depending on the size of the tomy tubes allow large boluses
should be initiated (usually via a cat. For most cats, 14- and 22-Fr tubes are ideal for of blenderized cat food to be
nasoesophageal tube; Figure 2). esophagostomy and gastrostomy, respectively. given because they are large
Jugular catheters are useful for bore and the stomach provides a
administration of intravenous storage compartment for the
(IV) therapy and collection of food. Slow infusion through a
serial blood samples, but their jejunostomy tube (low-fat,
insertion should be avoided high-protein diet) is a rational
when clinically evident bleeding therapy for cats with concurrent
tendencies are present. Use of acute pancreatitis; concurrent
peripheral catheters is recom- surgical placement of a gastros-
mended in cats with overt bleed- tomy tube is recommended be-
ing tendencies. All cats with HL cause it facilitates feeding after
should be evaluated for coagu- pancreatitis resolves. Alterna-
lopathies. In addition, subcuta- tively, partial or total parenteral
neous administration of vitamin nutrition can be administered
K1 (0.5 to 1.5 mg/kg at 0, 12, IV until pancreatitis resolves, af-
and 24 hours) is advised. For Figure 2—Cat with a nasoesophageal tube in place. ter which time a gastrostomy
recommendations on fluid ther- Elizabethan collars are often necessary to prevent re- tube can be placed.
apy, including selection, calcula- moval, especially after clinical improvement begins.
tion, and administration, see FEEDING GUIDELINES
Fluid Therapy for Anorectic Cats with HL should be fed
Cats.8 60 to 80 kcal/kg/day (i.e., approximately 250 to 300
After a patient is stable and able to safely tolerate the kcal/day for an average 4- to 5-kg cat).1,2,7 Because of
necessary sedation/anesthesia and manipulation, a more ongoing gastric stasis and long-term anorexia, a slow
substantial feeding tube can be placed for long-term increase in feeding over a few days is recommended to
therapy. Liver biopsies can also be performed for defini- minimize vomiting (see Suggested Feeding Schedule).
tive diagnosis. Because mortality rates are higher in cats Tube feeding can be performed by owners after cats
undergoing laparotomy, the least invasive means avail- are sent home. Owners should be instructed to warm
able for tube placement and biopsy should be used. the gruel, administer it slowly over a few minutes, and
For the long-term phase of therapy, many authors flush the tube with water after each feeding. Depending
prefer gastrostomy tubes (Figure 3), which can be placed on the consistency of the blenderized diet, the gruel
using percutaneous endoscopy, JorVet™ Eld gastrosto- may need to be strained to facilitate passage through
my tube applicators (Jorgensen Laboratories, Loveland, the tube. The tube may also be used for administration
CO), Cook ® gastrostomy tube introduction sets (Cook of medications provided tablets are well crushed and
Veterinary Products, Bloomington, IN), or surgery.1,3,5,7 dissolved. In the event a tube becomes clogged with
I recommend endoscopic biopsy of the gastrointestinal food particles, a 3.5-Fr red rubber catheter may be used
tract at the time of gastrostomy tube placement: HL to dislodge material from the tube lumen. If this is un-

LAPAROTOMY ■ LONG-TERM THERAPY ■ BIOPSY ■ PANCREATITIS

Compendium October 2000
Fluid Therapy for Anorectic Cats8
Fluid Type
■ Select isotonic balanced electrolyte fluids (e.g.,
lactated Ringer’s solution) for initial support.
■ Consider serum potassium and sodium
concentrations:
—Begin potassium supplementation with 20 mEq
potassium chloride/L. Adjust based on serum
potassium concentrations (see Table II).
—Avoid dextrose-containing solutions when possible
because they lower both serum potassium and
phosphorus concentrations through the action
of insulin.
—In cats with hypernatremia (hypertonic
dehydration), 0.45% saline is preferred.
—In cats with hyponatremia (hypotonic dehydration),
0.9% saline is preferred.
■ Add B-complex vitamins (2 ml/L).
■ Monitor packed cell volume, total solids, electrolytes,
and phosphorus daily. (Postalimentation
hypokalemia, hypophosphatemia, and anemia
are common and may be life threatening.)
■ Note: Hypoproteinemic cats may require colloids.
Fluid Needs
Fluid requirements = Maintenance needs + Replacement
needs + Ongoing losses
Maintenance needs = 66 ml/kg/d (30 ml/lb/d)
Replacement needs (L of fluid) = % Dehydration × Body
weight (kg)
Ongoing losses = An estimate of fluid lost through
vomiting, diarrhea, polyuria, etc.
Example: 8-lb cat with 6% dehydration that is vomiting
once daily
8 lb = 3.6 kg
successful, 2 to 4 ml of a carbonated beverage (e.g.,
cola) may be flushed into the tube, followed in 5 to 10
minutes by 10 ml of warm water.9
Food aversion may be a complicating factor in cats
with HL.7 Cats that refuse to eat a diet they associate
with nausea may continue to avoid the diet even after
full recovery. Exposing cats with HL to different com-
mercial diets during tube feeding may predispose them
to aversion of those diets. No food should be offered
orally for the first 10 days of nutritional support.7 After
FOOD AVERSION ■ SERUM BIOCHEMICAL PROFILES
Small Animal/Exotics
Maintenance needs = 66 ml × 3.6 kg = 240 ml/d
Replacement needs = 0.06 × 3.6 kg = 0.21 L (210 ml)
Ongoing losses (estimated amount of vomitus) = 15 ml
Total to be infused over initial 24 hours = 240 + 210 +
15 = 465 ml (20 ml/hr)
After rehydration and cessation of vomiting, this cat
can be maintained with 240 ml/d (10 ml/hr).
Note: Severely dehydrated cats may need front-loading
of replacement fluids over 4 to 6 hours.
Route of Administration
■ Intravenous fluids (an infusion pump is ideal; if
unavailable, small bags of fluids, microdrip sets,
and/or an in-line burette set is advised to prevent
overdosing of fluids)
—Unless bleeding tendencies are evident, jugular
catheters (i.e., catheters specifically designed for
use in the jugular vein) are preferred because they
are less likely to kink and may be used for serial
blood collection and measurement of central
venous pressure.
—Peripheral catheters (cephalic or lateral saphenous
vein) are usually adequate, but leg bending may
result in catheter kinking and/or slow fluid
infusion.
■ Subcutaneous fluids
—If 24-hr monitoring is unavailable, flush
intravenous catheters with 2–3 ml of heparinized
saline, cap securely, and cover overnight with a
loose wrap.
—Provided severe dehydration has been corrected,
give a bolus of subcutaneous fluids until the
intravenous infusion can be restarted the next day.
this time, cats expressing an interest in eating can be of-
fered small amounts of a novel food.
During the long-term phase of therapy, serum bio-
chemical profiles should be monitored every 1 to 2
weeks depending on the patient’s stage of recovery. Res-
olution of icterus and hepatic function begins once the
cat is receiving adequate energy and protein intake, but
most cats require 3 to 6 weeks of diet therapy before
clinicopathologic values normalize and the appetite re-
turns.7 When biochemical parameters normalize, most
Small Animal/Exotics Compendium October 2000

cats begin eating on their own stasis, many cats may not have
and tube feedings can gradually had a bowel movement for days
be reduced. Tube removal is per- to weeks before presentation.
formed only after a cat is consis- Removal of hard fecal material
tently eating its full caloric re- from the colon with a small
quirement for 1 week. glycerin enema or suppository
may promote normal gastroin-
ADDITIONAL THERAPEUTIC testinal motility.
RECOMMENDATIONS Cats with non–vitamin K re-
Several vitamin and dietary sup- sponsive coagulopathies may re-
plements, including carnitine, quire transfusions of plasma or
arginine, taurine, and antioxi- fresh whole blood. Appetite stim-
dants, have been advocated in the Figure 3A ulants (e.g., oxazepam, cyprohep-
treatment of feline HL (see Cur- tadine) are seldom useful and are
rent Recommendations for Di- not recommended until the re-
etary Supplements). Controlled covery phase of the disease, if at
studies of these supplements are all.1,3,5 Antibiotic therapy is indi-
needed for specific recommen- cated when secondary infection is
dations.1 present. Because of their catabolic
Cats presenting with signs con- effects, corticosteroids are con-
sistent with thiamine deficiency traindicated unless indicated to
(e.g., ventroflexion of the head treat an underlying disease.
and neck; Figure 4) should re- Ursodeoxycholic acid (Acti-
ceive two or three doses of sup- gall®, Novartis, East Hanover, NJ)
plemental thiamine (50 to 100 is used in humans with various liv-
mg intramuscularly, twice daily).1 er diseases and may be beneficial
Lipotropic compounds that may Figure 3B in cats with HL. 12 Ursodeoxy-
potentiate hepatoencephalopathy Figure 3—Cat with a gastrostomy tube in place. cholic acid promotes bile flow
(e.g., choline, methionine) are The tube may be covered with a bandage or prefer- through modulation of bile acids
contraindicated and should not ably with a T-shirt. Elizabethan collars are rarely and may increase hepatic peroxi-
be used.11 necessary. Shirts (which may be fashioned from cast somes and mitochondria. The rec-
Other therapies include the stockinet or human infant clothing) offer the ad- ommended dose is 50 mg/cat/day
use of antiemetics and promotil- vantages of comfort and easy tube access and may orally; however, controlled studies
ity drugs. Although vomiting be changed and washed by owners at home. are needed to evaluate the efficacy
may occur for many reasons of this drug in cats with HL.
(e.g., electrolyte imbalances, liv-
er dysfunction, secondary to underlying diseases), gas- COMPLICATIONS
tric stasis caused by prolonged anorexia is common in Complications frequently occur during nutritional
cats with HL. The absence of normal gut sounds (bor- therapy of feline HL, usually during the initial 72 hours,
borygmi) on abdominal auscultation is consistent with and include tube-associated problems, hypokalemia, hy-
gastric stasis. Gastric stasis can be treated with pro- pophosphatemia, and induction of hepatoencephalopa-
motility drugs and by allowing ample time for the thy. Because complications may be life threatening,
stomach to empty between feedings. Metoclopramide careful in-hospital monitoring of patients is essential
(0.2 to 0.4 mg/kg) can be administered through the during the initial stabilization phase of therapy.
feeding tube every 6 to 8 hours or subcutaneously 30 to
60 minutes before feedings or intravenously (1 to 2 Tube-Associated Problems
mg/kg/day, constant-rate infusion); oral cisapride (0.1 Tube-associated complications include local irritation
to 0.5 mg/kg every 8 to 12 hours, or 1⁄4 of a 10-mg and infection, improper placement, and premature re-
tablet for an average-sized cat) can also be used. Four moval. Nasoesophageal tubes often cause sneezing and
daily feedings are adequate, tend to reduce the inci- nasal discomfort. Vomiting of the tube, aspiration
dence of vomiting, and are practical for owner compli- pneumonia, and esophageal reflux are potential risks
ance. A volume of 10 ml/lb/feeding should not be ex- with nasoesophageal and esophagostomy tubes. 10
ceeded. Because of prolonged anorexia and gastric Esophagostomy, gastrostomy, and jejunostomy tubes

THIAMINE DEFICIENCY ■ GASTRIC STASIS ■ URSODEOXYCHOLIC ACID

Small Animal/Exotics
Suggested Feeding Schedule
Daily caloric requirements = 60–80 kcal/kg
Daily fluid requirements = 66 ml/kg
Day 1: Feed 25% of daily caloric requirement divided
into four feedings.
Day 2: Feed 50% of daily caloric requirement divided
into four feedings.
Day 3: Feed 75% of daily caloric requirement divided
into four feedings.
Day 4: Feed 100% of daily caloric requirement divided
into four feedings, but do not exceed 22
ml/kg/feeding (10 ml/lb/feeding).
Note: During hospitalization, fluid requirements
are supplemented parenterally. At home, adequate
amounts of water should be given through the tube to
ensure that requirements are met (most gruels are at
least 80% water, but additional water is sometimes
needed).
Example Feeding Schedule for an 8-lb Cat
8 lb = 3.6 kg
Energy requirements = 3.6 kg × 70 kcal/kg/d = 255
kcal/d
Hill’s Prescription Diet® Feline p/d (Hill’s Pet Nutrition,
Topeka, KS) contains 600 kcal/15-oz can; make a gruel
a
This volume does not exceed 22 ml/kg/feeding (10 ml/lb/feeding).
tend to be well tolerated by patients; cats rarely require
Elizabethan collars with these tubes. Minor stomal in-
fections are common with both esophagostomy and gas-
trostomy tubes.10 Owners should be instructed to check
and clean the tube stoma daily to prevent infection.
Improper placement of a gastrostomy tube may result
in obstruction of the pylorus and vomiting associated
with feeding. Tube placement should be checked in per-
sistently vomiting cats by administering a radiopaque,
iodinated contrast solution through the tube. Although
rare, premature tube extraction (less than 5 days) or
tube migration may result in peritonitis (gastrostomy
tube) or local infection (esophagostomy tube). Tube-as-
sociated complications are very rare when jejunostomy
tubes are placed using newly described techniques.13
Hepatoencephalopathy
Induction of hepatoencephalopathy is evidenced by
STOMAL INFECTIONS ■ PERITONITIS ■ PTYALISM
Compendium October 2000
by blenderizing one 15-oz can of the food with 7.5 oz
(1⁄2 can) of water. This gruel can readily be passed
through a 22-Fr gastrostomy tube. Remember to
warm the gruel, and flush the tube with approximately
10 ml water after each feeding.
Blenderized gruel = 600 kcal/22.5 oz; 22.5 oz × 30 ml/oz
= 675 ml; 600 kcal/675 ml = 0.9 kcal/ml
Total volume of gruel required to meet this cat’s daily
energy requirements = 255 kcal × 1 ml/0.9 kcal = 283
ml/d
Day 1: 283 ml × 0.25 = 70 ml, or four daily feedings of
17 ml each
Day 2: 283 ml × 0.50 = 140 ml, or four daily feedings of
35 ml each
Day 3: 283 ml × 0.75 = 212 ml, or four daily feedings of
53 ml each
Day 4: 283 ml × 1.00 = 283 ml, or four daily feedings of
70 ml eacha
Daily maintenance fluid requirements = 240 ml/d
provided the cat is not dehydrated and has no ongoing
fluid losses (see Fluid Therapy for Anorectic Cats).
Water consumed through the diet = 283 ml gruel × 0.8 =
226 ml/day. In this case, the gruel plus the water used
to flush the tube after feedings will provide daily fluid
requirements.
clinical signs (e.g., severe depression, ptyalism) that de-
velop after the initial feeding. This complication is un-
common cats with HL14; if it occurs, it may be treated
with low-protein diets and lactulose as discussed. Fast-
ing at this time to obtain an ammonia concentration to
document hepatoencephalopathy is not recommended.
Smaller, more frequent feedings may be helpful. Cats
should be monitored for exacerbation of hepatoen-
cephalopathy-associated clinical signs after feedings. In
most cases, clinical signs resolve within a few days, after
which time most cats can be gradually switched to a
higher-protein diet.
Electrolyte Imbalances
Hypokalemia and hypophosphatemia are life-threaten-
ing electrolyte imbalances that may be sequelae to ali-
mentation.15 The presumed mechanisms of hypokalemia
and hypophosphatemia in cats with HL are similar. At
Small Animal/Exotics Compendium October 2000

presentation, hypokalemia is
Current Recommendations
the most common elec-
trolyte abnormality in cats for Dietary Supplements
with HL ; clinical signs of ■ Oral L-carnitine (DL-carnitine may be toxic):
14

hypokalemia include lethar- 250–500 mg/cat/d, all at once or divided in

gy, muscle weakness, ventral
half, given in food
neck flexion (Figure 4), my-
ocardial depression, ileus, ■ Subcutaneous vitamin K1: 0.5–1.5 mg/kg at
and urine retention and may 0, 12, and 24 hr (excessive use may induce
progress to paralysis of the hemolysis)
respiratory muscles and ■ B-complex vitamins in intravenous fluids: 2
death.15 Even if appropriate
supplementation is imple- ml/L
mented, hypokalemia may ■ Oral vitamin Ea: 100 IU/kg/d given in food
worsen in the face of enteral ■ Oral vitamin Ca: 30 mg/kg/d given in food
feeding because insulin re- ■ Oral taurineb: 250–500 mg/cat/d, all at once
lease promotes intracellular Figure 4—Ventroflexion of the head and
or divided in half, given in food
uptake of potassium, thereby neck may occur because of severe potas-
lowering serum potassium a Vitamins E and C are antioxidants and may be useful sium depletion or thiamine deficiency.
concentrations (Table II). If because oxidative stress, which is common in cats, Treatment should include potassium
aggressive potassium-replace- may accompany the metabolic derangements and supplementation based on serial evalua-
protein deficiency associated with HL. Formation of tions of electrolyte concentrations and
ment therapy fails to nor- free radicals may damage hepatic peroxisomes.1,5
malize serum potassium con- bOptional. intramuscular thiamine injections (note
centrations within 48 hours, the use of a jugular catheter).
serum magnesium concen-
trations should be measured.15 Concurrent hypomagne- promoting intracellular uptake of phosphate and glucose
semia may cause refractory hypokalemia, which cannot for glycolysis.16,17 This transcellular shift of phosphate in
be corrected until the magnesium deficit is corrected. the face of phosphate depletion causes hypophos-
Clinical signs of hypophosphatemia include muscle phatemia. Renal phosphate loss secondary to IV fluid
weakness; clinical sequelae include hemolytic anemia, therapy may also be a contributing factor. In addition,
leukocyte dysfunction, decreased tissue oxygenation IV glucose infusions may contribute through the action
caused by decreased 2,3-diphosphoglycerate (2,3-DPG) of insulin. The role of hepatic dysfunction itself in the
concentrations, acute respiratory failure, and death.15,16 development of hypophosphatemia deserves further in-
The mechanism of hypophosphatemia in cats with HL vestigation; studies of cats with severe hypophosphatemia
may be secondary to low phosphorus intake, impaired in- have primarily involved cats with hepatobiliary disease
testinal phosphate absorption, high renal phosphate loss, (89% in one study of nine cats).16
and transcellular shift of phosphate from the extracellular The onset of hypophosphatemia is reported to occur
to the intracellular space.16,17 Nor-
mal serum phosphorus concentra- TABLE II
tions are often maintained in the Guidelines for Routine Intravenous Potassium Supplementation in Cats
face of severe phosphorus deple-
Serum
tion. Chronic malnutrition fol- Potassium Amount of Potassium Chloride to Add (mEq) Maximum Fluid
lowed by alimentation can result Concentration To 250 To 1 L of Infusion Rate
in refeeding syndrome, a term (mEq/L) ml of Fluid Fluid (ml/kg/hr) a
coined in human medicine to de-
scribe the metabolic derange- <2.0 20 80 6
ments associated with caloric re- 2.1–2.5 15 60 8
pletion of a starved patient. 15 2.6–3.0 10 40 12
3.1–3.5 7.5 30 17
Hypophosphatemia is the most 3.6–5.0 5 20 25
serious complication associated
aCalculated to ensure that a rate of 0.5 mEq/kg/hr is not exceeded.
with refeeding.
Administration of enteral nu- Adapted from Macintire DK: Disorders of potassium, phosphorus, and magnesium in criti-
cal illness. Compend Contin Educ Pract Vet 19(1):42, 1997.
trition stimulates insulin release,

HYPOKALEMIA ■ HYPOMAGNESEMIA ■ HYPOPHOSPHATEMIA ■ REFEEDING SYNDROME

Small Animal/Exotics
12 to 72 hours after initiation of enteral alimentation.16
If severe (serum phosphorus concentration below 2.2
mg/dl), hypophosphatemia can result in massive, acute
hemolysis. Because cats may be more sensitive to hy-
pophosphatemia-induced hemolysis than are other
species and because hemolytic anemia and hypophos-
phatemia have been reported in cats with HL, careful
postalimentation monitoring of hematocrit and serum
phosphorus concentrations is indicated.17 (Experimen-
tally, serum phosphorus concentrations must be reduced
to less than 0.5 mg/dl to induce hemolysis in dogs.16)
Adenosine triphosphate (ATP) depletion is the pro-
posed mechanism by which hypophosphatemia causes
hemolysis.16,17 ATP is necessary to maintain erythrocyte
membrane integrity, shape, and deformability. ATP de-
pletion causes malfunction of the sodium–potassium
pump, resulting in decreased cell deformability and os-
motic lysis. The spleen and liver may contribute by re-
moving rigid erythrocytes.
Cats with severe hypophosphatemia (below 2.2 mg/dl)
should receive IV potassium phosphate or sodium phos-
phate at 0.01 to 0.06 mmol/kg/hour. The higher dose is
often needed in severely affected cats.16 Parenteral potas-
sium phosphate supplements contain 3 mmol of phos-
phate and 4.4 mEq/ml of potassium, whereas sodium
phosphate solutions provide 3 mmol of phosphate and 4
mEq/ml of sodium. These phosphate supplements should
be administered in calcium-free solutions (e.g., 0.9%
saline) to prevent precipitation of insoluble calcium
phosphate. The amount of supplemental potassium in
the form of potassium chloride should be adjusted ac-
cordingly. Parenteral phosphorus should be used with
caution in patients with renal failure and is contraindi-
cated in patients with oliguria or hypercalcemia.
The use of dextrose-containing fluids should be
avoided in hypophosphatemic patients because such flu-
ids may worsen hypokalemia and hypophosphatemia
through the action of insulin. Phosphate binders (e.g.,
aluminum hydroxide, sucralfate) should also be avoided.
Cats receiving IV phosphorus supplementation
should be closely monitored for hemolysis, and serum
phosphate and serum calcium levels should be moni-
tored every 6 to 12 hours. In one study, four of five cats
treated with IV phosphate developed hypocalcemia (5.4
to 8.7 mg/dl)17; only one cat, however, exhibited clinical
signs of hypocalcemia (tetany, weakness). When serum
phosphorus levels rise above 2.3 mg/dl, cats can be
treated with oral phosphate supplementation, or IV dos-
es may be reduced by 50% to 75%. If serum phospho-
rus concentrations remain normal over the following 24
hours, doses should be further tapered or discontinued.
Cats with mild to moderate hypophosphatemia (2.3 to
3.3 mg/dl) may receive oral phosphate supplementation
HEMOLYSIS ■ ATP DEPLETION ■ PHOSPHATE SUPPLEMENTS ■ HYPOCALCEMIA
Compendium October 2000
unless vomiting is present.17 Serum phosphate levels
should be monitored every 12 hours until cats stabilize.
Oral supplementation may be accomplished by feeding
skim milk or commercial oral phosphate supplements.
Cow’s milk contains 0.029 mmol/ml of phosphate.15
The oral phosphorus dose is 0.5 to 2.0 mmol/kg/day. An
average 4-kg cat requires just over 2 oz of milk/day for
adequate supplementation. Although many cats can tol-
erate this quantity of milk, using lactose-free milk (Lac-
taid®, distributed by H. P. Hood, Chelsea, MA) and di-
viding the milk dose over the day are recommended to
prevent diarrhea caused by lactose intolerance.
CONCLUSION
Cats with HL require aggressive nutritional support
for recovery. In most cases, high-protein diets are indicat-
ed. Underlying diseases, if present, must be diagnosed
and treated concurrently. Icteric cats with HL must be
considered to be in critical condition. Their treatment
should be divided into an initial stabilization phase fol-
lowed by a long-term phase.2 Investigators using this
treatment approach report recovery rates of 90%.1,2 Re-
currence of HL is rare.4 Patients should be monitored
closely during the initial 72 hours after alimentation be-
cause most serious complications, including life-threat-
ening hypokalemia and hypophosphatemia, occur dur-
ing this period. Without aggressive nutritional support
and monitoring, most cats with HL die.1–3
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