Veterinary Vertex

Outpatient Treatment for Lily Toxicity in Cats

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Can lilies really be fatal for your feline friend? Discover the critical insights shared by our esteemed guests, Drs. Erica Reineke and Justin Lam, as they shed light on the alarming issue of lily toxicity in cats. We discuss the complexities of lily-induced acute kidney injury and examine the differences between inpatient and outpatient treatments. Our discussion reveals unexpected findings that could pave the way for a feasible outpatient treatment option, offering hope for cat owners who can't afford hospitalization.

As we look to the future of veterinary research on this pressing issue, Justin provides a glimpse into the ongoing quest to pinpoint the toxic components of lilies. The conversation navigates the ethical waters of conducting randomized control trials in veterinary settings and imagines a future where AI transforms data collection processes. Erica stresses the importance of preventing lily exposure and offers essential guidance for pet owners should an incident occur. This episode is an enlightening resource for both veterinarians and cat owners, packed with practical advice and a visionary perspective on the future of addressing lily toxicity in cats.

JAVMA article: https://doi.org/10.2460/javma.24.05.0355

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Sarah Wright:

You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode, we chat about the prevalence of acute kidney injury in outcomings in cats treated as inpatients versus outpatients following Lily exposure, with our guests and Justin Lam. Erica and Justin, thank you so much for being here today.

Justin Lam:

Yeah, thanks for having us.

Erica Reineke:

Yeah, excited to be back.

Sarah Wright:

So, Justin, your JAVMA article discusses the prevalence of acute kidney injury and outcome in cats treated as inpatients versus outpatients following ly exposure. Please share with our listeners the background on this article.

Justin Lam:

Yeah, so we've understood for, like you know, a few decades now, that lilies are toxic to cats and particularly can cause kidney injury and then cause reduction in kidney function, and then sometimes it can lead to more catastrophic things like kidney failure and even death.

Justin Lam:

And a lot of like what we know now regarding lily toxicosis came from a lot of early experimental studies where essentially, they they noted that this toxic component of of lilies, which we still don't quite know what it is exactly yet, appears to be in all parts of the plants.

Justin Lam:

But what we do know is that it is water-soluble, and so, based on that, currently our recommendations for cats that are exposed to lilies is to treat them in hospital with IV fluids, with or without anything such as giving activated charcoal or even inducing vomiting if we caught them in an early enough period of time and they eaten a large chunk of the flower and in the hopes of the fluids is to help support blood flow to the kidneys and then theoretically try to enhance this elimination of this toxin and by decreasing, and therefore decreasing, kidney injury. And a lot of this recommendation comes from a study that was kind of done here, actually, that Erica was a part of, and it's her paper, and I'll kind of let her talk more about that.

Erica Reineke:

Yeah, I was just going to mention we actually previously investigated outcome in a small study of 25 cats that were hospitalized following exposure to lilies back in 2013. And that paper was actually also published in JAVMA. But this was a much smaller study and in this study we documented a really excellent survival rate and an overall low incidence of kidney injury with, I believe it was only two cats that were discharged from the hospital with elevations in their kidney values and in that small study, no cats required renal replacement therapy or died. Thankfully. However, not every owner decides to hospitalize their cat following exposure. So, we decided as a team well, I think it was Justin's idea like he came to me and said should we look at the group of cats that don't hospitalize their cat following exposure and evaluate whether the incidence of kidney injury is higher in this group of cats compared to? You know what we would consider standard of care being treated in a hospital setting with IV fluids.

Sarah Wright:

That's what I like so much about your study was that it did look at that component. I think that's so important and so applicable, especially for people who are boots on the ground, maybe in some underserved communities too, where clients just can't afford that hospitalization that typically is gold standard. So definitely appreciate you sharing this with JAVMA and just bringing this to the attention of our readers too. So, Justin, what is an important take-home message from this article?

Justin Lam:

So kind of what Erica and you had alluded to. I think our study suggests that an outpatient treatment option is maybe potentially a viable option for those that you know can't pursue hospitalization with IV fluids and that, you know, we didn't really find a difference in the incidence of kidney injury between the two groups. I think, like, ultimately, in the end, you know, interpret with caution because you know we do need larger studies to really draw a stronger conclusion but thought that that was, you know, one of the most interesting findings from our study.

Sarah Wright:

So now, on a more personal note, Justin what sparked your research interest in lily toxicity?

Justin Lam:

Yeah, so just you know, as a vet working predominantly in the ER during like internship and now residency, I've encountered, you know, I think, on many occasions where the hospitalization was, you know, not a feasible management option for every family and so we'd have to think of and brainstorm other, you know other alternative treatment options to treat these cats.

Justin Lam:

And you know we've seen a handful of times. A lot of these cats come back daily for recheck kidney values and we actually have noticed a pattern that a lot of these cats can do quite well and actually never have incidents of kidney injury and they're not in hospital or they're able to be at home. And so we wanted to explore this as a potential treatment alternative. Try to document, okay, like, is there truly a difference in these treatments and what is you know, are we seeing a higher incidence of kidney injury and such, which you know is important for those that may not have access to, you know, 24-hour facilities or their pet is super scared and becomes fractious in hospital or may not have the means to pursue that? And so we thought that, I thought that this was really important to know and potentially try to document.

Sarah Wright:

We talked about some of the most important findings, but what was the most surprising finding from this article?

Justin Lam:

Yeah, I think the most surprising article is that we did have a large incidence of kidney injury in both groups, and they weren't statistically different in both the inpatient outpatient groups, which is a lot more than what was previously documented, but we kind of talked about this in our paper. How, um you know, we we did use a more strict grading criteria for acute kidney injury, so the iris staging um, AKI, or acute kidney injury, um grading scale, um, but the the most surprising thing also on top of that, was that not a lot of these cats were documented to have severe AKI so that's the average stage, like four and five kidney injuries where they have a creatinine level of greater than five and that a lot of majority of our cats had very low grade kidney injuries and only one had a grade 3. So, I thought that that was a little different than what we're used to hearing, at least in the literature.

Erica Reineke:

Yeah, I have a comment about that because I agree that I was surprised that the rate of kidney injury was higher than we expected. And I agree with Justin, I suspect it's because the criteria for staging is just very, very strict that if there's even just a 0.3 change in creatinine they will be categorized as having kidney injury, when some of injury, when you know some of that could be just natural variation in the creatinine, just because we know it varies from day to day in cats. So it is. I wonder if some of it you know, some of it, maybe we over-documented kidney injury in that group one cat, but cats. But really what I found was really interesting is we did have one outpatient cat that was documented to have an elevation in the blood creatinine at 24 hours and this cat ultimately transitioned to becoming an inpatient and was put on IV fluids at that point and then that cat's kidney injury completely resolved and went home with normal renal values. So I think I was.

Erica Reineke:

That made me happy too, for I mean it was only one cat that we saw that in. But you know, if an owner chose an outpatient treatment, if there is a change it doesn't preclude them transitioning to an inpatient protocol and potentially having an excellent outcome as well. We also didn't have any, like Justin said, any severe kidney injury, so a grade four or five, or cats requiring renal replacement therapy or dying. So I think that I agree with him, I think that was really interesting and I think that that suggests that probably those severe kidney injury cats are probably quite low in the cats. The percentage of them, I should say the percentage of cats that have such a severe kidney injury requiring dialysis treatment, let's say, is probably pretty low, which is good. I think we don't really know the true incidence, but it's probably not high.

Sarah Wright:

That actually leads great into my next question about what the next steps are for future research in this topic. So, Justin, what are your thoughts on that?

Justin Lam:

Yeah, I think I think we still don't know what the underlying toxic component is in lily.

Justin Lam:

So I think it would be really nice, you know, for someone to try to identify that.

Justin Lam:

I think I have like kind of like a ideal you know answer and then like a more realistic answer.

Justin Lam:

So I think, in an ideal world, like in human medicine, I think a randomized control trial would be, you know, the the best thing to try to compare these two different treatment strategies.

Justin Lam:

But, like, honestly, it it it might be a hard sell, like ethically, for owners to want to choose no treatment option or for us to randomize a cat that's been exposed to lilies to a no intervention treatment group when we know the potential consequences of lily exposure. And so you think a more realistic alternative would be to try to collaborate with other institutions and hospitals to just generate a greater population of cats that we can include in our study or in a new study, where then we can, you know, be able to draw a stronger conclusion from a higher powered study. I think another potential alternative would, or, in addition to doing that, would be to really look at like specific, like treatments within, like the outpatient group, so whether or not, the effect of sub-key fluids or decontamination by making them vomit or and or even like activated charcoal, will help, you know, in management of these cats in the future.

Sarah Wright:

So, if anyone's listening and commonly sees lily toxicity cats, definitely contact Justin, maybe for a future study. So, there you go, Justin, help you out there.

Justin Lam:

Thanks.

Sarah Wright:

So, AI is a very hot topic and we are seeing, I think, more of an integration of AI into veterinary medicine. So, Justin, do you see a role for AI in this area of research?

Justin Lam:

I definitely do. I think, maybe with this research and then also just in research in general, I think you know, for those that have like partaken in, you know, research, you know the whole data collection part can be very tedious and cumbersome, and I think that AI could potentially serve as a helpful tool to try to extract data from like large medical record systems, to make this process a little bit, you know, less tedious and then maybe therefore like encourage more literature to be published, whether in this topic or just in general, and then also make you know more literature available in a quicker manner as well.

Sarah Wright:

And for those of you just joining us, we're discussing the prevalence of acute kidney injury and outcome in cats treated as inpatients versus outpatients following little exposure, with our guests Erica Reinecke and Justin Lam. So, Justin, how did your training prepare you to write this manuscript?

Justin Lam:

Yeah, so during residency and kind of post vet school, we get a lot of training and just a lot of study material in regards to renal physiology, understanding of kitty physiology. It's allowed me to kind of think about whether or not you know we should be giving fluids to all these patients that are exposed to just toxins, particularly lily cats, and whether or not that we're truly promoting fluid diuresis or truly enhancing toxin clearance and whether or not it's truly beneficial. I think, also kind of during residency and with this paper, a large part of that support has been from my research mentor, Erica, who's here, so I think both of those in combination kind of helped me prepare for this manuscript.

Erica Reineke:

I mean, Justin did the heavy lifting. You know, he basically had the idea. I think one day we were sitting in the ER, and it came up and I said, yes, that's been on my list for a while, we should look at it. And then, you know, he just went with it from there. So, he did a great job.

Sarah Wright:

That's awesome.

Sarah Wright:

Well, hopefully we'll see much more from you, Justin. Now this next set of questions is going to be really important for our listeners, and the first one is about the veterinarian's perspective. What is one piece of information the veterinarian should know about the prevalence of acute kidney injury and outcome in cats treated as inpatients versus outpatients following lily exposure?

Justin Lam:

Yes, yeah, we kind of addressed it earlier. But I think an important thing to know is that maybe our study suggests that if you can't quite pursue hospitalization, that an outpatient treatment whether we give sub-Q fluids or not may still be a viable option for management of these cats who are exposed to lilies.

Sarah Wright:

Now, on the other side of the relationship, what's one thing clients should consider around the prevalence of acute kidney injury and outcome in cats treated as inpatients versus outpatients following lily exposure?

Erica Reineke:

All right, I'll take that one. So, I think it needs to be emphasized to the pet owners, to cat owners, that no matter what we found in our study, lilies can be extraordinarily toxic to cats and should never, ever, be in the same house where a cat lives. If your cat somehow is exposed to lilies, usually it's accidental, you know. Usually, it's the owner doesn't know what the flower looks like, so that happens. But if a cat should become exposed to lilies, we would definitely recommend immediate veterinary care, really really early, as timely interventions like potentially decontamination through inducing vomiting to try to remove plant material, or administration of charcoal potentially starting fluids, either IV or sub-Q, could be helpful in preventing kidney injury. We would recommend that a pet owner discuss with their veterinarian the best treatment strategy for their family and their cat.

Sarah Wright:

Very well said. So my husband's not a veterinarian and took him many years of me saying no lilies when we have flowers because he used to get confused with lavenders. But now he finally has it and he always tells a florist he's like no lilies.

Sarah Wright:

So, it's a rule.

Erica Reineke:

I know. I always told this story where my kids were quite young. I would walk through the grocery store with them and like point to the lily plants and say things like these should have a sign on them saying toxic to cats. Right, kids, they're toxic to cats. And then my kids would repeat like you know, little soldiers, yeah, mom, they're toxic to cats. So, like you know, because they're loud when they're young, they don't do that anymore. There's like one of them is 16 and one of them's 14. So if I try to get them to speak loudly, they just like roll their eyes at me. But I felt like I was doing a public service announcement at the time. But I still feel. I don't know how you guys feel, but I really do feel like these lilies that are grown like in bulk and taken to grocery stores you know, around Easter and Valentine's Day when we typically see them should have a little disclaimer on them. I think it wouldn't be that hard to do and it would potentially save some cats from being exposed.

Sarah Wright:

I agree, I have so many non-veterinarian friends that are cat owners and they're like we just didn't know. And then, fortunately, they find out when their cat is vomiting and is lethargic after being around their lilies, and then they bring it to the vet and learn. So, yeah, it'd be nice to be proactive about that. So maybe the study and the associate press release will help with that.

Sarah Wright:

We'll see!

Erica Reineke:

I hope so yeah.

Justin Lam:

Yea, that'd be really cool. Who can we talk to?

Erica Reineke:

Maybe they'll put your face on it, Justin like your face, lilies are bad

Justin Lam:

I'll be like.

Justin Lam:

It's like a picture of a cat I'm

Sarah Wright:

Don't do it, it's a trap all right.

Sarah Wright:

So, now I'll move on to the fun part of our podcast. So, we need to learn a little bit more about both of you. So, Justin, what was the first concert that you attended?

Justin Lam:

Okay, this is like an embarrassing answer, but in my parents in middle school took me to like a high school musical concert with like the original cast, so it was great, but I only remember like parts of it. But I guess I was really into high school musical as a kid where they felt the need to take me.

Sarah Wright:

So oh, my gosh, that's awesome.

Sarah Wright:

Actually, equally almost as embarrassing as I attended the High School Musical 2 premiere at Disneyland. It was pure coincidence, like was on vacation there with my family, um, and my sister and I were like, yes, we're going to this because we're here and it's happening, so

Justin Lam:

The classic.

Sarah Wright:

That's awesome.

Erica Reineke:

I love that for both of you

Sarah Wright:

So, Erica, what is the oldest or most interesting item on your desk or in your desk drawer?

Erica Reineke:

Yes, I thought I have some old things because we talked about this last time. You know I'm a bit dated, but I think the most interesting thing that I look at frequently is I have this little figurine of a duck-billed platypus that I was given when I spoke at a veterinarian conference in Australia and I just look at it and I think, gosh, what a weird creature you know a duck-billed platypus is Like. Do you guys know, do you guys remember the duck-billed platypus? Like it has webbed feet right a bill and like the male platypus, has venomous stingers in the heels of its feet. Such a weird creature and I think Australians are particularly proud of it. So, I don't know this kind of a weird memento of my speaking engagement.

Sarah Wright:

Right, that's super cool, though I love collecting little things too, like at conferences and like when you speak and you get like speaker gifts. I have them all. Actually, in my office I have this like little collection of all the trinkets and it's fun to look back on it. Yeah, definitely, definitely. Well, thank you both, Erica and Justin, so much for taking time out of your busy days to be here with me today to share more about your article with our listeners.

Erica Reineke:

Well, thanks for having

Justin Lam:

Thank you for having us,

Sarah Wright:

To our listeners

Sarah Wright:

You can read Erica and Justin's article in JAVMA. I'm Sarah Wright. Be on the lookout for next week's episode and don't forget to leave us a rating and review on Apple Podcasts or whatever platform you listen to.

People on this episode

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Lisa Fortier, DVM, PhD, DACVS

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Sarah Wright, DVM

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