Acceptance and effects of a therapeutic renal food in pet cats with chronic kidney disease

Introduction

Renal foods are used to manage chronic kidney disease (CKD) in dogs and cats, but their effectiveness may be limited by the ability to transition animals to them.

Material and Methods

In a prospective study, pet cats with previously undiagnosed kidney disease (20 International Renal Interest Society (IRIS) 1, 61 IRIS 2, 14 IRIS 3/4, 33 at risk for CKD) were transitioned to a renal food. Markers of renal function were measured and owners answered questionnaires about their pet over one year.

Results

All but eight cats (120/128; 94 per cent) successfully transitioned to the renal food. Most of the time, cats moderately or extremely liked the food (89 per cent), ate at least half (73 per cent) and were moderately or extremely enthusiastic while eating (68 per cent). Cats rarely disliked the food (2 per cent) or refused to eat it (1 per cent). Markers of renal function were unchanged in IRIS 1 and 2 cats and changed little in IRIS 3/4 cats. In all groups, owner-assessed quality of life improved initially and then remained stable. Mean bodyweight did not change in cats with CKD.

Conclusions

Most cats with CKD successfully transitioned to the renal food. The results also support previous studies that the renal food can help stabilise cats with CKD.

An evidence-based review of therapies for canine chronic kidney disease

Successful treatment and prevention of kidney disease in dogs requires a multi-dimensional approach to identify and eliminate causes or exacerbating factors, provide professional evaluation on a regular basis and implement a comprehensive treatment programme when necessary. Over the years, many therapeutic and preventive interventions have been developed or advocated for chronic kidney disease in dogs, but evidence of efficacy or effectiveness is often lacking or highly variable. Accordingly, the main objective of this systematic review was to identify and critically appraise the evidence supporting various aspects of managing canine chronic kidney disease.

Absence of urinary tract infection in dogs with experimentally induced hyperadrenocorticism

Objectives of this study were to determine occurrence of urinary tract infection and describe results of urine analysis and urine culture in dogs with experimentally induced hyperadrenocorticism. Dogs were randomly assigned to receive either hydrocortisone (nine dogs) or placebo (eight dogs) for 49 consecutive days. Before and on day 49 of treatment, evaluation of dogs included physical examination, abdominal ultrasound, urine culture, urinalysis, adrenal function testing, and measurement of urine protein and creatinine and activity of serum alkaline phosphatase. All dogs in the experimental group had clinical and laboratory findings of hyperadrenocorticism. Urine specific gravity was significantly decreased and urine protein-to-creatinine ratio was significantly increased in dogs with hyperadrenocorticism. Urinary tract infection did not occur in any dogs. We conclude that administration of hydrocortisone created a model of hyperadrenocorticism; however, urinary tract infection did not occur. Additional evaluation is needed to determine association between urinary tract infection and hyperadrenocorticism.

Detection of feline leukaemia virus in blood and bone marrow of cats with varying suspicion of latent infection

The purpose of this study was to determine if polymerase chain reaction (PCR) could be used to detect FeLV proviral DNA in bone marrow samples of cats with varying suspicion of latent infection. Blood and bone marrow samples from 50 cats and bone marrow from one fetus were collected, including 16 cats with diseases suspected to be FeLV-associated. Serum enzyme-linked immunosorbent assay (ELISA), blood and bone marrow immunofluorescent antibody test (IFA), and blood and bone marrow PCR were performed on each cat, and IFA and PCR on bone marrow of the fetus. Forty-one cats were FeLV negative. Five cats and one fetus were persistently infected with FeLV. Four cats had discordant test results. No cats were positive on bone marrow PCR only. It appears persistent or latent FeLV infection is not always present in conditions classically associated with FeLV.

Using the World Wide Web to enhance the problem-solving skills of third-year veterinary students

A Web site was created for the small animal problem-solving elective at Virginia Tech. In addition to signalment, history, physical examination findings, and results of routine laboratory tests, students were able to view images of cytologic and histologic specimens, radiographs, and endoscopic findings and hear examples of breath and cardiac sounds. Students commented that the availability of Web-based case materials allowed them increased opportunities to practice problem-solving skills.

Extraskeletal osteosarcoma in the duodenum of a cat

A three-year-old, male neutered domestic longhair cat was referred for evaluation of icterus, vomiting, and anorexia. Abdominal ultrasonography revealed a proximal duodenal mass obstructing the common bile duct. The mass was surgically resected, and a cholecystoduodenostomy was performed. The histopathological diagnosis was osteosarcoma. Thoracic radiographs showed no evidence of metastasis, and bone scintigraphy revealed no signs of a primary skeletal osteosarcoma. Four months after surgery, the cat had intermittent vomiting, marked weight loss, and died.

Treatment of severe chronic digoxin toxicosis in a dog with cardiac disease, using ovine digoxin-specific immunoglobulin G Fab fragments

Severe digoxin toxicosis in a 13-year-old mixed-breed dog with dilated cardiomyopathy was successfully treated with i.v. administration of ovine digoxin-specific IgG Fab fragments. Management of this dog following treatment with Fab fragments was complicated by hypomagnesemia and loss of the positive inotropic effect of digoxin.

Retrospective evaluation of urinary tract infection in 42 dogs with hyperadrenocorticism or diabetes mellitus or both

A retrospective study was performed to determine the proportion of dogs with hyperadrenocorticism or diabetes mellitus or both that had urinary tract infection (UTI) and to describe clinical and laboratory findings. Dogs with these endocrine disorders were included if results of quantitative urine culture were available and dogs were not receiving antimicrobials. Dogs with positive urine cultures were considered to have UTI and dogs with negative urine cultures were used as controls. Information including history, clinical signs, physical examination findings, and results of laboratory tests and urine culture was extracted from all records. Findings in dogs with UTI were compared with control dogs. There were 101 dogs with hyperadrenocorticism or diabetes mellitus or both that met inclusion criteria; 42 (41.6%) had UTI and 59 (58.4%) did not. UTI was present in 46% of dogs with hyperadrenocorticism, 37% of dogs with diabetes mellitus, and 50% of dogs with both endocrine disorders. There was no association between endocrine group and occurrence of UTI. Escherichia coli was the most common bacteria isolated, and cultures from 29 dogs (69%) showed growth of this organism. Of dogs with UTI, <5% had stranguria, pollakiuria, or discolored urine, whereas 60% had pyuria and 69% had bacteriuria. We conclude that UTIs are common in dogs with hyperadrenocorticism, diabetes mellitus, or both diseases. Clinical signs of UTI, however, are uncommon and results of urinalysis may be normal. Therefore, it is appropriate to recommend urine culture as part of the evaluation of dogs with these endocrine disorders.

Effects of a prostaglandin E1 analogue, misoprostol, on renal function in dogs receiving nephrotoxic doses of gentamicin

OBJECTIVE

To determine whether the prostaglandin E1 analogue, misoprostol, could preserve renal function in dogs receiving nephrotoxic doses of gentamicin.

ANIMALS

12 (6/group) healthy sexually intact male dogs.

PROCEDURE

All dogs were given high doses of gentamicin (10 mg/kg of body weight, i.v., q 8 h, for 8 consecutive days). Six dogs (treatment group) received misoprostol (3 microgram/kg, p.o., q 8 h for the duration of the study) and 6 dogs (control group) received vehicle (1 capsule, p.o., q 8 h). Renal function was assessed before treatment (day 0) and on days 3, 6, 9, and 11 after initiation of treatment by measurement of serum biochemical variables, urine specific gravity, and exogenous creatinine clearance. Serum electrolyte and protein concentrations and presence of proteinuria, glycosuria, and cylindruria were also determined. At the end of the study, renal histopathologic changed were evaluated.

RESULTS

Dogs receiving misoprostol had significant reduction in exogenous creatinine clearance with time, compared with dogs receiving vehicle (P = 0.0264). Dogs receiving misoprostol tended to develop more severe azotemia, hyperphosphatemia, and renal histopathologic changes; however, results were not significantly different between groups.

CONCLUSION

Misoprostol (3 microgram/kg, p.o., q 8 h) did not preserve renal function and may have exacerbated gentamicin-induced nephrotoxicosis in this group of dogs.

CLINICAL RELEVANCE

Supplementation of vasodilatory prostanoids may exacerbate renal dysfunction in dogs receiving high doses of gentamicin.

Pleural effusion in cats: 82 cases (1987 to 1995)

Eighty-two cases of feline pleural effusion were identified and reviewed to assess the type of fluid, underlying disease process, predisposing conditions, historical and physical examination findings, laboratory and cytology data, response to treatment and outcome. Pertinent findings included a high occurrence of pleural effusion with mediastinal lymphoma (and other types of intrathoracic neoplasia), pyothorax, cardiomyopathy and feline infectious peritonitis virus infection. Sixteen cases, eight with chylous effusion, had no underlying disease identified. Cats with pyothorax and effusion secondary to trauma had the best prognosis for complete recovery. Otherwise, the outcome was variable and the prognosis was guarded to poor.

Chylothorax associated with constrictive pericarditis in a dog

Chylothorax was associated with constrictive pericarditis in a 6-year-old mixed-breed dog. Clinical signs included hepatomegaly, bilateral jugular pulses, muffled heart sounds, and dyspnea. Pleural effusion was identified on thoracic radiographs. Thoracentesis yielded 3 L of chylous effusion, confirmed by the cholesterol/triglyceride ratio (0.14). Echocardiography revealed a thickened pericardium, with numerous fibrin tags, which was suggestive of constrictive pericarditis. Central venous, right atrial, and right ventricular pressures were high and on right ventricular diastolic pressure tracings, the square-root sign, which is indicative of constrictive pericarditis, was evident. Exploratory thoracotomy and pericardiectomy were performed. Histopathologic findings were consistent with chronic non-suppurative pericarditis. The dog's condition improved after surgery. On reevaluation 11 months later, central venous pressure and results of physical examination and thoracic radiography were normal. On the basis of these findings, we concluded that chylothorax was caused by constrictive pericarditis in this dog. Chylothorax is often associated with disorders that have a poor prognosis, but if constrictive pericarditis can be identified as the cause of the chylothorax, exploratory thoracotomy and pericardiectomy can provide a cure.

The effect of misoprostol on aspirin-induced gastroduodenal lesions in dogs

Misoprostol, a synthetic prostaglandin E1 analog, is effective in treating and preventing nonsteroidal antiinflammatory drug (NSAID)--induced gastrointestinal lesions in humans. The effectiveness of misoprostol in preventing aspirin-induced gastroduodenal injury was studied in 3 groups of 6 adult mixed breed dogs. Group I received 3 micrograms/kg misoprostol PO tid. Group II received 3 micrograms/kg misoprostol PO tid and 35 mg/kg aspirin PO tid. Group III received 35 mg/kg aspirin PO tid. Endoscopy was performed on days 0, 5, 14, and 30. Five regions of the upper gastrointestinal tract were qualitatively scored from 1 to 12 based on the presence of submucosal hemorrhage, erosion, or ulceration, with ulceration receiving a higher numerical score than submucosal hemorrhage. A total score was assigned based on the sum of the scores from all regions. Comparisons among groups on each day were performed using the Kruskal-Wallis test. Differences within a group among different time periods were determined using appropriate multiple comparisons. Significant difference in mean gastroduodenal lesion score was found among all groups at 5, 14, and 30 days. Mean total score on days 5, 14, and 30 were as follows: group I, 5.0, 5.2, 9.0; group II, 12.0, 12.7, 16.2; and group III, 26.0, 23.8, 21.5, respectively. Significant differences within a group among different time periods were found from days 0 to 5 in groups I and II, and from days 14 to 30 in group I. It was concluded that misoprostol effectively decreased endoscopically detectable mucosal lesions in dogs given aspirin.

Effects of short- and long-term administration of phenobarbital on endogenous ACTH concentration and results of ACTH stimulation tests in dogs

The effects of short-term phenobarbital administration were evaluated in 6 adult mixed-breed dogs that received phenobarbital (5 mg/kg of body weight, PO, q 12 h) for 8 consecutive weeks. Six additional dogs served as untreated controls. At 2-week intervals, endogenous adrenocorticotropic hormone (ACTH) concentration and cortisol concentration before and 2 hours after administration of porcine aqueous ACTH (2.2 IU/kg, IM) were measured. By means of one-way ANOVA, we were not able to detect a significant (P > or = 0.05) difference in endogenous ACTH concentration and cortisol concentration before and after exogenous ACTH administration within groups over time or between groups at any time. To evaluate effects of long-term phenobarbital administration, sera and plasma were collected from 5 epileptic dogs that had received phenobarbital for > 2 years and had serum phenobarbital concentrations > 20 micrograms/dl. Endogenous ACTH concentration and cortisol concentration, before and after administration of ACTH, were within established reference ranges for all 5 dogs. Together, these results suggest that phenobarbital administration alone does not affect endogenous ACTH concentration or response to exogenous ACTH administration in dogs, and that these may be valid screening tests for hyperadrenocorticism in most dogs receiving phenobarbital.

Prevention of cisplatin-induced nephrotoxicosis in dogs, using hypertonic saline solution as the vehicle of administration

We determined whether administration of cisplatin in hypertonic saline solution would prevent significant decrease in renal function, as measured by exogenous creatinine clearance, in healthy dogs. A single dose of cisplatin (70 mg/m2 of body surface) was mixed in 3% saline solution and was infused IV (6.5 ml/kg of body weight) over a 20-minute period to 6 healthy dogs. Exogenous creatinine clearance was determined prior to treatment of dogs with cisplatin and again on days 3 and 21 after administration of cisplatin. All 6 dogs vomited at least once within 12 hours of treatment with cisplatin; however, clinically important changes in appetite, body weight, or hydration status were not apparent during the 21-day study. Although mean values for exogenous creatinine clearance decreased from baseline on days 3 and 21, changes were not significantly different. Renal histologic lesions included mild, chronic, lymphoplasmacytic interstitial nephritis in 5 dogs, and presumably, were unrelated to treatment with cisplatin. Mild renal tubular atrophy (n = 2) and tubular necrosis (n = 1) may have developed secondary to treatment with cisplatin. Results of this study indicated that administration of a single dose of cisplatin in 3% saline solution to healthy dogs was not associated with significant decrease in glomerular filtration rate. This is a convenient protocol for administering cisplatin; however, additional study is required before it can be recommended for clinical patients, especially those with preexisting renal disease or those receiving multiple doses of cisplatin.

Effects of a 44-day administration of phenobarbital on disposition of clorazepate in dogs

The disposition of clorazepate, a benzodiazepine anticonvulsant, was determined in dogs after administration of a single oral dose of clorazepate (2 mg/kg of body weight) and after oral administration of clorazepate (2 mg/kg, q 12 h) concurrently with phenobarbital (5 mg/kg, q 12 h) for 44 consecutive days. Serum concentrations of nordiazepam, the active metabolite of clorazepate, were measured. After a single oral dose of clorazepate, maximal nordiazepam concentrations ranged from 569.6 to 1,387.9 ng/ml (mean, 880.2 +/- 248.9 ng/ml) and were detected 16.8 to 131.4 minutes (mean, 85.2 +/- 36 minutes) after dosing. After administration of phenobarbital for 44 consecutive days, maximal nordiazepam concentrations were significantly (P < 0.01) lower, ranging from 209.6 to 698.5 ng/ml (mean, 399.3 +/- 155.6 ng/ml) at 68.4 to 145.8 minutes (mean, 93 +/- 25.8 minutes) after dosing. Mean area under the curve (AUC) on day 1 (mean, 3.37 +/- 0.598 ng.min/ml) was significantly (P < 0.001) greater than AUC on day 44 (1.66 +/- 0.308 ng.min/ml). Oral clearance was significantly (P < 0.01) greater on day 44 (12.44 +/- 2.55 ml/min/kg), compared with that on day 1 (6.16 +/- 1.35 ml/min/kg). Values for area under the first moment curve, oral volume of distribution, mean residence time, and elimination half-life were not significantly altered by concurrent administration of phenobarbital. Administration of phenobarbital altered the disposition of clorazepate such that the amount of nordiazepam in circulation during each dose interval was significantly reduced. Adequate control of seizures in epileptic dogs, therefore, may require higher dosages of clorazepate when it is coadministered with phenobarbital.

Severe bilateral fibrosing pleuritis associated with chronic chylothorax in five cats and two dogs

Severe bilateral fibrosing pleuritis was diagnosed in 5 cats and 2 dogs with chronic chylothorax. All animals were dyspneic on initial examination and remained moderately to severely dyspneic after thoracentesis. Radiographic evidence of fibrosing pleuritis included rounded lung lobes and failure of the lungs to reexpand following effective pleural drainage. Fibrosing pleuritis was also suggested in several animals with radiographic evidence of pleural fluid, in which pleural fluid could not be retrieved. Macroscopically, the lung lobes of all animals were compressed and atelectatic to various degrees, and the pleura appeared to be diffusely thickened and roughened. In several animals, fibrous adhesions were found between the parietal and visceral pleura of some lobes. Lung lobes were markedly constricted and appeared as small, smooth, rounded hilar masses in 4 animals. Mild to moderate pulmonary edema was evident in 3 animals at necropsy. Six of the 7 animals died (2) or were euthanatized (4) within 72 hours after the diagnosis of fibrosing pleuritis. The fibrosing pleuritis developed in 1 animal with lymphoblastic lymphosarcoma and chylothorax after treatment via passive pleuroperitoneal drainage; this animal was euthanatized because of underlying neoplasia. One cat, in which decortication was performed and resulted in marked reexpansion of the lung lobes, died 4 hours after surgery with signs compatible with pulmonary edema. On the basis of our findings, we suggest that animals with chronic chylothorax are at risk to develop fibrosing pleuritis. Furthermore, animals with severe bilateral fibrosing pleuritis should be given extremely guarded prognoses.

Cholangiohepatitis in a dog

Cholangiohepatitis was diagnosed in a dog with a 4-day history of anorexia, vomiting, fever, and icterus. Additional findings included signs of depression, dehydration, hepatosplenomegaly, and abdominal discomfort. Exploratory laparotomy was performed, and specimens of liver, spleen, and bile were obtained. Histologic evaluation of liver and spleen revealed acute, suppurative cholangio-hepatitis and splenitis, respectively. Cultures of liver and bile yielded Klebsiella sp. The dog responded to rehydration and intravenous administration of chloramphenicol. Although uncommon, cholangiohepatitis should be suspected in dogs with anorexia, fever, vomiting, icterus, and signs of abdominal discomfort. Definitive diagnosis requires bacterial cultures of liver and bile. Administration of an appropriate antibiotic should resolve clinical signs.

Pneumothorax in a dog with a pulmonary abscess and suspected infective endocarditis

Nontraumatic pneumothorax was diagnosed in a dog with a pulmonary abscess and evidence of infectious endocarditis, including fever, mitral murmur, and vegetative lesion of mitral valve leaflets. Pneumothorax persisted after 4 days of continuous thoracic drainage. At exploratory thoracotomy, the diaphragmatic lung lobe was identified as the source of air leakage and was excised. Results of culturing of blood and lung tissue for aerobic and anaerobic bacteria were negative. Antibiotics were administered because of suspected bacterial endocarditis. Pneumothorax and fever resolved after surgical and medical treatments.

Serum hyperviscosity syndrome associated with multiple myeloma in two cats

Serum hyperviscosity syndrome was diagnosed in 2 cats with multiple myeloma. Clinical signs included pale mucous membranes, dehydration, retinal hemorrhages, dilated and tortuous retinal vessels, seizures, head-tilt, nystagmus, systolic murmur, and gallop rhythm. Laboratory abnormalities included hyperglobulinemia, azotemia, hyperphosphatemia, nonregenerative anemia, and thrombocytopenia. Both cats had IgG monoclonal gammopathy, Bence Jones proteinuria, increased numbers of bone marrow plasma cells, and high values for relative serum viscosity. Renal disease was suspected in both cats. Cardiac hypertrophy was documented in 1 cat and was suspected in the other cat. Chemotherapy, using melphalan, prednisone, and vincristine, caused short-term remission in both cats, and plasmapheresis was used to lower serum protein concentration in 1 cat. Serum hyperviscosity syndrome rarely develops in cats, but should be suspected when monoclonal gammopathy exists with signs of neurologic, cardiac, or retinal disease.

Chylothorax in cats: 37 cases (1969-1989)

Case records of 37 cats with chylothorax examined at 2 institutions were retrospectively evaluated. Dyspnea and coughing were the most common abnormalities noticed by the owners, and most cats were dyspneic on initial examination. There was no statistically significant difference in the gender distribution of cats studied when compared with reference populations; however, purebred cats appeared to be overrepresented in the study population. Four of the cats had unilateral pleural effusion (2 left side, 2 right side) and 9 cats had effusions that were primarily, but not exclusively, on the right side. Surgery was performed on 20 cats. Fifteen cats underwent thoracic duct or cisterna chyli ligation; 20% had complete resolution of pleural fluid. There was no significant difference in the survival rate of cats that underwent thoracic duct ligation and those that were treated by other means. Six cats had mesenteric lymphangiography performed; 2 cats had normal results, and the remainder had various degrees of thoracic lymphangiectasia. Two cats in which pleuroperitoneal shunts were placed and 2 of 3 cats that underwent pleurodesis were euthanatized or died after surgery.

Diagnosis and treatment of chylothorax associated with lymphoblastic lymphosarcoma in four cats

Chylothorax was diagnosed in 4 cats with lymphoblastic lymphosarcoma. Clinical findings included dyspnea, muffled heart sounds, and noncompressibility of the cranial portion of the thorax. All cats had high pleural fluid triglyceride concentration. Lymphosarcoma was diagnosed by cytologic evaluation of pleural fluid in 3 cats and by histologic evaluation of a cranial cervical lymph node in 1 cat. Two cats were euthanatized prior to any treatment, and the other 2 cats were managed by thoracic drainage, chemotherapy, and/or irradiation.

Disposition of clorazepate in dogs after single- and multiple-dose oral administration

Clorazepate dipotassium was administered orally to 8 healthy dogs at a dosage of 2 mg/kg of body weight, q 12 h, for 21 days. Serum disposition of nordiazepam, the principle metabolite of clorazepate, was determined after the first and last dose of clorazepate. Disposition variables were analyzed by use of model-independent pharmacokinetics by the predictive equations method and the trapezoidal rule method. Complete blood counts, serum chemical analyses, and urinalyses were performed before administration of clorazepate and at 10 and 21 days after administration of clorazepate. Maximal nordiazepam concentrations ranged from 446 to 1,542 ng/ml (814 +/- 334 ng/ml), at 59 to 180 minutes (97.9 +/- 42.0 minutes) after a single oral dose of clorazepate. Maximal nordiazepam concentrations ranged from 927 to 1,460 ng/ml (1,308 +/- 187.6 ng/ml), at 120 to 239 minutes (153 +/- 57.9 minutes) after multiple oral doses of clorazepate. Serum disposition was significantly altered after multiple doses of clorazepate. Using data determined by the predictive equations method, the mean residence time after multiple doses (712 +/- 214 minutes) was longer (P less than 0.05) than after a single dose (527 +/- 95.8 minutes). Oral volume of distribution after multiple doses of clorazepate (1.76 +/- 0.647 L/kg) was smaller (P less than 0.02) than after a single dose (3.18 +/- 1.52 L/kg). Oral clearance after multiple doses of clorazepate (3.09 +/- 0.726 ml/min/kg) was less (P less than 0.001) than after a single dose (6.54 +/- 2.15 ml/min/kg). Absorption half-life after multiple doses (72 minutes) was longer (P less than 0.01) than after a single dose (33 minutes).(ABSTRACT TRUNCATED AT 250 WORDS)

Uveitis in the dog and cat

Uveitis, inflammation of the vascular middle coat of the eye, may be a common manifestation of several diseases. Clinical signs of uveitis include ocular discharge, redness, and pain. Uveitis should be differentiated from other conditions causing similar clinical signs. Once uveitis is recognized, attempts to identify a specific cause should be undertaken. In some cases, an underlying cause is not identified, and treatment is aimed at preventing additional ocular damage.

Hypercalcemia secondary to cholecalciferol rodenticide toxicosis in two dogs

Hypercalcemia secondary to cholecalciferol rodenticide toxicosis was identified in two dogs. The first dog died shortly after admission. The second dog responded to treatment with sodium chloride solution, prednisolone, furosemide, and calcitonin. Treatment was needed for a longer period than anticipated and the serum calcium concentration did not stabilize for approximately one month. Although not conclusively demonstrated, calcitonin was considered the cause of severe anorexia. This new class of rodenticides has great toxic potential for dogs, and it is recommended that serum calcium concentration be carefully monitored as treatment for hypercalcemia is gradually withdrawn.

Hypophosphatemia. Causes and clinical consequences

Severe hypophosphatemia (i.e., serum phosphorus concentration below 1 mg/dl) occurs infrequently in veterinary patients. It is most often associated with diabetic ketoacidosis in small animals. Phosphate is necessary for the production of 2,3 diphosphoglycerate (2,3-DPG) and adenosine triphosphate (ATP); both are important for normal cellular metabolism. Consequences of severe hypophosphatemia may include hemolytic anemia, seizures, altered mentation, cardiomyopathy, and skeletal muscle weakness. Parenteral phosphate therapy is necessary in most cases of severe hypophosphatemia.