Anaemia is a condition in which not enough
red blood cells (RBC)
exist in the body.
Anaemia is relatively common in CKD cats,
so it is important to know about it and to be prepared to deal with it
promptly.
Untreated anaemia can kill a cat far more quickly than
the CKD, and a severely anaemic cat may look very ill, but fortunately
anaemia is very treatable, so don't give up hope.
Anaemia is a condition in which not enough
red blood cells (RBC)
exist in the body. Red blood cells contain a
protein called haemoglobin, which
transports oxygen round the body, so if a
cat does not have enough red blood cells,
oxygen is not reaching the cells where it is needed, and the cat
will not be able to function properly.
Anaemia is relatively common in CKD cats,
so it is important to know about it and to be prepared to deal with it.
Untreated anaemia can kill a cat far more quickly than
the CKD, and a severely anaemic cat may look very ill, but fortunately
anaemia is very treatable, so don't give up hope.
University of Georgia College of Veterinary Medicine
states that "anemia is not a poor prognostic
indicator in cats as most live for more than 300 days despite presenting
with anemia", but many cats live a lot longer.
Treating anaemia is not
only about lifespan, but also about quality of life. The difference
in a cat's behaviour and wellbeing once
severe anaemia is brought under control is often
quite astonishing. Anaemia is usually very responsive
to treatment, but most treatments take a week or so to take effect (apart
from blood transfusions, which kick in immediately). Therefore I
would recommend treating anaemia for at least two weeks before
contemplating euthanasia.
It is very important to treat anaemia
because it can have some serious effects on the body,
and in the worst case it can even kill. Symptoms you may see include:
In
an anaemic cat the
heart rate increases in an attempt to push the reduced amount of
haemoglobin around the body. This faster heart rate is called tachycardia.
Occasionally anaemia may cause a heart murmur.
High Blood Pressure
The heart tries to provide more blood,
and thus oxygen, to the body's cells by increasing the pressure with
which it pumps.
Breathlessness
Because there is less
oxygen in the body's tissues, the cat
breathes more often and more deeply in an attempt to
take in more oxygen.
Weakness
This is also caused by the lack of oxygen
in the tissues, which means the cells cannot work as effectively.
Oedema and Heart Failure
The heart can only compensate for the lack of
haemoglobin to a certain extent. Eventually, if the problem remains
untreated, blood will
not circulate properly and will build up, and
fluid will leak into body tissues. This causes swelling known as oedema.
If oedema occurs in the lungs, it is known as pulmonary oedema,
and if it is left untreated this can kill the cat.
One commonly seen symptom which you might not
associate with anaemia is eating litter or licking rocks or concrete. Some
cats may eat ice or snow. Many vets do not know this type of behaviour can
be a symptom of anaemia, but I hear of it so often, and when the cat is
tested, anaemia is virtually always present. Very occasionally, eating
litter or licking rocks or concrete is a sign of calcium imbalances
instead; but either way, if you see this symptom, take your cat to the
vet.
The problem should disappear once the anaemia
is under control, but in the meantime, switch to a paper- or corn-based
litter.
Almost all anaemic cats experience loss of appetite, often
severe, and extreme lethargy. You may also see pale eyelids or gums. They
tend to feel cold, so often seek out warm places.
As you can see, anaemia is potentially very
serious, and severely anaemic cats
often look and act extremely ill. My Thomas could
not even walk downstairs, and just walking to the litter tray was a
massive effort for him. Fortunately, anaemia is treatable.
Healthy kidneys produce a hormone called
erythropoietin, which stimulates the bone marrow to make the blood cells.
As the kidneys fail in CKD, they cannot produce enough erythropoietin, so
the bone marrow is not stimulated, blood cells are not produced, and a
particular type of anaemia called non-regenerative anaemia results.
And finally, even if a
cat is still able to produce red blood cells, these last for around
70-80 days in healthy cats, but only around half that time in CKD cats.
There are quite a few other causes of
anaemia, so the following list is not exhaustive:
AVitamin B deficiency can
cause anaemia, and is quite common in CKD cats who pee
more, and who therefore pee out a lot of Vitamin B because it is a water
soluble vitamin.
Inflammation or infection may also cause
anaemia. In
Selected diseases of the feline kidney
(2001), a presentation to the World
Small Animal Veterinary Association World Congress, Dr Stephen
DiBartola
explains that
pyelonephritis (a kidney infection) may cause non-regenerative anaemia
in some cats, and this happened to my cat every
time he got a bout of pyelonephritis.
The reason for this is, if a cat has an
infection, the cat's body will sequester iron away (i.e. iron is stored
rather than released into the bloodstream), because bacteria thrive on
iron. Since iron is necessary for blood cell production, anaemia may
result.
Iron metabolism in pathogenic bacteria (2000) Ratledge C & Dover LG Annual Review of
Microbiology54 pp881-941
explains more about this. Once the infection or
inflammation is under control, the anaemia should gradually improve.
Gastro-intestinal bleeding, particularly if the anaemia develops
suddenly, may cause anaemia. Most cats with
anaemia caused by CKD become anaemic gradually, so if
your cat becomes anaemic suddenly, consider this possibililty.
Feeding
onions
to cats causes a specific type of anaemia called
Heinz body anaemia, and it is possible
that garlic (which belongs to the onion family) may also be a risk.
A severe
flea
infestation may cause anaemia because fleas drink blood.
Mar Vista Vet
has more information about this.
The most common cause of anaemia
in otherwise healthy cats is an infective agent called haemoplasma,
one type of which is sometimes known as feline haemobartonellosis or
feline infectious anaemia.
Pet Place
has some information about it. It can be transmitted by fleas, and can
usually be treated with an antibiotic called doxycycline and occasionally
steroids. Unfortunately it does not always show up in tests, so some vets
treat for it even if the tests are negative.
Cats
with hyperthyroidism who are being treated with
methimazole may sometimes develop anaemia. If this is going to occur, it
usually does so within the first three months of use. Stopping the
medication usually resolves the problem within a couple of weeks.
Feline anaemias: a diagnostic challenge
(2002) is a paper on the various causes of anaemia
presented to the World Small Animal Veterinary Association World
Congress by Urs Giger.
Basic approach to anaemia diagnosis
(2005) is a paper on the various causes of anaemia presented to the
World Small Animal Veterinary Association World Congress by
Harold Tvedten.
There are two types of
anaemia, regenerative and non-regenerative. Regenerative anaemia
means that the cat's body may be able to correct the anaemia without any
external help, whereas with non-regenerative anaemia, the cat is going to
need some help in the form of some kind of treatment.
It is important to know
which type of anaemia you are dealing with because the treatments are
different. Most (but not all) cats with both
CKD and anaemia are suffering from a type of non-regenerative
anaemia caused by problems with production of a hormone
called erythropoietin (see
Why Anaemia Occurs in CKD
Cats). Before your vet can advise
on the best course of treatment, s/he must
decide:
Whether your cat has
non-regenerative anaemia rather than regenerative anaemia; and
If it is
non-regenerative, whether it is caused by the CKD or some other condition.
There
is a small chance of causing, or more likely, worsening anaemia if
a lot of blood is taken too
frequently from your cat for blood tests, so bloodtests should
ideally not be run too often on CKD cats. If
your vet wishes to test only for anaemia, it is not
usually necessary to draw a lot of blood - a
tiny drop taken from the ear may be sufficient (make sure the ear is warm),
so ask your vet if this method could be used, though some machines
do need more blood than this.
Veterinary Partnerhas a description of how this is done in diabetic cats, as does
Sugar Cats.
A few members of
Tanya's CRF Support Group
have been using a machine they
purchased from Ebay to measure PCV at home in order to spare
their cats the
stress of vet visits and themselves the cost of frequent tests
(see
Erythropoiesis Stimulating Agents). They
have found the
machine to be pretty accurate (it varied by about 2% from vet
readings). Personally, if I was dealing with severe anaemia (PCV below
18%), particularly if my cat was on an ESA such as
Epogen, I would prefer regular vet visits because when
PCV is so low, every percentage point matters, plus vet visits give
your vet the opportunity to check your cat over and
check blood pressure as well
as checking PCV. If you do buy one of these machines, please check its
readings against those from your vet's equipment.
One possible compromise would be what one member of
Tanya's CRF Support Group used to do. He would obtain the blood from his
cat's ear at home as outlined above, but then take the sample to his vet
for analysis. This saved his cat the stress of the vet trip, but still
gave an accurate result.
Packed Cell Volume (PCV) or Haematocrit
(HCT): Determining if Anaemia is Present
Your vet will
determine whether your cat has anaemia through a bloodtest called Packed
Cell Volume (PCV). PCV measures the ratio of red blood cells to total
blood volume. The blood is spun in a centrifugal machine and your vet
measures the total number of cells that are left. It does not distinguish
old blood cells from new but it is a still a useful and accurate test for
anaemia.
Some vets check
Haematocrit (HCT) instead, which is very similar to PCV. HCT actually refers
to the red cells that are left only; but since the other blood cells (white
cells and platelets) usually make up less than 1% of blood volume, the
difference between PCV and HCT is too small to be concerned about.
Only a small amount
of blood is needed for these tests (although more blood is needed for HCT than
for PCV) and many vets have the necessary equipment in their offices so you
can get a result in a few minutes.
Technically, a cat is anaemic if the PCV
level is below 30% (or with some labs, 25%), but you may not start to see
any differences in your cat's behaviour until the level is closer to 20%.
Below 20% is generally considered to be severe anaemia, and it really must
be treated as a matter of priority. Dehydration will make PCV look higher
than it really is, so once the cat is rehydrated, PCV will often
fall. In other words, your dehydrated cat may have,
say, a PCV of 26% which does not indicate anaemia, but once the
dehydration has been corrected, the PCV may have fallen to 20%, indicating
anaemia is present.
Cats with hyperthyroidism may have PCV or HCT levels in the high end of
the range.
Reticulocytes: Deciding if it is
Regenerative or Non-Regenerative Anaemia
The PCV test shows if your cat is anaemic,
but it does not show whether the anaemia is regenerative or
non-regenerative. Regenerative anaemia means that the cat's body may be
able to correct the anaemia without any external help, whereas with
non-regenerative anaemia, the cat is going to need some help in the form
of some kind of treatment. Most (but not all) cats with CKD and
anaemia are suffering from non-regenerative anaemia caused by
problems with production of a hormone called erythropoietin (see
Why Anaemia Occurs in CKD
Cats).
The only way to know for certain which type
of anaemia you are dealing with is by testing for reticulocytes. Reticulocytes are immature red blood cells
produced by the bone marrow. When seen in the blood stream, they are about
5-7 days old. Since anaemia means there is a lack of red blood cells, the
body's usual response is to try to generate more red blood cells, so
normally you would see reticulocytes if the anaemia is regenerative - this
shows that the bone marrow is still making blood cells. However, in
non-regenerative anaemia (as often seen in CKD), the lack of
the hormone called erythropoietin means the bone marrow is not able to make blood cells, or
not enough of them to replace old ones, so there will be few or no
reticulocytes present.
Unfortunately the reticulocyte test
(which at most laboratories only measures aggregate reticulocytes) is unlikely to be
reliable unless the anaemia is relatively severe.
Anaemia needs to be
pretty bad before a brisk regenerative response is considered necessary by
the cat's body, so there is little point testing for reticulocytes unless the PCV
has been below 20% for five days or longer. In
addition, most vets cannot test reticulocytes in house, so the test has to
be sent out to a lab, which takes more time.
Because of this, some
vets simply assume that a CKD
cat with anaemia is suffering from non-regenerative anaemia
caused by a lack of erythropoietin production and treat
accordingly. For cats with milder anaemia (PCV above
20%), they may recommend B vitamins. For cats with PCV below 20%,
it is trickier. In these cases, the anaemia
is a more urgent problem and you need to act quickly,
especially if your cat seems poorly, so your vet may recommend
the use of
Erythropoiesis
Stimulating Agents (ESAs)
(Epogen, Aranesp etc.), which
are used for
non-regenerative anaemia caused by a lack of
erythropoietin production. In view of the
possible risks associated with this
treatment, you might wish to wait five days and
have the reticulocyte test done to be sure you really are dealing with
non-regenerative anaemia; but on the other hand, ESAs
take up to two weeks to start taking effect, so waiting may be risky
because your cat will not be feeling well and the anaemia may worsen while
you wait.
My vet felt it was more
important that we start treating Thomas as quickly as possible.
Since Thomas had severe anaemia (his PCV was 18% and he was very weak and
breathless), she felt the most likely cause was non-regenerative anaemia
caused by the CKD, so we
began using an ESA immediately rather than wait several days or more for
the results of a reticulocyte test.
Reticulocytes
Test
This table shows what differing levels of
reticulocytes indicate. Remember, the table is only really
of any use for cats with severe anaemia (PCV below
20%).
The usual level of regeneration in a
healthy cat who is not anaemic is approximately 1% (around 50,000-
60,000 reticulocytes). In an anaemic cat,
you would expect it to be above this level, since you
would expect to see a marked response, i.e. the bone marrow should be
busily making new red blood cells if it can.It can only do this if there is sufficient erythropoietin
available. So if the reticulocyte count is low (below
1%) or even zero despite the PCV being below
20% for five days or longer, this indicates non-regenerative anaemia.
Degree of Regeneration
Reticulocytes in %
Absolute Reticulocytes
Normal/Negligible
Under 1.00
Under 60,000
Mild
1.00 - 2.5
60,000 - 100,000
Moderate
2.5 - 5.00
100,000 - 200,000
Marked
Over 5.00
Over 200,000
Even if the level looks acceptable, it may
not be sufficient to cope with the demand from the body for red blood
cells. In particular, since
reticulocytes are commonly expressed in percentage terms, they need to be
adjusted to allow for the degree of anaemia, i.e. 1% reticulocytes in a
cat with a PCV of 20% is twice as many as 1% reticulocytes in a cat with a
PCV of 10%.
Let's assume your cat's PCV is 18% and the
measured reticulocyte count is 0.75%. You multiply the PCV by the measured
count, then divide the result by the normal PCV level (35%). In this
instance, you would get an adjusted result of 0.39%, which indicates
non-regeneration.
In contrast, if your cat's PCV was 13% and
the measured reticulocyte count was 0.75%, your adjusted result would be
0.28. This also indicates non-regeneration, but it is more severe (i.e.
the lower the corrected value, the lower the regenerative response).
I know this is
complicated, and you're probably stressed enough about your cat's anaemia.
Basically, if your cat's PCV or HCT level has been below 20% for five days
or longer, ask your vet to do a reticulocyte test and let your vet tell
you if the anaemia is regenerative or not. But if your cat is severely
ill, you should definitely start treatment with
B vitamins
immediately,
and you may decide to start treatment with an
ESA before you get
the results of the reticulocytes test or even dispense with this test
altogether in the circumstances.
The differential diagnosis of feline anaemia (2006) is a presentation by Dr S Tasker to the
World Small Animal Veterinary Association World Congress 2006 which
explains more about reticulocytes and anaemia.
Cornell University College of Veterinary
Medicine provides more information on this complex subject:
click on the word Feline on the left of the page for further information,
including a table of reticulocyte counts.
If a cat cannot manufacture sufficient red blood cells,
s/he will become anaemic. Unfortunately the lifespan of red blood cells in
patients with kidney disease is approximately 50% that of healthy
cats, so this is another reason why CKD cats become anaemic.
A low red blood cell count is usually
indicative of anaemia. The red blood cells are often a
paler colour if
MCV is also low.
If the RBC count is high, this may be
indicative of dehydration.
Measures of Iron Deficiency
Haemoglobin, the main oxygen-carrying
protein of red blood cells, needs iron for its production.
Therefore a cat
with low iron levels may develop a type of
anaemia known as iron-deficiency anaemia. Since iron is
present in food,
particularly meat, iron deficiency anaemia from
lack of iron in the diet is rare in cats.
However, cats with inflammation or an infection may
have an iron deficiency because the body sequesters (hides away) iron if
inflammation or infection are present.
Iron metabolism in pathogenic bacteria (2000) Ratledge C & Dover LG Annual Review of
Microbiology54 pp881-941
explains more about this.
Cats with sudden
blood loss, such as from
gastro-intestinal bleeding, may
also have an iron deficiency.
Cats who are having blood taken frequently (once
a week or more) for testing may also be at risk of
anaemia if a lot of blood is being taken each time.
Cats with iron
deficiency anaemia are usually treated with an
iron supplement.
This is a measure of red blood cell size.
If your cat has a low MCV (known as microcytosis),
this means the red blood cells are smaller than usual,
which may indicate a lack of iron.
Possible causes of a lack of iron include gastro-intestinal bleeding
or
chronic liver disease.
If your cat's MCV is
low, you need to know if the cause is a lack of iron before rushing to
give an iron supplement. There are three main tests for iron deficiency,
though these can be hard to obtain and are not always reliable.
If your cat's MCV is
high, the red blood cells are larger than normal. Newly formed red blood
cells are usually larger than normal, so this might be a sign that your
cat's anaemia is regenerative. High MCV may occasionally may be seen in
cats with hyperthyroidism. High MCV levels may also indicate a lack of
Vitamin B12 and folic acid (Vitamin B9) - in these cases, the anaemia is
most probably non-regenerative.
Iron
This measures the
amount of iron
circulating in the blood.
This test should be a
fasting test, and iron supplements should not be given for 24 hours before
the test.
If serum iron is low but ferritin (see
below) is normal, the cat may have an infection.
Serum iron is normally
high if a cat has had a number of blood transfusions. These cats should
not be given iron supplements.
If a cat has anaemia of
chronic disease (e.g. caused by
Inflammatory Bowel Disease),
the serum iron will be low, TIBC will tend to be low, but ferritin will be
high.
MCHC
(Mean Cell Haemoglobin Concentration)
If your vet cannot check
ferritin or TIBC, you can be guided by the MCHC instead. As the name
suggests, this measures the concentration of haemoglobin in a red blood
cell. You can
calculate MCHC as long as you have a measurement for haemoglobin (Hb):
MCHC = (Hb divided by
PCV or HCT) x 100
If this is normal
(around 33%), you probably do not need to worry. If MCHC and MCV are both
low, this may indicate iron deficiency anaemia.
There are various treatments for anaemia,
and which one you should use depends upon
the cause and the severity of the anaemia. Your
vet can advise you which is the most appropriate treatment, though you
need to be aware that not all vets have used
ESAs
such as Procrit or Aranesp or know much about them.
If you know the cause of
your cat's anaemia, getting that under control should resolve the problem
e.g. if your cat has an infection, once it has gone your cat's anaemia
should gradually improve.
Even if you don't know
the precise cause, mild anaemia can often be improved with simple
treatments such as Vitamin B and sometimes iron (iron is not always
appropriate, see below). I recommend giving every
CKD cat a Vitamin B supplement, because it can be very helpful and is
not toxic since any excess is simply peed out.
Correcting Vitamin B Deficiencies
A lack of certain B Vitamins, such as
Vitamin B12 or Folic Acid (Vitamin B9), can cause non-regenerative
anaemia. Generally speaking, all CKD cats with mild to moderate anaemia (PCV
or HCT below 30% but above 20%) would probably benefit from a vitamin B supplement.
I
would also give a supplement to a cat with more severe anaemia. You will
probably still have to consider other treatments such as an ESA, but in
some cases a B vitamin supplement may be sufficient to help your cat.
Your
vet can prescribe a suitable Vitamin B supplement, or give your cat Vitamin B
injections. Be careful about using multivitamin supplements because they
may contain other vitamins such as A and D which are not usually suitable
for CKD cats.
Because B vitamin supplementation is so important for CKD cats, it has its
own page here.
Vitamin E
The Winn Feline Foundation
gave a grant to
Colorado State University
in 2010 for a study into "Vitamin E as a Novel Treatment for the
Anemia of Feline Chronic Renal Failure."
Vitamin E was selected for its antioxidant properties. As at October 2011
the study is still ongoing, but I will report on its findings once it is
completed. In the meantime, please do not
supplement Vitamin E without your vet's approval.
As explained above, you
should only use iron supplements when tests indicate that they are
required, so be guided by your vet regarding when and if to start one.
Pet Education
discusses iron requirements
in cats.
Iron supplements can be given orally
(usually daily) or a
monthly injection can be given, though the injection is into muscle so it
can be painful. Iron
supplements may cause constipation or stomach upsets.
In theory iron should be taken on an empty stomach, but taking it with
food may reduce the risk of stomach upsets.
Bacteria thrive
on iron. Therefore if a cat has an infection or
inflammation, the cat's body will sequester iron (i.e.
iron is stored
away rather than released into the bloodstream)
so as not to feedthe bacteria. This means
that the cat's body will be unable to use any iron you give. In
most cases, the infection or inflammation will only be short-term, and the
cat will be able to manage without a supplement.
Sequestering does not happen
with heme iron (iron from meat), so if your cat definitely needs
iron, you could ask your vet about feeding a small amount of
chicken liver(one or
two tablespoons, once or twice a week).
Most cats seem to like liver, and although you
should not give liver too often or in large quantities because it contains
very high levels of Vitamin A and is also high in
phosphorus, the above dosage should be safe, but do discuss with your vet.
Cats who begin treatment with an ESA
such as Epogen or Aranesp are usually given iron
supplements because the cat's body is busily making new red blood cells,
so there is an increased demand for iron to assist with this process.
If your cat does not respond to an ESA and you are giving the ESA in
sufficient quantities and frequently enough (see
Erythropoiesis
Stimulating Agents), consider the possibility of low iron levels and check
for iron deficiency as explained
above.
Pet
Place has some information about iron toxicity.
Iron dextran is an
injectible form of iron. It may be prescribed by your vet because it works
quickly and does not cause gastro-intestinal upsets, whereas oral iron may
cause an upset stomach and absorption can be a bit hit and miss. Iron
dextran also lasts about a month, so there is no need to medicate your cat
each day.
The downsides are that
it may cause a severe allergic reaction in a small number of cats, and the
fact that it lasts about a month can be a negative if the cat does not
really need supplemental iron.
If you do use iron
dextran, your vet will usually give the shot. You should not use oral iron
supplements if a shot has been given.
Fer-In-Sol
is an infant iron supplement
containing ferrous sulphate which may be suitable for some cats.
The formulation changed recently so the dropper is marked 0.5ml to provide
7.5mg of iron. A 10lb (4.5kg) cat might receive
5mg of iron a day, so the dosage appears to be 0.33 ml
once a day; but do check with your
vet about dosage, since this is not a veterinary product. Please note this
is only iron, so you may need to supplement B Vitamins separately.
UK
We used an iron supplement from Boots the
Chemist called Sytron, which contained 27.5mg of iron per 5ml. Your vet
can suggest an alternative brand and give advice on dosage.
Spatone
is
an interesting possibility. This is a spa water which contains naturally
occurring iron. The manufacturers claim that using iron in this way makes
it more easily absorbed into the body. The manufacturers know of several
dogs taking the product without problems, and one
Tanya's CRF Support Group
member is now
using this product on her cat with her vet's approval.
Spatone is sold in sachets, and a box of 28
sachets costs £6.90, though discounts may be available for four boxes of
28 sachets or more. It is available in Boots. The product does taste of iron, so the manufacturers
recommend giving the product in additional water. They suggest using
0.5-1.5 sachets per day in cats, which would be the equivalent of 100mg of
ferrous sulphate.
Apparently Spatone is
also available in Canada.
Combined Supplements Containing Iron
It can be easier to use a combined product. There are
two popular combined iron and vitamin B products on Tanya's Support Group:
NutriVed
B Complex Plus Iron
contains B vitamins and iron. The usual
dose is 0.1ml per lb of cat, twice a day (which equates to 5mg of iron
twice a day) so a 10lb (4.5kg) cat would need 1 ml twice a day, but do
check with your vet in case your cat needs a different dose. It
does contain sugar, so may not be suitable for diabetic cats.
I used NutriVed for my anaemic cat, Ollie, with no problems. I
simply mixed his twice daily dose into a small amount of
baby
food and he gobbled it up.
Thriving Pets sells NutriVed for US$9.95.
Handling costs US$2, shipping charges are determined by weight.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Healthy Pets
sells NutriVed at a cost of US$9.99 for 4
oz.
Natural Pets
also sell Nutrived for
US$9.99. This is essentially the same company as Healthy Pets, but I'm
giving it here in case it has offers available.
NutriVed Sources: UK
Natural Pets
sell NutriVed for US$9.99
and will ship to the UK. Shipping via USPS Express Mail for one or
two bottles costs around US$29.
Thriving Pets sells NutriVed for US$9.95.
Handling costs US$2, shipping charges are determined by weight. It will
ship to selected clients in selected countries.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Pet-tinic (Pet-Tabs Iron-Plus)
Pet-tinic,
now also known as Pet Tabs Iron Plus, is both an iron
supplement and Vitamin B supplement, though for some strange reason it
does not contain folic acid. The usual dose for a 10lb (4.5kg) cat
is 1 ml twice a day (which equates to 5.4mg of iron a day), but do check
with your vet in case your cat needs a different dose. It
does contain corn syrup, so may not be suitable for diabetic cats.
Pet-tinic Sources: USA
KV
Vet Supply sells Pet-tinic at US$6.85 for 4 oz, with free shipping for
orders over US$50. Search for item 40168.
Thriving Pets sells Pet-tinic for
US$12.95 for 4 oz. Handling costs US$2, shipping charges are determined by
weight.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Pet-tinic Sources: UK
KV
Vet Supply will ship Pet-tinic to the UK or Canada. It costs US$6.85
for 4 oz, but shipping is relatively expensive, so it is usually more cost
effective to order more than one bottle at a time. Search for item 40168.
Thriving Pets sells Pet-tinic for
US$12.95 for 4 oz. Handling costs US$2, shipping charges are determined by
weight. It will ship to selected clients in selected countries.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Iron and Vitamin B with Potassium (Kaminox
or Amino B & K)
If you are in the UK, you may be offered a product called
Kaminox. This is a combination of B vitamins, iron and potassium.
Alfamedic
provides a list of the ingredients.
In the USA there are two products available containing potassium and B
vitamins,
Renal K+ made
by Vetoquinol, and Amino B & K from
Emerson Ecologics. Amino B & K also
contains some iron but Renal K+ does not appear to.
I would not recommend using these products unless your cat
has
low
potassium levels, which not all CKD cats do;
giving potassium when it is not needed can be very dangerous.
ACE inhibitors such as
benazepril (Fortekor) may make potassium levels rise; so if your vet has
prescribed Fortekor, as so many British vets do, it might be wiser to use a
different type of B Vitamin without the potassium.
Iron and Vitamin B with Potassium: UK
Vet UK
sells Kaminox for £29.49 for 120ml, with free
UK shipping.
If anaemia is not too severe, anabolic
steroids may help improve anaemia or at least slow down its progression.
They may also be beneficial for CKD cats with
muscle wasting and as an appetite stimulant.
Steroids may damage the liver so your vet
will need to monitor your cat's liver values.
There is more information about steroids on
the
Treatments
page.
Erythropoiesis Stimulating Agents (ESAs)
Another possible treatment for anaemia is
an erythropoiesis stimulating agent. These treatments are sold under the
trade names of Epogen, Eprex, Procrit, Aranesp or NeoRecormon. This
is quite a complex subject, so it has its own page
here.
Cats can receive blood transfusions just
like humans. They are sometimes used in severely anaemic CKD cats who need
support whilst waiting for an ESA such as Epogen to take effect, or in
cats who have lost a lot of blood suddenly (e.g. a road
accident or severe gastro-intestinal bleeding) or who have developed the
antibody reaction to
ESAs. As a rough guide, it is worth considering a
transfusion for a cat with a PCV or HCT below 13%, especially if the cat
seems to be struggling to cope with the anaemia, or if the PCV or HCT has
fallen very suddenly, which gives the cat's body less time to adapt to the
anaemia.
A blood transfusion is not a major
procedure, and normally the cat only needs to stay at the vet's for 3-4
hours; just long enough to receive the blood (which is given slowly) and
to be monitored for a possible reaction (occasionally
diarrhoea and nausea are seen with a poorly matched transfusion). Ideally the cat's PCV or
HCT will
double, though this does not always happen. Nevertheless, most cats feel
and act much better immediately following their transfusion, and with a
well-matched donor (see
below), the
effects may last for 4-5 weeks, although it will be
less if the cat is experiencing ongoing blood loss (e.g. gastro-intestinal
bleeding).
If your cat has a blood
transfusion, you should not give him/her any supplements containing iron
because there is a risk of iron toxicity.
The Merck Veterinary Manual has an overview of blood transfusions. It explains how to calculate
what level of PCV or HCT you can expect to see after a well-matched
transfusion.
A (the most common, particularly in
non-pedigrees)
B (relatively common in pedigree cats); and
AB (rare)
However, unlike humans, cats do not have a
universal donor (in humans, if blood type is not yet known, the person can
be given the universal blood type, O negative, to tide them over with no
adverse effects), although type AB cats can receive blood from either type
A or B donors.
In an emergency case such as a cat who is
going to die anyway without the transfusion (e.g. after a traffic
accident), a vet may do a transfusion without checking the blood types,
and in the case of the average cat, this will often not result in disaster
the first time it is done, though it is far riskier for pedigree cats who
tend to have the rarer blood groups. If time permits (as it
usually does for CKD cats), it is far safer to type or cross-match a
cat's blood type before a transfusion. Unfortunately,
blood typing may not be accurate in cats with a PCV or HCT below 10%.
Whole blood transfusions in 91 cats: a clinical
evaluation
(2004) Weingart C, Giger U, Kohn B Journal of
Feline Medicine and Surgery6 (3) pp139-148 concludes that
"with proper donor selection and appropriate compatibility screening,
blood transfusions are well tolerated, appear effective, and may increase
chances of survival."
Typing means that you find a cat with the
same blood group as your cat, and obtain blood from that cat. For example,
if your cat has type B blood, then you find another cat with type B blood
to act as the donor.
Cross-matching means that further tests are done to
check whether the typed donor cat's blood is compatible with the
recipient's blood. This is important because there are further factors
within cats' blood, so even if typing has been done, there is still a risk
of a reaction if the blood has not been cross-matched, which in severe
cases may cause shock and even death. Even if a donor
cat's blood has been successfully cross-matched once, it is safest to
cross-match it again before using that cat as a donor once again, because
the recipient cat may have built up antibodies to the donor cat's blood.
DMS
Laboratories sells kits
for vets to type and cross match feline blood themselves.
Colorado
State University Diagnostic Laboratory will type feline blood in the USA for US$38.25, and
cross-match it for local clients for US$32 (click on Test Schedule, then
on Clinical Pathology), though your vet may know of a local laboratory
which can do this. If you cross-match, you do not need to type the blood
as well, that will be done as part of the cross-matching.
NationWide Laboratories
(UK) has an interesting article about feline blood
typing, and can type blood for you with results
available the same day.
The University of Bristol
offers feline blood typing for £23 and cross matching for £27, with both
tests being turned around on the day of receipt. Click on Submission
Forms, Immunology for the application form and on Information and
Services, Pathology Charges for current prices.
Obtaining Blood
The main problem with blood transfusions tends to be
finding a donor cat at all, particularly at short notice. You may be able
to use another cat in your family as the donor, or your vet may be able to
find a cat (many vets occasionally offer their own cats as donors).
When choosing a donor, naturally you want
one who has been tested and found to be free of infectious diseases such
as feline leukaemia. The donor also has to be healthy and big enough to
give blood without any adverse effects for himself/herself - usually a
donor must be at least 9-10 lb in weight. In addition, a donor usually
cannot give blood more often than every two months. If the donor cat meets
these criteria, there are no side effects for him/her, and it does not
appear to be any more stressful than a standard vet visit for either the
donor or the recipient.
Alternatively, there are a
limited number of feline blood banks which may be able to help,
including:
Cat Blood
Donorsin the UK
does not stock blood itself, but maintains a database of donor cats which
British vets can access free of charge.
Canada
The Canadian Animal Blood Bank
does not stock feline blood, but will provide advice and certain supplies
on obtaining blood safely. The US blood banks mentioned above may be able
to ship feline blood to Canada if required.
Oxyglobin
(Synthetic Blood)
Oxyglobin is a synthetic blood product
containing haemoglobin, which is approved for use in dogs as a single
treatment only. It does not contain red blood cells, so its effects are
short-lived (a couple of days). Since it is designed for dogs rather than
cats, there is a risk of volume overload when using Oxyglobin (only 4% of
a cat's body weight is accounted for by blood volume, whereas in dogs the
level is 7%). It is therefore better to use feline blood for a
transfusion, but in case of urgent need, a one-off use of Oxyglobin might
help buy you some time while you search for a suitable blood donor.
Unfortunately, as with ESAs, a cat may
eventually develop a reaction to blood transfusions, and the odds seem to
increase with each transfusion. The limit is thought to
be roughly five transfusions per cat. At the beginning, each
transfusion lasts around five weeks, but this time tends to reduce with
each transfusion until eventually a transfusion may only buy the cat a few
days. However, there have been a few members of
Tanya's CRF Support Groupwhose cats
have lived for much longer because of transfusions. One
cat managed nine months on transfusions after developing the
antibody reaction to Epogen, and he eventually only needed transfusions about once
a month. Another cat had forty transfusions over a
period of more than two years with no problems (the exact cause of
this cat's anaemia is unknown). He was given an antihistamine before each
transfusion to minimise the risk.
If your cat
has severe non-regenerative anaemiabecause of CKD but is
not yet critical (in which case your cat might need a transfusion
to tide him/her over until the ESA kicks in), I would recommend using ESAs
instead of transfusions, keeping transfusions in reserve in case your cat
does develop a reaction to ESAs, at which time you could probably buy your
cat some more time by using transfusions. This should be safe because
developing a reaction to an ESA such as Epogen does not increase the
chances of your cat developing a reaction to donated blood. Cats with the
antibody reaction to ESAs may need transfusions fairly frequently to start
with while the body is dealing with the ESA antibodies, but the period
between transfusions may lengthen over time as the antibodies go away
(this takes approximately 4-8 weeks, though may take longer in some cats).
It is a real effort for anaemic cats to do
simple things like jumping onto beds or climbing stairs; Thomas did not
use the stairs for three weeks and simply stayed upstairs until he became
stronger. It is a kindness to your cat if you can minimise the effort
required to do simple tasks like visiting the litter tray. If you have a
litter tray downstairs but your cat prefers to stay upstairs, place an
extra litter tray upstairs not too far from your cat's favourite spot (but
away from food and water). If the litter tray has a high edge which is
hard for your cat to climb over, you may need to provide a litter tray
with a lower edge until your cat has regained some strength.
Similarly, provide food and water near to
your cat's favourite place - he or she will be more inclined to eat if it
doesn't involve an epic trek to the food bowl.
Also try to reduce the amount of climbing your cat
has to do: Thomas decided his favourite place was the bed, so we arranged
a series of footstools, piano stools and so on in order to create a kind
of stairway up to the bed. We also placed Thomas's food bowls on the
bed and his water bowl on the bedside table so he only had to get down in
order to use the litter tray. But do be aware that occasionally a cat may
no longer jump and climb because of blindness caused by
hypertension.
Pet Planet in the UK sells a
number of different ramps and steps.
Anaemic cats feel very cold, even in
summer. The best treatment we could find, apart from treating the anaemia
of course, was a heat pad. This is a small flat heated pad with a fleecy
cover - it looks like a little flat cat-sized bed. Thomas had long legs
but we found the 12 inches square bed was fine for him because anaemic
cats tend to hunch up because they are cold.
Heat pads are designed for people with
problems such as arthritis, but are excellent as electric blankets for anaemic
cats because you just plug the heat pad into the mains, choose from three
temperatures and then the pad stays at the chosen temperature constantly,
unlike a hot water bottle. You must of course keep an eye on your cat
while he or she is using this since it is electrical equipment, and I
would not use one for a cat who is incapable of moving if s/he gets too
hot. We never had any problems with overheating, and Thomas found it very
comforting when his anaemia was bad, whilst Harpsie loved his when he
developed arthritis.
Litterboy
sells a variety of heated beds
in the USA - click on Shop by Sub-category and choose Heated Mats, Beds,
Sills.
Boots the Chemist
in UK sells a heatpad for £20.95
which is similar to the one we used for Thomas when he had anaemia.
Pets at Home
sells a non-electric thermal
bed for £32.99.
Summary
I know this can all seem
overwhelming, so here's a short summary:
If your cat is anaemic,
however severely and whatever the cause, start giving B vitamins immediately.
Vitamin 12 in the form of methylcobalamin may be particularly helpful. See
Vitamin B
for more information.
If you can ascertain a cause
other than the CKD, treat it - this may be sufficient to get the anaemia under
control. For example, anaemic cats with infections should improve a lot once
the infection is brought under control. Cats with gastro-intestinal bleeding
may need a treatment such as
sucralfate.
In some cases, treating these other problems may improve the anaemia to such
an extent that you will not need to start an ESA just yet.
If your cat has an iron
deficiency or is about to start an ESA such as Epogen or Aranesp, ask your vet
about an iron supplement. Otherwise it is usually better not to use iron
supplements, especially not in cats with infections.
In cases of mild anaemia
(PCV or HCT above 19%), anabolic steroids may help to some degree, though they
are not commonly used these days.
For severe non-regenerative anaemia (PCV or
HCT below 20%) caused by the CKD (because of a lack of the hormone,
erythropoietin, which the damaged kidneys can no longer properly produce), you
will need to consider the use of a synthetic version of the hormone such as
Epogen or Aranesp, especially if your cat is showing
symptoms
of anaemia. The
Erythropoiesis
Stimulating Agents page
explains more about these treatments in great detail.
If your cat's anaemia is extremely severe
(PCV or HCT below 13%), then whatever the cause you may need to provide a
blood transfusion to keep your cat going and buy you the time to get to the
bottom of the problem and start other treatments as appropriate.
Remember: anaemia is almost
always treatable, so don't give up hope! Thomas went from being unable to walk
downstairs to going outside hunting (yes, I know, not his best characteristic
but he had been a stray for years and old habits died hard) once his anaemia
was under control.
Harpsie doing his bit to
keep Thomas warm when he had anaemia.
TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE
EXTREMELY DANGEROUS.
I have
tried very hard to ensure that the information provided in this website is
accurate, but I am NOT a vet, just an ordinary person who has lived
through CKD with three cats. This website is for educational purposes
only, and is not intended to be used to diagnose or treat any cat. Before
trying any of the treatments described herein, you MUST consult a
qualified veterinarian and obtain professional advice on the correct
regimen for your cat and his or her particular requirements; and you
should only use any treatments described here with the full knowledge and
approval of your vet. No responsibility can be accepted.
If your cat
appears to be in pain or distress, do not waste time on the internet,
contact your vet immediately.
This site was
created using Microsoft software, and therefore it is best viewed in
Internet Explorer. I know it doesn't always display too well in other
browsers, but I'm not an IT expert so I'm afraid I don't know how to
change that. I would love it to display perfectly everywhere, but my focus
is on making the information available. When I get time, I'll try to
improve how it displays in other browsers.
You may print
out one copy of each section of this site for your own information and/or
one copy to give to your vet, but this site may not otherwise be
reproduced or reprinted, on the internet or elsewhere, without the
permission of the site owner, who can be contacted via the
Contact Me
page.
This site is a labour of love on my part. Please do not steal from me by taking credit for my work.
If you wish to
link to this site, please feel free to do so. Please make it clear that
this is a link and not your own work. I would appreciate being informed of
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