Feeling Overwhelmed? Take a Deep Breath and Start Here

Still Overwhelmed? Pat's Great Advice for Those New to CRF

Introduction - First, Take a Deep Breath

You've just been told your cat has CRF and you are scared and frightened. So you found this site, and now, to add to your woes, you feel overwhelmed by all the information here. Clearly this is a complicated disease and you are not sure you can deal with it!

Well, take a deep breath because, honestly, it is not that bad. I had no scientific training at all when I first began dealing with CRF, in fact I was a linguist who was intimidated by scientific subjects, which I absolutely hated at school. But I did manage to learn about it, because it was essential if I was going to save Thomas's life; and you can do the same. Remember, knowledge is power! You need to be able to understand what is going on with your cat so you can obtain the most suitable treatments for him/her.

The good news is, you won't need to learn everything at once; and you certainly won't need to learn as much as I have. This site aims to cover every eventuality regarding CRF, but most people find they only have a few issues to tackle, needing maybe 10-20 minutes a day (including time needed to give fluids if necessary). You are highly unlikely, for example, to be faced with all the symptoms or to need to use all the treatments mentioned below. Yes, CRF is scary at first, but given time you should find that it becomes a manageable and routine part of your lives.

This page is a summary page. The goal is to tell you:

• what the main test results mean;

• what are commonly seen symptoms of CRF; and

• what treatments are commonly used.

This page has links to more detailed information about each issue that is mentioned. However, I recommend that the first time you visit this page, you read it in its entirety without following any of the links, so as to obtain a general overview of what lies ahead.

I Don't Know What the Test Results Mean or Which Are Important

The tests which your vet runs will confirm the existence of CRF, and give some idea of how bad your cat's case is. Most people don't have the faintest idea what most of the test results mean, so to get you started, here is a summary which tells you what the main test results mean and what sort of symptoms they may cause. 

You should ask your vet for a copy of all the tests that are run, because these are helpful if you join the Feline CRF Information List. However, you can still join even if you do not yet have a copy of your cat's test results.

Tests: Bloodwork

Your vet will probably run :

1. a blood chemistry panel, which checks kidney function and looks for any other abnormalities caused by poorly functioning kidneys; and

2. a complete blood count (CBC), which looks at the cat’s blood cells. This enables the vet to check for anaemia, a common problem in CRF cats.

You will probably have 1-2 pages of results, but the six items discussed below are the most important for you to understand at the beginning. If your cat's results show other items that are out of range, such as calcium, you should be able to find more information about these on the What Do All Those Test Results Mean? page.

If your vet has not addressed any results which are out of range, be sure to ask them why. Not everything needs treating (high cholesterol, for example, is not a worry in cats as it is in humans) but the items mentioned below do need treating.

The USA uses a different measuring system to the rest of the world. The Feline CRF Information List tends to use the US measurement system, so if you join, you will get more responses if you convert your international values to American ones. The Veterinary Information Network converter will do this for you. Scroll down the list to find what you want to convert (e.g. creatinine) and enter your cat's value in the "Enter SI Units to Convert to US Units" box. There is no need to convert potassium or PCV/HCT, which are the same in both systems.

 BUN (blood urea nitrogen) or Urea

If you are in the USA, you should see blood urea nitrogen (BUN) on your cat's bloodwork. In Europe, you will probably see urea listed instead, which is not exactly the same thing but very close. 

BUN is one of the two main measures of kidney function (the other one is creatinine). In a cat with CRF, BUN will normally be elevated. BUN is a by-product of the breakdown of dietary protein during the digestive process. The kidneys filter it out of the blood and excrete it via urination. BUN rises in CRF because the damaged kidneys are no longer able to excrete it efficiently, so it builds up and makes the cat feel poorly. It is sometimes referred to as a uraemic toxin (there are several of those). BUN can also rise for other reasons though, such as dehydration, stress or a high protein diet, so it is not an entirely accurate measure of kidney function by itself.

It is important to try to control high levels of BUN because they can cause lack of appetite, stomach acid, nausea and vomiting. 

BUN can be controlled via fluid therapy and dietary management. Treatments for stomach acid are also very useful and can make a CRF cat feel much better.

You can read about BUN in more detail on the What Do All Those Test Results Mean? page. 

Creatinine (Crea)

Creatinine is another waste product excreted through the kidneys. It is generally considered to be a more accurate measurement of underlying kidney function than BUN or urea because it is less affected by diet, stress and dehydration.

Because creatinine is the basic measure of kidney function, you will probably not be able to reduce it to within normal range in a CRF cat, but that does not mean that it cannot reduce from the level you see at initial diagnosis. If you treat CRF effectively, it may well lead to improvements in creatinine levels, so try not to panic if your cat has high levels to start with.

You can read about creatinine in more detail on the What Do All Those Test Results Mean? page. 

Phosphorus (Phos, P or Pi)

Phosphorus and calcium are minerals which are important for nerve function, muscle contraction and bone formation. A healthy body has a natural balance between levels of phosphorus and calcium. CRF kidneys can no longer excrete phosphorus properly so levels of phosphorus rise (hyperphosphataemia), which can then adversely affect the cat's calcium levels, with potentially serious consequences (see secondary hyperparathyroidism). Not only that, but high phosphorus levels may make the CRF progress faster and can make a cat feel lousy. So controlling phosphorus levels is one of the most important steps in managing CRF and helping your cat feel better.

Symptoms of high phosphorus levels may include weakness, an unsteady walk, itching and scratching, loss of appetite, twitching and weight loss.

Your vet may say that your cat's phosphorus levels are within normal limits, but the high end of the normal range actually applies to kittens rather than to adult cats, particularly those with CRF. Dr Katherine James of the Veterinary Information Network and Dr Larry Nagode of Ohio State University strongly recommend actively controlling phosphorus levels once they are above 1.9 mmol/L/l (US: 6 mg/dl).

Phosphorus levels can usually be easily controlled by adding odourless, tasteless phosphorus binders to your cat's food, see below.

You can read about phosphorus in more detail on the What Do All Those Test Results Mean? page. 

Potassium (K+)

Potassium is an electrolyte (a type of salt), which the body needs in order to function properly at the cellular level. If potassium is out of balance, it can affect the muscles, including the heart.

Cats with CRF usually urinate a lot, and may also vomit, and this can cause loss of potassium, leaving levels low in the cat's body. However, a few CRF cats have the opposite problem of too high levels of potassium, particularly if they have high creatinine levels.

Low potassium levels (hypokalaemia) can have various effects, such as weakness (especially in the back legs), twitching, hoarseness or constipation. Severe cases may be unable to lift their heads because of a weak or stiff neck.

Although the range for potassium often starts at around 3.5, for CRF cats it is recommended to treat low potassium levels when they fall to 4.0 mmol/L/l (US: 4.0 mg/dl) or less The goal is to have a level of around 4.4 mmol/L/l (US: 4.4 mg/dl) or a little higher. The usual treatment method is a supplement in the form of a pill, though it does come in other forms too if your cat is difficult to pill.

Not all CRF cats have low potassium levels. Cats with a level of 4.4 or higher do not usually need supplementation of potassium. Cats with high levels of potassium (over 6.0) may experience twitching, seizures, and in the worst case scenario, even a heart attack.

There is information below about treating high or low potassium levels.

You can read about potassium in more detail on the What Do All Those Test Results Mean? page. 

TCO2

Acidity levels in the body tend to rise  in CRF cats i.e. the body’s pH becomes too low – this is known as metabolic acidosis. It is not the same thing as stomach acid, which is excess production of acid in the stomach only.

Unfortunately many vets do not watch for metabolic acidosis routinely, which is partly because it can be hard to measure. TCO2 or total carbon dioxide in the blood is the most accurate way to diagnose metabolic acidosis but TCO2 has to be measured on a special blood gas machine, which not many vets and not all laboratories have. If your vet or his/her laboratory cannot measure TCO2 at all, your vet may be able to test for carbon dioxide (CO2) levels instead - if they are low, they may also indicate metabolic acidosis. 

Metabolic acidosis can have a variety of effects, including muscle wasting, a bony spine, back leg weakness, vomiting, mouth ulcers, twitching and seizures, so it is very important to diagnose and treat it if it is present.

Treatments may include fluid therapy, potassium citrate or bicarbonate of soda.

You can read about metabolic acidosis in more detail on the What Do All Those Test Results Mean? page. 

PCV or HCT

The kidneys produce a hormone called erythropoietin, which stimulates the bone marrow to make red blood cells. Damaged CRF kidneys may no longer perform this task properly, and if red blood cells are not made, anaemia is the result.

PCV and HCT are both used to measure anaemia. Your vet will run one test or the other. PCV is not quite the same thing as HCT; but the difference between the two is too small to be concerned about. 

Technically, a cat is anaemic if his/her PCV level is below 30% (or with some laboratories, 25%), but you may not start to see any differences in your cat's behaviour until the level is in the low 20%s. Dehydration will make PCV look higher than it really is, so once a cat is rehydrated, PCV will often have fallen.

Symptoms of anaemia include weakness, loss of appetite, heavy breathing, feeling cold, eating litter or licking cement.

It is essential to treat anaemia. Cats with a PCV or HCT below 20% have severe anaemia, and you have to treat it quickly, because untreated severe anaemia can be life threatening. Cats who are severely anaemic may appear very ill (though some of them adapt to the anaemia if it happens gradually and cope quite well), but you should see a dramatic difference once the anaemia is under control. Treatments include iron or vitamin B supplements for milder cases, or the use of a synthetic hormone replacement (trade names are Epogen, Procrit or Eprex) for more serious cases.

You can read about anaemia in more detail on the Anaemia page. 

Other Tests

Blood Pressure

Hypertension (high blood pressure) is very common in CRF cats, because the kidneys produce renin, which controls blood pressure, but damaged kidneys may not do this effectively.

High blood pressure is very dangerous - it can cause strokes, seizures and blindness, and may even kill; but since it has few visible symptoms until a crisis occurs, it really needs to be measured with a blood pressure monitor.

Unfortunately, many vets do not have the equipment to measure blood pressure (even though it only costs about US$1000). Do ask your vet if s/he has this equipment, and if so, make sure s/he uses it to check your cat's blood pressure. If they do not have it, politely ask them to consider investing in it, and then call around other vets in your area (or ask your vet to do so) to see if you can find somebody who can measure your cat's blood pressure. If you cannot find anybody to measure it, check the Symptoms page for alternative checks, though they are far from ideal.

If blood pressure is consistently over 160, it should be treated. This is easily managed through the use of a medication called amlodipine (known as Norvasc in the USA and Istin in many parts of Europe).

You can read about high blood pressure in more detail on the What Do All Those Test Results Mean? page. 

Urinalysis

This is a test of your cat's urine. It may include a check of Urine Specific Gravity (USG), which tells your vet how dilute your cat's urine is (CRF cats usually have very dilute urine). It often will also give the vet some information on whether your cat has a urinary tract infection (UTI).

You can read about urinalysis in more detail on the What Do All Those Test Results Mean? page. 

Ultrasound

Sometimes vets want to run an ultrasound of a cat's kidneys. This can be helpful if a cat has larger than expected kidneys (which may indicate cancer, a blockage of some kind or a genetic disease known as PKD), or if you suspect a kidney infection. However, in many if not most cases of CRF, an ultrasound merely confirms that a cat has CRF and adds nothing to the overall treatment plan. If this is the case for your cat, it is probably worth passing on an ultrasound and saving your money.

You can read about ultrasound in more detail on the What Do All Those Test Results Mean? page. 

There are a number of other tests which are occasionally offered, and you can find more information about them on the What Do All Those Test Results Mean? page. 

So Just How Sick is My Cat?

People are often scared stiff when their vet says things like "your cat only has 25% kidney function remaining" but actually, it is normal not to be able to diagnose CRF until 66-75% of kidney function is gone. The  What is CRF? page explains why this is the case.

The word "failure" in CRF also terrifies most people when they first hear it, but in fact the word "chronic" is what matters. This means that in most cases, CRF is a progressive disease, and therefore death is not necessarily imminent.

The How Bad is It? page gives you some idea of how serious your cat's bloodwork results are but remember, these are not the be-all and end-all. How sick your cat is depends upon whether s/he is in crisis or not at diagnosis, and also on how well your cat copes with CRF - some cats can cope astonishingly well with horrible bloodwork.

Cat in Crisis: Crashing

Many cats who are diagnosed with CRF are in crisis (known as "crashing") because of dehydration. CRF cats tend to urinate more as their kidneys deteriorate. The cat then drinks more to compensate for the increased urination, but eventually s/he can no longer drink enough to keep up with the fluid lost from dehydration, and s/he crashes.

Before you go to the vet, here are some of the signs you may see:

• the cat will often be unable to get comfortable and may lie in the meatloaf position (a bit like a Sphinx; click for photo);

• you may notice a bad breath smell, and your cat may also have a generally strong body odour;

• he/she will have dull, perhaps sunken eyes and not make eye contact;

• your cat will probably refuse to eat and may also refuse to drink.

When you reach the vet, and bloodwork and other tests are run, you will usually be told that your cat's bloodwork values are very high. This occurs because severe dehydration artificially inflates most of the values.

I cannot emphasise this enough: it does not matter how bad your cat's values are at initial diagnosis, particularly if s/he is severely dehydrated. You have to wait and see what they look like when the cat has been stabilised. My Thomas's BUN was 241 at initial diagnosis (the top of the range was 36) yet he pulled through.

If your cat is in crisis, the first thing to deal with is the dehydration. This will usually be treated via intravenous (IV) fluids (a drip), which requires hospitalisation for a few days. Personally, I would want to put any cat of mine with creatinine of over 6 on IV for 3-4 days (one day is not enough).  As the cat becomes rehydrated, s/he should gradually start feeling and acting a little better, though some cats do not do well as in-patients and will only turn the corner once they return home.

The cat may continue to exhibit a loss of appetite, so it is essential that sh/e eats, via assist feeding if necessary. Since cats with high BUN tend to have problems with stomach acid, ask the vet to treat this too.

A cat with high bloodwork may also have anaemia, and will almost certainly have high phosphorus levels. Hypertension (high blood pressure) may also be present. Treatment needs to be started for all of these as appropriate. I do not advise starting Fortekor treatments for cats with high creatinine levels.

Your cat may still have high numbers when you bring him/her home, but don't panic, they may continue to fall with a home treatment programme, as happened to our Thomas. Once your cat is home, you can follow the advice for the stable cat below.

The Stable Cat

If your cat is not in crisis, then creatinine levels will usually be 300-350 or below (USA: 3-3.5 or below). Yes, those numbers are still a lot higher than they should be but really, they are considered medium level numbers. They may even be higher - some cats cope better with high numbers than others.

Whatever the level, if your cat is not in crisis and dehydrated, then it is highly unlikely that your cat needs IV fluids. I have heard recently of some vets putting non-crashing cats with creatinine of 300 (USA: 3) or lower on IV fluids, which seems like overkill to me - chances are these cats do not even need regular sub-cutaneous fluids, let alone IV fluids; plus it's much cheaper for you and less stressful for your cat if you can avoid IV fluids.

However, you will probably need to begin a home treatment programme. This need not be particularly complicated if your cat has been diagnosed early enough. In that case, you will probably merely need to focus on the things that will keep your cat stable (e.g. controlling phosphorus levels, and, for cats with creatinine over 300 (USA: 3.5), perhaps giving sub-Q fluids regularly to prevent dehydration), and comfortable (e.g. controlling constipation or stomach acid). Basically, you need to check the bloodwork and symptoms, see what issues may be a problem, and take the appropriate action.

Most people find they only need to spend 10-20 minutes a day dealing with their cat's additional CRF needs, and that includes time spent giving fluids (which not all cats need immediately). If you focus on any problems that are present and have a bit of luck on your side as well, you should soon see a big improvement in your cat's wellbeing. For more detailed information on the symptoms which you might be seeing, see the Index of Symptoms and Treatments page.

Even when a CRF cat is stable, it is normal for him/her to have the occasional bad day, particularly when first diagnosed. Try not to panic if this happens, just try to treat anything that may be contributing to the problem (e.g. if your cat is constipated, s/he won't feel great) and with luck you will find that once any problems are under control your cat will have a reasonable quality of life overall.

However severe your cat's case may be, if I were to give you only one piece of advice, it would be to make sure your cat eats. Cats who go just a short time (a day or two) without eating are at risk of hepatic lipidosis, a potentially life threatening liver problem. Not eating can also worsen dehydration and make the cat very weak; whereas food in the stomach can often make a cat feel better and stronger. See below and the Persuading Your Cat To Eat page for information on getting food into your cat.

If Your Vet Has Recommended Euthanasia

Recently I have been hearing from more and more people whose cats have only just been diagnosed, yet the vet is already recommending euthanasia. I hear things like "the vet said my cat has anaemia and it's untreatable, so I should put him to sleep", or "the vet says his bloodwork is so high that it can never reduce to a reasonable level" (this even for cats with creatinine of around 300, or 3.5 in US terms), and of course the classic "he's very sick, and it would be the kindest thing to do". Often these vets do not even offer any IV (intravenous fluids) treatment for high number cats, or if they do, they only offer one day, tell the person their cat's numbers have not improved after that short stint, and recommend euthanasia. In some cases people are told even before their cat is placed on IV that if s/he does not respond within 24 hours, they have to opt for euthanasia.

I'm not in the business of vet-bashing, but this trend does give me pause for thought. No vet has a crystal ball. And CRF cats can look horribly ill when they are first diagnosed, particularly if they are dehydrated. I was dehydrated myself last year following surgery, and I definitely looked as bad as I felt. Note I say that I felt bad; but I was not in actual pain. CRF is not generally considered to be a painful disease (although end stage PKD, a genetic kidney disease, may be painful if some of the cysts rupture). Dehydration basically feels like a bad hangover, with a bad headache and a queasy stomach. CRF cats often have stomach acid, so that feels like stomach ache. They may be constipated, and may have anaemia which makes them feel weak. But none of these things is outright painful. And all of these things are treatable, in fact often relatively simple treatments can soon make a CRF cat feel and act much better. 

So I would say that in most cases, you should definitely try treatments, for a period of two weeks if not longer, before opting for euthanasia. And if your cat has high bloodwork levels, then one day on IV fluids is simply not long enough to decide whether a cat is going to turn the corner or not! Read the rest of this page, particularly the Cat in Crisis section, see what problems your cat is experiencing, and do your best to treat them. I cannot promise that treating your cat is going to work. But there is a pretty good chance that it will. And even if it doesn't, at least you would have the peace of mind of knowing that you tried your best. And remember: it is not the vet's decision to put your cat to sleep, it is yours.

Commonly Seen Symptoms

This is a short list of symptoms which may be seen in CRF. Some of these problems, such as constipation, are not life threatening, but they can make a big difference to how well a cat feels. Others, such as not eating, can cause severe problems if left untreated.

Vomiting

Mouth Ulcers

Weakness, Especially in the Back Legs

Many CRF cats are weak at initial diagnosis. This may be because they are dehydrated, or anaemic. Other possible causes include high phosphorus levels, low potassium levels, metabolic acidosis, constipation and calcium imbalances. If you and your vet can work out what the cause is and treat it appropriately, you should find that this symptom improves greatly.

There is more information about weakness on the Index of Symptoms and Treatments page.

Constipation

The dehydration that accompanies CRF may cause constipation. Symptoms - apart from the obvious one of no poop in the litter tray - may include an ungainly walk, vomiting after using the litter tray, loss of appetite, pooping outside the litter tray, and, surprisingly, diarrhoea. Constipation can usually be treated easily and quickly.

Howling

CRF cats often howl, especially at night. Howling is sometimes the result of toxin levels in the blood. However, it may also have other causes such as deafness, hyperactive thyroid, high blood pressure or occasionally just old age and possibly cognitive dysfunction (senility). Certain medications such as periactin (Cyproheptadine), an appetite stimulant, or anabolic steroids, such as stanazole (Winstrol), can make a cat become vocal. 

Refusal to Eat

This is very common in CRF cats. Common causes include stomach acid, high phosphorus levels, dehydration, constipation, fluid retention and loss of sense of smell. Many cats refuse to eat the CRF prescription diets in particular. Treating the cause will usually help, though some CRF cats will always need encouragement to eat.

Twitching

Commonly Used Treatments

The following is a list of some of the treatments which you may be offered. If you are in the UK, I can virtually guarantee that you will only be offered some or all of the first four treatments mentioned, and possibly antibiotics too; but many of the other treatments are equally, if not more important, depending upon your cat's condition. 

Diet

Diet is a popular way of trying to treat CRF. Your vet may prescribe a prescription diet, which is a food that is relatively low in protein and phosphorus. The reasoning is that the low protein is less work for the kidneys to process, whilst lower phosphorus is beneficial for CRF cats, who often have high phosphorus levels.

If your cat will eat these foods, then by all means feed them, though try to introduce them gradually, which increases the chances of your cat accepting any new food.

Unfortunately, loss of appetite is very common in CRF cats, and these foods can be a little dry and many cats find them lacking in flavour. Your vet may tell you it is essential that your cat only eats this food, but cats who go just a short time (a couple of days or so) without eating are at risk of hepatic lipidosis, a potentially life threatening liver problem. So if your cat refuses to eat the prescription food, don't panic - not eating is far worse for him/her.

If you are in the middle of a crisis, feed whatever your cat will eat – baby food (without onion), Hill's a/d. Anything to get some nourishment into him/her. See the Persuading Your Cat To Eat page for tips.

Also try to treat any possible problems, such as stomach acid, anaemia, etc., - once these are under control, you may well find that your cat’s appetite returns.

You can look into getting your cat onto a better diet once s/he is more stable, but be sure to introduce any new food gradually. If you do not succeed, you don't need to despair: it is still more important that your cat eats than that he/she eats prescription foods. The studies that showed low protein food is necessary in CRF were actually done on rats and humans, not cats. Recent studies on cats have not so far shown a clear benefit to cats of a low-protein diet, so low protein intake for CRF cats may not be as critical as was once thought (see Food Composition and Nutritional Requirements).

However, once BUN (urea) is consistently over 60-80, most cats tend to feel better with less protein in the diet to process (but don't worry about this if your cat is in crisis, just get food into him/her, chances are the BUN will fall anyway once the crisis is under control). You may opt to use prescription foods, or try to find other foods with lower levels of protein and phosphorus.

If you are keen to feed a prescription diet, but your cat refuses the food, try a different brand. There are five brands available in the UK:

• Hills k/d. This comes in two formulations, regular, and k/d with chicken - many people find their cats prefer the latter.  Hill's also makes a  g/d diet, designed for early stage CRF when numbers are hardly elevated;

• Royal Canin Waltham Feline Renal Veterinary Diet;

• Purina PVD NF;

• Eukanuba Renal Formula; and

• Specific Kidney Support.  

There are six brands available in the USA:

• Waltham Royal Canin Renal LP21;

• Hill's k/d. This comes in two formulations, regular, and k/d with chicken - many people find their cats prefer the latter. Hill's also makes a g/d diet, designed for early stage CRF when numbers are hardly elevated;

• IVD Select Care Modified (known as MediCal in Canada);

• Eukanuba Multi-Stage Renal Diet;

• Hi Tor Neo. This food is available without a prescription, and is relatively high in fat content, which might be helpful in a cat who is getting too thin;

• Purina NF Kidney Function Brand Formula.

See Obtaining Supplies Cheaply for online suppliers of prescription diets at reduced prices in UK, USA and Canada.

If your cat refuses to eat any prescription foods, aim at least to feed a food low in phosphorus – see the Tinned Food Data and Dry Food Data pages for possible foods. Royal Canin and Techni-Cal are low in phosphorus in the UK, and Sensible Choice is a popular brand in the USA. Certain flavours of Fancy Feast are not necessarily that bad for CRF cats.

There is a lot more information on the Food Composition and Nutritional Requirements, Which Foods to Feed and Persuading Your Cat To Eat pages.

Vitamins

In contrast, additional doses of Vitamins A, C and D are not appropriate for CRF cats.

Please see Food Composition and Nutritional Requirements for more information about vitamins.

ACE inhibitors: Fortekor (benazepril) or Enacard (enalapril)

If you are in any country other than the USA, your vet will almost certainly prescribe a drug called Fortekor (known as Lotensin in USA). Occasionally in the USA vets prescribe a similar medication called Enacard.

These drugs are actually heart medications known as ACE inhibitors. Some recent studies into the use of benazepril in particular indicate that these drugs may help with CRF, at least in the early stages, and therefore Fortekor is approved in Europe and Canada for the treatment of chronic renal failure in cats.

Unfortunately, although Fortekor was approved some years ago, the full scientific studies have still not been published. The evidence that is currently available is not clearcut, and therefore in American veterinary circles the use of Fortekor to treat CRF is controversial. Certainly it is not a miracle treatment; it seems to help some cats but not others. 

The main reason why I am reluctant to use ACE inhibitors is because when first used, these drugs may cause an increase in creatinine, so you should check your cat's bloodwork 7-10 days after starting them, which many vets do not seem to do. I myself would only choose to use Fortekor in a cat with a CRF-related condition known as proteinuria. Personally, I would also not use this treatment if my cat's creatinine level was over 300 (USA: 3.5), because I would be worried that the possible increase in creatinine from using the drug might be enough to push my cat over the edge.

If your cat has hypertension, particularly if s/he has gone blind, ACE inhibitors are not what you need: a drug called amlodipine (Norvasc or Istin) is the drug of choice for CRF cats with hypertension, and may enable your cat to regain his/her sight.

For more information about using Fortekor or Enacard, please see the Treatments page.

Steroids

If you are in the UK and other parts of Europe, you will probably be offered steroids. If you are in the USA, most vets do not seem to use steroids routinely.

Steroids are intended either as an appetite stimulant or as a general pick me up, but they do have possible risks. I did find Thomas did better overall on steroids but he was extremely ill when first diagnosed; cats who are diagnosed early probably would not benefit particularly. You should familiarise yourself with the possible risks before deciding whether to use them.

For more information about using steroids, please see the Treatments page.

Fluid Therapy

If your cat is severely dehydrated with high blood values at diagnosis, then regardless of your location, your vet will probably offer intravenous (IV) fluid therapy (a drip) to rehydrate your cat.

If your cat has lower numbers upon diagnosis or following IV treatment, but the creatinine is over 300 (US: 3.5), you will probably find that he/she does better with regular sub-cutaneous fluids (known as sub-cuts in the UK) to help prevent dehydration. Unfortunately, whilst sub-Qs are routinely offered in the USA, they are very uncommon and hard to obtain in Europe.   

Most cats receiving sub-Qs need about 100ml a day, no more. Your vet can show you how to give sub-Qs to your cat yourself at home, and they can really help to make your cat feel better, although you do need to be sure that your cat does not have a heart condition before using them.

If your cat has creatinine below 3-3.5, the chances are that s/he can maintain hydration without sub-Qs. Sub-Qs are a strain on the kidneys, so there is no point giving them before the benefits outweigh the risks. If your vet recommends them for a cat with creatinine below 3-3.5, ask why.

See Intravenous Fluids and Sub-Cutaneous Fluids for more information.

Stomach Acid

The most effective treatments for stomach acid are Slippery Elm Bark, from health food stores (see Holistic Treatments) and/or a drug called famotidine, trade name Pepcid AC (not Pepcid Complete).

With Pepcid AC, you usually start with a quarter of a 10mg tablet once every other day, but if necessary you can go up to a quarter of a 10mg tablet twice a day (all with your vet's approval, of course).

The Treatments page has more information about Pepcid, and other practical tips on controlling stomach acid and nausea.

Mouth Ulcers

Slippery Elm Bark, which as mentioned above can help with stomach acid, can also be made into a syrup and used to help heal mouth ulcers - this has been found to be a very effective treatment by many people. See Holistic Treatments for more information about Slippery Elm Bark and how to make the syrup.

For severe mouth ulcers, antibiotics may be necessary; while for really obstinate ulcers, you may need to consider using a treatment called sucralfate, which forms a protective coating over the ulcers and allows them to heal. Trade names for this drug include Antepsin in the UK, Carafate in the USA and Ulcogant in Germany.

The Treatments page has more information about treating mouth ulcers.

Constipation

Slippery Elm Bark may also help with this (see Holistic Treatments), or you may wish to ask your vet about Lactulose, which is available OTC in most countries but prescription-only in USA; you usually give 1-2ml twice a day, but you can dose to effect. See Treatments for more information on Lactulose and other treatments for constipation.

Potassium Imbalances

If your cat’s level is 4.0mmol/L (US: 4.0mg/dl) or lower, ask your vet for a potassium supplement – the most common one is Tumil-K. However, do not give potassium supplements without your vet's knowledge and approval - high potassium levels can be dangerous. See Treatments for more information. 

If your cat's potassium levels are high, the first thing to do is to run another blood test because the most common cause of high potassium levels is an error in the measurement. If your cat really does have high potassium levels, the Treatments page has more information on how to deal with this. 

High Phosphorus

If your cat's phosphorus level is above 1.9 mmol/L/l (US: 6 mg/dl), you should ask your vet about using a phosphorus binder: these bind with the excess phosphorus in the intestines and therefore reduce the load on the kidneys. Phosphorus binders must be given with food, and ideally an hour or so apart from other medications.

You may be offered a binder called Epakitin or Ipakitine but this is not always the best choice. Another common choice by vets is Alternagel, but this is peppermint-flavoured, which most cats hate.

The phosphorus binders which bind best contain aluminium hydroxide. Many vets are not aware that these can be obtained in odourless and flavourless formulations and simply added to the cat's food without the cat knowing. Details can be found in Treatments and Obtaining Supplies Cheaply.

Metabolic Acidosis

This means the cat's pH levels are out of balance, causing excess acidity. If your cat’s bloodwork contains something called TCO2 or CO2 and this is below 16, ask your vet about using bicarbonate of soda or potassium citrate to help with this problem. See Treatments for more information.

Cyproheptadine

Whilst cyproheptadine may stimulate your cat to eat, it is better if you can find the cause of your cat's inappetance and treat it. But cyproheptadine can certainly be a useful tool for inappetance at initial diagnosis. I would certainly rather give this than something such as Valium (diazepam).

The Persuading Your Cat To Eat page has more information about cyproheptadine and other appetite stimulants.

Azodyl

Azodyl is essentially a type of probiotic. Probiotics are commonly used to re-balance the bacteria in the gut, particularly after using antibiotics - there is more about them in the antibiotics section.

Azodyl contains strains of three types of bacteria, and the manufacturers of Azodyl claim that their strains of these bacteria have a particularly high affinity for some of the major uraemic toxins found in CRF. Azodyl is intended to bind with and reduce the levels of these uraemic toxins in CRF cats.

I have heard reports from several people who have used Azodyl. Most people seem to think it has helped their cats, though one person said that it made his cat vomit, and some people think it did not make any difference.

Giving Azodyl to cats may be problematic. Firstly, the required dosage is quite high: a cat weighing 5-9 lbs would require three capsules a day according to a table provided by Kibow Biotech which shows dosage requirements according to weight.

Secondly, Azodyl is enteric-coated, which means it is intended to release its contents in the intestines rather than the stomach. For this reason the capsules are intended to be given whole; however, they are a size 1 capsule, which is rather large for many cats. Some people open the capsules and sprinkle the contents on food, though there is no guarantee that the contents will reach the intestines as is intended if you do this. If you do opt for this method of administration, the manufacturers advise doubling the dose.

Whilst Azodyl may be of use to some cats, if you have trouble administering it, I would give it a miss. It is not an essential treatment, and can be pretty expensive.

Antibiotics

Antibiotics are not routinely used in CRF, though some vets appear to prescribe them routinely. However, they may well be necessary for cats with urinary tract or kidney infections, dental infections or severe mouth ulcers. 

The Treatments page has more information about antibiotics.

Anaemia

If your cat’s PCV or HCT level is below 30% (25% for some laboratories), your cat has anaemia. Treatment depends upon how severe the anaemia is:

• If PCV is between 20% and 30%, an iron supplement, B Vitamins or anabolic steroids such as Winstrol-V or Nandoral may be enough to control it.

• if PCV is below 20%, your cat has severe anaemia and you need to treat it more aggressively. If this is CRF-related non-regenerative anaemia, you should consider using a treatment called erythropoietin (rhEpo) which has the trade names of Epogen, Procrit or Eprex, particularly if your cat's PCV is closer to 15% than to 20%. Many vets are extremely negative about using Epogen, but you need to understand that severe anaemia will kill your cat before the CRF does. We began using Epogen for Thomas when his PCV reached 18%. For us, it was a no-brainer since the alternative was to sit back and watch Thomas die of anaemia, and we never regretted using it.

• The above treatments take time to take effect. If your cat's anaemia is particularly severe (PCV below 15%), you may need to consider a blood transfusion to tide you over until the other treatments kick in.

Please see the Anaemia page for more information.

Hypertension (High Blood Pressure)

This is present in up to two thirds of CRF cats, so do ask your vet to monitor your cat's blood pressure; many do not do so routinely. If your cat has suddenly gone blind, the most common cause is hypertension; and if you act quickly enough, your cat may be able to regain some or all of his/her sight.

Even if your cat has not gone blind, if hypertension is present, it must be treated. The treatment of choice for CRF cats with hypertension is a drug called amlodipine (trade names are Norvasc or Istin) This is very well tolerated by the majority of cats, is less likely than some other treatments to cause the opposite problem of low blood pressure, and is the only treatment which gives your cat a chance of regaining his/her sight if it has been lost. See Treatments for more information.

Metacam (meloxicam)

Metacam is a non-steroidal anti-inflammatory drug (NSAID). In cats it is intended to be used as a one-off treatment as a painkilling injection following surgery. However, meloxicam appears to be being used more and more frequently off-label for cats in its liquid (oral) form on an ongoing basis, such as for arthritis. Unfortunately Metacam is toxic to the kidneys and may trigger acute or chronic renal failure. If your cat is taking Metacam when or shortly before CRF is diagnosed, ask your vet about stopping it with immediate effect. There is more information about Metacam here.

Financing Treatment

It is all very well knowing about the treatment options available, but that can be very depressing if money is a factor, as it is for most people. It can be particularly horrifying if your cat crashes and requires hospitalisation - some large city hospitals charge a fortune for such services.

The good news is that you should not need all the treatments described above; and for home treatments, it is usually possible to purchase most of the supplies you require cheaply online. For the average cat who needs sub-Q fluids and phosphorus binders, it is often possible to spend as little as US$5 a week treating your cat once s/he is stable. Other treatments, including Epogen which many vets believe costs up to $300 a vial, can also be obtained cheaply - a vial of Epogen bought online, if you know where to look, costs as little as US$30.

The Coping with CRF page gives tips on coping with the financial burden and finding ways of paying for your cat's care, whilst the Obtaining Supplies Cheaply page gives details of reasonably priced suppliers in UK, Canada and USA.

Pat's Great Advice for Those New to CRF

That is your crash course in CRF. Unfortunately I know you are probably still feeling overwhelmed, so here is some advice for you from Pat, who has been in your shoes. Pat cared for her cat SEM when he had CRF. In early 2006, she wrote a wonderful message to a person with a newly diagnosed CRF cat. She says it all so well here, far better than I could, that I asked her if I could repost her message here.

"I am sorry you have a need to be here but you have come to a good place. First, I can't think of a single individual who hasn't landed here in an emotional heap. It seems not to matter the numbers of the cat or the circumstances of the individual, everyone is devastated.

So... your sweet cat is exactly the same cat the day before the diagnosis as the day after. The only thing that has changed is information in your head. These cats set such very fine examples for us - if they're feeling well, all is well. If they're not feeling well, they need some help. My advice is to face the fear squarely, see it for what it is, and know that it has now moved in with you. But it doesn't require your attention, let it simmer away on the back burner with the lid on and do as it will. In the meantime, you can educate yourself by reading the overwhelming CRF site bit by bit so you can get a jump on anything that develops. That old stitch in time saves nine :-)

There is no cure for CRF (at present). And life itself is a terminal condition. There's simply nothing to be done about that. But there is something to do about cats and CRF and that something is to learn about kidneys and their function and what helps and what doesn't and what shouldn't be done. In the meantime, your girl will not be worrying her pretty head, she will be doing normal cat things:-)

Do get a copy of your blood work and post the numbers to the group (with normal ranges included), and keep copies of all tests and lab reports etc. It is hard dealing with a chronic condition, which is why I urge you to deal with the crux of the matter now and set it aside. There's no way to avoid going up and down emotionally with these cats, that will happen as a matter of course, but if you can, see your cat as very much alive because she is and should remain so for a good long time to come with your attention and love. And her heart is doing the beating, her lungs the breathing, her tongue the washing up. Life still courses through her. If you go crazy, she will have lost a loyal and articulate ally. We surely don't want that to happen:-)"

One last word from me

I know CRF is a scary diagnosis - I've been there twice. The first time, with Tanya, I was not online and although I tried to help her, in retrospect there was so much more I could have done to help her.

It is different for you. You have this website. By all means feel frightened but remember: it is your responsibility to help your cat. Don't view this as scary, because it sure beats the alternative of helplessly watching your cat die, as I basically did with Tanya. Read the site. Educate yourself about the basic items above. In the vast majority of cases, there is hope. You can do it.