KEY ISSUES: HOW BEST TO HELP YOUR CKD CAT
When they first receive the CKD diagnosis, people usually have two main questions:
The How Bad Is It? page can help you with the first question. This page aims to help with the second.
I have written this page for two reasons:
Although this website is relatively simple in its design, it is also
extremely comprehensive, and sometimes people feel overwhelmed at
initial diagnosis and just want a CKD primer. Here I am giving you the
key issues on which to focus in order to help your cat feel better and
give him/her the best chance of survival.
There are a lot of options out there for treating CKD, and many products
competing for your money. If your cat has just been diagnosed, or
his/her condition is worsening after a period of stability, you may be
tempted to buy into these products, hoping for a miracle cure.
Unfortunately, although many of the treatments out there are quite
expensive, very few of them are essential, and most of them are
unproven. Please see the Essential Treatments page to ascertain which
treatments are essential. That page and this section should help you understand which are the proven, essential treatments
for any issues which you might be facing. If you are short of money, you
will be relieved to hear that the majority of the key treatments are
usually available at pretty reasonable prices.
There are ten key issues, which might sound like a lot. However, many
cats will not need all ten to be managed immediately, in fact they may
never have problems with some of them, such as kidney stones; but I would read up on them all
anyway, just so you are prepared in case of need.
So take a deep breath, and start learning about CKD. I suggest you read
this page all the way through the first time, so you get an overview of
the main issues that you may need to deal with. Then you can go through
it all again and click on the links which take you to more in depth
information on the topics which affect you at the moment.
I have written this page for two reasons:
Although this website is relatively simple in its design, it is also extremely comprehensive, and sometimes people feel overwhelmed at initial diagnosis and just want a CKD primer. Here I am giving you the key issues on which to focus in order to help your cat feel better and give him/her the best chance of survival.
There are a lot of options out there for treating CKD, and many products competing for your money. If your cat has just been diagnosed, or his/her condition is worsening after a period of stability, you may be tempted to buy into these products, hoping for a miracle cure. Unfortunately, although many of the treatments out there are quite expensive, very few of them are essential, and most of them are unproven. Please see the Essential Treatments page to ascertain which treatments are essential. That page and this section should help you understand which are the proven, essential treatments for any issues which you might be facing. If you are short of money, you will be relieved to hear that the majority of the key treatments are usually available at pretty reasonable prices.
There are ten key issues, which might sound like a lot. However, many cats will not need all ten to be managed immediately, in fact they may never have problems with some of them, such as kidney stones; but I would read up on them all anyway, just so you are prepared in case of need.
So take a deep breath, and start learning about CKD. I suggest you read this page all the way through the first time, so you get an overview of the main issues that you may need to deal with. Then you can go through it all again and click on the links which take you to more in depth information on the topics which affect you at the moment.
What to Feed
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I know your vet may have told you that your cat simply must eat the prescription diet, that anything else will kill him or her. Eating that food is certainly the ideal. If your cat will eat it, fabulous! Feed it to your cat happily.
But in 11 guidelines for conservatively treating chronic kidney disease (2007) Polzin D, Veterinary Medicine December 2007, Dr Polzin makes the shocking observation that "in many or most dogs and cats with chronic kidney disease, death or euthanasia results directly or indirectly from starvation."
Think about that for a moment. Many CKD cats do not die because they have CKD. They die because they are allowed to starve to death! Are you going to allow your cat to starve to death?
Food is life. Nobody can live long without it. So the first rule is:
GET FOOD INTO YOUR CAT!
Now by food, you may think I mean a prescription kidney diet. If your cat will eat it, absolutely. But if your cat falls into the extremely large category of cats who would rather starve (literally) than eat prescription food, then don't force the issue. You may eventually be able to get your cat onto a diet appropriate for a CKD cat (though quite a lot of people never manage that, and their cats still do fine), but it takes time, and you don't want your cat to not eat in the meantime. Feeding your cat won't kill him or her, but as Dr Polzin points out, starvation can. Plus if you allow a cat to go without eating, s/he can quickly develop a condition called hepatic lipidosis (fatty liver disease) where the liver starts to function abnormally; this can happen after just a day or two of not eating, and can be life-threatening. Mar Vista Vet has more information about this. The American Animal Hospital Association recommends that you should contact your vet if your cat has not eaten for one or two days.
So if your cat has not eaten today, then right now, right this minute, I would like you to go and give your cat some food he or she is prepared to eat. Just make sure it doesn't contain any garlic or onion.
If you are in the USA, Fancy Feast Classic is a good bet - you can read here which are the best varieties to try. Fancy Feast is known as Gourmet Gold in the UK and is available from most supermarkets - try the pate types. Or try baby food - many cats will eat this when they will eat nothing else. Or simply feed your cat's favourite food. Most cats will eat Hill's a/d prescription food. If you're in the UK, nip out to the chippy and buy some cod and give it to your cat without the batter. It doesn't matter what you feed (within reason), as long as it is meat- or fish-based and gets eaten. The Persuading Your Cat to Eat page has more suggestions on choosing a tempting food. Your stress levels will immediately go down if your cat eats something. Your cat will feel better with something in his/her tummy.
Longer term there are a lot of things to learn about food and nutrition for CKD cats, and ways to encourage your cat to eat the prescription diet. Here are links with more detailed information on dietary and nutritional issues:
But always, the most important thing is that the cat eats.
Vomiting, Loss of
Appetite, Weight Loss
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Vomiting and weight loss are often the symptoms that lead to the initial diagnosis of CKD. The vast majority of CKD cats will vomit a lot, at least at first.
This will usually be combined with a loss of appetite. Many CKD caregivers are tearing their hair out trying to get their cats to eat. It is stressful for you, it is stressful for your cat.
Why do CKD cats stop eating and/or vomit a lot? There are a number of possible causes. The site will help you work out if there is a particular reason why your cat won't eat, and help you find a way to solve that problem. The most common causes are dehydration, excess stomach acid, high phosphorus levels and anaemia.
If you are seeing both loss of appetite and vomiting, particularly vomiting white foam, plus other symptoms such as resting the head on the water bowl or teeth grinding, then the most likely explanation is increased stomach acid caused by the CKD. If you focus on treating this, which is usually pretty manageable, it will help your cat feel much better.
The best treatment for vomiting caused by stomach acid is a type of medicine called histamine H2 antagonists. Examples of such medications are Pepcid AC (famotidine) and Zantac 75 (ranitidine). Essentially what these medicines do is block the production of stomach acid, so the cat doesn't feel so queasy. The good news is, these medicines are available over the counter in most countries (although you should of course obtain your vet's approval to use these treatments) and are not expensive, and they usually work fast. If you like a more holistic approach, a cheap, effective treatment is slippery elm bark.
If these treatments don't work, there are other possible causes of these symptoms. But the majority of CKD cats do have stomach acid and will benefit from having it controlled.
Here is information on these issues:
Hydration Go to page
Another common symptom that may lead to the initial diagnosis of CKD is increased urination. Because they are peeing more, CKD cats usually drink more too, but eventually they cannot drink enough to keep up and they become dehydrated.
Some cats who become dehydrated will "crash". Dehydrated cats who crash usually have extremely high blood test results. Don't worry about this, because you cannot assess how severe the CKD is until the cat has been stabilised and rehydrated.
Usually cats who crash will need to be treated in hospital and placed on a drip (intravenous fluids or IV) for a few days to help them become stabilised. One day is unlikely to be long enough, and even after a few days, their numbers may not improve immediately. Do not be talked into euthanasia at this point, give your cat a chance to come home and gradually improve.
Many CKD cats will not crash and will not need to be hospitalised, but they may still be experiencing dehydration. For these cats, giving subcutaneous (under the skin) fluids at home, known as sub-Qs in the USA and sub-cuts in the UK, is a very helpful treatment. However, it is best not to start this treatment too early, or to be too aggressive with the treatment. Sub-Qs may be risky for cats with heart disease.
Generally speaking, cats with creatinine over 3.5 (US) or 300 (international), will benefit from sub-Qs. The usual amount to give is around 100ml of fluid a day. Unfortunately, sub-cuts are relatively uncommon in the UK, so you may need to persuade your vet to allow you to give them.
Here are links on fluid therapy:
Control of Phosphorus Levels Go to page
Healthy kidneys excrete phosphorus from the body. The damaged kidneys of a CKD cat are unable to do this as effectively as they should, so phosphorus levels in the body increase. High phosphorus levels will make a cat feel lousy, and can even make the CKD progress faster, so it's really important to get them under control. Symptoms of high phosphorus levels include loss of appetite, itching and weakness.
The prescription foods for CKD cats contain reduced levels of phosphorus (plus lower levels of protein, though it is debatable how essential that is, see Nutritional Requirements). If your cat's phosphorus levels are only mildly elevated, and your cat is prepared to eat prescription food, the phosphorus levels will probably go down to a safe level. But if your cat has high phosphorus levels or refuses to eat a prescription diet, you will need to take action. Here are the recommendations for phosphorus control:
What are phosphorus binders? Well, as the name suggests, they are products which are intended to bind with the excess phosphorus in food in the intestine and thus stop the phosphorus being absorbed into the cat's body.
The best type of binder is aluminium hydroxide, which comes in powder or gel form for you to mix with your cat's food. Many vets recommend products which are peppermint-flavoured, which most cats hate. However, odourless and tasteless binders do exist and are available without prescription. Phosphorus binders can be hard to find locally but are easily obtainable online at reasonable cost. They take about a week to kick in, and once your cat's phosphorus levels are at the desired level, your cat should be feeling and acting a lot better, and problems caused by the high phosphorus levels should disappear.
The All About Phosphorus page has information about high phosphorus levels and phosphorus binders, including which to use and how much:
Hypertension (High Blood Pressure) Go to page
This is pretty common in CKD cats unfortunately, and may even arise in cats with mild CKD. It's even more likely if your cat has hyperthyroidism (an overactive thyroid).
Unfortunately hypertension can be hard to detect. It may cause a cat to be lethargic or to twitch, but not every cat will show symptoms, or will not show any symptoms until more severe ones become apparent, such as seizures, blindness or a stroke. If your CKD cat has recently gone blind, the most likely cause is hypertension. The good news is, if you start treatment as quickly as you can, your cat may regain some or all of his vision. If your CKD cat is having seizures because of hypertension, getting it under control should stop the seizures.
Ideally you want to get your cat's blood pressure checked regularly. Unfortunately not all vets have the equipment to measure blood pressure in cats. If your vet cannot test your cat's blood pressure, but your cat has gone blind, I would ask to start treatment anyway.
Here is a guide as to when to start treatment:
Some vets (especially those in Europe) prescribe drugs called ACE inhibitors (a common one is benazepril, trade name Fortekor or Lotensin) to treat hypertension. However, the absolute best treatment for hypertension in cats is a medication called amlodipine (trade names are Norvasc in the USA and Canada and Istin in Europe and Australasia), which is not too expensive. Why is it the best treatment?
Amlodipine takes about a week to get blood pressure under control, and some cats may become lethargic for a few days until their bodies get used to the medication, but after that the cat should start feeling and acting better.
Here is more information on hypertension:
Anaemia Go to page
Anaemia is quite common in CKD cats. It makes a cat feel really tired and weak, and can also cause loss of appetite and breathlessness. In the worst case, it can cause heart problems. So you see, it's very important to treat it if it is present.
The most common reason for anaemia in CKD cats is because the kidneys produce a hormone called erythropoietin which regulates the production of red blood cells; but damaged kidneys can no longer produce this hormone properly, so fewer red blood cells are produced and anaemia can occur. This type of anaemia is known as non-regenerative anaemia.
In most cases, this type of anaemia does not occur until the CKD is relatively advanced i.e. when creatinine is over 5 (US) or 450 (international), although there are exceptions to this rule. But if your cat has anaemia and creatinine is under 5 (US) or 450 (international), I would ask your vet to rule out other possible causes, such as gastro-intestinal bleeding, or infection or inflammation, because they need different types of treatment.
The degree of anaemia is determined by the levels of PCV or HCT in your cat's blood work. The following table shows the degrees of anaemia and the best treatments to use for each stage, assuming this is anaemia caused by a lack of erythropoietin:
What do I mean by ESAs? This is an abbreviation for erythropoiesis stimulating agents, artificial forms of erythropoietin. Commonly used ESAS include Aranesp, Epogen or Procrit in the USA, and Aranesp, Eprex or NeoRecormon in Canada or Europe. ESAs are a very effective treatment, but some vets do not like to use them because, since they are designed for humans, there is a possibility of cats developing antibodies to it. However, this does not happen that often (certainly not as often as many vets seem to think it does), and when it does, it simply means that the anaemia gradually returns and you are back where you started. But if this is going to happen, it does not normally happen for 4-5 months, during which time your cat will have regained a good quality of life. It is also much less likely to happen with Aranesp.
Make no mistake, anaemia can kill. Fortunately, it can be treated. If a cat has severe anaemia (PCV or HCT between 15% and 19%), in most cases you will need to start using an ESA, though you could simply try B vitamins and iron for a week or two instead and see if they help. However, this can be a bit of a risky approach because ESAs take a couple of weeks to kick in, during which time your cat could be getting sicker.
Some vets think ESAs costs hundreds of dollars but that is nonsense. Aranesp is relatively expensive, at around US$160 a vial (which contains several treatments), but it does not need to be given too frequently, every 7-10 days to start with, but this soon reduces to only once every 2-4 weeks. Epogen or Procrit cost as little as US$35-40 a vial, and a vial contains approximately 4-5 treatments, depending upon how much your cat weighs. In the UK you will pay around £100-110 for 12-24 treatments.
Here are pages which tell you all you need to know about anaemia in CKD cats, including where to obtain ESAs at reasonable prices:
Constipation Go to page
Constipation can be a problem for CKD cats. Constipation can be really uncomfortable and can cause vomiting, weakness and loss of appetite, so if your cat has it and you get it under control, your cat should feel a lot better and a lot happier.
Constipation is not difficult to treat in most cases. The usual treatment is a medication called Lactulose, though in recent times a similar type of product called Miralax is becoming increasingly popular. Lactulose requires a prescription in the USA but is over the counter in most other countries. Alternatively you can use a natural product called slippery elm bark. All these treatments will start working quickly, though if the cat is severely backed up, the vet may need to perform an enema first; but these treatments should then keep the constipation under control.
You can read more about constipation on the Constipation page:
Potassium Imbalances Go to page
These are very common in CKD cats. In most cases, the cat will have potassium levels that are too low. This is because the body loses potassium via the increased vomiting and urination usually seen in CKD.
The main symptom of low potassium levels is weakness, especially in the back legs (there are other causes of this but low potassium levels are a very common cause). It may also cause constipation and cause problems holding the head up.
Reference ranges for potassium vary from lab to lab but as a general rule the magic number at which action is required is 4. Take a look at your cat's blood test results or ask your vet what the level is. If you cannot see a measurement for potassium, look for K or K+, the chemical symbol for potassium.
Treating low potassium levels is pretty easy. You simply use a potassium supplement. These come in oral or injectible forms, and they work fast. When I adopted him, my Ollie was unable to walk properly because of low potassium levels. Within two doses (an evening dose and another dose the next morning), I could see a dramatic improvement. After 48 hours he could walk normally again!
One thing to bear in mind: many vets do not realise that you need potassium to be above 4, preferably around 4.4. Ollie's level was 3.5, and for the lab my vet uses, that was the bottom end of normal, so she didn't think he needed a supplement because technically it was normal. But I asked her to humour me, and we were both thrilled to see how well it worked. Being within normal range was simply not enough for Ollie and many other CKD cats.
But please do not rush to use a potassium supplement unless it is truly needed, and never use it without your vet's knowledge and approval. High potassium levels can be very dangerous.
Occasionally a CKD cat will have high potassium levels, and others may develop them if too much potassium supplementation is given, or if it's given when it's not needed. If your cat's level is above 6, then you need to do something about it because it is potentially very dangerous (high potassium levels can cause seizures or even a heart attack). Fortunately, in the majority of cases, if the potassium level is 6 or over, it is a false reading. So the first thing to do is to ask your vet to run bloodwork to check your cat's potassium levels again.
You can read more about potassium here:
Metabolic Acidosis Go to page
Metabolic acidosis means the levels of acid in the cat's body are too high. It is not the same thing as excess stomach acid.
Metabolic acidosis is relatively common in CKD cats. Unfortunately it can be difficult to measure metabolic acidosis, so many vets do not bother to check for it. It is important to treat it if it is present though, because it can cause a number of symptoms, such as weight loss, particularly muscle loss, a bony spine and mouth ulcers (all of these symptoms may have other causes too). Fortunately metabolic acidosis is relatively easy to treat.
Kidney Stones Go to page
Cats whose bloodwork rises suddenly may have kidney stones. These may cause acute kidney injury, but some cats will be left with CKD. Kidney stones are difficult to treat, but newer treatments offer some hope.
Summary Go to page
OK, so that is your CKD crammer. To recap:
CKD can be very complicated, but the above issues are the most critical. Getting any of these issues which are present under control will greatly increase your cat's comfort and chances of living a long, happy life despite the CKD. Try to treat your cat for at least two weeks and see how things go. With the proper treatments and a bit of luck on your side, your cat should be doing a lot, lot better two weeks from now. In the meantime, continue to explore this site, but don't be too discouraged if your cat's numbers seem high - the numbers only tell part of the story.
If you would like some support as you set off on your CKD journey, come and join us at Tanya's CKD Support Group.
This page last updated: 05 September 2011
Links on this page last checked: 26 April 2012
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.
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