Controlling
toxins can help your CKD cat feel much better.
This page
discusses
treatments for specific problems, such as mouth ulcers.
It also
discusses treatments which are intended to help generally with the CKD
toxin load rather than treat specific problems, such as Azodyl and Astro's
CRF Oil.
Controlling Nausea, Vomiting,
Appetite Loss and Excess Stomach Acid
The toxins of CKD can cause problems in all these areas.
This important topic now has its own page
here.
Fluid therapy is intended to prevent dehydration, not to flush out toxins
in any way. Therefore you should only give enough to maintain hydration
rather than giving lots of unnecessary fluid. However, if your cat is or
becomes dehydrated, the toxins will build up in the cat's body. Therefore
giving sufficient fluids to maintain hydration may
help with minimising toxins.
Mouth ulcers can be very painful, so treating them is important for your
cat's wellbeing. Gastro-intestinal bleeding can cause anaemia and is
potentially very serious, so getting it under control is extremely
important.
If you want to try holistic methods, slippery elm bark can 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 on
Tanya's CRF Support Group. See
Holistic Treatments for more information about
slippery elm bark and how to make the syrup.
Another natural remedy for mouth ulcers is to mix white cheddar
cheese with water to make a paste and spread it on the gums. The enzymes
in the white cheddar cheese are supposed to eat the bacteria and help
alleviate the infection, though I have not tried this myself and would not
recommend it for dental problems other than mouth ulcers (see
Related
Diseases for more information on dealing with dental problems
generally). I did try eel serum homeopathic remedy for Tanya, and I would
say it did help, though perhaps not as much as the slippery elm bark might have done.
For severe
mouth ulcers, antibiotics may be necessary.
For really
obstinate ulcers, particularly in End Stage Renal Disease, you should
consider using a treatment called
sucralfate, which forms a protective
coating over the ulcers and allows them to heal.
Do not use Bonjela to treat mouth ulcers. It contains salicylate, which is
toxic to cats.
It can be hard to
get a cat with mouth ulcers to eat because they hurt so much. One
possible short-term solution is
baby
food - this is
runny so your cat may be able to lap it up with his/her
tongue, avoiding the ulcers. Alternatively you can use pureed food. See Persuading Your Cat to Eat
for more tips.
Gastro-Intestinal Bleeding
Slippery elm bark, which as mentioned above can help with
mouth ulcers, may also help with some milder cases of gastro-intestinal bleeding.
More serious cases will need sucralfate. If the bleeding has caused
severe anaemia, your cat might also need a
blood
transfusion to tide him or her over the crisis.
Sucralfate
Sucralfate may be helpful for both mouth ulcers and gastro-intestinal bleeding. It
forms a protective coating over the ulcerated areas of the stomach and
allows them to heal.
Trade names for this drug include Antepsin in the UK, Carafate in the USA
and Ulcogant in Germany. In the USA there is now a veterinary version of
sucralfate called
Gastrafate, which is supposed to be more
concentrated and therefore more effective.
Sucralfate sometimes comes in tablet form, but it dissolves easily in
water. You can make it relatively thick if you are applying it to mouth
ulcers, or into more of a slurry if it is for stomach ulcers. Most people
draw the mixture into a syringe and give it that way.
You should give sucralfate on an empty stomach in
order for it to work properly.
Pet Place has some information about
sucralfate, including dosage suggestions (no need to register to read the
article, just click on Close at the bottom of the irritating pop-up).
In many cases, diarrhoea will only last for a day. However, if it goes on
any longer, or stops and then starts again, I'd recommend a trip to the
vet because the cat may become quickly
dehydrated
(which does not only mean water loss,
the cat may also be losing potassium).
Slippery elm
bark
appears to be able to help with both diarrhoea and constipation. It
soothes the lining of the gut and gives the digestive system time to heal.
Psyllium
may also help firm up the stool.
Occasionally a cat may appear to have diarrhoea, but it
is in fact constipation with a small amount of liquid squeezing around the
hard stool. This requires treatment for
constipation.
If the diarrhoea is a result of
changing food too suddenly, stop feeding the new food and go back to your
cat's old food until the problem is under control. Then gradually
re-introduce the new food as described in
Which Foods to Feed.
If your vet agrees, you can try a medication containing
pectin and kaolin for a few days. However, be sure you use a formulation
suitable for cats; kaopectate used to be suitable, but as the
American Medical Veterinary Association
explains, the formulation has changed and is no longer safe for cats.
Pet Pectillin
is a brand of pectin and kaolin which is safe for cats, available
from
Arcata Pet.
Although loperamide (Imodium) is available without a
prescription, please do not use it without your vet's knowledge and
approval. According to
Pet Place, it is a controversial
treatment for animals, and can cause side effects in some cats,
particularly those suffering from certain conditions including kidney
disease. It is also hard to work out a cat-sized dose. Other treatments
outlined here are much safer.
East meets west: integrative veterinary medicine
(2007) Silver RJ has
some suggestions for a short-term rice water-based diet suitable for a cat
with diarrhoea (it is about halfway down the page). Check with your vet
before using this.
Diarrhoea and Probiotics
If the diarrhoea is caused by antibiotics, you may need
to re-balance the bacteria in the gut with
probiotics. A small amount of natural, unflavoured yoghurt may help, but since many cats are lactose intolerant,
there is a risk that this might actually make the diarrhoea worse. You may
therefore find it easier to buy a commercial product in capsule form instead.
There are a number of different types available.
East meets west: integrative
veterinary medicine (2007) Silver RJ recommends using a product with
1-10 billion CFU units per day (scroll down to
Probiotic Cultures near the bottom of the page).
Consumer Lab
has a report on what probiotics do and how to choose one. Here are some to
consider:
Acidophilus is
a good choice for rebalancing gut bacteria -
Pet Education discusses this.
Effects of lactobacillus acidophilus DSM13241 as a probiotic in healthy
adult cats (2006) Marshall-Jones ZV, Baillon M-LA,Croft JM
& Butterwick RF American Journal of Veterinary Research67(6)
pp1005-1012 concluded that "administration of this probiotic results in
beneficial systemic and immunomodulatory effects in cats."
Culturelle contains lactobacillus. A typical feline dose
is half a capsule in the morning and half a capsule in the evening while
the cat is on antibiotics, but check with your vet.
Benebac is
designed especially for pets, and is available from
Revival Animal Health among others.
FortiFlora is a nutritional supplement for cats which contains a
probiotic, though it also contains vitamins, amino acids and iron. I
therefore think it is perhaps not the best choice of probiotic, but some
cats love it, so it may be helpful if added in small quantities to make
food or pills more tempting. It is available from
Entirely Pets.
Probiotics are currently being considered as a
treatment for CKD in their own right; see
below for more
information.
Bad breath will often improve as dehydration is treated and the toxin
levels in the body are controlled. If your cat's breath does not improve,
ensure your vet rules out
dental problems.
Itching
Treating the uraemia will usually reduce the toxin levels and stop the
itching. If your cat has
high phosphorus levels, reducing these can also
help. Occasionally itching may be related to low levels of
Vitamin B6, in
which case you should discuss supplementation with your vet.
Howling (Particularly at Night)
If this is caused by high toxin levels, it should decrease in frequency
and volume as you get the toxins under control.
Howling is often
a sign of hypertension, so ask your vet to rule this out. It may also be caused by deafness,
hyperthyroidism, or occasionally just old age and possibly
cognitive
dysfunction (senility).
Probiotics are colonising microorganisms (bacteria or flora) which are
sometimes referred to as "friendly bacteria" or "good bacteria." Bacteria live in
the lower gastro-intestinal tract, and are essential to gut health. Many
commercial diets contain probiotics but
Bacteriological evaluation of dog and cat diets that claim to contain
probiotics (2003) Weese JS & Arroyo L Canadian
Veterinary Journal44 pp212–215 concluded that "Overall,
commercial pet foods that claim to contain probiotics appear to contain
very low numbers of viable organisms, and often do not contain the species
listed on the label... Results of this study indicate that these
commercial diets are not good sources of probiotics."
This is not necessarily a problem because we all contain gut bacteria
naturally, but some people choose to give probiotics orally as well. I am
not aware that this is essential for most cats, but it can be helpful
to re-balance the bacteria in the gut
after using
antibiotics, which cause
diarrhoea in some cats. There is also some research indicating that
probiotics may help with CKD, see below.
Probiotics and GI health (2010) Steiner JM CVC in Baltimore
Proceedings explains more about probiotics.
What are
Prebiotics?
Prebiotics
encourage the intestinal bacteria (or flora) to grow. They are commonly
fermentable fibre, particularly a type of fermentable fibre
called fructooligosaccharides (FOS). Fermentable fibre provides a source
of nutrients for the gastro-intestinal bacteria, i.e. essentially they
are food for probiotics.
(2010) S Perea Natura Pet Technical Information Series2(9) is a helpful
overview.
The Use of Probiotics and Prebiotics in CKD
There is some research into the use of these products as a means of diverting toxins from the kidneys, in order to
reduce their workload.
Prebiotics
Most of the
urea produced by
the body is excreted via the kidneys, but the remainder is excreted via the large intestine. In
CKD, the kidneys may struggle to cope with
excreting urea, leading to it building up in the cat's body. The use of
fermentable fibre (or
prebiotics) in CKD is aimed at diverting more
of the urea to the large intestine/faecal route, thus relieving the
workload imposed on the kidneys. This process is sometimes referred to as
"nitrogen trapping."
One member of Tanya's CRF Support Group has, with her vet's approval, been
giving her cat a tiny amount of locust bean gum (a prebiotic) mixed with
water and added to canned food every day as a dietary supplement and thinks
it has helped her cat and improved his bloodwork. If you wish to do
something similar, please discuss it with your vet and remember, more is not
always better. Please check
fermentable fibre for the pros and cons of using fibre.
Probiotics
Recent studies indicate that it may be possible to
use probiotics to reduce toxins in a similar manner.
Pilot study of probiotic dietary supplementation for
promoting healthy kidney function in patients with chronic kidney disease
(2010) Ranganathan N, Ranganathan P, Friedman EA, Joseph A, Delano B, Goldfarb
DS, Tam P, Venketeshwer Rao A, Anteyi E & Musso CG Advances in Therapy27(9)
pp634-647 investigated the use of probiotics in human patients with CKD
and found "The main outcomes of this preliminary trial include a significant
reduction of BUN, enhanced well-being, and absence of serious adverse
effects, thus supporting the use of the chosen probiotic formulation for
bowel-based toxic solute extraction."
Can the bowel substitute for the kidney in advanced
renal failure? (2008) Friedman EA
Current Medical Research and Opinion25(8) pp1912-8 has an
excellent overview of the various ways of reducing toxins in CKD,
including what it calls "bacterial enzyme nitrogen recycling within
the gut."
Azodyl
is a product designed to help cats with CKD by reducing the
workload of the kidneys.
It contains a prebiotic,
psyllium, a
type of fibre commonly used to control constipation, together with strains
of
three particular probiotics:
Enterococcus (Streptococcus) thermophilus (KB19)
Lactobacillus acidophilus (KB27); and
Bifidobacterium longum (KB31)
These probiotics are
not unique, but these particular strains are. The manufacturers claim that
their strains
of these bacteria, which they have
patented, have a particularly high affinity for some of the major
uraemic toxins found in CKD.
Azodyl
is intended to bind with and reduce the levels of these uraemic toxins in
CKD cats
(rather like the "nitrogen trapping" use of
fermentable fibre in CKD), hence its name, which is a play on
azotaemia and dialysis.
Kibow Biotech, which
makes Renadyl (previously known as Kibow Biotics), the human version of Azodyl, calls
this "enteric dialysis". Azodyl also seems to have some similarities to
oral adsorbents such as
Ipakitine/Epakitin, which also bind with uraemic toxins.
I have been asked why I think Azodyl and Renadyl are the same when Azodyl
contains
Enterococcus thermophilus, whereas Renadyl contains
Streptococcus thermophilus. It is my understanding that
they are actually the same -
The regulatory
environment (c. 1997) Pendleton B
Direct-fed Microbial, Enzyme & Forage Additive Compendium says in the
table on the bottom of the first page that
Enterococcus thermophilus was formerly catalogued as Streptococcus thermophilus,
but I am awaiting confirmation of this from the manufacturer.
Kibow Biotechexplains
more about the principles behind the product.
Does Azodyl Work?
Since Azodyl is classified as a dietary or nutritional supplement,
clinical trials are not required by the American Food & Drug
Administration. However,
Probiotic amelioration of azotemia in 5-6th
nephrectomized Sprague Dawley rats (2005)
Ranganathan N,
Patel B,
Ranganathan P,
Marczely J,
Dheer R,
Chordia T,
Dunn SR,
Friedman EAScientific World Journal
5 pp652-60 is a study on rats who were treated with
probiotics, including probiotics provided by Kibow Biotech (which did not
appear to be identical to Azodyl). The study seemed to show that Bacillus
pasteurii and Sporolac (Lactobacillus sporogenes) were particularly
effective. Sporolac is produced by Sankyo Co Ltd in India, where it is
commonly used in farm animals.
The manufacturers of Azodyl state that Azodyl is not a true probiotic and
does not change the bacteria in the gastro-intestinal tract. This is why
Azodyl needs to be given every day.
It is debatable whether Azodyl truly improves kidney
function, but if it reduces BUN levels, it may at least help cats feel
a little better.
I have heard
from a number of people who have used Azodyl. Most people seem to think it
has helped their cats, though some people find that it can make a cat
vomit, and others could not see any discernible difference. It may take
up to a month before you see any benefit from using Azodyl, though
apparently some people see results (usually in the form of better
appetite) within two weeks.
Azodyl appears to be a safe product and I would be happy to
try it myself, but it is not essential, so don't get stressed if you can't find it or afford it,
or if you find it too difficult to give (see
below for ways to
give it, and information on whether the way it is administered affects its
effectiveness).
Azodyl FAQs answer a number of commonly raised questions about Azodyl.
Kibow Biotech explains more about the reasoning behind Azodyl.
Kibow Biotech reports on its studies into
the use of probiotics.
Azodyl is
widely available in the USA and Canada but can be difficult to obtain
elsewhere.
Azodyl was
created by Kibow Biotech, and was introduced to the US and Canadian
markets in July 2006 by Vetoquinol, the manufacturers of
Ipakitine/Epakitin. Many
vets stock it and it is also available from online pet pharmacies. Vetoquinol may
purchase the manufacturing and marketing rights for Azodyl for the rest of
the world in due course, but as at 2012 there were no plans to introduce
the product in Europe because Vetoquinol do not wish to go through the
necessary registration process.
The human version of Azodyl, which
contains twice as many bacteria (30 billion) as Azodyl (15 billion), and which is safe to use in
cats, is already available in some other markets under the name of
Renadyl.
Renadyl is not yet available in Europe but the manufacturers have told me
they expect to have a distribution channel in place for it within Europe
some time during 2012 (this date has slipped from 2011, and I wouldn't be
surprised if it slipped again).
In theory you
can import Azodyl into Europe from the USA, and some suppliers who are prepared
to ship to Europe are
below. Since the product should ideally be kept chilled, you are
taking a bit of a risk because it may not be usable if it gets held up by
Customs or en route for any reason, but some people have imported it with
no problems, and the manufacturer has stated that the bacteria can survive
for up to fourteen days at temperatures of 25° Celsius, 77° Fahrenheit.
How to Give Azodyl
Giving Azodyl
to cats may be problematic. Firstly, the required dosage is quite high: a
cat weighing 5-9 lbs would require two capsules a day according to a table
provided by
Vetoquinol 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 (this is so the
bacteria are not killed off by stomach acid). For this reason the
capsules are intended to be given whole; however, since the product was
originally developed for use in humans, the capsules were size 1, which is
rather large for many cats; this may be one reason why some cats throw up
the entire capsule, sometimes several hours after it has been given.
Therefore some
people opened the capsules and gave the contents separately, often mixing
them with food. The Veterinary
Information Network
ran a trial into Azodyl to
investigate whether giving Azodyl in this way affected the product's effectiveness. Unfortunately, the study,
Azodyl, a synbiotic, fails to alter azotemia in cats
with chronic kidney disease when sprinkled onto food (2011)
Rishniw M & Wynn SG Journal of Feline Medicine and Surgery13(6)
pp 405-9, found that giving Azodyl by opening the capsule and sprinkling
its contents onto food or mixing it into a slurry had no effect on BUN or
creatinine levels.
I discussed the
results of this trial with the manufacturer, who told
me that in the above study the capsule contents were mixed into a full
meal. However, they recommend opening the capsule and mixing the contents with a small
amount (about a teaspoonful) of fatty food, such as cream cheese, cream,
full fat yoghurt or a pat of butter. This should then be given on an empty stomach one
hour before feeding a full meal, in order to give the probiotics the right
environment to work properly. It should not be mixed with liquids as this
will activate the bacteria in the product too early, making it less
effective.
Following complaints from many
users about the difficulty in giving Azodyl in the intended, optimal
manner, the manufacturers launched a smaller capsule in April 2012 under
the name of Azodyl Small Caps, which can still hold the correct number of
bacteria (15 billion) but which is smaller because it has less filler.
Azodyl Small Caps are sold in 90 per container versus 60 per container for standard
Azodyl. To the left is a photo from Virginia and Jellybean of the two
Azodyl capsule types together with a quarter, to give you an idea of the
difference in sizes.
Many people
find it easier to give Azodyl intact in the Small Caps form, but some
still prefer to open the capsules.
In these cases, most people seem to give Azodyl
first thing in the morning mixed with a little butter or cream, and then
wait an hour before giving their cat breakfast. Members of Tanya's
CRF Support Group
are generally positive about Azodyl when given in this way.
In the
Palmquist study mentioned
above, Renadyl,
the human version of Azodyl, was found to be effective even when mixed
with meals. This could be because Renadyl contains twice as many
bacteria as Azodyl, so more bacteria survived. One member of Tanya's
CRF Support Group is successfully using this product
mixed directly with meals. So if you wish to continue mixing the product
into meals, you might wish to use Renadyl instead (for suppliers,
see below).
Azodyl should
not be given at the same time as
antibiotics; separate them by 6 hours.
Azodyl Storage
Azodyl should
be kept in the fridge, otherwise the bacteria may die. They can probably
survive for some time in normal weather (up to fourteen days at
temperatures of 25° Celsius, 77° Fahrenheit, according to
the manufacturers), so if you leave Azodyl out overnight there is
unlikely to be cause for concern, but if you buy online it is safest to
have Azodyl shipped chilled, especially if you live in a hot climate, because there is no guarantee that it was
shipped chilled to the retailer.
I would try to order early in the morning so it should be shipped to you
on the same day; if you order after midday, it might well be packed that
day but not actually shipped until the next day.
Azodyl Suppliers
Azodyl is widely available from vets in USA and Canada, but can often be
purchased more cheaply online - see below.
If you live in Europe, Azodyl is not
available and the only way to buy it is to order it from a US supplier.
You can also order the stronger human version, Renadyl, from a US
supplier, but it may be available within Europe sometime in 2012.
Renadyl is as safe to use in cats as Azodyl.
I
understand that it is not currently possible to import Azodyl
into Australia, but that it may be permitted in due course.
USA
Entirely Pets sells 60 Azodyl capsules for US$29.99 plus
shipping of US$29.95 or 180 capsules for US$87.99. Shipping is free on orders over
US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled.
Entirely Pets sells 90 Azodyl Small Caps capsules for US$43.99 (normally US$57.99) plus shipping. Shipping is free on orders over
US$85
(may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled.
Thriving Pets sells 60 Azodyl capsules
for US$31.95, plus shipping. Shipping is free on orders over US$55
(may not apply for the required chilled shipping). I used
Thriving Pets within the USA myself for other items with no problems.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Thriving Pets sells 90 Azodyl Small Caps capsules for US$39.95
plus shipping. Shipping is free on orders over US$55
(may not apply for the required chilled shipping). I used
Thriving Pets within the USA myself for other items with no problems.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Thriving Pets
also sells Renadyl, the human version of Azodyl. 90 capsules
cost US$44.95 plus shipping, so it actually costs slightly less than
Azodyl but the product is twice the strength, which may be helpful if you
wish to mix it with your cat's meals.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Kibow Biotech sells three bottles of Renadyl for US$135 plus
ground shipping costs of US$14.95.
Amazon sells
Azodyl via a variety of suppliers at various prices. Make sure they will
use chilled shipping.
Canada
Canada Chemists
sell 60 Azodyl capsules for
CAN$30.25.
Click on Pets Health, then on Vitamins and Supplements.
Entirely Pets
sells 60 Azodyl capsules for US$29.99 plus
shipping of US$29.95 or 180 capsules for US$87.99. Shipping is free on orders over
US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled. They will ship to Canada. I have
heard from two UK residents whose orders arrived after only two days
(ordered on a Monday, arrived on a Wednesday) and were still nicely
chilled.
Entirely Pets
sells 90 Azodyl Small Caps capsules for US$43.99 (normally US$57.99) plus shipping. Shipping is free on orders over
US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled. They will ship to Canada. I have
heard from two UK residents whose orders arrived after only two days
(ordered on a Monday, arrived on a Wednesday) and were still nicely
chilled.
Thriving Pets
sells 60 Azodyl capsules
for US$31.95, plus shipping. Shipping is free on orders over US$55 (may
not apply for the required chilled shipping). I used
Thriving Pets within the USA myself for other items with no problems.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Thriving Pets
sells 90 Azodyl Small Caps capsules for US$39.95 plus shipping. Shipping
is free on orders over US$55 (may not apply for the required chilled
shipping). I used
Thriving Pets within the USA myself for other items with no problems.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Thriving Pets
also sells Renadyl, the human version of Azodyl. 90 capsules
cost US$44.95 plus shipping, so it actually costs slightly less than
Azodyl but the product is twice the strength, which may be helpful if you
wish to mix it with your cat's meals.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
gives contact details for the Canadian
distributor of Renadyl.
Europe
If you import Azodyl into the UK from the USA, it may sometimes be delayed
because if Customs decide you need to pay duty, Parcelforce write to tell
you this and do not deliver until you have paid, rather than simply
delivering the parcel and asking you to pay at that time (which is what
UPS do). If you have a tracking number, follow it and try calling
Parcelforce once you think they have your parcel so you can pay over the
phone or go and collect your parcel personally.
Allivet sells 60 Azodyl capsules for US$30.99 plus shipping of
around US$35-45. One member of
Tanya's CRF Support Group in
Hong Kong ordered from this supplier and the Azodyl was still chilled when
it arrived.
Entirely Pets
sells 60 Azodyl capsules for US$29.99 plus
shipping of US$29.95 or 180 capsules for US$87.99. Shipping is free on orders over
US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled. I have heard from two UK residents whose
orders arrived after only two days (ordered on a Monday, arrived on a
Wednesday) and were still nicely chilled.
Entirely Pets
sells 90 Azodyl Small Caps capsules for US$43.99 (normally US$57.99) plus shipping. Shipping is free on orders over
US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled. I have heard from two UK residents whose
orders arrived after only two days (ordered on a Monday, arrived on a
Wednesday) and were still nicely chilled.
Thriving Pets
sells 60 Azodyl capsules
for US$31.95, plus shipping. Shipping is free on orders over US$55 (may
not apply for the required chilled shipping). I used
Thriving Pets within the USA myself for other items with no problems.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Thriving Pets
sells 90 Azodyl Small Caps capsules for US$39.95 plus shipping. Shipping
is free on orders over US$55 (may not apply for the required chilled
shipping). I used
Thriving Pets within the USA myself for other items with no problems.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Thriving Pets
also sells Renadyl, the human version of Azodyl. 90 capsules
cost US$44.95 plus shipping, so it actually costs slightly less than
Azodyl but the product is twice the strength, which may be helpful if you
wish to mix it with your cat's meals.
If you enter the word "tanya" (without the ") in the promotional code box,
you will receive a 10% discount on orders over US$55.
Kibow Biotech
sells three bottles of Renadyl for
US$135 plus
shipping costs. Unfortunately, following the change of name from Kibow
Biotics to Renadyl, international shipping costs a ridiculous US$150. I
guess they have to recoup the costs of the name change somehow.
The manufacturer of
Astro's CRF Oil also makes a product called Astro's Nitrogen Scrub,
although it is not mentioned on the manufacturer's website. This product
is a "highly refined glycoprotein powder" made from acacia gum powder (gum
arabic) and appears to be a type of prebiotic. It is supposed to be mixed with a probiotic such as kefir
(available from health food stores) or live yoghurt, so I'm not sure how you are supposed to know
if it is the Astro product or the probiotic which is working, but the
manufacturer claims that in tests the Nitrogen Scrub alone produced
reductions in BUN and creatinine of as much as 20% when dosed at 0.5g/kg
of bodyweight.
The product is apparently designed in this manner so as to make it easier
to ship without the risk of killing off the live bacteria, as is the case
with probiotics. It is in powder form so you can control the dose. Some
people simply mix it into food rather than adding it to kefir. Astro's
Nitrogen Scrub costs
US$22.95 for a 140 gm jar and can be ordered by emailing the manufacturer.
I don't know many people who have used the scrub, but I've heard from one
person has used it for a year and thinks that it probably has helped
overall. Others felt it helped with appetite. Please check with your vet
before using.
Antioxidants
help combat inflammation by mopping up free radicals which can cause
damage to cells and are associated with aging and disease. The Research
page has some information about an antioxidant called
bardoxolone
which appears to help reverse the decline in kidney function seen in
diabetics.
Oxidative stress and chronic
kidney disease (2008) Brown SA The Veterinary Clinics of North
America. Small Animal Practice38(1) pp157-66 concludes that "newer data
indicate that dietary supplementation with specific antioxidants is an
important consideration for limiting renal oxidant stress and progression
of CKD."
The Winn Feline Foundation
gave a grant to
Colorado State University
in 2010 for a study into the use of "Vitamin E as a Novel Treatment for the
Anemia of Feline Chronic Renal Failure."
Vitamin E was selected for its antioxidant properties. As at April 2012
the study is still ongoing and is open to new participants. You can read
more about it here, and your cat may be eligible to participate,
see the
Research Participation
page. I will report on its findings once it is completed. In the meantime,
please do not supplement Vitamin E without your vet's approval.
Co-enzyme Q10 (CoQ10), also known
as ubiquinone or ubiquinol, is an
antioxidant that is used by the body in energy production. It is
important for heart function, and is sometimes used in people and cats
with heart disease for that reason (see
Heart Problems).
It is one of the ingredients in
Astro's CRF Oil.
A human trial,
Randomised double-blind placebo-contolled trial of
co-enzyme Q10 in patients with end stage renal failure
(this link often doesn't work properly, you may need to search for
this study on this site) (2003) Singh R,
Kumar A, Niaz MA, Singh RG, Gujrati S, Singh VP, Singh M, Singh UP, Taneja
C, Rastog SS
Journal of Nutritional and Environmental Medicine13(1) pp
13-22, indicated that CoQ10 may reduce creatinine and BUN levels in some
patients. I am not aware of any studies into using CoQ10 in CKD cats, but
I have heard from a few people who think it has done the same for their
CKD cats.
Renal preservation effect of ubiquinol, the reduced
form of coenzyme Q10 (2011)
Ishikawa A, Kawarazaki H, Ando K, Fujita M, Fujita T & Homma Y Clinical
and Experimental Nephrology15(1) pp30-3 found that ubiquinol
appears to support renal function in rats who had had a kidney surgically
removed.
Effect of topical application of coenzyme Q10 on
adult periodontitis (1994) Hanioka
T, Tanaka M, Ojima M, Shizukuishi S & Folkers K Molecular Aspects of
Medicine15 Suppl pp241-8 found that the topical application of
CoQ10 appeared to improve periodontitis in humans. There
were similar findings in more recent research by Nihon University School
of Dentistry presented to The 63rd Meeting of the Vitamin Society of
Japan, Hiroshima, Japan on 4th and 5th June 2011.
Generally speaking CoQ10 is normally considered to be a safe
supplement with few side effects, though please do not give it without
your vet's approval. It may lower blood glucose levels, so extra care
should be taken if you and your vet decide to use it in a diabetic cat.
CoQ10 is available from health food stores. If you
decide to use it, it should be given with fat or oil, so it is normally
given with food. A possible starting level would be 10mg a day for a 15 lb cat, though some people give higher amounts. Holisticat
recommends 30mg a day for cats with heart disease, though some
people find their cats have stomach upsets and diarrhoea at this level, so
you might want to start lower and increase the dose gradually.
If you do decide to try CoQ10 with your vet's
agreement, please do not stop using it suddenly. There have been several
cases of humans and one cat with heart disease who were using CoQ10
relapsing after it was stopped suddenly. This might not be such a risk
with cats with CKD rather than heart disease, but if you do decide to stop
using it, it would probably be safer to do so gradually.
The Mayo Clinic reports that "there is
initial data from one small trial [in humans] to support the use of CoQ10
in the treatment of kidney failure. More research is needed before a
recommendation can be made."
Astro's CRF Oil was created by a
human doctor to treat his own CKD cat, and has been on the market since
January 2007.
The manufacturer
states that the product was tested on an informal basis on 18 CKD cats in
the Montreal area over a period of about eight months.
This product is basically a
combination of
essential fatty acids,
Vitamin E and
CoQ10
(ubiquinon), both antioxidants, but in a concentrated formula.
Astro's CRF Oil contains approximately 565mg
EPA, 340 mg
DHA, 15mg of Ubiquinon (CoQ10) and
200 IU of
natural
Vitamin E (D-tocopherol) per 1.5ml dose. It is
claimed that combining these ingredients creates a synergistic effect. The
intention is for the product to have a strong anti-inflammatory effect,
which it is hoped will help the kidneys. Astro's CRF Oil is only
available from the creator's website (link is in the previous paragraph). A 60 ml bottle costs US$29.95 and
you give 1.5 ml a day so it lasts about 40 days.
Essential fatty
acids do have an
anti-inflammatory effect. However, one kidney specialist vet has informed me
that oversupplementation can throw off the correct ratio of Omega-3s to
Omega-6s, and might be detrimental in some cases. Having said that, many people on Tanya's
CRF Support Group use the product and most people seem to like
it, reporting that their cats seem
"better", albeit in some unmeasurable way. A small percentage
found that it made their cats vomit more though, so they stopped using it.
Almost everyone I have heard from has mentioned that their cat hates the taste and smell of Astro's CRF Oil. Ideally
you want to mix it with food, in which case it might may help to build up to the full dose gradually.
You can also mix it with a small amount of food and syringe it in - if you
do this, be sure to give it at the side of the mouth. Some people put
it in a gelcap. If your cat
doesn't like Astro's CRF Oil, you can consider giving essential fatty acids
and antioxidants separately instead.
I don't consider Astro's CRF Oil to be an essential product, but it is probably worth a try
if you can obtain it where you live and your cat tolerates it. If you do use
it, please see the advice about not stopping products
containing CoQ10 here.
The product's website states that using this
product may enable you to stop other treatments such as sub-Qs, but I cannot
see why an anti-inflammatory product might help prevent dehydration. I
certainly would not recommend stopping any of your cat's current treatments,
particularly sub-Qs, without your vet's knowledge and approval.
Adsorbents are
products that bind with something else, and adsorbents used in the
treatment of CKD usually bind with toxins, thus improving wellbeing.
Phosphorus binders are an obvious example of an oral adsorbent, but this
section focuses on newer types of adsorbents.
Almost all of the research into the use of these newer
products has taken place in Japan, and some of these adsorbents seem to be
routinely used in Japan when treating human CKD patients; therefore, if
you are in Japan, you may also be offered these treatments for your cat.
However, one such treatment, Ipakitine, was developed in Germany.
Ipakitine
has been available in the UK since December 2002 and in the rest of Europe
for even longer. Ipakitine was introduced into the USA in 2005, under the
slightly different name of
Epakitin.
Ipakitine is partly a phosphorus binder, containing calcium carbonate.
However, it also contains an adsorbent called chitosan, which is said to
help with uraemic toxins.
Chitosan is a polysaccharide
similar to cellulose and is obtained from the shells of crustaceans (shell
fish such as crabs).
When protein is eaten and
digested, an amino acid in the food called tryptophan is converted into
indoxyl, which in turn is converted by the body into indoxyl sulphate, a
type of uraemic toxin. Chitosan is said to bind with the indoxyl, so it
cannot be converted to indoxyl sulphate, thus reducing toxin levels, which
helps the cat to feel better. Chitosan is also said by the manufacturer to
help reduce BUN/urea levels, and indirectly to reduce creatinine levels.
The manufacturer appears to be basing these claims largely on the results
of human trials (see
clinical
trials).
Chitosan may also reduce
cholesterol levels, but high cholesterol levels are not normally a concern
for cats as they are for humans; it is also said to increase levels of
haemoglobin.
In the USA, Epakitin is marketed as both a "nutraceutical"
and a "nutritional supplement". In the marketing literature, emphasis
seems to be placed on its role as a phosphorus binder, but many vets seem
to sell it to clients whose cats do not have elevated phosphorus levels,
so they are presumably advocating it for its chitosan-related effects.
From my discussions with German
users of Ipakitine, it seems to be commonly prescribed in Germany for cats
who refuse to eat a prescription diet; I presume this is both for its
phosphorus-binding effects and for its toxin-binding effects (since higher
levels of
protein in the diet may cause increased
BUN levels).
My own vet in the UK has seen
falls in creatinine and urea in some cats when using Ipakitine and no
other treatments. I used it myself for Ollie who did
not have very high phosphorus levels, and to whom none of the
cautions below applied.
It did appear to reduce his phosphorus levels.
Ipakitine comes in powder form, and is apparently tasteless. It is
sprinkled on the cat’s food for a period of up to six months, although it
may be used for longer if your vet agrees. Dosage is weight-related, and
phosphorus levels do not appear to be taken into account when determining
how much to give.
Ipakitine Clinical Trials
Effects of an intestinal phosphorus binder on serum
phosphorus and parathyroid hormone concentration in cats with reduced
renal function (2008) Brown SA,
Rickertson M & Sheldon S International Journal of Applied Research in
Veterinary Medicine6(3) pp155-160 reports on a small
randomised placebo-controlled study of twelve cats at the University of
Georgia College of Veterinary Medicine (partly funded by the
manufacturers) which indicated that Epakitin reduced phosphorus levels in
the cats, who were fed a commercial (non-prescription) diet and who were
in
IRIS Stages 1 and 2. The study did not find that Ipakitine
reduced BUN or creatinine levels in this study, however the cats in this
study did not have naturally occurring renal failure, which the cats in
the 2004 study below did.
ünchener tierärztliche Wochenschrift
117 pp310-315 found
that Ipakitine reduced phosphorus and BUN (urea) levels in the CKD cats in
the trial.
Effect of iron (III) chitosan intake on the reduction of serum phosphorus
levels in rats
(2000) Baxter J, Shimizu F, Takiguchi Y, Wada M, Yamaguchi T The
Journal of Pharmacy and Pharmacology 52 pp863-74 indicated
that a compound of iron and chitosan might be a more effective phosphorus
binder than the commonly used binders. This is, however, not the same
product as Ipakitine, and cats are not rats.
Effect of chitosan on renal function in patients with chronic renal
failure
(1997) Jing SB, Li L, Ji D, Takiguchi Y,
Yamaguchi T The Journal of Pharmacy and Pharmacology 49
pp721-23 describes a human trial into the effects of chitosan on 80
patients undergoing long term haemodialyis in Japan. The patients'
cholesterol levels reduced and their haemoglobin levels increased, and
their appetites improved; reductions in BUN/urea and creatinine were also
seen after four weeks of treatment.
Ipakitine Cautions
Products containing calcium are not normally suitable for cats with high
calcium levels (hypercalcaemia).
The risk of hypercalcaemia is lower with calcium carbonate-based binders
(which is what Ipakitine contains) than with other calcium-based binders,
but if your cat is taking Ipakitine, it would probably be wise to monitor
his/her calcium levels. Ipakitine should not be used in cats taking
calcitriol.
Calcium-based phosphorus binders
are not as effective as aluminium hydroxide based binders, and the type of
calcium contained in Ipakitine (calcium carbonate) is the least effective
type of calcium-based binder: calcium acetate type binders bind three
times as much phosphorus as calcium carbonate based ones. Therefore for a cat with higher phosphorus
levels (over 7 USA, 2.25 international), I personally would opt to use an
aluminium hydroxide phosphorus binder instead of Ipakitine.
Even for cats with lower phosphorus levels, if the cat's phosphorus
multiplied by total calcium is higher than 70 in US values or 5 in
international values, the cat is at risk of
tissue
calcification. In such a case, again I would opt for
using an aluminium hydroxide binder, in order to get the
phosphorus levels under control as quickly as possible.
Kremezin (AST-120) is an oral adsorbent based on charcoal which has been used to treat human
CKD patients in Japan since 1991. It has been tested on humans (these
trials continue) and on rats with surgically-induced kidney disease, but
not on cats as far as I am aware.
Kremezin was developed by Kureha Chemical Industries and has been marketed in Japan
for the treatment of feline CKD by Sankyo Lifetech under the trade name of
Covalzin.
I have heard from a couple of Japanese people who have used it on their
cats without any problems, and they thought it might have helped their
cats.
This part of Sankyo Lifetech's business was sold to
Novartis in 2007. I assumed they planned to introduce Covalzin into
Western markets but they haven't done so as yet. The human version of Kremezin
has not been made commercially available in the USA to date, although
JCN Network reports that Kureha Chemical
Industries introduced Kremezin in South Korea in 2005.
I have heard
from a couple of people using
activated charcoal, which has a similar mechanism to Kremezin. Activated
charcoal is used to treat human overdoses by absorbing toxins. I have no
knowledge of appropriate doses for CKD cats. Please do not use this without
your vet's knowledge and approval. Charcoal may darken stools.
Following complaints from many
users about the difficulty in giving Azodyl in the intended, optimal
manner, the manufacturers launched a smaller capsule in April 2012 under
the name of Azodyl Small Caps, which can still hold the correct number of
bacteria (15 billion) but which is smaller because it has less filler.
Azodyl Small Caps are sold in 90 per container versus 60 per container for standard
Azodyl. To the left is a photo from Virginia and Jellybean of the two
Azodyl capsule types together with a quarter, to give you an idea of the
difference in sizes.