Tanya's Comprehensive Guide to Feline Chronic Kidney Disease - Key Issues: Helping Your Cat Feel Better and Prolonging Life

I have written this page because 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.

Don't be concerned when you see how many key issues there are. Many cats will not need all of them to be managed immediately, and indeed they may never have problems with some of them, such as kidney stones. However, any problem that is listed here needs to be taken seriously if present.

There are many treatment options 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 some of these products, hoping for a miracle cure. Unfortunately, although many of these treatments 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. Yes, I know Kidney Support Gold and AminAvast advertise widely and have some truly wonderful testimonials, but most people on my support group are not impressed with them, so personally, I'd save your money.

So take a deep breath, and start learning about CKD. The page is divided into two categories (some do overlap):

Helping your cat feel better
Prolonging your cat's life

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.

Helping Your Cat Feel Better

The goals of this website are to help your cat feel better and ideally to live longer. I have deliberately put feeling better first: who wants to live longer if they feel terrible? Fortunately CKD is not generally considered to be a painful disease, but there are still things to try to make your cat feel more comfortable and therefore happier.

Your Cat Must Eat!

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? I doubt it!

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 therapeutic kidney diet. I know your vet may have told you that your cat simply must eat such a food, 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.

However, if your cat falls into the extremely large category of cats who would rather starve (literally) than eat therapeutic kidney foods, then don't force the issue. You may eventually be able to get your cat onto a diet appropriate for a CKD cat, but it takes time, and you don't want your cat to not eat in the meantime. 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. The American Animal Hospital Association recommends that you should contact your vet if your cat has not eaten for one or two days. Mar Vista Vet has some information about hepatic lipidosis, and mentions that a cat who has eaten only half to three quarters of his or her normal food intake for two weeks is also at risk.

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 s/he is prepared to eat. Just make sure it doesn't contain any garlic or onion.

If you are in the USA, there is a good chance your cat will be prepared to eat Fancy Feast Classic. This food is too high in phosphorus to feel long term, but as a one day thing, it should be fine. 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 diet food.

If you are in the UK, Fancy Feast is known as Gourmet Gold in the UK and is available from most supermarkets — try the pâté types. Alternatively you can nip out to the chippy and buy some cod and give it to your cat without the batter.

It does not 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 therapeutic kidney 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

Vomiting and weight loss are often the symptoms that lead to the initial diagnosis of CKD. Many CKD cats will vomit a lot, at least at first, and it is often white foam.

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, nausea, 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 the increased toxins associated with CKD (sometimes referred to as uraemia). If you focus on treating this, which is usually pretty manageable, it will help your cat feel much better.

If you like a more holistic approach, a cheap, effective treatment is slippery elm bark, which seems to help many CKD cats.

Other popular treatments include ondansetron (Zofran) or maropitant (Cerenia).

Some people use medications called histamine H2 antagonists, such as famotidine.(Pepcid AC) or ranitidine (Zantac 75), or proton pump inhibitors (PPIs) such as omeprazole. Essentially these medicines block the overproduction 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.

Here is information on these issues:

Hydration

CKD cats usually urinate more and so they 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 intravenous fluids (IV fluids or a drip) for a few days to help them become stabilised. One day is unlikely to be long enough, and even after a few days, the bloodwork 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 mg/dl (US) or 300 µmol/L (international), will benefit from sub-Qs. The usual amount to give is around 100ml of fluid a day (less for small cats or cats with heart disease). 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:

B Vitamins

A lack of vitamin B may cause a number of symptoms, including loss of appetite, or occasionally non-regenerative anaemia.

B vitamins are water-soluble, so are often lacking in CKD cats, who lose much of their vitamin B through increased urination. Cats who are not eating much will also probably not be taking in enough B vitamins.

B vitamin supplements are safe and can often help a CKD cat feel better. Vitamin B12 in the form of methylcobalamin may be particularly helpful. These products are widely available over the counter at reasonable prices, but do not use them without your vet's knowledge and approval.

B vitamins

Constipation

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. A commonly used treatment is a medication called MiraLAX, though some people use a different medication called lactulose. 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:

Prolonging Life

The above treatments can be very effective at making your cat feel more comfortable. The following treatments may also help your cat feel more comfortable, but most importantly, getting these problems under control may also slow the progression of CKD in your cat.

What is different about chronic kidney disease in cats? (2007) Polzin DJ Supplement to Compendium: Continuing Education for Veterinarians 30(3A) pp41-43 says "All patients with CKD are potentially at risk for progressive kidney disease. Progression may occur as a consequence of the primary renal disease, in association with a variety of secondary factors that may promote progressive renal disease, or both. An important therapeutic goal for managing patients with CKD is to minimize or prevent progressive loss of renal function. Treatment designed to limit progression of kidney disease may involve a variety of interventions, including diet therapy, minimizing proteinuria, controlling hypertension, and modulating the renin-angiotensin-aldosterone system."

Control of Phosphorus Levels

One of the kidneys' rôles is to 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 rise. High phosphorus levels will make a cat feel horrible, and may 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.

Therapeutic kidney diets contain reduced levels of phosphorus, and if your cat's phosphorus levels are only mildly elevated, feeding such a diet may be sufficient to reduce them to the desired level.

If your cat has high phosphorus levels (over 6 mg/dl US or 1.9 mmol/L international) even after feeding a therapeutic kidney diet for 3-4 weeks, you will need to speak to your vet about using phosphorus binders.

What are phosphorus binders? Well, as the name suggests, they are products which bind with excess phosphorus in food in the intestine and thus stop the phosphorus being absorbed into the cat's body. There are several products which can be used for this purpose. They usually take 7-10 days to start working, 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 following pages have information about high phosphorus levels and controlling phosphorus levels with diet. The phosphorus binders page explains more about the various types of binders, which to use and how much:

Hypertension (High Blood Pressure)

Hypertension is common in CKD cats, and may even arise in cats with mild CKD. It is even more likely if your cat has hyperthyroidism (an overactive thyroid). Cats whose bloodwork rises suddenly may have hypertension.

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:

Systolic Blood Pressure Measurement	Risk of Damage to Organs	Treatment Plan
Under 140	Minimal	No treatment necessary at this time, scratch it from your list of worries for now.
140-159	Low	Treatment is not normally necessary. However, it may be appropriate to begin or increase blood pressure medications if ocular or neurological signs are present.
160 - 179	Moderate	Begin or increase blood pressure medications.
Over 180	Severe	Begin or increase blood pressure medications.

Some vets (especially those in Europe) prescribe drugs called ACE inhibitors (a common one is benazepril, trade name Fortekor or Lotensin) to treat hypertension.

If you are in the USA, you may well be offered telmisartan, because, as the US Food and Drug Administration reports, telmisartan (under the trade name of Semintra) was approved in the USA in 2018 for the treatment of hypertension in cats.

However, most experts agree that amlodipine (trade names are Norvasc in the USA and Canada and Istin in Europe and Australasia) is the drug of choice, though for severe hypertension you may need to use another medication in addition to the amlodipine.

Why is amlodipine considered to be the best treatment?

It has very few side effects.
It is unlikely to cause blood pressure to fall too far, which is an important consideration if your vet is not 100% sure if your cat has hypertension because s/he lacks the equipment to measure blood pressure, or your cat is too agitated to get an accurate reading.
If your cat has gone blind because of hypertension, amlodipine may help the retinas re-attach and your cat could regain some or all of his/her vision. Fortekor will not help with blindness.
It is not too expensive.

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

Anaemia is also relatively 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, anaemia can kill, so it is very important to treat it if it is present.

Anaemia can have a number of possible causes, such as gastrointestinal bleeding, or infection or inflammation, and treating any such problems which are present should resolve the anaemia.

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 results. 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 mg/dl (US) or 450 µmol/L (international), although there are exceptions to this rule.

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:

Level of PCV or HCT	Severity of Anaemia	Treatment Plan
Under 15%	Very severe	You need to start ESAs. If symptoms are present, you may also need to consider a blood transfusion to tide your cat over until the ESA kicks in. Also use B vitamins and iron (as long as no infection is present)..
Between 15% and 19%	Severe	You will probably have to start using ESAs, plus B vitamins and iron (as long as no infection is present).
Between 20 and 25% (or bottom end of normal range)	Mild	Begin using B vitamins and iron (as long as no infection is present).
Within normal range	Not anaemic	No treatment necessary at this time, scratch it from your list of worries for now.

What do I mean by ESAs? This is an abbreviation for erythropoiesis stimulating agents, artificial forms of erythropoietin. Commonly used ESAS include darbepoetin (Aranesp), epoetin alfa (Epogen or Procrit) in the USA, and darbepoetin (Aranesp), epoetin alfa (Eprex) or epoetin beta (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 them. 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. Also 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%) caused by a lack of erythropoietin, 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$200 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$50 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:

Proteinuria

Healthy cats only have tiny amounts of protein in their urine because their kidneys do not allow the protein to leak through. If this mechanism is not working properly, there will be excess levels of protein in the urine. This is called proteinuria.

Proteinuria may make the CKD progress faster, and is also used for staging the CKD. Unfortunately it can be difficult to treat but certain heart medications (ACE inhibitors or ARBs) may help.

Proteinuria

Urinary Tract Infections and kidney Infections (Pyelonephritis)

Urinary tract infections are relatively common in CKD cats because the dilute urine seen in CKD allows bacteria to thrive. In the worst case, the bacteria may travel up to the kidneys and cause infection there.

Cats whose bloodwork rises suddenly may have such an infection. It is extremely important to treat these infections because they may make the CKD progress faster (in some cases, they may even cause CKD), and may make the cat feel very uncomfortable or downright ill. CKD cats often require a lengthy course of antibiotics.

Pyelonephritis and urinary tract infections

Potassium Imbalances

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 an affected cat may have problems holding his or her 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 mEq/l or mmol/l. 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.

Potassium Level (mEq/l or mmol/l)	Treatment Plan
Below 4	Ask your vet about using a potassium supplement.
Between 4 and 4.3	Treatment is not essential. However, discuss with your vet and be prepared to take action if the level falls below 4, or if your cat already has symptoms of potassium deficiency.
4.4 or above, and still within lab range	Target range. Relax — you don't need to do anything. Scratch potassium from your list of worries for now.
Over 6	Worryingly high. Ask vet to re-check level because with luck it is a false reading. If it is correct, your cat needs urgent treatment.

Treating low potassium levels is pretty easy. You simply use a potassium supplement. These come in oral or injectable 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.

This is because occasionally a CKD cat will have high potassium levels, or the cat will develop them if too much potassium supplementation is given, or if it is given when it is 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

Metabolic acidosis means the levels of acid in the cat's body are too high. It is not the same thing as gastric hyperacidity.

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.

All about metabolic acidosis

Kidney Stones

Cats whose kidney values rise 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.

Kidney stones

Summary

OK, so that is your CKD crammer. To recap:

Your cat has to eat. You will make sure s/he takes in some food, no matter what it is. You will work on switching to a therapeutic kidney diet later if necessary.

If your cat is vomiting (especially white foam) and/or has a poor appetite, you will try treating for nausea and gastric hyperacidity to see if that helps.

If your cat is at risk of dehydration, you will speak to your vet about starting sub-Qs.

Speak to your vet about giving your cat a B vitamin supplement, especially vitamin B12 in the form of methylcobalamin.

If your cat has constipation, you will speak to your vet about using a treatment such as lactulose, MiraLAX or slippery elm bark.

If your cat's phosphorus level is above 6 mg/dl or 1.9 mmol/L, you will ask your vet about using a phosphorus binder.

If your cat's blood pressure is above 160, or if your vet cannot measure your cat's blood pressure (o it is lower) but there are serious symptoms such as blindness, you will speak to your vet about starting a medication called amlodipine.

If your cat has anaemia, you will speak to your vet about treating it as follows:

If your cat's PCV or HCT is above 20% but still below normal, you will ask about using a vitamin B and iron supplement.

If your cat's PCV is 15-19%, in addition to these treatments you will speak to your vet about whether to use an ESA such as Aranesp or Epogen.

If your cat's PCV or HCT is below 15%, you will also ask your vet whether your cat might need a blood transfusion to tide him/her over until the other treatments kick in.

If your cat has protein in the urine, you will speak to your vet about treatment options.

If your cat has a urinary tract or kidney infection, you will ensure your vet treats it with antibiotics.

If your cat's potassium level is below 4, you are going to ask your vet for a potassium supplement.
If your cat's potassium level is above 6, you are going to ask your vet to re-run the test because most probably it is a false reading.

If you suspect that your cat has metabolic acidosis or kidney stones, you will talk to your vet about how best to treat these problems.

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.

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This page last updated: 24 August 2020

Links on this page last checked: 24 August 2020

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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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