Which Treatments To
Use When
These days many vets place CKD into one of four stages
according to the International Renal Interest Society's guidelines. You
can read about the different stages
here.
Nutritional management of feline chronic kidney
disease (2008) Elliott J, Elliott D
Veterinary Focus 18(2) pp39-44 recommends different treatments based on which stage
your cat is in, as follows:
Stage 2 and early Stage 3:
Creatinine
between 2.1 and 4.5 mg/dl or 185 µmol/L and 400 µmol/L international
The goal is to
slow progression using the following:
-
Management of
high phosphorus levels through dietary phosphate restriction
-
Management of
proteinuria
-
Management of
hypokalemia (low potassium levels)
-
Management of
hypertension (high blood pressure)
Late Stage 3 and Stage 4:
Creatinine over 4.5 mg/dl US or 400
µmol/L
The goal is to
control imbalances that lead to higher toxin levels and therefore affect
quality of life, as follows:
-
Minimise
azotemia (elevated
BUN and creatinine levels)
-
Limit
hyperphosphatemia by means of dietary restriction and intestinal phosphate
binders
-
Fight against
anorexia to maintain sufficient energy intake
-
Manage metabolic
acidosis
Treatment recommendations for CKD in cats
(2019) International Renal Interest Society have more
detailed suggestions. They say
"The importance of administering treatments which address the clinical
signs of CKD and improve the cat's quality of life assume greater
importance and exceeds the importance of treatments designed to slow
progression by stage 4."
What This
Means in Practice
Most people read this page shortly after diagnosis when they are feeling
overwhelmed. The technical jargon means nothing to them, but they are
desperate to help their cat and are vulnerable to the marketing hype found
on some websites. Therefore below I have divided treatments into
categories, explaining which treatments are essential, which are optional
and which are appropriate in some circumstances.
The main ways of telling whether a treatment is appropriate are firstly,
by checking for symptoms of a problem (e.g. eating litter is often a sign
of anaemia) and secondly by seeing what is out of range in test results,
then discussing your concerns with your vet.
In practice,
most people with cats in the early stages of CKD will have to use treatments for
appetite loss, nausea and vomiting, and something
for phosphorus control. Later on, they may also need to use subcutaneous fluids
in order to prevent dehydration, and a potassium supplement if their cat's
potassium levels are too low. In due course, they may need to treat hypertension, anaemia
and metabolic acidosis. In all cases, any infections should be dealt with
promptly.
If money is a concern, as it is for
most people, you'll be relieved to hear that the most commonly needed
treatments only cost about US$5-10 a week. It is only when you need to treat
severe anaemia using erythropoiesis stimulating agents
(ESAs), such as Epogen, Aranesp, Procrit, Eprex or NeoRecormon, that the
cost will be higher, but even these products can be obtained relatively
cheaply (I give sources for a vial of Epogen costing around US$50, and
the frequency of use reduces after a few weeks, which reduces the price
further).
Try to be proactive - keep a close eye out for
symptoms and start treating any that arise as soon as possible. At the
same time, you may find that some treatments are too stressful for your
cat - they all are individuals, and some cope better than others.
Feline CKD therapeutic goals: do not throw away your
shot
(2018) Wooten SJ DVM360 Magazine discusses the
risks of what Dr St Denis (quoted in the article) calls polypharmacy and
says "Just because you can prescribe more medication to manage CKD doesn’t
mean you should" because this may affect your bond with your cat and your
cat's quality of life. Even if you decide not to use some treatments, you
should be able to use others, so just do the best you can, and check the
Tips on
Medicating Your Cat page for tips on how to make medicating your cat
easier for both of you.
Don't give up hope.
Renal dysfunction in small animals
(2016) Brown SA Merck Veterinary Manual says "With
appropriate therapy, animals can survive for long periods with only a
small fraction of functional renal tissue, perhaps 5%-8% in dogs and cats."
How to speak for Spot by Dr Nancy Kay is
about how to decide which treatments would be the best choice for your dog
in your particular circumstances but the principles apply to cats too.
Essential Treatments
Food
The one
essential treatment for all cats is food. Although a therapeutic kidney
food can be helpful, if your cat won't eat it, it's not helpful at all.
If your cat
hasn't eaten for a couple of days, s/he needs food now. Cats who don't
eat can develop a lifethreatening liver condition called hepatic lipidosis,
which can happen after just a day or two of not eating. The site will help
you identify possible causes of inappetence and how to treat them, but
right now, this minute, if your cat hasn't eaten today, I want you to stop
reading and go and get some food into your cat. Try any cat food you have
in the house — at this point, anything is better than nothing.
If your cat
won't eat what you have in stock and you are in the USA, pop out to the
supermarket and buy some Gerbers Stage 2 meat-based baby foods and some
Fancy Feast Classic pate-style foods. You can check on what you need to
buy
here and
here. If you're near a pharmacy, also buy
some Pepcid AC regular (not Complete or Extra Strength); you want the 10mg
size). You are going to ask your vet if you can use the Pepcid AC for your
cat.
If you are in
the UK, it can be trickier to find a really tempting food, but I find my
cats like Gourmet Gold pâté varieties, available from most supermarkets.
You can also pop to the chippy and buy some fish (give it to your cat
without the batter).
Baby food and
fish from the chippy are not balanced foods and cannot be fed longer term.
The Fancy Feast and Gourmet Gold foods are complete foods but are too high
in phosphorus for a CKD cat to eat regularly. But using these foods in a
crisis should be fine, and your cat will feel better for eating, and
you'll feel happier too. Once your cat
has eaten, you can read up
on how to get your cat to eat,
how to get your cat to eat the therapeutic kidney diet, what to do if you don't
succeed and the nutritional requirements of CKD cats in the
Diet and Nutrition section.
Essential Treatments in Some Circumstances
These problems
are all explained in more detail in the
Key Issues section. Don't worry,
it is highly unlikely that you will have to deal with all of them —
remember, they are only appropriate in some cases.
Blood
Pressure Control
If your cat's
blood pressure is consistently over 160 mmHg, s/he has hypertension. In order to
avoid blindness, heart problems and strokes, you need to ask your vet
about starting a medication for hypertension called amlodipine (Norvasc or
Istin).
As a bonus, once your cat's blood pressure is under control, you
should see an improvement in your cat's wellbeing (if your cat has already
gone blind, s/he may even regain some vision), and you may also see
improved blood test results.
See
All About
Hypertension for more information.
Phosphorus
Control
Many CKD cats
have elevated phosphorus levels, which make the cat feel lousy and may
make the CKD progress faster.
If your cat's phosphorus level is over 6 mg/dl
(USA) or 1.9 mmol/L (international), your cat would benefit from a phosphorus
binder.
See
Phosphorus Control
for more information.
Loss of Appetitie, Vomiting and Nausea
Most CKD cats
have one or more of these problems. One common symptom is vomiting,
especially white foam. There are some simple, quick, free or cheap
treatments that work well for some cats.
See
Appetite Loss,
Nausea and Vomiting
for more information.
Fluid
Therapy
Most CKD cats eventually become dehydrated. If this is an acute situation,
the cat will need intravenous fluids (IV fluids, or a drip) at the vet's.
Even cats who are not in
crisis will eventually need treatment in order to maintain hydration and avoid a crisis developing. In
most cases, this will be when creatinine levels are consistently over 3.5
mg/dl
(USA) or 300 µmol/L(international), and the treatment is subcutaneous fluids.
See
Fluid Therapy
for more information.
Anaemia
Anaemia is
relatively common in CKD cats. If your cat's PCV or HCT measurement is
below normal, ask your vet about using a Vitamin B supplement.
If your
cat's PCV or HCT level is below 20%, you will need to consider using a
type of treatment known as an erythropoiesis stimulating agent (ESA), such
as Epogen, Aranesp, Procrit, Eprex or NeoRecormon.
See
All About
Anaemia for more information.
Potassium
Many (but not
all) CKD cats
have low potassium levels, which can cause weakness (especially in the
back legs) and other problems.
If your cat's level is below 4 mEq/l (USA) or 4 mmol/l (international), ask your
vet about using a potassium supplement.
See
Potassium Imbalances
for more information.
Metabolic
Acidosis
This means that
the acid levels in the body are out of balance. It is not the same thing
as stomach acid. It is more common in more advanced CKD.
See
Metabolic Acidosis
for more information.
Kidney Stones
If your cat has
kidney stones, treatment is essential.
See
Kidney Stones
for more information.
Pyelonephritis
If your cat has
a kidney infection, treatment is essential.
See
Pyelonephritis
for more information.
Proteinuria
Proteinuria
means there is excess protein in your cat's urine. This may make the CKD
progress faster, so you must try to treat it if possible.
See
Proteinuria
for more information.
Optional Treatments
Most of these
treatments (except benazepril and calcitriol) are not used for a specific
purpose, but are attempts to help the cat feel better and perhaps slow the
progression of the CKD.
B
Vitamins
B vitamins can
help with appetite, energy levels and anaemia. Any excess is peed out so
they are usually a very safe treatment. Although they are optional, I
think they are a good choice for any CKD cat, because they may help and
should not harm.
See
The B
Vitamins for more information.
Azodyl or Renadyl
Azodyl is a
type of probiotic specially developed to help with renal toxins. Most
people I've heard from who uses it thinks it helps their cat feel better,
though some think it makes their cats vomit. However, it is expensive, not available outside the USA (though I've found
possible sources), and needs to be shipped cold.
If you can
afford and obtain Azodyl, I'd consider using it, though other
probiotics may also be of use. If you can't obtain Azodyl/Renadyl, don't worry too
much.
See
Treatments for more information.
Astro's
Oil
This is a
treatment which combines
essential fatty acids and antioxidants. Some people find their cats seem to do
better overall when taking this, but some cats don't like the taste. If
you can get your cat to take it, I think it's fine, but if you can't, I
wouldn't worry about it. See
Treatments
for more information.
Benazepril (Fortekor)
This is
approved in Europe, Australia and Canada for the treatment of CKD in cats.
If you are in the UK, I virtually guarantee you left the vet's clutching
some therapeutic kidney food and some Fortekor.
Benazepril is
actually a heart medication, and the evidence for its use in CKD is not
particularly strong; plus in some cases, it may worsen bloodwork, at least
initially. It can, however, be effective in treating a problem sometimes
seen in CKD cats known as proteinuria (where protein leaks into the
urine). Personally, I would use it in a cat with proteinuria, and I would
probably use it for additional blood pressure control if amlodipine
(mentioned above) was not sufficient, but I
probably wouldn't bother with it otherwise.
See
Proteinuria for more information.
Calcitriol
This is a
treatment used for a condition known as secondary hyperparathyroidism,
which is common in CKD cats. The first step in reducing the risk of
secondary hyperparathyroidism is to control phosphorus levels (see above).
See
Treatments for more information.
Save Your Money
Kidney
Support Gold
This contains
ingredients inappropriate for CKD cats on a longer term basis.
See
Holistic
Treatments for more information.
RenAvast
I wouldn't
buy it.
See
Holistic
Treatments
for more information.
Obtaining Medications