As the kidneys gradually lose their ability to regulate and remove waste
products effectively, these waste products (sometimes referred to as
toxins) build up in the blood. This is known as uraemia and can make a cat feel very unwell.
Generally speaking, cats with creatinine over 3 mg/dl
(US) or 265 µmol/L (international) will have problems with uraemia.
This page discusses treatments which are intended to help generally with the CKD
toxin load.
It also discusses treatments for specific problems, such as mouth ulcers.
What is Uraemia?
One of the main roles of the kidneys is filtering the blood to
regulate and remove waste products (toxins). Kidneys damaged by CKD gradually lose their ability to
do this properly, so these waste products build up in
the blood: this is called azotaemia, and can make a cat feel very unwell.
The clinical signs and symptoms that azotaemia causes are collectively
known as uraemia. To date 146 uraemic toxins have been found.
Generally speaking, you will probably start seeing signs of
uraemia in cats who are properly hydrated
but whose creatinine is over 3 mg/dl
(US) or 265 µmol/L (international).
BUN and
creatinine are not major toxins, but BUN levels correlate with uraemic toxin levels, i.e. if BUN is
elevated, it is highly likely that uraemic toxins (which are less easy to
measure) are also elevated.
Parathyroid hormone is one example of a uraemic toxin.
Another uraemic toxin is indoxyl sulfate. When protein is eaten and
digested, an amino acid in the food called tryptophan is converted into
indole, which is then converted into indoxyl, which in turn is converted
by the body into indoxyl sulphate.
Detection of indoxyl
sulfate levels in dogs and cats suffering from naturally occurring kidney
diseases (2015) F P Cheng FP, Hsieh MJ, Chou CC, Hsu WL & Lee YJ
Veterinary Journal205(3) pp399-403 found that indoxyl sulfate
(IS) levels also high in cats with naturally occurring CKD, and that there
is a correlation between IS levels and IRIS staging levels of BUN and
creatinine.
AST-120
for the management of progression of chronic kidney disease (2014)
Schulman G, Vanholder T & Niwa T International Journal of Nephrology
and Renovascular Disease7 pp49–56 states "Uremic toxins such
as indoxyl sulfate contribute to the pathogenesis of chronic kidney
disease (CKD) by promoting glomerulosclerosis and interstitial fibrosis
with loss of nephrons and vascular damage." It also says "elevated indoxyl
sulfate levels were associated with increased mortality, even after
adjustment for multiple variables."
The fecal microbiome
and serum concentrations of indoxyl sulfate and p-cresol sulfate in cats
with chronic kidney disease (2019) Summers SC, Quimby JM, Isaiah
A, Suchodolski JS, Lunghofer PJ & Gustafson DL Journal of Veterinary
Internal Medicine33(2) pp662-669 found that CKD cats have less
diversity in their microbiome and "Indoxyl sulfate concentration is
significantly increased with CKD, and cats with stage 2 CKD may suffer
from a similar uremic toxin burden as do cats with later stage disease."
Some of the treatments below are aimed at reducing indoxyl sulfate levels.
It is possible that doing this may help the cat feel better, though
whether it could also help slow the progression of the CKD is debatable.
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 tried 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.
Mouth Ulcers: Other
Treatments
For really
obstinate ulcers, talk to your
vet about using sucralfate, which forms a protective
coating over the ulcers and allows them to heal.
For severe
mouth ulcers, antibiotics may be necessary.
Mouth Ulcers: Eating
It can be hard to
get a cat with mouth ulcers to eat because the ulcers 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.
If the ulcers are really severe, you may have to
consider a
feeding tube.
Fascetti AJ & Delaney S University of California at Davis says
"The
waste products may also enhance blood loss by leading to the formation of
gastrointestinal ulcers and a reduction in blood clotting ability."
Gastrointestinal bleeding can cause anaemia and is potentially very
serious, so getting it under control is extremely important, but
unfortunately it is not always apparent, though one possible symptom is
diarrhoea.
Renal Disease
(2006)
Polzin DJ
Delaware Valley Academy of Veterinary Medicine
says "Uremic
enterocolitis, manifested as diarrhea, may occur in dogs and cats
with severe uremia, but it is typically less dramatic and less common than
uremic gastritis. Owners of 80 cats with spontaneous CKD did not report
diarrhea. However, when present, uremic enterocolitis is often
hemorrhagic.
Considerable gastrointestinal hemorrhage may initially escape clinical
detection."
See
Symptoms for more information on possible symptoms and
Diagnosis for more information on how to test for gastrointestinal
bleeding.
Gastrointestinal Bleeding:
Holistic Treatments
Slippery elm bark, which as mentioned above can help with
mouth ulcers, may also help with some milder cases of gastrointestinal bleeding.
Yunnan baiyao is a herb which is used in humans to control bleeding.
Angell Animal Medical Center has also used it in animals for many years.
Yunnan baiyao, to use or not to use? (2017) Whelan M Angell Animal
Medical Center explains more about the use of yunnan baiyao and says that
it "currently appears safe since there have been no reported adverse
effects."
Yunnan baiyao for patients with hemorrhage, neoplasia (2017) McKenzie
B Veterinary Practice News reports on the use of yunnan baiyao and
states that there is very little supporting research into its use. I am
not aware of any studies in cats.
Members of Tanya's CKD Support Group have used yunnan baiyao in their cats
with gastrointestinal bleeding and many have found it helpful. However,
A prospective
evaluation of oral Yunnan Baiyao therapy on thromboelastographic
parameters in apparently healthy cats (2019) Patlogar JE, Tansey C,
Wiebe M, Hybki GC, Trostel T, Murphy LA & Nakamura RK Journal of
Veterinary Emergency and Critical Care (San Antonio)29(6)
pp611-615 gave 250mg of yunnan baiyao twice daily for one week. 17.6% of
the cats exhibited vomiting and
HCT and
RBCs were reduced.
None of the cats became anaemic, but the results do suggest that yunnan
baiyao is not as useful for gastrointestinal bleeding as was hoped. As
ever, do not use it without talking to your vet first.
Gastrointestinal Bleeding: Other
Treatments
Proton pump inhibitors appear to help some human patients with
gastrointestinal bleeding.
Approach to acute upper gastrointestinal bleeding in adults (2018)
Saltzmann JR UpToDate talks about gastrointestinal bleeding in
humans before and after endoscopy and says
"acid suppressive therapy with H2 receptor antagonists has not been shown
to significantly lower the rate of ulcer rebleeding. By contrast,
high dose antisecretory therapy with an intravenous infusion of a PPI
significantly reduces the rate of rebleeding compared with standard
treatment in patients with bleeding ulcers." It also says "PPIs may
also promote hemostasis in patients with lesions other than ulcers. This
likely occurs because neutralization of gastric acid leads to the
stabilization of blood clots."
I do not know if the same applies to cats with gastrointestinal bleeding,
who have not usually undergone an endoscopy, and the PPI in the above
scenario was given intravenously, not orally, but it might be worth talking
to your vet about using a PPI such as
omeprazole.
More serious gastrointestinal bleeding 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.
Diarrhoea
There are a number of possible causes of diarrhoea in
CKD cats,
which are discussed in the
Symptoms chapter.
Depending upon the cause, diarrhoea may only last for a day. However, if
it goes on any longer, or stops and then starts again, I would recommend a
trip to the vet because cats with diarrhoea may become
dehydrated
(which does not only mean water loss,
the cat may also be losing potassium).
Although it is not overly common, in CKD cats uraemia may be a cause of
diarrhoea, and this in turn may be a sign
of gastrointestinal bleeding.
Renal Disease
(2006)
Polzin DJ
Delaware Valley Academy of Veterinary Medicine
says "Uremic
enterocolitis, manifested as diarrhea, may occur in dogs and cats
with severe uremia, but it is typically less dramatic and less common than
uremic gastritis. Owners of 80 cats with spontaneous CKD did not report
diarrhea. However, when present, uremic enterocolitis is often
hemorrhagic.
Considerable gastrointestinal hemorrhage may initially escape clinical
detection."
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.
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.
East meets west: integrative veterinary medicine (2007) Silver RJ
Delaware Valley Academy of Veterinary Medicine 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.
If
your cat has chronic digestive problems, your vet may recommend a
therapeutic food such as Hill's i/d, which has protein and phosphorus
levels acceptable for most CKD cats (40% and 0.79% respectively for the
canned food).
Diarrhoea: Holistic
Treatments
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.
Some people find
pumpkin or
similar types of fibre, traditionally used to treat
constipation, may
also help with diarrhoea, because they may help rebalance the gut bacteria
(see probiotics below).
Diarrhoea: Kaolin and
Pectin
Another
possible option is to use a medication containing kaolin and pectin for a
few days, with your vet's approval.
Kaolin is a
kind of clay. Drugs
explains "When given orally, kaolin, especially light
kaolin, adsorbs substances from the GI tract and increases the bulk of
feces. Kaolin improves stool consistency within 24 to 48 hours; however,
it does not decrease the number of stools passed or reduce the amount of
fluids lost."
Pectin is a
kind of fibre, found in many plants and fruits.
Drugs says "Pectin has
been used in the management of diarrhea for many years. Pectin
supplementation was as effective as green bananas in the management of
persistent diarrhea in children. Both pectin and banana reduced the volume
of stool, improved stool quality, decreased the amount of oral replacement
solutions and intravenous fluids for hydration needed, and shortened the
duration of illness. In a study of 44 critically ill, tube-fed adults
receiving antibiotics, there was a trend toward decreased diarrhea in
those receiving fiber and pectin. Pectin stimulates epithelial growth in
the colon, thus reducing diarrhea. Additional suggested mechanisms of
action in the GI tract include the effect of peptic oligosaccharides on
the intestinal microflora."
It is difficult
to find products combining both kaolin and pectin in the USA because, as
Web MD explains about human products,
"Kaolin has been used for years in combination with pectin (Kaopectate)
for diarrhea. However in April 2003, the U.S. Food and Drug Administration
(FDA) found that there wasn't enough scientific support for
kaolin's use in treating diarrhea. Since April 2004, drug
manufacturers have not been allowed to put kaolin in diarrhea medicine."
A human product
called kaopectate was a popular choice for cats, but as a result of the
FDA's directive, the formulation has changed and is no longer safe for
cats, as explained by the
American Veterinary Medical Association.
Pet Pectillin
is a brand of pectin and kaolin which is safe for cats.
Drugs has some
information about it.
Pro
Pectalin is another product containing kaolin and pectin available in
both gel and tablet form, though it also contains a
probiotic called
E. faecium. It is
available from
Chewy and
Amazon among others.
You can also buy kaolin, and then buy pectin separately. The apple pectin
product sold by some supermarkets for making preserves usually contains
additives, so is not suitable for this purpose. Twinlabs apple pectin
tablets are available in many health stores.
Drugs
recommends giving kaolin at least three hours apart from other
medications.
Diarrhoea: Probiotics
Probiotics
("good" bacteria) may help with diarrhoea, particularly when a
cat is receiving antibiotics. Antibiotics aim
to eradicate the bacteria causing an infection. However, they will also
eradicate "good" bacteria which normally protect the body from infection,
and in some cases this can lead to diarrhoea.
See
below for more on probiotics and which may
help with diarrhoea.
Diarrhoea: Loperamide
(Imodium)
Loperamide
(Imodium) is a mild narcotic that also has an effect on diarrhoea by
slowing down gastrointestinal contractions.
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. Plumb's
Veterinary Drug Handbook says "Not commonly used in cats and its use
is controversial; cats may react with excitatory behavior." It also advises
against the use of loperamide in patients with severe renal insufficiency.
It can be hard
to work out and measure a cat-sized dose of loperamide. Plumb's Veterinary Drug Handbook
says "a) For Diarrhea: Using the suspension 0.04 -- 0.06 mg/kg PO twice daily
(Tams 1999).
b) 0.08--0.16 mg/kg PO q12h (Willard 2003)."
How to manage feline chronic diarrhea Part II: treatment (2010) Cook AK & Purcell S
Veterinary Medicine says on page 8 "0.04 to 0.06 mg/kg orally
every 12 hours."
How to manage feline chronic diarrhea Part II: treatment (2010) Cook AK & Purcell S
Veterinary Medicine also says on page 8 "we think that these drugs
are rarely appropriate in feline patients and can cause adverse reactions,
including respiratory depression and excitatory behavior."
Other
treatments outlined here are much safer, but your vet might occasionally
prescribe loperamide for short-term use for intractable diarrhoea.
Loperamide is available without a prescription, but please do not use it
without your vet's knowledge and approval.
Sucralfate(Carafate, Antepsin)
Sucralfate is sucrose aluminium hydroxide. It has previously been used as a
phosphorus binder but is not overly effective for that purpose.
However, it is very good at forming a protective coating over ulcerated
areas of the digestive tract, including the mouth, which allows
ulceration to heal. Members of my support group who have used sucralfate have found it very
helpful for both mouth ulcers and gastrointestinal
bleeding.
Trade names include Carafate in the USA,
Antepsin in the UK
and Ulcogant in Germany. There is also a feline version called
Mucosalfate, see formulations below.
11 guidelines for conservatively treating chronic
kidney disease
(2007) Polzin D
Veterinary MedicineDec 2007 recommends (page 5)
"Providing mucosal protection with sucralfate" and adds "Sucralfate is added when gastrointestinal ulcers and hemorrhage
are suspected."
Sucralfate is widely available but unfortunately may be difficult to
obtain in the
UK where it has been out of stock since 2014 due to manufacturing problems.
The
manufacturer explains more about this. It may be back in stock by the
time you read this, but if you are struggling to find it, one member of Tanya's CKD
Support Group was able to source sucralfate via her vet from Idis Pharma,
the details of which are in the manufacturer's statement above; it was not
cheap (more than £100).
Pet Place has some information about
sucralfate, including dosage suggestions.
SucralfateFormulations
Sucralfate is sold in 1g (1000mg) tablets and in a 1g/10ml suspension.
In the USA there is also a veterinary brand called
Feline Mucosalfate
which comes in paste form for use on mouth ulcers.
SucralfateDosage
A
common dose is ¼-½ (0.25-0.5) a gram three to four times a day. This is
the same as 250-500mg three to four times a day.
Plumb's Veterinary Drugs Handbook (7th Ed.) says
"It is empirically dosed at ¼-½ of a 1 gram tablet (250 – 500 mg) for toy
breed dogs and cats."
The Mucosalfate
paste has its own dosing as outlined
here.
SucralfateHow To Give
Most people mix the suspension form of sucralfate with
water, draw the mixture into a syringe and give it that way.
Plumb's Veterinary Drugs Handbook (7th Ed.) says
"May be
crushed and suspended in water or compounded into a suspension (see
Compatibility/Compounding Considerations) and used within 14 days."
If you buy sucralfate in tablet form, it dissolves
easily in water.
You can make the mixture relatively thick if you are
applying it to mouth ulcers, or into more of a slurry if it is for stomach
ulcers.
You should give sucralfate on an empty stomach in
order for it to work properly.
SucralfateSide Effects
Plumb's Veterinary Drugs Handbook (7th Ed.) mentions
that vomiting may be seen in cats.
SucralfateInteractions
Sucralfate must be
give separately (two hours apart) from antibiotics in the
fluoroquinolone
family because it may reduce the effectiveness of the antibiotics. This
includes enrofloxacin (Baytril), marbofloxacin (Marbocyl), pradofloxacin
(Veraflox) and orbifloxacin (Orbax).
Drugs has some information about this.
Plumb's Veterinary Drug Handbook used to recommend giving sucralfate at least two hours apart from
famotidine (Pepcid AC), because the
sucralfate could bind with the famotidine and thereby reduce its
effectiveness. However, the most recent edition of Plumb's does not
mention this requirement, so it appears that you do not need to separate
sucralfate and famotidine after all.
In CKD, the kidneys may struggle to cope with the
excretion of urea and
uraemic toxins, leading
to these toxins building up in the cat's body and making the cat feel
unwell.
The treatments described above relate to specific
problems linked to uraemia. The rest of this page focuses on general
treatments that may help with uraemia, including the following possible symptoms:
Bad Breath
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 continues to itch and scratch, you need to consider other
possible causes, such as
high phosphorus
levels.
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.
I would
recommend always having blood pressure checked in a howling cat.
Toxin Reduction: Fluid Therapy
People often refer to fluid therapy as removing the toxins from the body,
often by flushing
Dialysis certainly
removes toxins; however, it is extremely expensive, so rarely used in
cats in practice.
Intravenous fluids
are sometimes used in CKD cats
to flush through the kidneys to correct severe
dehydration and any resulting electrolyte imbalances, and to remove toxins
from the blood. Flushing the kidneys in this way is known as diuresis.
It is
usually reserved for cats with high
bloodwork values, i.e. creatinine over around 6-7 mg/dl (US) or 550-650
µmol/l (international). IV fluids are also used for cats who have suffered an
acute insult to the kidneys (acute
kidney injury), such as a
kidney infection or
kidney stones.
In some cases, IV fluids may succeed in flushing out kidney
stones.
Subcutaneous
fluids are intended to maintain your cat's hydration
levels, so you are unlikely to be giving enough fluid to flush out toxins.
This is intentional; you should not increase the amount you give. Maintaining
your cat's hydration levels should minimise the risk of toxins building
up.
Toxin
Reduction: Using the Gastrointestinal Tract (Probiotics and Prebiotics)
There has long been interest in whether other bodily
mechanisms might be useful for relieving the load on damaged CKD kidneys.
Most of the
urea
produced by the body is excreted via the kidneys, but the remainder is
excreted via the large intestine, so some researchers have looked
at whether it is possible to use the gastrointestinal
tract to help remove uraemic toxins. Reducing the load on the kidneys
by diverting the excretion of urea from the kidneys to the
gastrointestinal tract is sometimes referred to as "nitrogen trapping."
Bowel as a substitute in renal failure
(1996) EA Friedman American Journal of Kidney Diseases28(6)
pp943-50 states "Extraction, modification, or recycling of nitrogenous
wastes by the gastrointestinal tract is a potentially low-cost means of
substituting for missing renal function. Multiple approaches to the bowel
as a substitute kidney have been attempted."
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."
One way of doing this is through the use of probiotics and/or prebiotics.
The manufacturer of Renadyl, a product containing both prebiotics and
probiotics, has trademarked the term "enteric dialysis" to describe the
mechanism of its product.
Nutritional management of renal disease: an evidence-based approach
(2014)
Sanderson SL Today's Veterinary Practice 4(1) pp51-56
explains the theory behind enteric dialysis.
How helpful this can be is debatable, because BUN and creatinine are not
major toxins themselves. However, BUN levels correlate with uraemic toxin
levels, i.e. if BUN is elevated, it is likely that other uraemic toxins (which
are less easy to measure) are also elevated. However, it is not known
whether these mechanisms do reduce levels of uraemic toxins.
Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge
Symposium pp18-20 says "Oral probiotics operate as “enteric dialyzers,” relying on the intestinal
tract to eliminate wastes normally excreted by the kidneys. Live bacteria
can catabolize urea and other uremic toxins, effectively trapping them
within the lumen of the bowel to be excreted in the feces. Bacteria that
have been used for this purpose include Streptococcus thermophilus,
Lactobacillus acidophilus, and Bifidobacteria species. These bacteria are
generally regarded as safe and are not known to have any adverse or
disease-inducing effects in normal or uremic dogs or cats. Preliminary
studies in rats and Gottingen mini pigs with induced CKD suggest that oral
probiotic supplementation may moderate azotemia, consequently slowing the
progress of disease and prolonging survival. Observational studies of cats
and dogs with spontaneous CKD have also shown decreases in blood urea
nitrogen and serum creatinine levels after initiation of probiotic
therapy. Reductions in these surrogate markers alone, however, do not
prove that probiotics remove the essential uremic toxins. Further studies
are needed to determine the usefulness of “enteric dialysis” in managing
CKD in domestic animals."
Probiotics are colonising microorganisms (live bacteria). Some people
worry when they see the word "bacteria" because they associate it with
bacterial infections, but there are many bacteria which are beneficial to
health, sometimes referred to as "friendly bacteria" or "good bacteria."
Many of these bacteria live in the lower gastrointestinal tract, and are
essential to gut health. They used to be called the intestinal flora but
the preferred term these days is the microbiome.
Commercial diets often 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. Adding probiotics to the diet is
therefore not usually necessary for healthy cats, though
Use of
probiotics in small animal veterinary medicine (2017) Jugan MC,
Rudinsky AJ, Parker VJ & Gilor C Journal of the American Veterinary Medical Association 250(5) pp519-528
says that doing so is unlikely to do any harm.
However, probiotics may be helpful
to help cats with
diarrhoea, particularly to help
re-balance the bacteria in the gut for cats who develop diarrhoea after using
antibiotics. There is also some research
indicating that probiotics may help with CKD, see
below.
Sometimes
probiotics are combined with prebiotics, in which case they may be
referred to as synbiotics.
Literature review — probiotics (2011) Lefebvre S Banfield Applied
Research and Knowledge TeamAug 2011 pp1-12 has an excellent
overview of the use of probiotics in cats and dogs.
Probiotics {2013) Ridgway MD Clinician's Brief pp21-23
discusses the use of probiotics in animals.
Probiotics and GI health (2010) Steiner JM CVC in Baltimore
Proceedings explains more about probiotics.
Probiotics and prebiotics
(2010) S Perea Natura Pet Technical Information Series2(9) is a helpful
overview.
Probiotics: Use in CKD
There is some research (from Kibow Biotech, manufacturer of Renadyl, see
below) into the use of probiotics to help CKD patients.
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."
Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge
Symposium pp18-20 says "Oral probiotics operate as “enteric dialyzers,” relying on the intestinal
tract to eliminate wastes normally excreted by the kidneys. Live bacteria
can catabolize urea and other uremic toxins, effectively trapping them
within the lumen of the bowel to be excreted in the feces. Bacteria that
have been used for this purpose include Streptococcus thermophilus,
Lactobacillus acidophilus, and Bifidobacteria species. These bacteria are
generally regarded as safe and are not known to have any adverse or
disease-inducing effects in normal or uremic dogs or cats. Preliminary
studies in rats and Gottingen mini pigs with induced CKD suggest that oral
probiotic supplementation may moderate azotemia, consequently slowing the
progress of disease and prolonging survival. Observational studies of cats
and dogs with spontaneous CKD have also shown decreases in blood urea
nitrogen and serum creatinine levels after initiation of probiotic
therapy. Reductions in these surrogate markers alone, however, do not
prove that probiotics remove the essential uremic toxins. Further studies
are needed to determine the usefulness of “enteric dialysis” in managing
CKD in domestic animals."
Presentation recap ACVIM 2011(2011), referring to
Probiotic Therapy of Chronic Kidney
Disease (2011) Polzin DJ ACVIM Forum 2011 says "preliminary
observational data in dogs and cats with renal disease suggests that these
supplements improve quality of life and may reduce blood urea nitrogen and
creatinine concentrations. Probiotics likely have a role in the treatment
of renal disease, but when and how to use these agents requires further
study." Dr Polzin found that the BUN and creatinine levels of four dogs on
dialysis receiving Azodyl did not improve.
Probiotics and today's pets (2018) McKenzie B says regarding the use
of probiotics for CKD in cats, "At least one commercial probiotic has
been marketed for this purpose and has been the subject of several
studies. Though small and with typical limitations, these
controlled studies have not found any convincing evidence of a meaningful
impact of this probiotic on renal disease in dogs or cats."
Probiotics: Species and Strains
There are many species and strains of bacteria.
We all have a unique mix of bacteria in our gastrointestinal tracts, but
cats have different strains to dogs or humans, and
an individual cat will have completely different species and strains to
another cat.
Bacteria commonly found in cats include:
Bifidobacterium is found mainly in the gastrointestinal tract, and may be
helpful for gastrointestinal problems such as constipation and diarrhoea.
MedlinePlusUS National Library of Medicine
has some information about it.
Pet MD (2017) says "Bifidobacterium tends to live in the small intestine,
whereas Enterococcus generally resides in the colon (large intestine). So
each strain could have a different function when it comes to promoting
health. Bifidobacterium is more involved with digestion and the
Enterococcus aids with the formation of normal feces and helping to
maintain colonic health."
Lactobacillus
Lactobacillus is found in the gastrointestinal and urinary tracts.
MedLinePlusUS National Library of Medicine has some
information about it.
Lactobacillus is useful for many different health concerns. In cats, a
type called Lactobacillus acidophilus
(L. acidophilus) is
a good choice for rebalancing gut bacteria and therefore may be helpful for diarrhoea.
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."
Enterococcus
Enterococcus is commonly found in the gastrointestinal tract, usually in
the colon.
Pet MD says "Bifidobacterium tends to live in the small intestine,
whereas Enterococcus generally resides in the colon (large intestine). So
each strain could have a different function when it comes to promoting
health. Bifidobacterium is more involved with digestion and the
Enterococcus aids with the formation of normal feces and helping to
maintain colonic health."
It has been known for some time that enterococcus appears to be more
likely to develop
antibiotic resistance than some other species.
Bacteriological evaluation of dog and cat diets that claim to contain
probiotics (2003) Weese JS & Arroyo L Canadian
Veterinary Journal44 pp212–215 states “concern has been
expressed over the use of enterococci, because they can be opportunistic
pathogens and probiotic strains of enterococci are able to transfer the
vanA gene: the gene responsible for Vacomycin resistance.” This is
referring to
Probiotic
enterococcus faecium strain is a possible recipient of the vanA gene
cluster (2001) Lund B Clinical Infectious Diseases32(9)
pp1384–1385, which says "Although enterococci generally have low pathogenicity,
they increasingly are a cause of nosocomial [occurring in hospital] infection in the United States
and Europe, especially in immunocompromised patients. This might be
explained in part by the intrinsic tolerance of these enterococci against
several antimicrobial agents and to harsh conditions, and their tendency
to gain antibiotic resistance. The nature of E. faecium has led
to discussions regarding the safety of using E. faecium as a food
supplement."
Antibiotic susceptibility analysis of Enterococcus spp. isolated from
urine (2004) Rudy M, Nowakowska M, Wiechuła B, Zientara M &
Radosz-Komoniewska H Przeglad Lekarski61(5) pp473-6 says
"Recently increase of enterococcal infections has been observed. These
bacteria, mainly Enterococcus faecalis and Enterococcus faecium are
members of the normal flora of gastrointestinal tract but also are typical
opportunistic pathogens. Enterococci are characterized by natural
resistance to numerous antibiotics (among them cephalosporins), and also
by easy acquired resistance to antibiotics. Infections caused by
multiresistant strains are difficult in treatment, chronic, recurrent and
sometimes fatal are described. Enterococcal infections are caused often by
E. faecalis, rarely by E. faecium."
Don't feed foods containing enterococcus (2009) Weinberg S believes
there may be a connection between feeding foods containing Enterococcus
bacteria and cats developing urinary tract infections involving
enterococcus
bacteria. Therefore some people are reluctant to use enterococcus in their
cats.
However, one strain of enterococcus, Enterococcus faecium SF68, was developed not to
have the problem with resistance, and has been widely used and studied in
cats.
Enterococcus faecium (SF68) is now being added to some cat foods and is
present in a number of probiotics for cats. Research indicates that it
appears to be safe to use in healthy kittens. It can be very effective for
diarrhoea.
Pilot study to
evaluate the effect of oral supplementation of Enterococcus faecium SF68
on cats with latent feline herpesvirus 1 (2009) Lappin MR, Veir JK,
Satyaraj E & Czarnecki-Maulden G Journal of Feline Medicine and Surgery11(8) pp650-654 found it also appeared to be helpful for cats with
feline herpes (cat flu).
Purina Institute provides an overview of its research into the SF68
strain.
Probiotics: Choices
Your choice of
probiotic depends partly on why you are giving it. If you are trying to
help with diarrhoea, there are several proven probiotics. If you are
interested in using probiotics to help with uraemic toxins,
Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge
Symposium pp18-20 says "Oral probiotics operate as “enteric
dialyzers,” relying on the intestinal tract to eliminate wastes normally
excreted by the kidneys. Live bacteria can catabolize urea and other
uremic toxins, effectively trapping them within the lumen of the bowel to
be excreted in the feces. Bacteria that have been used for this purpose
include Streptococcus thermophilus, Lactobacillus acidophilus, and
Bifidobacteria species. These bacteria are generally regarded as safe and
are not known to have any adverse or disease-inducing effects in normal or
uremic dogs or cats."
When choosing a
probiotic for your cat, ideally you need a product that contains several different
strains, but not too many. I would aim for a product containing around six
different strains.
It is also
important to choose a product with live, viable bacteria.
As discussed above,
adding probiotics to commercial cat food is hit and miss, and even in
supplement form many probiotics fail to deliver on their promises. It is
therefore essential to choose your product carefully.
Probiotics need to reach the intestines alive in order to be effective,
which can be tricky because stomach acid may kill many of them. Some
products use a process called "microencapsulation" to protect the
probiotics, whilst others use an enteric coating. Ideally you would give
them on an empty stomach, but if you give with food, you may need to give
a higher dose.
East meets west: integrative veterinary medicine (2007) Silver RJ
Delaware Valley Academy of Veterinary Medicine recommends using a product with 1-10 billion CFU
(colony forming units) per day (scroll down to
Probiotic Cultures near the bottom of the page).
Whether to
choose a product marketed for cats is much debated. There are few
regulations regarding probiotics for cats in most countries (though the EU
has banned the use of the word "probiotics" from marketing literature
generally), so many probiotic supplements may not be effective for your
cat, even those marketed for cats.
Assessment of commercial probiotic bacterial contents and label accuracy
(2011) Weese JS & Martin H Canadian Veterinary Journal52(1)
pp43-46 examined probiotics targeted for animal use and found "Only
4/15 (27%) products that had specific claims of viable organisms met or
exceeded their label claim. Only 2 of these also had an acceptable label,
which properly described the contents. Deficiencies in veterinary
probiotic quality remain. Veterinarians and owners should scrutinize
commercial probiotics and demand evidence of quality control and efficacy."
The two products which were found to meet their label claims were FortiFlora
(see below) and Prostora (which is for dogs).
Consumer Lab
has a report on what probiotics do and how to choose one.
If you are giving probiotics and find them helpful, you will have to keep
giving them if you wish to continue to see a benefit.
Proviable also contains
prebiotics in the form of FOS, which may lead to an increase in calcium
levels (see
below). It may therefore be
better not to give Proviable longer-term. It also contains
yucca,
an adsorbent.
VSL#3
VSL#3 is a
prescription-only human probiotic which contains eight strains as follows:
Streptococcus thermophilus
Bifidobacterium breve
Bifidobacterium longum
Bifidobacterium infantis
Lactobacillus paracasei
Lactobacillus acidophilus
Lactobacillus delbrueckii
subsp. Bulgaricus
Lactobacillus plantarum
Each sachet contains 450 billion CFU. The recommended human dose is
1-2 sachets per day. For cats, a tenth of a sachet once a day might be a
suitable dose, but be guided by your vet.
Prebiotics, probiotics and intestinal health (2012) Tremayne J
Veterinary Practice News says ""Veterinary probiotics are less regulated than drugs," says Joseph
Bartges, DVM, PhD, Dipl. ACVIM, Dipl. ACVN, professor of medicine and
nutrition at the University of Tennessee in Knoxville. "There's less
confidence that you are getting what the label claims. I believe in using
probiotics in animals but I prefer to use one called VSL#3 marketed for
human use because it contains 450 billion live bacteria per packet. This
probiotic is manufactured by VSL Pharmaceuticals Inc.""
The human product contains 450 billion CFU in a packet and 112.5 billion
CFU in a capsule. The dog version contains 112.5 billion CFU in a capsule.
The recommended veterinary dose is 1-2 capsules per day for dogs under 20
lbs. The capsules can be opened and sprinkled on food. Some people use the
human products because they often work out cheaper.
Pharmaca reports on a law suit between Visbiome (below) and VSL#3.
FortiFlora
Fortiflora is made by Purina, and only
contains one probiotic, enterococcus faecium (SF68).
It also contains
vitamins, amino acids and iron. Some people are uncomfortable using enterococcus-based probiotics (see
above), and some do not
like the fact that FortiFlora contains animal digest (which I understand
is hydrolysed pork). Most cats do not agree with their humans, finding
FortiFlora very yummy.
Although FortiFlora only contains one probiotic, it has been tested and
amongst other things, it has been found to be effective in treating
shelter cats with diarrhoea.
Purina Institute provides an overview of the
research into the SF68 strain.
It is also one of only two products in the
above study which
were found to found to meet their label claims (the other product was a
canine product).
Many people use and like FortiFlora, and find it
particularly effective for diarrhoea. As mentioned earlier, most cats love the taste of it too,
so it can be helpful to make pills or food more tempting. Discuss with your vet.
Culturelle is a human product
which also only contains one probiotic, Lactobacillus rhamnosus GG. Some
members of Tanya's CKD Group use it when their cat is receiving
antibiotics.
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.
Probiotics: Side
Effects and Interactions
Side effects are usually mild and gastrointestinal, such as vomiting or
wind. Starting with a low dose and increasing gradually may help if you
see such side effects.
Do not give probiotics at the same time as antibiotics, separate them by
3-4 hours.
There is some debate as to whether probiotics are appropriate for patients
with pancreatitis. There is more about this on the
Pancreatitis
page.
Prebiotics
encourage the gastrointestinal bacteria (or flora) to grow by providing a source
of nutrients for them, i.e. essentially
prebiotics
are food for probiotics.
They are commonly
fermentable fibre, particularly a type of fermentable fibre called
fructooligosaccharides (FOS).
Inulin, which
is found in Renadyl,
is a prebiotic. So is
psyllium,
which is found in both Azodyl and Renadyl (see
below).
Sometimes
prebiotics are combined with probiotics, in which case they may be
referred to as synbiotics.
(2010) S Perea Natura Pet Technical Information Series2(9) is a helpful
overview.
Prebiotics: Use in CKD
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.
There has long been interest in whether other bodily mechanisms might be
useful for relieving the load on damaged CKD kidneys, and some researchers have looked
at whether it is possible to use the gastrointestinal tract to help remove
more of the uraemic toxin load. See
above for more on this.
Prebiotics (fermentable fibre) provide a
source of carbohydrate for the bacteria in the gut. These bacteria increase in number when provided with additional
fermentable fibre, and the more bacteria there are, the more nitrogen is
excreted in the faeces.
Therapeutic kidney diets contain fermentable fibre,
because some is always needed to feed the gut bacteria. Iams has patented
a Nitrogen Trap Fiber System containing beet fibre for use in their
therapeutic kidney diets. Hill's uses both beet fibre and locust bean gum.
PetCoach discusses beet pulp.
Nutritional management of feline chronic kidney
disease (2008) Elliott J, Elliott D Veterinary Focus
18(2) pp39-44 states "classic uremic toxins, unlike urea nitrogen, are
medium sized molecules, too large to easily pass through the membrane
barrier. It is therefore unlikely that these toxins may be used by the
bacteria to cater for their nitrogen needs. Conversely, the beneficial
effects of fermentable fibers can help to regulate the digestive disorders
that accompany CKD."
Too much fibre may also prevent your cat from absorbing
sufficient nutrients or calories from his/her food. Fibre may also affect
taurine levels in some foods. I would therefore recommend discussing
additional fibre with your vet before adding it, and avoiding its use in a
cat who already has high calcium levels.
Kibow Biotech has recently (2018) released a new product called Fortis
which contains six prebiotic fibres. The manufacturer suggests using it in
conjunction with Azodyl
or Renadyl.
Prebiotics: Locust Bean Gum
One member of Tanya's CKD Support Group, with her vet's approval, gave 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. She believed it
helped her cat and improved his bloodwork.
She used a heaped 1/8th of a teaspoon of locust bean gum, mixed with 2
tablespoons of water, and added to a 3 oz can of wet food. It must be mixed
with water before being added to the wet food because otherwise it can swell
and cause choking. Do not try to mix it with dry food.
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.
Prebiotics: Acacia Gum (Astro's Nitrogen Scrub)
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.
Originally the Scrub was supposed to be mixed with a probiotic such as
kefir (available from health food stores) or live yoghurt. The Scrub was apparently designed in this manner so as to make it easier
to ship without the risk of killing off the live bacteria contained in a
probiotic, which may happen when you ship probiotics without chilled
shipping. The manufacturer apparently now states that you no longer need
to mix it with a probiotic.
The Scrub is in powder form so you can control the dose. Some
people simply mix it into their cat's food. A typical dose might be half a teaspoon per 7 lbs of
cat once a day but it is recommended that you start lower and build up to
this level. Do not exceed 2 g per day because this could apparently
increase your cat's calcium levels. It should not be given at the same
time as slippery elm bark or antibiotics.
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 couple of years and she thinks that it probably has helped
overall. Others felt it helped with appetite. Personally, I wouldn't
bother with it, but if you do decide to try it, please check with your vet
before using.
Azodyl and Renadyl are products which are intended to help cats with CKD by reducing the
workload of the kidneys. They are not identical but
the main ingredients in both are
probiotics and
prebiotics, so you may see them referred to as synbiotics,
the term for a product containing both probiotics and prebiotics.
Azodyl
Azodylis designed for the veterinary market and is sold by
Vetoquinol. Azodyl's
name is a play on
azotaemia and dialysis.
It contains:
psyllium,
a type of fibre commonly used to control constipation which is also a
prebiotic
In terms of probiotics, it contains 45 billion CFUs (colony forming units,
see
above) per capsule, so one Renadyl
capsule is three times as strong as an Azodyl capsule.
Although Azodyl and Renadyl are not exactly the same, they do contain the
same probiotics. I am sometimes asked about this, because Azodyl
contains
Enterococcus thermophilus, whereas Renadyl contains
Streptococcus thermophilus. However, 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.
Azodyl/Renadyl Mechanism
The probiotics contained in these products are
not unique, but these particular
strains are, in fact they are patented.
The manufacturers claim that these strains have a particularly high affinity for some of the major
uraemic toxins found in CKD. The idea is that
Azodyl and Renadyl should bind with and thus reduce the levels of these
uraemic toxins in CKD cats, which the manufacturer of Renadyl calls
enteric dialysis (a
term it has trademarked).
Azodyl FAQs answer a number of commonly raised questions about Azodyl.
Kibow Biotech explains more about the reasoning behind Azodyl.
Azodyl/Renadyl Research
Since Azodyl and Renadyl are classified as dietary or nutritional supplements,
the American Food and Drug Administration does not require them to undergo
clinical trials. Therefore there are only limited studies available. In October 2017
Kibow Biotech, the manufacturer of Renadyl, announced a
placebo-controlled large scale clinical trial into the use of Renadyl in
human patients (the Hope Study) in the USA..
Intestinal bacterial microflora - a potential source of chronic
inflammation in patients with chronic kidney disease
(2006) Kotanko P Nephrology Dialysis Transplantation21(8)
pp2057-2060 concludes "Intestinal bacteria contribute to the uraemic syndrome by the production
of uraemic toxins. Additional evidence suggests that translocation of
bacteria and endotoxins from the gut to the blood takes place in kidney
failure. Consequently, it is plausible to assume that the gut contributes
to the chronic inflammatory state in dialysis patients. The availability
of iron in the intestinal lumen may increase growth and virulence of
intestinal bacteria and affect the intestinal barrier adversely. Oral iron
chelation may be beneficial in reducing the intestinal iron load. Basic
research and clinical studies are needed to further define the
significance of intestinal bacteria and their products in uraemia.
Interventions aimed at restoring and maintaining the physiological
intestinal microflora in dialysis patients should be tested rigorously in
clinical trials."
(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 reports on a trial of Renadyl in human patients in four locations. BUN levels fell and the
patients felt better.
Presentation recap ACVIM 2011(2011) reports on
Probiotic Therapy of Chronic Kidney
Disease (2011) Polzin DJ ACVIM Forum 2011, which found that the
BUN and creatinine levels of four dogs on dialysis receiving Azodyl did
not improve.
The
effects of a probiotic on blood urea nitrogen and creatinine
concentrations in large felids (2011) McCain S, Allender MC,
Schumacher J & Ramsay E Journal of Zoo and Wildlife Medicine42(3)
pp426-429, looked at the effects of Azodyl on tigers, lions, cougars and a
leopard, all of whom had BUN over 35 mg/dl and creatinine over 3 mg/dl. It
found "creatinine but not BUN significantly decreased over time." The
decrease occurred mainly between two and six months after starting the
supplement.
Kibow Biotech reports on its studies into
the use of probiotics.
Azodyl/Renadyl Concerns
One concern is that using enteric dialysis may lead to an artificial
reduction in creatinine and BUN levels, making the CKD look less severe
than it actually is.
Chronic progressive renal disease in the cat: recognition and management (2009) Wolf AM CVC in Kansas City Proceedings
quotes Dr Larry Nagode (formerly at Ohio State University College of
Veterinary Medicine, now deceased):
"I feel both Epakitin and Azodyl are best considered as masterpieces of
marketing of possibly questionable real use in therapy of CRF in dogs and
cats—although veterinary users through a profit sharing arrangement with
Vetoquinol involving a retail "markup" can turn a tidy profit by
prescribing them for clients. I say this in part because of lack of data I
am aware of that Azodyl removes "real" uremic toxins from patients guts
and "word of mouth" I have heard that this perturbation of the normal
intestinal bacterial flora in these patients has often led to significant
diarrheal and other intestinal "upset" problems—how often this has been so
I have no idea. Vetoquinol marketed Epakitin first and Azodyl more
recently so that the "urea and creatinine lowering" capacity originally
being part of the justification for use of Epakitin is now the rationale
for added use of Azodyl. Why sell clients one product when you can sell
them two??. My cynicism with respect to these products may well be
misplaced and they may well be outstanding wonderful products for our dogs
and cats—but until I can find data that solidly supports this view I
remain skeptical."
Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge
Symposium pp18-20 says "Preliminary studies in rats and Gottingen mini pigs with induced CKD
suggest that oral probiotic supplementation may moderate azotemia,
consequently slowing the progress of disease and prolonging survival.
Observational studies of cats and dogs with spontaneous CKD have also
shown decreases in blood urea nitrogen and serum creatinine levels after
initiation of probiotic therapy. Reductions in these surrogate markers
alone, however, do not prove that probiotics remove the essential uremic
toxins. Further studies are needed to determine the usefulness of “enteric
dialysis” in managing CKD in domestic animals."
Azodyl FAQs respond to these concerns as follows: "AZODYL reduces the
BUN and Creatinine values. This occurs because the bacteria consume
non-protein nitrogen molecules found in the gut. BUN and Creatinine are
the markers used for evaluation of renal function. Uremic toxins build up
during renal failure as the kidneys are unable to remove them. It does
stand to reason that if we reduce the levels of BUN and Creatinine we may
develop a false sense of increased renal function. BUT, does anything
improve renal function? NO, once we lose the nephron (the functional
element of the kidney) it is not replaced. Early on, a compensatory
mechanism occurs whereby the remaining nephrons “pick-up the slack”. Soon
they “burn themselves out”. This compensatory mechanism is detrimental. We
recommend administration of AZODYL once the kidneys display signs of
Azotemia. We define azotemia as persistent increases in BUN and
creatinine. Clinically, azotemia is an indication that we have lost 75% of
the functional nephrons. With 25% or less of the nephrons remaining we
know we are on the downward slide. We can continue to monitor the
decreased renal function as the BUN and Creatinine rise and offer no
systemic support to the animal or we can try to improve the quality of
life. We have opted to improve the quality of life. If we remove these
uremic toxins we help to minimize or possibly prevent the effects of a
uremic crisis. With all that said let’s look at it another way. In human
medicine we offer dialysis. This procedure eliminates toxins that build up
in the body, thereby improving the quality of life. Without the elevation
of these toxins and the markers of renal function we could assume the
kidneys are doing better. NOT THE CASE. We already know that renal
function is so compromised that the animal (or human) will suffer the
effects from a uremic crisis. We can prevent that by reducing the effects
of the uremic toxin build up."
Azodyl and Renadyl cannot reverse kidney disease but
if they reduce BUN levels, they 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 cause vomiting, and others could not see any discernible difference.
There may or may not be a difference in bloodwork.
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/Renadyl Side
Effects and Interactions
The most commonly reported side effects are vomiting and occasionally
diarrhoea.
Renadyl and Azodyl contain psyllium, and Renadyl also contains inulin, and there is some debate as to
whether these might increase calcium absorption, which could mean
they are not suitable for
cats with high calcium levels. See
below for more on this.
Drugs is the
Canadian version of information on Azodyl and states "not for use in
animals with diabetes." This is thought to be because Azodyl contains psyllium,
a type of fibre (carbohydrate), and Canadian laws require that this be
mentioned in case it affects the cat's blood glucose levels. Apparently
the manufacturer has not received any reports of Azodyl having any adverse
effects on diabetic cats.
Renadyl was
recalled in Canada in June 2021 but it appears this was only because
the inulin it
contained was not declared on the label.
How to Give Azodyl/Renadyl
Giving Azodyl
Giving Azodyl
to cats may be problematic. Firstly, the required dosage is quite high: a
cat weighing 5-10 lbs would require two capsules a day according to
Vetoquinol.
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.
The
previous version of Azodyl was only available in large capsule form (size
1), which is rather large for many cats; this may be one reason why some
cats threw up the entire capsule, sometimes several hours after it had
been given.
The manufacturer therefore switched to a smaller capsule. 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 (though the
larger Azodyl capsule size is no longer commercially available, so in
practice you will only be offered the small capsule).
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, investigated whether opening the capsule and sprinkling the
contents on to food affected the product's efficacy.
Unfortunately, the study
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 study 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. Given in this way, the Azodyl should still
be about 80% effective. It should not be mixed with liquids as this
will activate the bacteria in the product too early, making it less
effective.
From what I
hear, 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; they then give the second
Azodyl dose about an
hour before dinner in the same way. Members of Tanya's CKD Support Group
are generally positive about Azodyl when given in this way,
and it apparently has very little taste, so most cats do not notice it in
their treat.
Giving Renadyl
In the
Palmquist study mentioned
above,
Renadyl was found to be effective even when mixed with meals.
Renadyl says "The gel cap
product is more efficacious when taken immediately after each meal."
This could be because Renadyl contains three times as many
bacteria as Azodyl, so more bacteria survived. One member of Tanya's CKD Support Group
has successfully used this product
mixed directly with meals after apparently being told this would reduce
the efficacy of the product but not remove it completely.
Azodyl/Renadyl Availability
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. 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 there are currently no plans to introduce
the product in Europe because Vetoquinol does not wish to go through the
necessary registration process.
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
at some point. In the meantime, you can order from the USA, but shipping
costs will not be cheap.
Azodyl and Renadyl Storage and Shipping
People are often confused as to how best to have Azodyl or Renadyl shipped
to them and how to store it once it has arrived. This is because the
manufacturers of the two products offer conflicting advice:
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
Azodyl FAQs), so if you leave Azodyl out overnight there is
unlikely to be cause for concern. However, 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.
Kibow Biotech, the manufacturer of Renadyl, says Renadyl is "fully stable
without refrigeration for at least 2 weeks," so it can be shipped without
chilling. It does recommend that it is kept in the fridge upon receipt.
Azodyl/Renadyl 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 or the UK, Azodyl and Renadyl are not
available and the only way to buy them is by ordering from a US supplier.
This also applies to Asia, although a deal was struck with a distributor
in India in 2018, so Renadyl may become available locally.
I
understand that it is not currently possible to import Azodyl
into Australia, but that it may be permitted in due course.
An authorised Azodyl seller, sells 90 Azodyl capsules for US$70 plus
shipping. I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled.
Sells 90 Azodyl capsules for US$69.95
plus shipping. I used
Thriving Pets within the USA myself for other items with no problems.
The tanya discount
code mentioned elsewhere on my website does not apply if your basket
includes Azodyl.
Sells 60 Renadyl capsules for US$49.50
plus shipping. I used
Thriving Pets within the USA myself for other items with no problems. You
can choose whether to ship with or without a cold pack (which costs an
extra US$5).
The tanya discount
code mentioned elsewhere on this site does not apply if your basket
includes Renadyl.
An authorised Azodyl seller, sells 90 Azodyl capsules for US$70 plus
shipping. They will ship to Canada, click
here for more
information. I have used Entirely Pets myself to buy Azodyl within the USA with
no problems, it arrived chilled.
Sells 90 Azodyl capsules for US$69.95 plus shipping. I used Thriving Pets
within the USA myself for other items with no problems.
The tanya discount
code mentioned elsewhere on my website does not apply if your basket
includes Azodyl.
Sells 60 Renadyl capsules for US$49.50
plus shipping. I used
Thriving Pets within the USA myself for other items with no problems. You
can choose whether to ship with or without a cold pack.
The tanya discount
code mentioned elsewhere on my website does not apply if your basket
includes Renadyl.
Europe
In theory you can import Azodyl or Renadyl into Europe from the USA. Since
Azodyl 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.
Renadyl is "fully stable without refrigeration for at least 2 weeks," so
it can be shipped without chilling. It does recommend that it is kept in
the fridge upon receipt.
An authorised Azodyl seller, sells 90 Azodyl capsules for US$70 plus
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.
Sells 90 Azodyl capsules for US$67.95 plus shipping. I used Thriving Pets
within the USA myself for other items with no problems.
The tanya discount
code mentioned elsewhere on my website does not apply if your basket
includes Azodyl.
The manufacturer sells three bottles of Renadyl for US$148.50. I have thus far heard of
successful shipments to the UK, Italy. Shipping to Europe costs around
US$50.
Sells 60 Renadyl capsules for US$49.50
plus shipping. I used
Thriving Pets within the USA myself for other items with no problems. You
can choose whether to ship with or without a cold pack.
The tanya discount
code mentioned elsewhere on my website does not apply if your basket
includes Renadyl.
If you import Azodyl or Renadyl into the UK from the USA and duty is due, it may sometimes be delayed
depending upon which delivery company is delivering it. UPS simply deliver
your parcel and ask you to pay at that time. Unfortunately, Parcelforce write to tell
you duty is due and do not deliver until you have paid, and in the
meantime
your parcel will be sitting unchilled in Customs. 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. It is better to order on a
Monday, so your parcel does not end up sitting in Customs all weekend.
Asia
ET Healthworld reports that in 2018 Kibow Biotech entered into an
alliance with Centaur Pharma that will enable Centaur Pharma to market
Renadyl in India.
Adsorbents are products that bind with something else. The most commonly
used adsorbent in the treatment of CKD in cats is phosphorus binders, which are so
important that they have their own page
here.
This section focuses on other adsorbents which are intended to bind with
some of the uraemic toxins seen in CKD and thus improve wellbeing.
There is ongoing research into whether oral adsorbents might not only help
CKD patients feel better, but might also reduce damage to the kidneys and
slow the progression of kidney disease. Much of the research into the use
of these products has taken place in Japan, and at least one of these adsorbents
is routinely used in Japan when treating human CKD patients.
However, one treatment, Ipakitine/Epakitin, was developed in Germany.
Unlike the strong evidence for phosphorus control delaying the progression
of CKD, there is currently little evidence that these products do the same.
Oral adsorbents for preventing or delaying the progression of chronic
kidney disease (2014)
Wu HM, Sun HJ, Wang F, Yang M, Dong BR & Liu GJ The Cochrane Database
of Systematic Reviews15(10) reviewed the results of fifteen research
studies from Japan, China and the USA. It concludes "there is evidence of
limited quality that
AST-120, Ai Xi Te and Niaoduqing granules may have
positive effects on delaying the decline of kidney function. There were no
serious adverse events for any of the interventions in patients with CKD.
Given the lack of information for our primary outcomes, the low
methodological quality of most studies, and the small sample sizes, there
is no strong evidence on the effectiveness of these oral adsorbents."
Calcium Carbonate-Based
Phosphorus Binders With Added Adsorbents
There are a
number of calcium carbonate-based phosphorus binders on the market. Basic
calcium carbonate is available from any pharmacy very cheaply and without a prescription, so, presumably to justify their high prices, the
manufacturers of branded products add other ingredients, and in some cases
these are adsorbents.
Chitosan is a polysaccharide
similar to cellulose and is obtained from the shells of crustaceans (shell
fish such as crabs).
Chitosan Mechanism
When protein is
eaten and digested, an amino acid in the food called tryptophan is
converted into indole. Indole is then converted into indoxyl, which in
turn is converted by the body into
indoxyl sulphate, a type of uraemic
toxin.
AST-120
for the management of progression of chronic kidney disease (2014)
Schulman G, Vanholder T & Niwa T International Journal of Nephrology
and Renovascular Disease7 pp49–56 says "Uremic toxins such as
indoxyl sulfate contribute to the pathogenesis of chronic kidney disease
(CKD) by promoting glomerulosclerosis and interstitial fibrosis with loss
of nephrons and vascular damage."
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.
Indoxyl sulphate is only one of a number of uraemic toxins, so products
containing chitosan to bind it are unlikely to be sufficient to help your cat feel better
in isolation.
Chitosan is also said to
help reduce BUN/urea levels, and indirectly to reduce creatinine levels. These
claims appear to be based largely on the results
of human trials (see
clinical
trials).
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 examined the effects of chitosan on 80
human patients undergoing long term haemodialysis 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.
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 states
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 calcium-based phosphorus binders, and cats are not rats.
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
manufacturer of Epakitin) which indicated that Epakitin reduced phosphorus levels in
the cats, who were fed a commercial non-therapeutic diet and who were
in
IRIS Stages 1 and 2. The study did not find that Ipakitine
reduced BUN or creatinine levels, however the cats in this
study did not have naturally occurring kidney disease, which the cats in
the 2004 study below did.
Yucca schidigera is a plant found largely in Mexico which is thought to
have anti-inflammatory properties. It is sometimes used to help with
arthritis.
There is very little research into the use of yucca in cats, but it
appears to be safe in small amounts.
Easypill Kidney Support Cat is a
calcium carbonate-based phosphorus binder made by Vetinnov in France and
available in a number of European countries. As the name suggests, this
product is intended to offer high palatability. The product contains:
Rather strangely for a phosphorus binder, Easypill Kidney Support Cat contains 1.19% phosphorus on
a dry matter analysis basis.
I was told this is because chicken hydrolysate, which is used to make the
product palatable to cats, contains phosphorus.
The recommended dose is one 2mg pellet per day for three months.
I have not heard from anybody who has used this product as yet.
Activated
charcoal is sometimes used to treat human overdoses. Like
chitosan, its
mechanism is related to its effect on indoxyl sulfate (see
below for more on this).
The effect of
activated charcoal on adenine-induced chronic renal failure in rats
(2014)
Ali BH, Alza'abi M, Ramkumar A, Al-Lawati I, Waly MI, Beegam S,
Nemmar A, Brand S & Schupp N Food and Chemical Toxicology65
pp321-8 looked at the effects of activated charcoal on rats with
artificially induced renal failure. It concludes "The results suggest that
charcoal is a useful sorbent agent in dietary adenine-induced CRF in rats
and that its usability as a nephroprotective agent in human kidney disease
should be studied."
I have heard from a couple of people using activated charcoal, and they
felt it seemed to help their cats feel a bit better. I have no knowledge
of appropriate doses for CKD cats. Please do not use this without your
vet's knowledge and approval.
Possible
side effects include nausea, vomiting and constipation. Charcoal may
darken stools.
AST-120: Covalzin
(Kremezin)
AST-120 is an oral adsorbent developed by
Kureha Chemical Industries which is based on activated charcoal,
though according to
AST-120
for the management of progression of chronic kidney disease (2014)
Schulman G, Vanholder T & Niwa T International Journal of Nephrology
and Renovascular Disease7 pp49–56, "It differs from activated charcoal in its
uniform composition, and it has a lower adsorption ability for amylase,
pepsin, lipase, and chymotrypsin than charcoal."
AST-120
Mechanism
When protein is eaten and
digested, an amino acid in the food called tryptophan is converted into
indole, which is then converted into indoxyl, which in turn is converted by the body into
indoxyl sulphate, a
type of uraemic toxin.
AST-120
for the management of progression of chronic kidney disease (2014)
Schulman G, Vanholder T & Niwa T International Journal of Nephrology
and Renovascular Disease7 pp49–56 states "elevated indoxyl
sulfate levels were associated with increased mortality, even after
adjustment for multiple variables."
AST-120 binds
with the indole, so it cannot be converted to indoxyl and then into
indoxyl sulphate, thus reducing toxin levels, which helps the cat feel
better.
AST-120
for the management of progression of chronic kidney disease (2014)
Schulman G, Vanholder T & Niwa T International Journal of Nephrology
and Renovascular Disease7 pp49–56 also says "Uremic toxins such as
indoxyl sulfate contribute to the pathogenesis of chronic kidney disease
(CKD) by promoting glomerulosclerosis and interstitial fibrosis with loss
of nephrons and vascular damage. AST-120, an orally administered
intestinal sorbent, adsorbs indole, a precursor of indoxyl sulfate,
thereby reducing serum and urinary concentrations of indoxyl sulfate."
This is similar
to the mechanism for products containing
chitosan,
but it takes place one stage earlier than chitosan (which binds with
indoxyl, not indole).
Indoxyl sulphate is only one of a
number of uraemic toxins, so AST-120 alone is unlikely to be sufficient to
help your cat feel better.
AST-120 Availability
AST-120 is marketed under the name of Kremezin for the treatment of human
CKD patients in Japan, where it has been used for this purpose since 1991. It is also available in South Korea and
the Philippines. It is not currently commercially available in the USA or
Europe, though trials have taken place in the USA and Europe.
AST-120 is also marketed under the trade name of Covalzin for the
treatment of feline CKD. It is available in Japan, and I have also heard
from people in South Korea and Hong Kong who have used it. In 2018 one
person obtained it in the USA but I have not heard how things went.
I have heard from a couple of people in Japan who have used Covalzin on their
cats without any problems, and they thought it might have helped their
cats.
AST-120
Research
AST-120 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.
Randomized placebo-controlled EPPIC trials of AST-130 in CKD (2015) Schulman
G, Berl T, Beck GJ, Remuzzi G, Ritz E, Arita IK, Kato A & Shimizu M
Journal of the American Society of Nephrology26(7)
pp1732–1746 reports on two trials into the use of AST-120 in human CKD
patients in the USA and Europe and found that it did not appear to slow
the progression of CKD, in contrast to the results seen in similar
patients in Japan. It states "In conclusion, the benefit of adding AST-120
to standard therapy in patients with moderate to severe CKD was not
supported by the data from these trials."
AST-120
How to Give
A box of Covalzin
contains 90 small sachets, each containing 400mg in small pieces. The
typical dosage
for a cat is one sachet a day, which can be mixed into food or given in
gelcaps. It should be given one hour apart from other medications or
supplements.
AST-120
Side Effects
Possible side effects in humans are usually gastrointestinal, such as
constipation, diarrhoea or nausea, according to
AST-120
for the management of progression of chronic kidney disease (2014)
Schulman G, Vanholder T & Niwa T International Journal of Nephrology
and Renovascular Disease7 pp49–56. If your cat develops
constipation while using Covalzin, speak to your vet about whether stop
the Covalzin until you have the constipation under control.
Renaltec
(Porus One)
Porus One is a charcoal-based
adsorbent from Germany that was released in German-speaking countries
(Germany, Austria and Switzerland) in February 2018 and which is now
widely available in many parts of the world. It became available in the USA in 2021 via
Dechra. As at 2023, it had been used more than 10 million times.
Contrary to one online report, Porus One is not the same as AST-120 (Covaltec).
Its active ingredient is called renaltec, which is 100% carbon, but in a
very patented refined form, which I am told means it moves more smoothly through
the digestive tract and binds selectively with toxins such as
indoxyl sulfate or
p-kresyl sulfate. There is more information about how it works
here.
The effect of Renaltec
on serum uremic toxins in cats with experimentally induced chronic
kidney disease (2024) Paschall RE, Quimby JM, Lourenço BN, Summers
SC & Schmiedt CW Veterinary Sciences11 379 found that
levels of uraemic toxins (in particular, indoxyl sulfate and p-cresol
sulfate) in CKD cats reduced with the use of Porus One, amd it appeared
to improve metabolic acidosis, though there were also small increases in
BUN and creatinine. Please note the cats in the study did not have
naturally occurring CKD (i.e. a large percentage of their kidneys had
been surgically removed, apparently for the purposes of an earlier
study).
Serum levels of the uraemic toxin indoxyl sulfate (IS) (2019) is a
report from the manufacturer on a study of eighteen cats over the age of
ten. One of the cats had elevated creatinine levels and three had elevated
SDMA levels. Six cats had elevated phosphorus levels. Twelve of the cats
were given Renaltec for eight weeks, the other six were controls. Indoxyl
sulfate levels fell by more than 60% in the cats given Renaltec, and
phosphorus and SDMA levels reduced in most of them.
Porus
One is provided in 500mg sachets which are sprinkled on the cat's food
and mixed in. It is given once daily. There are 30 sachets in a pack. It
is quite gritty in texture.
Because of its binding properties, Porus One should be given two hours
apart from any other medications, as mentioned by
Drugs. However,
Dechra states that Porus One does not have to be separated from
phosphorus binders.
If you are in the UK, you may also be offered a cat treat product called
Add One, which is supposed to increase the palatibility of Porus One.
One person was told it needs to be given for at least sixty 60 days before
you might see some improvement in your cat's bloodwork.
Renaltec
(Porus One) Suppliers
Porus One is expensive, costing around US$45 or £40 a month. This equates to a sizeable annual cost of
over US$500 or £450 a year, which is a lot of money.
Although Porus One has been available for some years now,
I still have not heard from too many people about it. Feedback to
date has been broadly favourable, with a number of people saying their cat's
creatinine levels have improved, though a couple of people felt it did not
help in any way.
Antioxidants
Antioxidants
help combat inflammation by mopping up free radicals which can cause
damage to cells and are associated with aging and disease.
In humans, it is known that the degree of
oxidative stress reflects the stage of CKD, and it is thought that
antioxidants may help reduce levels of oxidative stress and slow the
progression of CKD in cats.
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."
Antioxidants
PetCoach explains more about antioxidants.
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.
Response of patients in classes III and IV of
cardiomyopathy to therapy in a blind and crossover trial with coenzyme Q10
(1985) Langsjoen PH, Vadhanavikit S & Folkers K Proceedings of the
National Academy of Sciences of the United States of America82
pp4240-44 concluded that "CoQ10 deficiency might be a major
if not the sole cause of cardiomyopathy and that
CoQ10 is likely a lifetime
therapy for the cardiac patient."
Ubiquinone is
converted in the body into ubiquinol. Some people therefore prefer to give
ubiquinol, believing it to be more bio-available.
CoQ10 is one
of the ingredients in Astro's Oil (see
below).
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
appeared to support renal function in rats who had had a kidney surgically
removed.
Randomized double-blind placebo-controlled trial of coenzyme Q10 in
chronic renal failure: discovery of a new role (2009) Singh RB, Khanna
HK & Niaz MA Journal of Nutritional and Environmental Medicine10(4) pp
281-288 looked at the effect of CoQ10 on human patients, some of whom were
receiving dialysis.
It concludes "Treatment with coenzyme Q10 improves renal function in
patients with chronic renal failure and decreases the need for dialysis in
patients on chronic dialysis. Long-term follow-up in a large number of
patients would be necessary to confirm these results."
Coenzyme Q10 dose-escalation study in hemodialysis patients: safety,
tolerability and effect on oxidative stress (2015) Yeung CK, Billings FT, Claessens AJ, Roshanravan B, Linke L, Sundell
MB, Ahmad S, Shao B, Shen DD, Ikizler TA & Himmelfarb
J BMC Nephrology16 looked at the use of CoQ10 in human
patients on dialysis and concluded "In summary, CoQ10 appears to be safe and well tolerated in subjects
receiving MHD and may reduce oxidative stress by improving mitochondrial
function. Further studies are needed to investigate the potential
metabolic and clinical benefits associated with longer term CoQ10
supplementation."
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.
I am not aware
of any studies into the use of CoQ10 in cats, CKD or otherwise, but I have heard from a few
people who think it helps their CKD cats feel better overall.
Co-enzyme Q10: Dosage
If you
decide to use CoQ10 with your vet's approval, 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.
CoQ10 is available from health food stores.
It is also available from
Amazon and
Amazon UK.
Co-enzyme Q10: Side Effects and Interactions
Possible side effects
include nausea or abdominal discomfort, though starting with a low dose
and only increasing gradually may help minimise the chance of these
occurring.
CoQ10
may not be appropriate if your cat is on blood thinners such as aspirin or
clopidogrel.
PennState Hershey
says "There have been reports that CoQ10 may make medications such as
warfarin (Coumadin) or clopidogrel (Plavix) less effective at thinning the
blood. If you take blood thinners, ask your provider before taking CoQ10."
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.
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. cat. I would not stop it suddenly, see the next
paragraph.
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.
Antioxidants: Astro's Oil
Astro's Oil Advanced Renal Care Formula,
previously called 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.
The current version of the product may be "advanced" but it is actually
weaker than the earlier versions.
Each 1.5ml dose of
Astro's Oil contains approximately (figures in brackets show the content of
the earlier versions):
100 IU of
natural
vitamin E (D-tocopherol)
(200 mg)
Therefore this product is basically a
combination of
essential fatty acids,
and two antioxidants.
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.
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, some people on Tanya's CKD Support Group use
Astro's Oil and most people seem to like
it, reporting that their cats seem
"better", albeit in some immeasurable way. A small percentage
found that it made their cats vomit more though, so they stopped using it.
Astro's Oil is only available from the creator's website (link is in the
first paragraph). A 60 ml bottle costs US$32.95 and you give 1.5 ml a day so
it lasts about 40 days.
Almost everyone I have heard from has mentioned that their cat hates the
taste and smell of Astro's 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 Oil, you can consider giving essential fatty acids
and antioxidants separately instead.
I don't consider Astro's Oil to be an essential product, but it is
unlikely to do any harm. If you do use
it, please see the advice about not stopping products
containing CoQ10 suddenly
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 maintain hydration. I
certainly would not recommend stopping any of your cat's current treatments,
particularly sub-Qs, without your vet's knowledge and approval.
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.
This site was
created using Microsoft software, and therefore it is best viewed in
Internet Explorer. I know it doesn't always display too well in other
browsers, but I'm not an IT expert so I'm afraid I don't know how to
change that. I would love it to display perfectly everywhere, but my focus
is on making the information available. When I get time, I'll try to
improve how it displays in other browsers.
This site is a labour of love, from which I do not make
a penny. Please do not steal from me by taking credit for my work.
If you wish to
link to this site, please feel free to do so. Please make it clear that
this is a link and not your own work. I would appreciate being informed of
your link.