TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

ALL ABOUT ANAEMIA

 

ON THIS PAGE:


What is Anaemia?

Why Anaemia Occurs in CKD Cats


Other Causes of Anaemia


Major Symptoms and Risks


Diagnosis, Including PCV or HCT, RBCs, Reticulocytes and Iron


Treatments, Including Vitamins, Iron and Blood Transfusions


Summary


 

 

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Nausea, Vomiting, Appetite Loss and Excess Stomach Acid


Maintaining Hydration


The Importance of Phosphorus Control


All About Hypertension


All About Anaemia


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Kidney Stones


 

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SYMPTOMS


Alphabetical List of Symptoms and Treatments


Fluid and Urinary  Imbalances (Dehydration, Overhydration and Urinary Issues)


Waste Product Regulation Imbalances (Vomiting, Appetite Loss, Excess Stomach Acid, Gastro-intestinal Problems, Mouth Ulcers Etc.)


Phosphorus and Calcium Imbalances


Miscellaneous Symptoms (Pain, Hiding Etc.)


 

DIAGNOSIS: WHAT DO ALL THE TEST RESULTS MEAN?


Blood Chemistry: Kidney Function, Potassium, Other Tests (ALT, Amylase, (Cholesterol, Etc.)


Calcium, Phosphorus, Parathyroid Hormone (PTH) and Secondary Hyperparathyroidism


Complete Blood Count (CBC): Red and White Blood Cells: Anaemia and Infection


Urinalysis (Urine Tests)


Other Tests: Ultrasound, Biopsy, X-rays etc.


Renomegaly (Enlarged Kidneys)


Which Tests to Have and Frequency of Testing


Factors that Affect Test Results


Normal Ranges


International and US Measuring Systems


 

TREATMENTS


Which Treatments are Essential


Fluid and Urinary Issues (Fluid Retention, Infections, Incontinence, Proteinuria)


Waste Product Regulation (Mouth Ulcers, GI Bleeding, Antioxidants, Adsorbents, Azodyl, Astro's CRF Oil)


Phosphorus, Calcium and Secondary Hyperparathyroidism (Calcitriol)


Phosphorus Binders


Miscellaneous Treatments: Stem Cell Transplants, ACE Inhibitors - Fortekor, Steroids, Kidney Transplants)


Antibiotics and Painkillers


Holistic Treatments (Including Slippery Elm Bark)


ESAs (Aranesp, Epogen etc.) for Severe Anaemia


General Health Issues in a CKD Cat: Fleas, Arthritis, Dementia, Vaccinations


Tips on Medicating Your Cat


Obtaining Supplies Cheaply in the UK, USA and Canada


Working with Your Vet and Recordkeeping


 

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Nutritional Requirements of CKD Cats


The B Vitamins (Including Methylcobalamin)


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Home > Key Issues > Anaemia

 


Overview


  • Anaemia is a condition in which not enough red blood cells (RBC) exist in the body.

  • Anaemia is relatively common in CKD cats, so it is important to know about it and to be prepared to deal with it promptly.

  • Untreated anaemia can kill a cat far more quickly than the CKD, and a severely anaemic cat may look very ill, but fortunately anaemia is usually very treatable, so don't give up hope.

  • Treating anaemia in a CKD cat is worthwhile. The University of Georgia College of Veterinary Medicine has stated that "anemia is not a poor prognostic indicator in cats as most live for more than 300 days despite presenting with anemia." Some cats whose anaemia is properly controlled live a lot longer than this.


What is Anaemia?


 

Anaemia is not a disease, but a symptom; it can have many causes. It occurs when not enough red blood cells (RBC) exist in the body. Red blood cells are produced in the bone marrow and are released into the bloodstream. They contain a protein called haemoglobin, which transports oxygen around the body, so if a cat does not have enough red blood cells, oxygen is not reaching the cells where it is needed, and the cat's body will not be able to function properly.

 

There are two classes of anaemia, regenerative and non-regenerative. When the number of red blood cells in the body drops, the bone marrow should start producing more red blood cells.

  • Regenerative anaemia: increased loss. New red blood cells are being produced in the bone marrow but they are being lost or destroyed more quickly than they should.

  • Non-regenerative anaemia: decreased or no production. The bone marrow is not making new red blood cells.

In cats, non-regenerative anaemia is more common than regenerative anaemia.

 

Cats can be prone to developing anaemia because, as International Cat Care explains, "their RBCs have a shorter lifespan (around 70 days) than many other animals (around 110-120 days in dogs and humans) - this means they have a higher turnover of RBCs and anaemia can therefore develop quite rapidly if anything interferes with this."

 

Untreated anaemia can kill a cat far more quickly than the CKD, and a severely anaemic cat may look very ill, but fortunately anaemia is often very treatable, so don't give up hope. University of Georgia College of Veterinary Medicine has stated that "anemia is not a poor prognostic indicator in cats as most live for more than 300 days despite presenting with anemia." Analyzing feline anemia (2006) Lewis HB Banfield July/Aug pp18-23 found that 68% of 3-8 year old cats diagnosed with anaemia were still alive one year after diagnosis, and 49% of cats over 8 years of age were still alive one year after diagnosis. This despite the fact that some of the cats had forms of anaemia that can be challenging to treat.

 

Treating anaemia is not only about lifespan, but also about quality of life. The difference in a cat's behaviour and wellbeing once severe anaemia is brought under control is often quite astonishing. Anaemia is usually very responsive to treatment, but most treatments take a week or so to take effect (apart from blood transfusions, which kick in immediately). Therefore I would recommend treating anaemia for at least two weeks before contemplating euthanasia.

 

How Stuff Works has a simple article about how blood cells are made. 

Understanding anaemia is an excerpt from a book by Ed Uthman.

Pet Place has an overview of anaemia in cats (no need to register, just click on Close at the bottom of the pop-up).

 


Why Anaemia Occurs in CKD Cats


 

Any cat can develop anaemia, but for CKD cats, there are a number of CKD-related reasons why this may happen. As a result, according to Anemia of chronic kidney disease (2009) Langston CL CVC in San Diego Proceedings, "Anemia is a common abnormality noted in patients with CKD, affecting 32 to 65 per cent of cats with CKD."

 

Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 outlines the causes of anaemia in CKD cats in more detail.

 

Cornell University College of Veterinary Medicine explains more about the causes of anaemia in CKD (scroll down to Chronic Kidney Disease).

 

Here are the main causes of anaemia in CKD cats:

 

Lack of Erythropoietin


The main reason why CKD cats develop anaemia is because of a hormone called erythropoietin. This hormone is produced by the kidneys and it stimulates the bone marrow to make blood cells. This process is known as erythropoiesis.

 

As the kidneys fail in CKD, they cannot produce enough erythropoietin, so the bone marrow is not stimulated, red blood cells are not produced, and non-regenerative anaemia results.

 

Uraemia


One of the kidneys' jobs is to regulate and remove waste products. As CKD progresses, the kidneys cannot do this effectively so these waste products build up in the blood. This is called uraemia.

 

Uraemia can have a number of effects on the body, and some of these can contribute to anaemia. For example, uraemic toxins such as parathyroid hormone, which is also not processed properly by damaged kidneys, may also adversely affect erythropoiesis. Role of secondary hyperparathyroidism in erythropoietin resistance of chronic renal failure patients (2002) Drücke TB & Eckardt K-U Nephrology Dialysis Transplantation 17Supp.5 pp17-21 mentions this, but states that it is less of a factor than iron deficiency or inflammation.

 

Even if a cat is still able to produce red blood cells, these last for around 70-80 days in healthy cats, but only around half as long as that in CKD cats. This is probably because, as Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011  states, "An unidentified uremic toxin is suspected of affecting the red blood cell lifespan."

 

Uraemia can also be a factor in gastrointestinal bleeding, which can cause or worsen anaemia. Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 also states "CKD and uremia also predispose animals to gastrointestinal bleeding, with subsequent blood loss."

 

Vitamin B Deficiencies


Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 states "B vitamins, such as vitamin B12, folic acid, niacin, and vitamin B6, are important for erythrogenesis." Vitamin B deficiencies are quite common in CKD cats, because they urinate more, and since the B vitamins are water soluble, they lose increased quantities in the process, leading to non-regenerative anaemia.

 

Iron Deficiency


Red blood cells contain a protein called haemoglobin, which transports oxygen around the body. Haemoglobin needs iron for its production. Therefore a cat with low iron levels will struggle to create new red blood cells and can develop a type of anaemia known as iron-deficiency anaemia.

 

This form of anaemia can be either regenerative or non-regenerative. Cornell University College of Veterinary Medicine says "iron deficiency in adult animals usually is caused by chronic blood loss." However, it goes on to say that "If blood loss continues long enough that body iron stores are depleted and absorption of dietary iron is inadequate to meet the demand created by increased red blood cell production, then iron becomes a limiting factor and effective erythropoiesis is decreased."

 

If the cat has concurrent diseases contributing to the anaemia, such as infections that cause the body to sequester (hide) iron (see below), it is more likely that the iron deficiency anaemia will be non-regenerative.

 


Other Causes of Anaemia


 

There are quite a few other possible causes of anaemia, and it is possible to have more than one cause. For example, a CKD cat may have anaemia caused by a lack of erythropoietin, but might have a urinary tract infection which is also contributing to the anaemia. You and your vet should therefore not immediately assume that your CKD cat's anaemia is caused by a lack of erythropoietin, because a different or additional type of treatment might be necessary, depending upon the cause.

 

Feline anaemias: a diagnostic challenge (2002) is a paper on the various causes of anaemia presented to the World Small Animal Veterinary Association World Congress by Urs Giger.

Basic approach to anaemia diagnosis (2005) is a paper on the various causes of anaemia presented to the World Small Animal Veterinary Association World Congress by Harold Tvedten.

Merck Veterinary Manual discusses anaemia in a quite technical but useful manner.

Cornell University College of Veterinary Medicine discusses the various causes of anaemia.

 


Non-Regenerative Anaemias


When the number of red blood cells in the body drops, the bone marrow should start producing more of them, but in non-regenerative anaemia, the bone marrow does not do this. In cats, non-regenerative anaemia is more common than regenerative anaemia.

 

Inflammation or Infection


Inflammation is a common cause of anaemia, particularly in cats with chronic diseases such as CKD. Iron status of cats with chronic kidney disease (2015) Gest J, Langston C & Eatroff A Journal of Veterinary Internal Medicine 29 pp1489-1493 states "Of an interesting note, TIBC is decreased in inflammation. With TIBC significantly lower in cats with CKD compared to health cats, this study’s results support the presence of inflammation in this group of CKD cats." Anaemia is also often seen in cats with cancer or inflammatory bowel disease (IBD).

 

Infection may also cause non-regenerative anaemia, partly because of associated inflammation and partly because of how the body deals with bacterial infections. Bacteria thrive on iron, so if a cat has an infection, the cat's body will sequester iron (i.e. iron is stored within the body rather than released into the bloodstream). Since iron is necessary for blood cell production, iron deficiency anaemia may result. Iron metabolism in pathogenic bacteria (2000) Ratledge C & Dover LG Annual Review of Microbiology 54 pp881-941 explains more about this.

 

If this is the only reason your cat has anaemia and you are able to get the cause of the inflammation or infection under control, the anaemia may improve or even be fully resolved. One of my cats (who did not have CKD) was prone to pyelonephritis (kidney infections) and every time he developed pyelonephritis, he became anaemic. Once the infection was successfully treated with antibiotics, his anaemia would resolve with no other treatment.

 

Anemia of inflammation and chronic disease is an article about these problems in humans by the National Institute of Diabetes and Digestive and Kidney Diseases.

 

Gastrointestinal Bleeding


As stated above, gastrointestinal bleeding may be caused by uraemic toxins and may contribute to the development of non-regenerative anaemia.

 

Gastrointestinal bleeding may also happen for other reasons, which may mean the anaemia is regenerative, at least initially. Cornell University College of Veterinary Medicine says "Chronic external blood loss, particularly when slow or intermittent, results in a slowly developing anemia, which at first is regenerative (increased reticulocyte count). If blood loss continues long enough that body iron stores are depleted and absorption of dietary iron is inadequate to meet the demand created by increased red blood cell production, then iron becomes a limiting factor and effective erythropoiesis is decreased."

 

Acute gastrointestinal bleeding tends to cause anaemia to develop quickly, whereas most cats with anaemia caused by a lack of erythropoietin become anaemic gradually. Therefore if your cat's PCV level (a measure of anaemia; see below) falls suddenly, ensure your vet considers gastrointestinal bleeding as a possible cause.

 


Regenerative Anaemias


 

With regenerative anaemia, new red blood cells are being regenerated as normal in the bone marrow but for some reason they are being lost or destroyed more quickly than they should. There are several types of regenerative anaemia, and they are sometimes divided into the following classes:

  • haemorrhagic: the red blood cells are being lost through blood loss

  • haemolytic: the red blood cells in the bloodstream are being destroyed

Apart from the tests for anaemia mentioned below, a total protein test, may help your vet decide which type of regenerative anaemia is more likely, because total protein tends to fall if there is blood loss present.

 

Fleas


A severe flea infestation may cause blood loss anaemia, especially in kittens, because fleas drink blood. Mar Vista Vet has more information about this.

 

Fleas may also cause feline infectious anaemia.

 

Gastrointestinal Bleeding


The blood loss resulting from gastrointestinal bleeding may cause regenerative anaemia, though if it continues for a long time, it may eventually become non-regenerative. Cornell University College of Veterinary Medicine says "Chronic external blood loss, particularly when slow or intermittent, results in a slowly developing anemia, which at first is regenerative (increased reticulocyte count). If blood loss continues long enough that body iron stores are depleted and absorption of dietary iron is inadequate to meet the demand created by increased red blood cell production, then iron becomes a limiting factor and effective erythropoiesis is decreased."

 

As mentioned above, gastrointestinal bleeding in CKD cats may be caused by uraemic toxins.

 

Acute gastrointestinal bleeding tends to cause anaemia to develop quickly, whereas most cats with anaemia caused by a lack of erythropoietin become anaemic gradually. Therefore if your cat's PCV level (a measure of anaemia; see below) falls suddenly, ensure your vet considers gastrointestinal bleeding as a possible cause.

 

Iron Deficiency Anaemia


Red blood cells contain a protein called haemoglobin, which transports oxygen around the body. Haemoglobin needs iron for its production. Therefore a cat with low iron levels will struggle to create new red blood cells and can develop a type of anaemia known as iron-deficiency anaemia.

 

This form of anaemia can be either regenerative or non-regenerative. Cornell University College of Veterinary Medicine says "iron deficiency in adult animals usually is caused by chronic blood loss." It goes on to say that "If blood loss continues long enough that body iron stores are depleted and absorption of dietary iron is inadequate to meet the demand created by increased red blood cell production, then iron becomes a limiting factor and effective erythropoiesis is decreased."

 

If the cat has concurrent diseases contributing to the anaemia, such as infections that cause the body to sequester (hide) iron, it is more likely that the iron deficiency anaemia will be non-regenerative.

 

Medication-Related Anaemia


 

Methimazole for Hyperthyroidism


Cats with hyperthyroidism who are being treated with methimazole may sometimes develop anaemia, though this is rare. If it is going to occur, it usually does so within the first three months of use. Stopping the medication usually resolves the problem within a couple of weeks.

 

Can methimazole cause anemia in hyperthyroid cats? (2013) Peterson ME explains more about this problem.

 

Aluminium Hydroxide Toxicity


If you are using aluminium hydroxide as a phosphorus binder, in rare cases aluminium  toxicity may occur and this may cause anaemia.

 

One possible early sign of aluminium toxicity is a change in MCV. This is a measure of red blood cell size. If your cat has a low MCV (known as microcytosis), this means the red blood cells are smaller than usual. Although this may simply indicate iron deficiency, it may also be a sign of aluminium toxicity. This sign normally appears before you see physical symptoms, so be sure to monitor your cat's MCV levels if you are using aluminium hydroxide.

 

Convenia (Cefovecin)


Convenia is an injectable antibiotic in the cephalosporin class which is approved in the USA for the treatment of skin infections in dogs and cats and urinary tract infections in dogs. In Europe it is approved for these conditions but also for the treatment of urinary tract infections in cats.

 

In rare cases antibiotics in this class, including Convenia, may cause haemolytic anemia.

 

Oxidative Damage: Onions or Garlic


Feeding onions or garlic to cats causes a specific type of haemolytic anaemia called Heinz body anaemia.

 

Feline Infectious Anaemia (FIA): Myoplasma Haemofelis


The most common cause of anaemia in otherwise healthy cats is feline infectious anaemia. This is caused by an infective agent called haemoplasma, one type of which is myoplasma haemofelis (previously known as feline haemobartonella felis). This attaches itself to the cat's red blood cells, and the cat's immune system tries to destroy it, but in the process it also destroys the red blood cells. If the cat's body cannot create new red blood cells quickly enough, the cat will develop anaemia.

 

This condition is transmitted by parasites, usually fleas, but unfortunately it does not always show up in tests. Newer PCR tests are more reliable at detecting the infective agent  but you may need to wait for the results.

 

Since FIA can make cats very ill, some vets treat for it even if the tests are negative or delayed. The usual treatment is an antibiotic called doxycycline, which is given for 3-4 weeks. Occasionally corticosteroids are also necessary. If the cat is severely anaemic, a blood transfusion may be required.

 

Pet Place has some information about FIA.

Mar Vista Vet has some good, detailed information on FIA.

Effectively treating cats with FHM (2006) Fazio KA Banfield pp36-42 discusses treatment options.

 

Immune-Mediated Haemolytic Anaemia (IMHA)


Immune-mediated haemolytic anaemia is caused by an autoimmune reaction which leads the cat's own body to kill off its red blood cells. This can cause severe anaemia which can be difficult to treat. The usual causes in cats are myoplasma haemofelis infection (see FIA above) and feline leukaemia.

 

Possible treatments include corticosteroids and cyclosporine, though blood transfusions are also often necessary, preferably of packed red blood cells rather than whole blood. Immune mediated hemolytic anemia: can we beat this disease (2011) Mineo H Veterinary Medicine explains more about treatment options.

 

Veterinary Partner has an overview of IMHA.

IMHA: diagnosing and treating a complex disease (2008) Shaw N & Harrell K Veterinary Medicine discusses IMHA.

 

Hypophosphataemia (Low Phosphorus Levels)


Hypophosphataemia (low phosphorus levels in the blood may cause haemolytic anaemia, according to Immune mediated hemolytic anemia: can we beat this disease (2011) Mineo H Veterinary Medicine. The Merck Veterinary Manual says that this is usually "secondary to diabetes, hepatic lipidosis and refeeding syndrome."

 

Low phosphorus levels are very rare in CKD cat, who tend to have elevated phosphorus levels.

 

Erythrocyte Pyruvate Kinase Deficiency (PK Deficiency) Anaemia


Abyssinian, Somali and Bengal cats may develop this inherited form of anaemia. The Veterinary Genetics Laboratory at the University of California at Davis has some information about this.

 


Symptoms and Risks of Anaemia


 

It may appear that your cat's anaemia has come on suddenly, which may be the case for a cat with gastrointestinal bleeding. However, anaemia tends to develop gradually in a cat with a lack of erythropoietin, so the cat's body adapts to it and the cat may therefore not display any signs until the anaemia is relatively advanced.

 

Severely anaemic cats often look and act extremely ill. My Thomas was unable to walk downstairs, and just walking to the litter tray was a massive effort for him.

 

Fortunately, anaemia is usually treatable. Here are the symptoms you may see:

 

Breathlessness


Because of the shortage of red blood cells, which carry oxygen around the body, there is less oxygen in the body's tissues. Therefore the cat breathes more often and more deeply in an attempt to take in more oxygen.

 

Weakness


This is also caused by the lack of oxygen in the tissues, which means the cells cannot work as effectively.

 

Eating Litter or Licking Concrete


One commonly seen symptom which you might not associate with anaemia is eating litter or licking rocks or concrete. Some cats may eat ice or snow. Many vets do not know this type of behaviour can be a symptom of anaemia, but I hear of it so often, and when the cat is tested, anaemia is virtually always present. Very occasionally, eating litter or licking rocks or concrete is a sign of calcium imbalances instead; but either way, if you see this symptom, take your cat to the vet.

 

The problem should disappear once the anaemia is under control, but in the meantime, switch to a paper- or corn-based litter.

 

Feline compulsive behavior (2005) Moon-Fanelli A mentions that eating litter may be a sign of anaemia.

Pet Place mentions the case of an anaemic cat who ate litter.

The Mayo Clinic says that eating ice may be a sign of anaemia.

 

Faster Heart Rate


In an anaemic cat, the heart rate increases in an attempt to push the reduced amount of haemoglobin around the body. This faster heart rate is called tachycardia. Occasionally anaemia may cause a heart murmur.

 

Hypertension (High Blood Pressure)


The heart tries to provide more blood, and thus oxygen, to the body's cells by increasing the pressure with which it pumps. Hypertension can lead to blindness or strokes, so it is important to treat it if present.

 

Oedema and Heart Failure


The heart can only compensate for the lack of haemoglobin to a certain extent. Eventually, if the problem remains untreated, blood will not circulate properly and will build up, and fluid will leak into body tissues. This causes swelling known as oedema. If oedema occurs in the lungs, it is known as pulmonary oedema, and if it is left untreated this can kill the cat.

 

The University of North Carolina has some information on the risks of anaemia in connection with heart failure in humans.

 

Other Symptoms


Almost all anaemic cats experience:

  • loss of appetite, often severe

  • extreme lethargy

  • pale eyelids or gums

  • feeling cold, so they often seek out warm places.


Diagnosis


 

It can be difficult ascertaining the exact cause of anaemia, and to complicate matters, more than one cause may be present. Your vet will initially determine whether your cat is anaemic by looking at red blood cells (RBC) and packed cell volume (PCV) or haematocrit (HCT), but may also need to do further tests (reticulocytes and measures of iron) in order to ascertain the cause.

 

Cornell University College of Veterinary Medicine has a diagnostic algorithm for anaemia generally

Cornell University College of Veterinary Medicine has a diagnostic algorithm for non-regenerative anaemia in particular.

Anemia diagnostic tree (2010) Kiss CM & Pierce BJ NAVC Clinician's Brief also has a diagnostic tree helping you to distinguish between both.

Taking Blood For Testing


Your vet needs to take blood from your cat in order to run tests for CKD and anaemia. This is potentially problematic for CKD cats because, according to Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011, "The frequent blood sampling of hospitalized patients, especially small pets, can contribute to anemia." This can also be true for cats who are not hospitalised but who are having blood tested every few days.

 

If your vet wishes to test only for anaemia, it is not usually necessary to draw a lot of blood - a tiny drop taken from the ear may be sufficient (make sure the ear is warm), so ask your vet if this method could be used, though some machines do need more blood than this. Veterinary Partner has a description of how to take blood from the ear in diabetic cats, as does Sugar Cats.

 

Home Blood Testing


A few members of Tanya's CKD Support Group have been using a home haematocrit tester to measure PCV at home in order to spare their cats the stress of vet visits and themselves the cost of frequent tests. Of course if you are using an erythropoiesis stimulating agent (ESA) for your anaemic cat, you cannot avoid vet visits completely because you need to monitor blood pressure in cats using an ESA.  Personally, if I was dealing with severe anaemia (PCV below 18%), particularly if my cat was on an ESA such as darbepoetin or epoetin (Aranesp or Epogen), I think I would prefer regular vet visits. But for a stable anaemic cat, especially one who does not do well at the vet's, a home tester might be worth considering.

 

SpinCrit Centrifuge is the model most people have bought for home use. They have found the machine to be pretty accurate (it varied by about 2% from vet readings). It is expensive at around US$210-245 plus shipping (US$10 USA, US$35 Canada, US$45 Europe), but over time it may pay for itself, and it is certainly less stress than regular trips to the vet. Sadly it has been unavailable since October 2015, but perhaps will become available again. You may be able to buy another model, such as this one on Amazon costing US$144.65 but I don't know how accurate it is.

 

If you do buy a home tester, I would recommend checking your first few readings against readings at the vet's, to make sure you are doing it properly and to reassure your vet that you are obtaining accurate readings at home.

 

One possible compromise is to do what one member of Tanya's CKD Support Group used to do. He would obtain the blood from his cat's ear at home as outlined above, but then take the sample to his vet for analysis. This saved his cat the stress of the vet trip, but still gave an accurate result.

 

Regenerative and Non-Regenerative Anaemia


There are two types of anaemia, regenerative and non-regenerative:

  • Regenerative anaemia: increased loss of red blood cells. Red blood cells are being lost or destroyed more quickly than they should be, but new ones are being regenerated as normal in the bone marrow. Therefore the cat's body may in time be able to correct the anaemia without any external help. For example, if your cat is anaemic because you have fed onions, your cat's body should be able to resolve the problem in time once you stop feeding onions.

  • Non-regenerative anaemia: decreased or no red blood cell production. The bone marrow is not trying to make new red blood cells or not enough of them, so the cat is going to need some help in the form of some kind of treatment.

Many (but not all) cats with both CKD and anaemia are suffering from a type of non-regenerative anaemia caused by problems with production of a hormone called erythropoietin (see why anaemia occurs in CKD cats), but your cat may have another type of anaemia, and there may even be more than one cause present.

 

Red Blood Cells (RBC): Erythrocytes


A low red blood cell count is usually indicative of anaemia, because if a cat cannot manufacture sufficient red blood cells or if the red blood cells are being destroyed faster than the cat can make them, s/he will become anaemic.

 

Cats can be prone to developing anaemia because, as International Cat Care explains, "their RBCs have a shorter lifespan (around 70 days) than many other animals (around 110-120 days in dogs and humans) - this means they have a higher turnover of RBCs and anaemia can therefore develop quite rapidly if anything interferes with this."

 

It is even worse for CKD cats. The lifespan of red blood cells in patients with kidney disease is approximately 50% that of healthy cats. Older cats also tend to have shorter lived red blood cells, as do patients with infections or inflammation. Since all of these apply to most CKD cats, these cats are even more prone to developing anaemia.

 

Red blood cells are often a paler colour if MCV is also low.

 

If the RBC count is high, this may be indicative of dehydration.

 

Blood cell guide is a helpful guide to blood cells from IDEXX.

Cornell University College of Veterinary Medicine has some information on red blood cells.

 

Packed Cell Volume (PCV) or Haematocrit (HCT)


Your vet will usually determine whether your cat has anaemia and how severe it is via a blood test called packed cell volume (PCV). PCV measures the ratio of red blood cells to total blood volume. The blood is spun in a centrifugal machine and your vet measures the total number of cells that are left. It does not distinguish old blood cells from new but it is a still a useful and accurate test for anaemia.

 

Some vets check haematocrit (HCT) instead, which is very similar to PCV. HCT actually refers to the red blood cells that are left only; but since the other blood cells (white cells and platelets) usually make up less than 1% of blood volume, the difference between PCV and HCT is too small to be concerned about.

 

Only a small amount of blood is needed for these tests (although more blood is needed for HCT than for PCV) and most vets have the necessary equipment in their offices so you can get a result in a few minutes. Some people test at home (see above).

 

Technically, a cat is anaemic if the PCV level is below 30% (or with some laboratories, 25%), but you may not start to see any differences in your cat's behaviour until the level is closer to 20%. Below 20% is generally considered to be severe anaemia, and it really must be treated as a matter of priority.

 

Your vet will need to look at the PCV in combination with other values. For example, cats with both a low PCV level and low total protein levels, in particular low albumin levels, may have gastrointestinal bleeding or chronic infection or inflammation (see above). Cats with infection or inflammation will usually have a low PCV combined with certain changes in white blood cell counts.

 

Dehydration will make PCV look higher than it really is, so once the cat is rehydrated, PCV will often fall. For example, your dehydrated cat may have, say, a PCV of 24% which does not indicate anaemia, but once the dehydration has been corrected (perhaps through IV or subcutaneous fluids), the PCV may have fallen to 20%, indicating anaemia is present.

 

Cats with hyperthyroidism may have PCV or HCT levels at the high end of the range.

 

Reticulocytes


The PCV test shows if your cat is anaemic, but it does not show whether the anaemia is regenerative or non-regenerative. Regenerative anaemia means that the cat's body may be able to correct the anaemia without any external help, whereas with non-regenerative anaemia, the cat is going to need some help in the form of some kind of treatment.  Many cats with CKD and anaemia are suffering from non-regenerative anaemia caused by problems with production of a hormone called erythropoietin (see why anaemia occurs in CKD cats) but they may have other problems contributing to their anaemia.

 

The only way to know for certain if you are dealing with regenerative or non-regenerative anaemia is by testing for reticulocytes. Reticulocytes are immature red blood cells produced by the bone marrow. When seen in the blood stream, they are about 5-7 days old. Since anaemia means there is a lack of red blood cells, the body's usual response is to try to generate more red blood cells, so normally you would see reticulocytes if the anaemia is regenerative - this shows that the bone marrow is still making blood cells. However, in non-regenerative anaemia the bone marrow is not able to make blood cells (as happens in CKD-related non-regenerative anaemia, where, the lack of the hormone known as erythropoietin means the bone marrow cannot produce RBCs), or not enough of them to replace old ones, so there will be few or no reticulocytes present. 

 

Unfortunately the reticulocyte test (which at most laboratories only measures aggregate reticulocytes) is unlikely to be reliable unless the anaemia is relatively severe. Anaemia needs to be pretty bad before a brisk regenerative response is considered necessary by the cat's body, so there is little point testing for reticulocytes unless the PCV has been below 20% for five days or longer (because reticulocytes take at least five days to be seen in blood). In addition, most vets cannot test reticulocytes in-house, so the test has to be sent out to a lab, which takes more time.

 

Because of this, some vets simply assume that a CKD cat with anaemia is suffering from non-regenerative anaemia caused by a lack of erythropoietin production and treat accordingly. For cats with milder anaemia (PCV above 20%), they may recommend B vitamins. For cats with PCV below 20%, it is trickier. In these cases, the anaemia is a more urgent problem and you need to act quickly, especially if your cat seems poorly, so your vet may recommend the use of erythropoiesis stimulating agents (ESAs) such as darbepoetin alfa (Aranesp) or  epoetin alfa (Epogen, Eprex or Procrit), or occasionally epoetin beta (NeoRecormon) which are used for non-regenerative anaemia caused by a lack of erythropoietin production. In view of the possible risks associated with this treatment, you might wish to wait five days and have the reticulocyte test done to be sure you really are dealing with non-regenerative anaemia; but on the other hand, ESAs can take up to two weeks to start taking effect, so waiting may be risky because your cat will not be feeling well and the anaemia may worsen while you wait.

 

My vet felt it was more important that we start treating Thomas as quickly as possible. Since Thomas had severe anaemia (his PCV was 18% and he was very weak and breathless), she felt the most likely cause was non-regenerative anaemia caused by the CKD, so we began using an ESA immediately rather than wait several days or more for the results of a reticulocyte test. This was the correct choice for Thomas.

 

Reticulocytes Test


This table explains what the various levels of reticulocytes mean. Remember, the table is only really of any use for cats with severe anaemia (PCV below 20%).

 

The usual level of regeneration in a healthy cat who is not anaemic is approximately 1% (around 50,000- 60,000 reticulocytes). In an anaemic cat, you would expect it to be above this level, since you would expect to see a marked response, i.e. the bone marrow should be busily making new red blood cells if it can. It can only do this if sufficient erythropoietin and iron are available. So if the reticulocyte count is low (below 1%) or even zero despite the PCV being below 20% for five days or longer, this indicates non-regenerative anaemia.

 

Degree of Regeneration Reticulocytes in %

Absolute Reticulocytes

Normal/Negligible Under 1.00 Under 60,000

Mild

1.00 - 2.5

60,000 - 100,000

Moderate

2.5 - 5.00

100,000 - 200,000

Marked Over 5.00 Over 200,000

 

Even if the level looks acceptable, it may not be sufficient to cope with the demand from the body for red blood cells. In particular, since reticulocytes are commonly expressed in percentage terms, they need to be adjusted to allow for the degree of anaemia, i.e. 1% reticulocytes in a cat with a PCV of 20% is twice as many as 1% reticulocytes in a cat with a PCV of 10%.

 

Let's assume your cat's PCV is 18% and the measured reticulocyte count is 0.75%. You multiply the PCV by the measured count, then divide the result by the normal PCV level (35% for many laboratories). In this instance, you would get an adjusted result of 0.39%, which indicates non-regeneration.

 

In contrast, if your cat's PCV was 13% and the measured reticulocyte count was 0.75%, your adjusted result would be 0.28. This also indicates non-regeneration, but it is more severe (i.e. the lower the corrected value, the lower the regenerative response).

 

I know this is complicated, and you're probably stressed enough about your cat's anaemia. Basically, if your cat's PCV or HCT level has been below 20% for five days or longer, ask your vet to do a reticulocyte test and let your vet tell you if the anaemia is regenerative or not. But if your cat is severely ill, you should definitely start treatment with B vitamins immediately, and deal with any other obvious problems, such as infection. You may decide to start treatment with an ESA before you get the results of the reticulocytes test or even dispense with this test altogether in the circumstances.

 

The differential diagnosis of feline anaemia (2006) is a presentation by Dr S Tasker to the World Small Animal Veterinary Association World Congress 2006 which explains more about reticulocytes and anaemia.

Cornell University College of Veterinary Medicine provides more information on reticulocytes. It also has a table showing absolute reticulocytes here.

 

Iron Levels


Haemoglobin, the main oxygen-carrying protein of red blood cells, needs iron for its production. Therefore a cat with low iron levels may develop a type of anaemia known as iron-deficiency anaemia.

 

Since iron is present in food, particularly meat, iron deficiency anaemia from lack of iron in the diet is rare in cats. However, cats with inflammation or an infection may have an iron deficiency because the body sequesters (hides away) iron if inflammation or infection are present. Iron metabolism in pathogenic bacteria (2000) Ratledge C & Dover LG Annual Review of Microbiology 54 pp881-941 explains more about this.

 

Cats with sudden blood loss, such as from gastrointestinal bleeding, may also have an iron deficiency. Cats who are having blood taken frequently (once a week or more) for testing may also be at risk of anaemia if a lot of blood is being taken each time.

 

These are the various tests used to check iron levels in the body:

Mean Corpuscular Volume or Mean Cell Volume (MCV)


This is a measure of red blood cell size.

 

Cornell University College of Veterinary Medicine has more information about MCV.

 

Cornell University College of Veterinary Medicine has an MCV calculator.

 

Normocytic MCV


This means the MCV is normal. This tends to be what you see in CKD cats with non-regenerative anaemia caused by a lack of erythropoietin who do not have an iron deficiency.

 

Macrocytic MCV


This means the MCV is high, indicating the red blood cells are larger than usual. Newly formed red blood cells are usually larger than normal, so this might be a sign that your cat's anaemia is regenerative. High MCV may occasionally may be seen in cats with hyperthyroidism.

 

High MCV levels may also indicate a lack of Vitamin B12 and folic acid (Vitamin B9) - in these cases, the anaemia is most probably non-regenerative.

 

Microcytic MCV


This means the MCV is low, indicating the red blood cells are smaller than usual. This may indicate a lack of iron. Possible causes include gastrointestinal bleeding or chronic liver disease. Low MCV may also be seen in CKD cats. Iron status of cats with chronic kidney disease (2015) Gest J, Langston C & Eatroff A Journal of Veterinary Internal Medicine 29 pp1489-1493 states "TSAT and MCV (mean corpuscular volume)-a microcystosis- were significantly lower in anemic cats compared to non-anemic cats with CKD. This indicates a finding of both an absolute and a functional iron deficiency. The functional anemia is likely secondary to decreased erythropoiesis by diseased kidneys as well as anemia of inflammation."

 

Microcytosis is also a possible early sign of aluminium toxicity. Aluminium toxicity is extremely rare but may need to be ruled out if you are using aluminium hydroxide phosphorus binders.

 

If your cat's MCV is low, you need to know if the cause is a lack of iron before rushing to give an iron supplement. There are three main tests for iron deficiency, though these can be hard to obtain and are not always reliable.

 

Iron


This measures the amount of iron circulating in the blood. This test should be a fasting test, and iron supplements should not be given for 24 hours before the test.

 

If serum iron is low but ferritin (see below) is normal, the cat may have an infection. If a cat has anaemia of chronic disease (e.g. caused by CKD or Inflammatory Bowel Disease), the serum iron will be low, TIBC will tend to be low, but ferritin will be high.

 

Serum iron is normally high if a cat has had a number of blood transfusions. These cats should not be given iron supplements.

 

Cornell University College of Veterinary Medicine has some information about iron.

 

Ferritin


This is a measurement of how much iron is stored in the body in soluble form.

 

Low levels can indicate iron deficiency or chronic inflammation.

 

High levels can indicate iron overload.

 

Cornell University College of Veterinary Medicine has some information about ferritin.

 

TIBC (Total Iron Binding Capacity)


This measures the capacity of the blood to transfer iron to the cells where it is needed. Iron status of cats with chronic kidney disease (2015) Gest J, Langston C & Eatroff A Journal of Veterinary Internal Medicine 29 pp1489-1493 states "total iron binding capacity was found to be significantly lower in CKD cats versus healthy cats." It goes on to say "TIBC is decreased in inflammation. With TIBC significantly lower in cats with CKD compared to healthy cats, this study’s results support the presence of inflammation in this group of CKD cats."

 

If a cat is suffering from an iron overload, iron levels will be high and TIBC will be low or normal.

 

If a cat has an iron deficiency, serum iron will be low, but TIBC will be elevated.

 

If a cat has anaemia of chronic disease (e.g. caused by Inflammatory Bowel Disease), the serum iron will be low, TIBC will tend to be low, but ferritin will be high.

 

Cornell University College of Veterinary Medicine has some information about TIBC.

 

MCHC (Mean Cell Haemoglobin Concentration)


If your vet cannot check ferritin or TIBC, you can be guided by the MCHC instead. As the name suggests, this measures the concentration of haemoglobin in a red blood cell. You can calculate MCHC as long as you have a measurement for haemoglobin (Hb):

  • MCHC = (Hb divided by PCV or HCT) x 100

If this is normal (around 33%), you probably do not need to worry.

 

If MCHC and MCV are both low, this may indicate iron deficiency anaemia.

 

If MCHC is high, ask your vet to check if the sample is haemolysed.

 

Cornell University College of Veterinary Medicine has some information about MCHC.

 


Treatments                                                                                                        


 

It is very important to treat anaemia because it can have some serious effects on the body, and in the worst case it can even kill. There are various treatments for anaemia, and which one you should use depends upon the cause and the severity of the anaemia. 

 

If you know the cause of your cat's anaemia, getting it under control may resolve the problem e.g. if your cat has an infection, getting it under control with antibiotics should mean that your cat's anaemia gradually resolves.

 

If you don't know the cause of your cat's anaemia, your vet will need to consider and rule out possible causes until you know the most likely cause (don't forget there may be more than one cause). Please read above on how to do this.

 

I would recommend B vitamins for every anaemic cat, whatever the cause.

 

Other possible treatments include flea treatments if your cat has fleas, antibiotics if your cat has a bacterial infection, treatments for gastrointestinal bleeding such as sucralfate, and corticosteroids if your cat has an autoimmune disease. However, since anaemia is often multifactorial in CKD cats, you will need to remain alert and take action as appropriate.

Possible Treatment Plan for CKD Cats


Since this website is intended for CKD cats, here is a table showing the usual treatment protocol for CKD cats with anaemia caused by a lack of erythropoietin. Some of these treatments are also appropriate for cats with other forms of anaemia, for example severely anaemic cats from any cause may need a blood transfusion.

 

Severity of Anaemia

Treatment Requirements

PCV or HCT Level

Vitamin B

Supplement

Erythropoiesis Stimulating Agent (Aranesp, Epogen etc.) Iron Supplements

Blood Transfusion

Over 20%

Yes No No* No

Between 15% and 19%

Yes Yes Yes** No

Below 15%

Yes Yes Yes** Possibly

Below 10%

Yes Yes Yes** Yes

*Unless your cat is known to be iron deficient

**Cats without infections can be given iron in any form. Cats with an infection should not be given iron except in the form of heme iron (see below)

Correcting Vitamin B Deficiencies 


I recommend giving every CKD cat a vitamin B supplement, because it can be very helpful and is not toxic since any excess is simply passed out via urination. Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 says "B vitamins, such as vitamin B12, folic acid, niacin, and vitamin B6, are important for erythrogenesis. Supplementation is recommended in polyuric patients; however, the contribution of vitamin supplementation to the overall correction of anemia is minimal."

 

I am not sure I agree that vitamin B supplementation has a minimal effect on anaemia. In my experience, for some CKD cats with mild to moderate anaemia (PCV or HCT of 20-30%, this may be the only treatment you need.

 

CKD cats with more severe anaemia (PCV below 20%) should also be given vitamin B but will usually also need an ESA and iron supplement.

 

Your vet can prescribe a suitable Vitamin B supplement, or give your cat Vitamin B injections. Be careful about using multivitamin supplements because they may contain other vitamins such as A and D which are not usually suitable for CKD cats. 

 

Because B vitamin supplementation is so important for CKD cats, it has its own page here.

 

Erythropoiesis Stimulating Agents (ESAs)                                               


If your cat has non-regenerative anaemia caused by a lack of erythropoietin and the PCV is below 20%, you will have to consider using an erythropoiesis stimulating agent or ESA. These treatments are sold under the trade names of Epogen, Eprex, Procrit, Aranesp and NeoRecormon. This is quite a complex subject, so it has its own page here.

 

Iron Supplements: Overview


As explained above, you should only use iron supplements:

  • when tests indicate that they are required; or

  • if you are giving your cat an ESA.

so be guided by your vet regarding when and if to start one. If your cat has a blood transfusion, you should not give him/her any supplements containing iron because there is a risk of iron toxicity. Pet Education discusses iron requirements in cats. Pet Place has some information about iron toxicity.

 

Cats who begin treatment with an ESA such as Epogen or Aranesp are usually given iron supplements because the cat's body is busily making new red blood cells, so there is an increased demand for iron to assist with this process. Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 states "It is advisable to administer iron at the start of ESA therapy and with continued ESA usage to ensure adequate response." ISFM consensus guidelines on the diagnosis and management of feline chronic kidney disease (2016) Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I, Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine & Surgery 18 pp219-239 state "iron supplementation is generally recommended to ensure iron deficiency does not contribute to the anaemia."

 

If your cat does not respond to an ESA even though you are giving the ESA in sufficient quantities and frequently enough (see Erythropoiesis Stimulating Agents), consider the possibility of low iron levels and check for iron deficiency as explained above

 

Managing iron deficiency anemia (2014) Kvitko-White H & Cook AK explains more about treating iron deficiency anaemia.

Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 has information about when and how to supplement iron when using ESAs.

Use of erythropoietin and calcitriol for chronic renal failure in dogs and cats (2005) Sanderson S Presentation to the World Small Animal Veterinary Association World Congress 2005 explains more about when and how to supplement iron when using ESAs.

 

Iron Supplements: Your Choices


Iron supplements are available as follows:

  • orally, usually given daily at home. Oral iron supplements may cause an upset stomach and absorption can be a bit hit and miss.

  • injectable, usually given monthly at the vet's. The injection is into muscle so it can be painful, but it works well and quickly. It may cause a severe allergic reaction in a small number of cats, and the fact that it lasts about a month can be a negative if the cat does not really need supplemental iron.

  • obtained from food sources (heme iron), which may be appropriate in some cases.

For cats on ESAs, injectable iron is recommended.

 

Injectable Iron Supplements (Iron Dextran): Dosage


The most commonly used form of injectable iron is iron dextran. If you use this form, your vet will usually give the shot once a month. You should not use oral iron supplements if a shot has been given.

 

Injectable iron is the recommended form of iron for cats on ESAs. ISFM consensus guidelines on the diagnosis and management of feline chronic kidney disease (2016) Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I, Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine & Surgery 18 pp219-239 recommend 50mg of iron dextran injected intramuscularly once at the start of ESA therapy and repeated monthly.

 

Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 states "Intramuscular iron dextran given every three or four weeks may be a better alternative [to oral iron]. Dosages are typically 50 mg/cat."

 

Drugs has some information about iron dextran.

 

Oral Iron Supplements: Dosage


There are a number of possible brands to use (see below). The dosage for oral iron supplements for patients on ESAs is as follows:

 

Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 recommends "50 to 100 mg/day for cats (10 to 20 mg of elemental iron)."

 

ISFM consensus guidelines on the diagnosis and management of feline chronic kidney disease (2016) Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I, Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine & Surgery 18 pp219-239 recommend 50-100mg of ferrous sulfate given by mouth daily, but state this is "less ideal" than injectable iron.

 

Iron deficiency in dogs and cats Ewing P Angell Animal Medical Center states that these dosages also apply to the treatment of iron deficiency anaemia.

 

Oral Iron Supplements: Brands


Bear in mind when looking for a suitable product for your cat that 100mg of ferrous sulfate contains 20mg of elemental iron.

 

Spatone


Spatone is worth considering if your vet agrees. Spatone is a spa water which contains naturally occurring iron. The manufacturers claim that using iron in this way makes it more easily absorbed into the body. The manufacturers know of several dogs taking the product without problems, and several Tanya's CKD Support Group members have used it with their vets' approval.

 

According to the manufacturer, one sachet (20ml) of Spatone "typically contains 5mg of elemental iron." Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 recommends 10-20mg of elemental iron per day so if you are giving iron to a cat on an ESA, you would need to give 2-4 sachets of Spatone a day.

 

However, Spatone is supposed to have a high absorbability (up to 40%), so the manufacturer suggests using ½ to 1½ (0.5-1.5) sachets per day in cats, which they state would be the equivalent of 100mg of ferrous sulphate (20mg of elemental iron),

 

Spatone is sold in boxes of 28 or 42 sachets. The product does taste of iron, so the manufacturers recommend giving the product in additional water.

 

USA

Amazon

sells 28 sachets of Spatone for US$18.85.

 

UK

Boots

sells 28 sachets of Spatone for £11.49, but it is sometimes included in their 3 for 2 offers.

 

Amazon UK

sells 42 sachets of Spatone for £9.63.

 

Canada

Amazon

sells 28 sachets of Spatone for CAN$19.06.

 

Iron with B Vitamins: Pet-Tinic (Pet-Tabs Iron-Plus)


Pet-Tinic, also known as Pet Tabs Iron Plus, is both an iron supplement and Vitamin B supplement, so some people who wish to give their cats both of these use it, though for some strange reason it does not contain folic acid.

 

Because Pet-Tinic is not designed purely as an iron supplement, it does not contain a large amount of iron. It contains 12.5mg of iron per teaspoon (5ml), and the dosage recommended by the manufacturer for a 10lb (4.5kg) cat is 1 ml twice a day, which equates to only 5mg of iron a day. A cat requiring 50mg of iron a day would therefore require four teaspoons of Pet-Tinic a day, which is a lot. Check with your vet in case your cat needs a different dose or a different product.

 

Pet-Tinic does contain corn syrup, so may not be suitable for diabetic cats.

 

Thriving Pets

Sells Pet-Tinic for US$17.95 for 4 oz plus shipping. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Will ship to some other countries (no discount for international orders).

 

Amazon

Sells Pet-Tinic for US$18.95 for 4 oz with free shipping on orders over US$49.

 

Other Brands USA


Fer-In-Sol (USA)

is an infant iron supplement containing ferrous sulphate which may be suitable for some cats, though it does contain a small amount of alcohol. One ml of Fer-In-Sol contains 15mg of iron, so a cat requiring 50mg of ferrous sulfate would require 3 ml, or a little over half a teaspoon. Most people seem to think it tastes terrible.

 

Other Brands: UK


Sytron

is a paediatric iron supplement which contains a form of iron called sodium feredetate. This is supposed to be gentler on the stomach than some other iron supplements. It contains 190 mg of sodium feredetate per 5 ml (teaspoon), which is equivalent to 27.5 mg of iron per 5 ml (teaspoon). I used this for Thomas with no problems.

 

Oral Iron Supplements From Food


Some people prefer to give their cats iron through more natural means if possible. This is sometimes because their cat has an infection. You should not give iron to cats with a bacterial infection because bacteria thrive on iron. Therefore if a cat has an infection or inflammation, the cat's body will sequester iron (i.e. iron is stored away rather than released into the bloodstream) so as not to feed the bacteria. This means that the cat's body will be unable to use any iron you give it, but it may build up in the cat's liver.

 

In most cases, the infection or inflammation will only be short-term, and the cat will be able to manage without a supplement. Sequestering does not happen with heme iron (iron from meat), so if your cat definitely needs iron, you could ask your vet about obtaining iron via meat.

 

Some people have had success feeding a small amount of chicken liver (one or two tablespoons, once or twice a week). Most cats seem to like liver, and although you should not give liver too often or in large quantities because it contains very high levels of Vitamin A and is also high in phosphorus, the above dosage should be safe, but do discuss with your vet. If you would prefer not to handle raw liver, Stewart's Flavor Enhancer is available in sprinkle on beef liver or chicken liver form. Discuss how much to use with your vet.

 

Chicken heart may be a better choice. It does not contain as much iron as liver (only two thirds of the amount in liver), but it contains much less phosphorus and vitamin A. Petco sells Good Lovin Freeze Dried Chicken Hearts, which may be suitable.

 

Iron Supplements: Side Effects and Interactions


Iron supplements may cause constipation or stomach upsets. In theory iron should be taken on an empty stomach, but taking it with food may reduce the risk of stomach upsets.

 

Aluminium hydroxide (a phosphorus binder) should ideally be given separately from iron, because the binders may reduce the absorption of the iron. RxList has some information about this interaction.

 

If your cat has a blood transfusion, you should not give him/her any supplements containing iron because there is a risk of iron toxicity.

 

You should not give iron to cats with a bacterial infection because bacteria thrive on iron. Therefore if a cat has an infection or inflammation, the cat's body will sequester iron (i.e. iron is stored away rather than released into the bloodstream) so as not to feed the bacteria. This means that the cat's body will be unable to use any iron you give it, but it may accumulate in the cat's liver.

 

Always check the dosage of iron you are giving with your vet, because giving too much iron can be very dangerous. Toxicology brief: the toxicity of iron, an essential element (2006) Albretsen J Veterinary Medicine Feb 2006 discusses the risks and effects of too much iron and mentions that amongst other problems it may cause metabolic acidosis,

 


Blood Transfusions                                                                     


Introduction


Cats can receive blood transfusions just like humans. Transfusions are used in severely anaemic cats such as CKD cats who need support whilst waiting for an ESA to take effect, or in cats who have lost a lot of blood suddenly (e.g. following a road accident or severe gastrointestinal bleeding); they may also be needed in cats who have developed the antibody reaction to ESAs.

 

Generally speaking, you may have to consider a transfusion for a cat with a PCV or HCT below 13-15%, especially if the cat has severe symptoms and is struggling to cope with the anaemia (e.g. if the cat has oedema or heart failure), or if the PCV or HCT has fallen very suddenly, which gives the cat's body less time to adapt to the anaemia.

 

Transfusion medicine -do's and don'ts (2010) is a presentation by Dr U Giger to the 35th World Small Animal Veterinary Association 2010 World Congress.

Feline anaemias - therapeutic options and transfusion therapy (2002) is a paper presented by Urs Giger to the World Small Animal Veterinary Association World Congress.

Canine and feline transfusions: tips, tricks and techniques for success Houchen H & Woodson B is a helpful article about blood transfusions.

Idiosyncrasies in feline blood transfusions (2012) Schumacher D Veterinary Technician May 2012 ppE1-5 has an overview of blood transfusions and possible problems.

 

How Blood Transfusions Are Performed


Although there are some risks, a blood transfusion is not usually considered to be a major procedure. The blood is taken either from a donor cat provided by the clinic or by a client who has other cats eligible to be donors, or from a blood bank (see below). Whole blood may be used or packed red blood cells.

 

The blood is fed through an intravenous drip into the cat. Normally the cat only needs to stay at the vet's for 3-4 hours; just long enough to receive the blood (which is given slowly) and to be monitored for a possible reaction (occasionally diarrhoea and nausea are seen with a poorly matched transfusion, and fever is sometimes seen).

 

If your cat has a blood transfusion, you should not give him/her any supplements containing iron because there is a risk of iron toxicity.

 

Blood Transfusion Effectiveness


Ideally the cat's PCV or HCT will double, though this does not always happen, particularly with CKD cats - Anemia of chronic kidney disease (2009) Langston CL CVC in San Diego Proceedings says "The transfused cells will have a shortened lifespan due to the uremic environment and due to minor incompatibility reactions." Nevertheless, most cats feel and act much better immediately following their transfusion, and with a well-matched donor (see below), the effects may last for 4-5 weeks, although it will be less if the cat is experiencing ongoing blood loss (e.g. gastrointestinal bleeding).

 

The Merck Veterinary Manual has an overview of blood transfusions and explains how to calculate what level of PCV or HCT you can expect to see after a well-matched transfusion.

 

Assessment of five formulae to predict post-transfusion packed cell volume in cats (2014) Reed N, Espadas I, Lalor SM & Kisielewicz Journal of Feline Medicine & Surgery 16(8) pp651-656 found that the following formula was both the easiest to use and the most accurate at predicting the PCV level following a transfusion, though the actual result could still differ by up to 8%:

  • The post transfusion increase in PCV (%) will be the volume of donor blood transfused in ml divided by the weight of the recipient cat in kg multiplied by two.

  • To take an example: a 4.5kg (10 lb) cat given 50ml of donor blood would be expected to have a post-transfusion increase in PCV of 5.5%, and one given 30ml of blood would be expected to have an increase in PCV of 3.3%.

Feline Blood Groups


Like humans, cats have different blood groups, though there are fewer known feline blood groups:

  • A      the most common, particularly in non-pedigrees

  • B      relatively common in pedigree cats

  • AB   rare

However, unlike humans, cats do not have a universal donor (in humans, if blood type is not yet known, the person can be given the universal blood type, O negative, to tide them over with no adverse effects), although type AB cats can receive blood from either type A or B donors.

 

In an emergency case such as a cat who is going to die anyway without the transfusion (e.g. after a traffic accident), a vet may do a transfusion without checking the blood types, and in the case of the average cat, this will often not result in disaster the first time it is done, though it is far riskier for pedigree cats who tend to have the rarer blood groups. If time permits (as it usually does for CKD cats), it is far safer to type or cross-match a  cat's blood type before a transfusion. Unfortunately, blood typing may not be accurate in cats with a PCV or HCT below 10%.

 

Whole blood transfusions in 91 cats: a clinical evaluation (2004) Weingart C, Giger U, Kohn B Journal of Feline Medicine and Surgery 6 (3) pp139-148 concludes that "with proper donor selection and appropriate compatibility screening, blood transfusions are well tolerated, appear effective, and may increase chances of survival."

Feline blood typing and transfusion - a practical approach (2006) Kohn B & Weingart C Presentation to the 31st World Small Animal Veterinary Association World Congress has a good overview of blood transfusions.

Cornell University College of Veterinary Medicine has information on feline blood groups and transfusions.

International Cat Care has a table showing the frequency of the different blood groups in various breeds.

 

Typing and Cross-Matching


Typing means that you find a cat with the same blood group as your cat, and obtain blood from that cat. For example, if your cat has type B blood, then you find another cat with type B blood to act as the donor.

 

Cross-matching means that further tests are done to check whether the typed donor cat's blood is compatible with the recipient's blood. This is important because there are further factors within cats' blood, so even if typing has been done, there is still a risk of a reaction if the blood has not been cross-matched, which in severe cases may cause shock and even death. Even if a donor cat's blood has been successfully cross-matched once, it is safest to cross-match it again before using that cat as a donor once again, because the recipient cat may have built up antibodies to the donor cat's blood. 

 

If you cross-match, you do not need to type the blood as well, that will be done automatically as part of the cross-matching.

 

Typing and Cross-Matching USA


Your vet may be able to arrange this for you. Here are some possibilities.

 

DMS Laboratories sells kits for vets to type and cross match feline blood themselves.

Colorado State University Diagnostic Laboratory will type feline blood in the USA for US$29.25, and cross-match it for local clients for US$22 (click on Test Price List).

 

Typing and Cross-Matching UK


Your vet may be able to arrange this for you. Here are some possibilities.

 

NationWide Laboratories (UK) can type blood with results available the same day.

Langford Veterinary Services (University of Bristol) offers feline blood typing for £33.60 and can apparently also cross-match, with both tests being turned around on the day of receipt.

 

Obtaining Blood


Finding a donor cat at all, particularly at short notice, is usually the main problem with blood transfusions. You may be able to use another cat in your family as the donor, or your vet may be able to find a cat (some vets occasionally offer their own cats as donors). 

 

When choosing a donor, naturally you want one who has been tested and found to be free of infectious diseases such as feline leukaemia. The donor also has to be healthy and big enough to give blood without any adverse effects for himself/herself - usually a donor must be at least 9-10 lb in weight. In addition, a donor usually cannot give blood more often than every two months. If the donor cat meets these criteria, there are usually no side effects for him/her, and it does not appear to be any more stressful than a standard vet visit for either the donor or the recipient.

 

Alternatively, there are a limited number of feline blood banks which may be able to help, including:

 

USA


Animal Blood Resources International stocks feline blood.

The Veterinarians' Blood Bank stocks feline blood.

Blue Ridge Veterinary Blood Bank is located in Virginia. It does not stock feline blood but can provide it upon request.

 

UK


Cat Blood Donors in the UK does not stock blood itself, but maintains a database of donor cats which British vets can access free of charge.

 

Canada


The Canadian Animal Blood Bank does not stock feline blood, but will provide advice and certain supplies on obtaining blood safely. The US blood banks mentioned above may be able to ship feline blood to Canada if required.

 

Other Sources of Blood


Since it can be difficult to obtain feline blood, some people are obliged to use alternatives:

 

Canine Blood


If you are unable to obtain feline blood, and it is an emergency, you can consider using a blood donation from a dog. Xenotransfusion with canine blood in the feline species: review of the literature (2013) Bovens C & Gruffydd-Jones T Journal of Feline Medicine and Surgery 15(2) pp62-7 found that using canine blood may buy you up to four days, but it can only be used once because subsequent use will cause anaphylactic shock, which often kills the cat.

 

Pet360 tells of one cat's experiences with a canine blood transfusion.

 

Oxyglobin (Synthetic Blood)


Oxyglobin is a synthetic blood product containing haemoglobin, which is approved for use in dogs as a single treatment only. It does not contain red blood cells, so its effects are short-lived (a couple of days). Since it is designed for dogs rather than cats, there is a risk of volume overload when using Oxyglobin (only 4% of a cat's body weight is accounted for by blood volume, whereas in dogs the level is 7%). It is therefore better to use feline blood for a transfusion, but in case of urgent need, a one-off use of Oxyglobin might help buy you some time while you search for a suitable blood donor.

 

Sadly the manufacturer of Oxyglobin went bust but another company has apparently taken over its production.

 

Hemoglobin Oxygen Therapeutics is the manufacturer's website.

Dechra is the distributor's website.

Veterinary Practice News explains how Oxyglobin can buy time while you are waiting for a delivery of fresh blood.

Clinical use of a haemoglobin-based oxygen carrying solution (Oxyglobin) in 48 cats (2002-2006) (2008) Weingart C, Kohn B Journal of Feline Medicine & Surgery 10(5) pp431-8 found that Oxyglobin worked well at improving anaemia in anaemic cats but was risky for cats suffering from heart disease.

 

Blood Transfusion Cost


The cost of a blood transfusion varies widely, depending upon where you are and how you source the blood. If you have to obtain blood from a blood bank it will cost more, but fresh blood may be available from a donor cat at your vet's, or one of your own cats may be a suitable donor.

 

The costs will include some or all of the following:

  • blood typing and cross-matching

  • blood tests such as PCV

  • blood cost or provision of donor cat cost

  • testing of donor if one is used

  • hospital fees, including giving the blood intravenously and post-transfusion care

As a rough guide, one member of Tanya's CKD Support Group in the UK paid £300 in 2014. The approximate fee in the USA is in the region of US$500-1000.

 

Antibody Formation to Blood Transfusions


Most CKD cats will not need a blood transfusion, and with luck those who do need a transfusion will only need one, perhaps to tide them over until an ESAs kicks in.

 

For those cats who do need more than one transfusion, unfortunately, as with ESAs, a cat may eventually develop an antibody reaction to blood transfusions (i.e. the cat's body believes the donated blood is a foreign body and starts to reject it), and the odds seem to increase with each transfusion.

 

The limit is thought to be roughly five transfusions per cat, and the more transfusions that are given, the less time they are expected to last. For example, when you first start giving transfusions, each transfusion may last up to five weeks, depending upon the cause of the anaemia, but this time tends to reduce with each transfusion until eventually a transfusion may only buy the cat a few days.

 

Having said that, there have been a few members of Tanya's CKD Support Group whose cats have lived for much longer because of repeated transfusions. One cat managed nine months on transfusions after developing the antibody reaction to Epogen, and he eventually only needed transfusions about once a month. Another cat had forty transfusions over a period of more than two years with no problems (the exact cause of this cat's anaemia was unknown but it did not appear to be linked to his CKD). He was given an antihistamine before each transfusion to minimise the risk.

 

Sometimes there will be a delayed reaction to a blood transfusion, which can happen up to two weeks after the transfusion. The usual sign of a problem is a gradual but persistent drop in PCV. The usual treatment is another blood transfusion. Transfusion reactions and treatment (2015) Perry S Presentation to Michigan Veterinary Conference Proceedings explains more about this and other possible problems.

 

Transfusions for Cats with the Antibody Reaction to ESAs


If your cat has severe non-regenerative anaemia because of CKD but is not yet critical (i.e. the PCV is above 13-15%), I would recommend using ESAs instead of transfusions. By doing this, you can keep transfusions in reserve just in case your cat does develop a reaction to ESAs, at which point you could probably buy your cat some more time by using transfusions.

 

If your cat does develop a reaction to an ESA such as darbepoetin (Aranesp) or epoetin (Epogen or Eprex), the good news is that this does not increase the chances of your cat developing a reaction to donated blood.

 

Cats with the antibody reaction to ESAs may need transfusions fairly frequently to start with while the body is dealing with the ESA antibodies, but the period between transfusions may lengthen over time as the ESA antibodies go away (this takes up to eight months, though may take longer in some cats).

 


Making your Cat Comfortable


 

Minimising Effort


It is a real effort for anaemic cats to do simple things like jumping onto beds or climbing stairs; Thomas did not use the stairs for three weeks and simply stayed upstairs until he became stronger. It is therefore a kindness to your cat if you can minimise the effort required to do simple tasks  such as visiting the litter tray. If you have a litter tray downstairs but your cat prefers to stay upstairs, place an extra litter tray upstairs not too far from your cat's favourite spot (but away from food and water). If the litter tray has a high edge which is hard for your cat to climb over, you may need to provide a litter tray with a lower edge until your cat has regained some strength.  

 

Similarly, provide food and water near to your cat's favourite place - he or she will be more inclined to eat if it doesn't involve an epic trek to the food bowl.

 

Heated Beds


Anaemic cats feel very cold, even in summer. The best treatment we could find, apart from treating the anaemia of course, was a heated bed. Some heated beds look like ordinary cat beds, and some look like small flat heated pads with a fleecy cover. Thomas had long legs but we found a 12 inch square bed was fine for him because anaemic cats tend to hunch up because they are cold.

 

There are a number of different types of heated beds available:

  • electric beds which maintain a constant temperature. With some you can choose from up to three temperature settings and then the pad stays at the chosen temperature constantly.

  • electric beds which only warm up once the cat settles on them. You may be able to choose the temperature settings with this type of bed too.

  • non-electric beds which reflect the cat's body heat back, thus keeping the cat warm

You must of course keep an eye on your cat while s/he is using the electrical type, and I would not use any of these beds for a cat who is incapable of moving if s/he gets too hot. We never had any problems with overheating, and Thomas found his bed very comforting when his anaemia was bad, whilst Harpsie loved his when he developed arthritis.

 

Heated Beds USA


Amazon

sells a heated bed which is very popular with members of my support group for US$26.77.

 

Chewy

sells a self-warming bed for US$21.49.

 

Amazon

sells another heated bed for US$26.99 plus shipping.

 

Hammacher

sells a cat bed which some members of my support group like, but it is expensive at US$89.95.

 

Drs Foster & Smith

sell a number of heated beds in the USA.

 

Heated Beds UK


Boots

sells a heatpad for £29.99 which is similar to the one we used for Thomas when he had anaemia.

 

Pets at Home

sells a non-electric thermal bed for £32.99.

 

The Cat Gallery

sells self-heating beds in two sizes.

 

Amazon UK

sells a ceramic heated bed for £26.65

 

Cat Steps


Also try to reduce the amount of climbing your cat has to do: Thomas decided his favourite place was the bed, so we arranged a series of footstools, piano stools and so on in order to create a kind of stairway up to the bed.  We also placed Thomas's food bowls on the bed and his water bowl on the bedside table so he only had to get down in order to use the litter tray. But do be aware that occasionally a cat may no longer jump and climb because of blindness caused by hypertension.

 

Cat Steps USA


Drs Foster and Smith

sell a number of ramps and steps in the USA.

 

Cozy Cat Furniture

sell a selection of steps in the USA.

 

Cat Steps UK


Pet Planet

sells a number of different ramps and steps.

 

The Cat Gallery

sells a three step stair for £37.50. They also have another cheaper two step one.

 


Other Treatments


These treatments are at the end of this page because they are unlikely to be suitable or of much benefit for most cats.

 

Anabolic Steroids


If anaemia is not too severe, some vets offer anabolic steroids to help improve anaemia or at least slow down its progression. They may also be beneficial for CKD cats with muscle wasting and as an appetite stimulant.

 

When I first began this website, anabolic steroids were much more popular so I did use anabolic steroids for Thomas and they did seem to help with his general wellbeing but his anaemia was too severe for them to help with that.

 

Although anabolic steroids are still offered to anaemic cats by some British vets, they are much less popular in the USA. Steroids may damage the liver, so if you do use them your vet will need to monitor your cat's liver values. Anemia of chronic kidney disease (2009) Langston CL CVC in San Diego Proceedings says "Anabolic steroids have been recommended for the treatment of the anemia of CKD. Results have been variable and generally disappointing. Their use cannot be recommended due to the lack of efficacy and the potential for hepatotoxicity."

 

There is more information about anabolic steroids in the Treatments chapter.

 

Vitamin E


Vitamin E is an antioxidant, and there have been studies into the role of antioxidants in improving health. The Winn Feline Foundation gave a grant to Colorado State University in 2010 for a study into "Vitamin E as a Novel Treatment for the Anemia of Feline Chronic Renal Failure." This study was completed in 2013 but Winn Feline Foundation reported that "administration of vitamin E did not appear to affect the clinical presentation, degree of oxidative stress, or level of anemia in cats with chronic kidney disease."

 

See Nutritional Requirements for more information on Vitamin E.

 


Summary


 

I know this can all seem overwhelming, so here's a short summary:

  • If your cat is anaemic, however severely and whatever the cause, start giving B vitamins immediately. Vitamin 12 in the form of methylcobalamin may be particularly helpful. See Vitamin B for more information.

  • If you can ascertain a cause other than the CKD, treat it - this may be sufficient to get the anaemia under control. For example, anaemic cats with infections should improve a lot once the infection is brought under control. Cats with gastrointestinal bleeding may need a treatment such as sucralfate. In some cases, treating these other problems may improve the anaemia to such an extent that you will not need to start an ESA just yet.

  • If your cat has an iron deficiency or is about to start an ESA such as darbepoetin (Aranesp) or epoetin (Epogen or Eprex), ask your vet about an iron supplement. An iron supplement may also be necessary if your cat has iron deficiency anaemia. Iron supplements should not be given to cats with infections or cats who have had blood transfusions.

  • In cases of mild anaemia (PCV or HCT above 19%), anabolic steroids may help to some degree, though they are not commonly used these days.

  • For severe non-regenerative anaemia (PCV or HCT below 20%) caused by the CKD (because of a lack of the hormone, erythropoietin, which the damaged kidneys can no longer properly produce), you will need to consider the use of an erythropoiesis stimulating agent (Aranesp, Epogen, Eprex or NeoRecormon), especially if your cat is showing symptoms of anaemia. The Erythropoiesis Stimulating Agents page explains more about these treatments in great detail.

  • If your cat's anaemia is extremely severe (PCV or HCT below 13%), then whatever the cause you may need to provide a blood transfusion to keep your cat going and buy you the time to get to the bottom of the problem and start other treatments as appropriate.

Remember: anaemia is almost always treatable, so don't give up hope! Thomas went from being unable to walk downstairs to going outside hunting (yes, I know, not his best characteristic but he had been a stray for years and old habits died hard) once his anaemia was under control.

 

 

Back to Page Index

This page last updated: 27 June 2016

 

Links on this page last checked: 26 June 2016

 
 

*****

 

TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

 

I have tried very hard to ensure that the information provided in this website is accurate, but I am NOT a vet, just an ordinary person who has lived through CKD with three cats. This website is for educational purposes only, and is not intended to be used to diagnose or treat any cat. Before trying any of the treatments described herein, you MUST consult a qualified veterinarian and obtain professional advice on the correct regimen for your cat and his or her particular requirements; and you should only use any treatments described here with the full knowledge and approval of your vet. No responsibility can be accepted.

 

If your cat appears to be in pain or distress, do not waste time on the internet, contact your vet immediately.

 

*****

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