ON THIS PAGE:
Let's Get Started
Is There Any Hope?
I Don't Know What the Test
Results Mean or Which Are Important
So Just How Sick is My Cat?
Commonly Seen Symptoms
Commonly Used Treatments
What You Need to Know
What Happens in
Causes of CKD
How Bad is It?
Is There Any
Appetite Loss and Excess Stomach Acid
The Importance of
All About Constipation
Coping with CKD
Tanya's Support Group
Alphabetical List of Symptoms and Treatments
and Urinary Imbalances (Dehydration, Overhydration and Urinary
Waste Product Regulation Imbalances (Vomiting, Appetite Loss, Excess
Stomach Acid, Gastro-intestinal Problems, Mouth Ulcers Etc.)
Phosphorus and Calcium Imbalances
(Pain, Hiding Etc.)
WHAT DO ALL THE TEST RESULTS MEAN?
Blood Chemistry: Kidney Function, Potassium, Other Tests
(ALT, Amylase, (Cholesterol, Etc.)
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)
Tests to Have and Frequency of Testing
Factors that Affect Test Results
International and US Measuring Systems
Which Treatments are Essential
Finding a Good Vet and Record Keeping
Fluid and Urinary Issues (Fluid Retention, Infections, Incontinence,
Waste Product Regulation
(Mouth Ulcers, GI Bleeding,
Adsorbents, Azodyl, Astro's CRF Oil)
Phosphorus, Calcium and PTH (Calcitriol)
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,
Medicating Your Cat
Obtaining Supplies Cheaply in the UK, USA and Canada
Working with Your Vet
DIET & NUTRITION
Nutritional Requirements of CKD Cats
The B Vitamins (Including
What to Feed (and What to Avoid)
Persuading Your Cat to Eat
Food Data Tables
Canned Food Data
Dry Food Data
Cat Food Manufacturers
Canned Food Data
Dry Food Data
UK Cat Food Manufacturers
2007 Food Recall USA
Tips on Giving
to Give Subcutaneous Fluids with a Giving Set
to Give Subcutaneous Fluids with a Syringe
Subcutaneous Fluids - Winning Your Vet's Support
Polycystic Kidney Disease (PKD)
OBTAINING SUPPLIES CHEAPLY
Coping with Your Loss
Other People's Losses
Other Illnesses (Cancer, Liver) and
Diese Webseite auf Deutsch
Three CKD Cats: Tanya, Thomas and Ollie
My Multi Ailment Cat,
Me on Facebook
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What You Need to Know First
This page is a summary page. The goal is to
This page has links to more detailed information about each issue that is
mentioned. However, I recommend that the first time you visit this page, you
read it in its entirety without following any of the links, so as to obtain
a general overview of what lies ahead.
Overwhelmed? Let's Get Started
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You've just been
told your cat has CKD and you are scared and frightened. So you found this
site, and now, to add to your woes, you feel overwhelmed by all the
information here. Clearly this is a complicated disease and you are not sure
you can deal with it!
Well, take a deep
breath because, honestly, it is not that bad. I had no scientific training
at all when I first began dealing with CKD, in fact I was a linguist who was
intimidated by scientific subjects, which I absolutely hated at school. But
I did manage to learn about CKD, because it was essential if I was going to
save Thomas's life; and you can do the same. Remember,
knowledge is power! You need to be able to understand what is going on with
your cat so you can obtain the most suitable treatments for him/her.
The primary goal
when treating CKD is to help your cat feel better. Fortunately in most cases
this is an achievable goal.
goal is to prolong life. This goal is secondary because there is not much
point prolonging life if there is no quality to that life. However, since it
is usually possible to help the cat feel better, obviously you want to then
keep your cat with you as long as you can.
The good news is,
you won't need to learn everything at once; and you certainly won't need to
learn as much as I have. This site aims to cover every eventuality regarding
CKD, because each cat presents with a different set of symptoms, so
including them all helps new readers spot the issues that apply in their
particular case; but you are highly unlikely to be faced with all the
symptoms or need to use all the treatments. Here are some possible
Most people will
be faced with two or three issues to start with. Virtually every CKD cat has
a problem with not eating and may vomit, especially white foam. Virtually
every CKD cat has high phosphorus levels, as shown in their blood tests.
percentage of CKD cats will be anaemic, and/or will have hypertension (high
blood pressure). If your cat is eating litter or licking concrete, s/he is
probably anaemic. If your cat has gone blind or is having seizures, s/he
could well have hypertension.
you are facing, in most cases it will be treatable. Yes, CKD is
scary at first, but given time you should find that it becomes a manageable
part of your lives. Most people find they quickly get into a routine and
only need to find maybe 10-20 minutes a day to help their cat, including
time needed to give fluids at home if necessary.
If even this page looks too overwhelming, try the
Key Issues page instead.
This page talks about what the tests mean, what symptoms you might be seeing
and which treatments help. The Key Issues page simply gives a short overview
of the most important things to focus on to help your cat feel better and
increase his/her chances of survival. After you've read it, you can always
come back here for more detailed information or dip into the other pages of
Is There Any Hope?
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CKD is a
progressive disease of the kidneys. This means the kidneys gradually get
worse, they do not suddenly seize up and stop functioning, it can take
years. Also, don't panic if your vet says your cat
has lost a massive amount of kidney function - it is not usually possible to
diagnose CKD until at least 66% (two thirds) of kidney function has gone,
and many cats are not diagnosed until 75% or even more has gone. Some cats
manage quite well on extremely limited kidney function (less than 10%), so take a couple of weeks to
see if your cat is one of them.
If your cat has
high blood test results at diagnosis, there could still be hope. Cats often
have off the scale test results when first diagnosed, but these results may
not accurately reflect the true situation. Numbers can be artificially
elevated if the cat is dehydrated, has an infection, has kidney stones or
has high blood pressure. So again, take a couple of weeks to treat any
problems that are present and then see how things stand.
Below I give an
overview of which tests will help you spot possible problems, which symptoms
are commonly seen, and which are the most helpful treatments.
I Don't Know What the Test Results Mean or Which
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The tests which your vet runs will confirm the existence
of CKD, and give some idea of how bad your cat's case is. Most people don't have the faintest idea what most of the
test results mean, so to get you started, here is a summary which tells you what the main test results mean and what
sort of symptoms they may cause. If you would prefer a very short
The Cat Practice has a brief overview.
You should ask your vet for a copy of all the tests that
are run, because these are helpful if you join
Tanya's CKD Support Group. However, you can still join even if you do not yet have a
copy of your cat's test results.
Your vet will probably run :
a blood chemistry panel, which checks kidney function
and looks for any other abnormalities caused by poorly functioning
a complete blood count (CBC), which looks at the catís
blood cells. This enables the vet to check for anaemia, a common problem
in CKD cats, and to look for signs of infection.
You will probably have 1-2 pages of results, but the six
items discussed below are the most important for you to understand at the
beginning. If your cat's results show other items that are out of range,
such as calcium, you should be able to find more information about these in the
If your vet has not addressed any results which are out
of range, be sure to ask them why. Not everything needs treating (high
cholesterol, for example, is not a worry in cats as it is in humans) but the
items mentioned below do need treating.
The USA uses a different measuring system to the rest of
Tanya's CKD Support Group tends to use the US measurement system, so
if you join, you will get more responses if you convert your
international values to American ones. The
Information Network converter will do this for you. Scroll down the
list to find what you want to convert (e.g. creatinine) and enter your cat's
value in the "Enter SI Units to Convert to US Units" box. There is no need
to convert potassium or PCV/HCT, which are the same in both systems.
(blood urea nitrogen) or Urea
If you are in the
USA, you should see blood urea nitrogen (BUN) on your cat's bloodwork. In Europe,
you will probably see urea listed instead, which is not exactly the same thing but
BUN is one of
the two main measures of kidney function (the other one is
creatinine). In a cat
with CKD, BUN will normally be elevated. BUN is
a by-product of the breakdown of dietary protein during the digestive
process. The kidneys filter it out of the blood and excrete it via
urination. BUN rises in CKD because the damaged kidneys are no longer
able to excrete it efficiently, so it builds up and makes the cat feel
poorly. BUN is not a toxin in itself, but if it is elevated, then the
chances are high that actual toxins (which are difficult to measure, but
which make the cat feel poorly) will also be elevated. BUN can also rise for other reasons though, such as dehydration,
stress or a high protein diet, so
it is not an entirely accurate measure of kidney function by itself.
It is important
to try to control high levels of BUN because they can cause lack of
appetite, excess stomach acid, nausea and vomiting.
BUN can be
controlled via fluid therapy and
dietary management. Treatments for
vomiting and excess stomach acid are also very useful and can make a
CKD cat feel much better.
You can read
about BUN in more detail in the
another waste product excreted through the kidneys. It is generally
considered to be a more accurate measurement of underlying kidney function
than BUN or urea because it is less affected by diet, stress and
creatinine is the basic measure of kidney function, you will probably not
be able to reduce it to within normal range in a CKD cat, but that does
not mean that it cannot reduce from the level you see at initial
diagnosis. If you treat CKD effectively, it may well lead to improvements in creatinine levels, so try not to panic if your cat has high levels to
You can read about creatinine
in more detail in the
(Phos, P or Pi)
Phosphorus and calcium are minerals
which are important for nerve function, muscle contraction
and bone formation. A healthy body has a natural balance between
levels of phosphorus and calcium. CKD kidneys can
no longer excrete phosphorus properly so levels of phosphorus
rise (hyperphosphataemia), which
can then adversely affect the cat's calcium levels, with potentially serious
secondary hyperparathyroidism). Not only that, but high phosphorus levels may
make the CKD progress faster and can make a cat feel lousy. So controlling
phosphorus levels is one of the
most important steps in managing CKD and helping your cat feel better.
Symptoms of high phosphorus levels may include weakness, an unsteady walk,
itching and scratching, loss of appetite, twitching and weight loss.
Your vet may say that your cat's phosphorus levels are within normal
limits, but the high end of the normal range actually applies to kittens
rather than to adult cats, particularly those with CKD. You should aim to
actively control phosphorus levels once they are above 1.9 mmol/L (US: 6 mg/dl). This can be done by
feeding a low phosphorus food (usually a prescription diet) or by adding odourless,
tasteless phosphorus binders to your cat's food, see
read about phosphorus in more detail on the
All About Phosphorus page.
Potassium is an
electrolyte (a type of salt), which the body needs in order to function
properly at the cellular level. If potassium is out of balance, it can
affect the muscles, including the heart.
Cats with CKD
usually urinate a lot, and may also vomit, and this can cause loss of
potassium, leaving levels low in the cat's body. However, a few CKD cats
have the opposite problem of too high levels of potassium, particularly if
they have high creatinine levels.
levels (hypokalaemia) can have various effects, such as weakness
(especially in the back legs), twitching, hoarseness or constipation.
Severe cases may be unable to lift their heads or have a stiff
Although the range for potassium often starts at around
3.5, for CKD cats it is often recommended to treat low potassium levels when
they fall below 4.0 mmol/L (US: 4.0 mg/dl). The goal is to have a level of
around 4.4 mmol/L
(US: 4.4 mg/dl) or a little higher. The usual treatment method is a
supplement in the form of a pill, though it does come in other forms too
if your cat is difficult to pill.
Not all CKD cats have low potassium levels. Cats with a
level of 4.4 or higher do not usually need supplementation of potassium.
Cats with high levels of potassium (over 6.0) may experience twitching,
seizures, and in the worst case scenario, even a heart attack.
information below about
treating high or low potassium levels.
You can read
about potassium in more detail on the
All About Potassium page.
Acidity levels in the
body tend to rise in CKD cats i.e. the bodyís pH becomes too low Ė this is known as
metabolic acidosis. It is not the same thing as stomach acid, which is excess production of acid in the
Unfortunately many vets do not watch for metabolic acidosis routinely, which
is partly because it can be hard to measure. TCO2 or total carbon dioxide in the blood is
the most accurate way to diagnose metabolic acidosis but TCO2 has to be measured on a special blood
gas machine, which not many vets and not all laboratories have. If your vet or
his/her laboratory cannot measure TCO2 at all, your vet may be able to test for carbon dioxide (CO2) levels instead -
if they are low, they may also indicate metabolic acidosis.
acidosis can have a variety of effects, including muscle wasting, a bony
spine, back leg weakness, vomiting, mouth ulcers, twitching and seizures, so
it is very important to diagnose and treat it if it is present.
Treatments may include fluid therapy, potassium citrate or bicarbonate of
You can read
about metabolic acidosis in more detail on the
Metabolic Acidosis page.
PCV or HCT
The kidneys produce a
hormone called erythropoietin, which stimulates the bone marrow to make
red blood cells. Damaged CKD kidneys may no longer perform this task
properly, and if red blood cells are not made, anaemia is the result.
HCT are both used to
measure anaemia. Your vet will run one test or the other. PCV is not quite
the same thing as HCT; but the difference between the two is too small to be
cat is anaemic if his/her 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 in the low 20%s. Dehydration will make PCV look higher than it really is, so once a cat is rehydrated, PCV will
often have fallen.
anaemia include weakness, loss of appetite, heavy breathing, feeling cold,
eating litter or licking cement.
It is essential
to treat anaemia. Cats with a PCV or HCT below 20% have severe anaemia,
and you have to treat it quickly, because untreated severe anaemia can be
life threatening. Cats who are severely anaemic may appear very ill
(though some of them adapt to the anaemia if it happens gradually, and cope
quite well), but you should
see a dramatic difference once the anaemia is under control.
include iron or vitamin B supplements for milder cases, or the use of a
synthetic hormone replacement known as
ESAs (trade names are Epogen, Procrit or Eprex) for more serious cases.
You can read
about anaemia in more detail on the
Hypertension (high blood
pressure) is very common in CKD cats, because the kidneys produce renin,
which controls blood pressure, but damaged kidneys may not do this
pressure is very dangerous - it can cause strokes, seizures and blindness,
and may even kill; but since it has few visible symptoms until a crisis
occurs, it really needs to be measured with a blood pressure monitor.
many vets do not have the equipment to measure blood pressure (even though
it only costs about US$1000). Do ask your vet if s/he has this equipment,
and if so, make sure s/he uses it to check your cat's blood pressure. If
they do not have it, politely ask them to consider investing in it, and then
call around other vets in your area (or ask your vet to do so) to see if you
can find somebody who can measure your cat's blood pressure. If you cannot
find anybody to measure it, check the
All About Hypertension page for alternative checks, though they are far from ideal.
If blood pressure
is consistently over 160, it should be treated. This is easily managed
through the use of a medication called
amlodipine (known as Norvasc in the
USA and Istin in many parts of Europe).
This is a test of
your cat's urine. It may include a check of
which tells your vet how dilute your cat's urine is (CKD cats usually have
very dilute urine). It often will also give the vet some information on
whether your cat has a
urinary tract infection (UTI).
Urinalysis also can show if a cat has
proteinuria (protein leaking into the
You can read
about urinalysis in more detail in the
want to run an ultrasound of a cat's kidneys. This can be helpful if a cat
has larger than expected kidneys (which may indicate cancer, a blockage of
some kind or a genetic disease known as
PKD), or if you suspect a kidney
infection. However, in many if not most cases of CKD, an ultrasound merely
confirms that a cat has CKD and adds nothing to the overall treatment plan.
If this is the case for your cat, it is
probably worth passing on an ultrasound and saving your money.
You can read
about ultrasound in more detail in the
There are a
number of other tests which are occasionally offered, and you can find more
information about them in the
So Just How Sick is My Cat?
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Most people panic
if their cat's results are out of normal range, especially if they are many
times higher than they should be. They are not exactly reassured when their vet
then says "your cat only has x% of kidney function remaining." If the vet
the old style terminology, chronic renal failure, the word "failure" also terrifies most people when
they first hear it.
Take a deep
breath. Here are some crucial points to remember:
It doesn't really
matter how bad your cat's test results look at initial diagnosis, especially
if your cat in in crisis (e.g. needs to go on a drip, or has an infection).
You firstly need to stabilise your cat before you can see the true
situation. Even then, some cats cope well with high numbers, hence your new
mantra, treat the cat, not the numbers.
It is normal
not to be able to diagnose CKD until at least 66-75% of kidney function is
gone. The What
Happens in CKD page explains why this is the case.
The word "chronic" is what matters. This
means that in most cases, CKD is a progressive disease, and therefore death
is not necessarily imminent. And chronic is usually treatable!
How Bad is It? page gives you some idea of how serious your
cat's bloodwork results are but remember, these are not the be-all and
end-all. How sick your cat is depends upon whether s/he is in crisis or not
at diagnosis, and also on how well your cat copes with CKD - some cats can
cope astonishingly well with horrible bloodwork.
Below I talk a
bit more about some common scenarios when you first get the diagnosis:
Cat in Crisis: Crashing
Many cats who are
diagnosed with CKD are in crisis (known as "crashing"),
often because of severe dehydration. CKD cats tend to urinate
more as their kidneys deteriorate. They then
drink more to compensate for the increased urination, but eventually they
can no longer
drink enough to keep up with the fluid lost from dehydration, and they
Before you go to
the vet (which you should do as soon as possible if you think your cat is
crashing), here are some of the signs you may see:
the cat will
often be unable to get comfortable and may lie in the
(a bit like a Sphinx but not exactly the same: click on the link for a photo which gives a rough idea);
you may notice a
bad breath smell, and your cat may also have a generally strong body odour;
he/she will have
dull, perhaps sunken eyes and not make eye contact;
your cat will
probably refuse to eat and may also refuse to drink.
When you reach
the vet, and bloodwork and other tests are run, you will usually be told
that your cat's bloodwork values are very high. This occurs because severe
dehydration artificially inflates most of the values.
emphasise this enough: it does not matter how bad your cat's values are at
initial diagnosis, particularly if s/he is severely dehydrated. You have to
wait and see what they look like when the cat has been stabilised. My
Thomas's BUN was 241 mg/dl at initial diagnosis (the top of the range was 36) yet
he pulled through.
If your cat is in crisis, the first thing to
deal with is the dehydration. This will usually be treated via intravenous (IV)
fluids (a drip), which requires hospitalisation for a few days. Personally,
I would want to put any cat of mine with creatinine of over 6 on IV for 3-4
days (one day is not enough). As the cat becomes rehydrated, s/he
should gradually start feeling and acting a little better, though some cats
do not do well as in-patients and will only turn the corner once they return
The cat may continue to exhibit a loss of appetite, so it
is essential that sh/e eats, via assist feeding if necessary. Since cats
with high BUN tend to have problems with excess stomach acid, ask the vet to treat
this (the excess stomach acid) too.
A cat with high
bloodwork will almost certainly have high phosphorus levels, and may also
have anaemia, though anaemia may not be apparent in blood tests until the
dehydration has been corrected. Hypertension (high blood pressure) may also
be present. Treatment needs to be started for all of these as appropriate. I
do not advise starting benazepril (Fortekor) treatments for cats with high
creatinine levels because this medication may cause a worsening of kidney
values when first begun (see
Your cat may still have high numbers when you bring
him/her home, but don't panic, they may continue to fall with a home
treatment programme, as happened to our Thomas. Once your cat is home, you can
follow the advice for the stable cat below.
The Stable Cat
If your cat is not in crisis, then creatinine levels will
usually be 300-350 or below (USA: 3-3.5 or below). Yes, those numbers are
still a lot higher than they should be but really, they are considered
medium level numbers. They may even be higher - some cats cope better with
high numbers than others.
Whatever the level, if your cat is not in crisis and
dehydrated, then it is highly unlikely that your cat needs IV fluids. I have
heard recently of some vets putting non-crashing cats with creatinine of 300
(USA: 3) or lower on IV fluids, which seems like overkill to me - chances
are these cats do not even need regular subcutaneous fluids, let alone IV
plus it is much cheaper for you and less stressful for your cat if you can
avoid IV fluids.
However, you will probably need to begin a home treatment
programme. This need not be particularly complicated if your cat has been
diagnosed early enough. In that case, you will probably merely need to focus
on the things that will keep your cat stable (e.g. controlling phosphorus
levels, and, for cats with creatinine over 300 (USA: 3.5), perhaps giving
sub-Q fluids regularly to prevent dehydration), and comfortable (e.g.
controlling constipation or excess stomach acid). Basically, you need to check
the bloodwork and symptoms, see what issues may be a problem, and take
the appropriate action.
Most people find they only need to spend 10-20 minutes a
day dealing with their cat's additional CKD needs, and that includes time
spent giving fluids (which not all cats need immediately). If you focus on any problems that are present
and have a bit of luck on your side as well, you
should soon see a big improvement in your cat's wellbeing. For more detailed
information on the symptoms which you might be seeing, see the
of Symptoms and Treatments page.
Even when a CKD cat is stable, it is normal for him/her
to have the occasional bad day, particularly when first diagnosed. Try not
to panic if this happens, just try to treat anything that may be
contributing to the problem (e.g. if your cat is constipated, s/he won't
feel great) and with luck you will find that once any problems are under
control your cat will have a reasonable quality of life overall.
However severe your cat's case may be, if I were to give you only one piece of advice, it would
be to make sure your cat eats. Cats who go just a short time (a day or two)
without eating are at risk of a condition called hepatic lipidosis, a potentially
life threatening liver problem. Not eating can also worsen dehydration and
make the cat very weak; whereas food in the stomach can often make a cat
feel better and stronger. See
below and the
Cat To Eat
page for information on getting food into your cat.
If Your Vet
Has Recommended Euthanasia
Recently I have been hearing from more and more people
whose cats have only just been diagnosed, yet the vet is already
recommending euthanasia. I hear things like "the vet said my cat has anaemia
and it's untreatable, so I should put him to sleep", or "the vet says his bloodwork is so high that it can never reduce to a reasonable level" (this
even for cats with creatinine of around 300, or 3.5 in US terms), and of
course the classic "he's very sick, and it would be the kindest thing to
Often these vets do not even offer any IV (intravenous fluids)
treatment for high number cats, or if they do, they only offer one day,
tell the person their cat's numbers have not improved after that short
stint, and recommend euthanasia. In some cases people are told even before
their cat is placed on IV that if s/he does not respond within 24 hours,
they have to put their cat to sleep.
I'm not in the business of vet-bashing, but this trend
does give me pause for thought. No vet has a crystal ball. And CKD cats can
look horribly ill when they are first diagnosed, particularly if they are
dehydrated. I was dehydrated myself one time following surgery, and I
definitely looked as bad as I felt. Note I say that I felt bad; but I was not in actual pain.
CKD is not generally considered to be a painful disease (although end stage
PKD, a genetic
kidney disease, may be painful if some of the cysts rupture, but this is
rare). Dehydration basically
feels like a bad hangover, with a bad headache and a queasy stomach. CKD
cats often have excess stomach acid, so that feels like stomach ache. They may be
constipated, and may have anaemia which makes them feel weak. But none of these things is outright
painful. And all of these things are treatable, in fact often relatively
simple treatments can soon make a CKD cat feel and act much better.
So I would say that in most cases, you should definitely
try treatments, for a period of two weeks if not longer, before opting for
euthanasia. And if your cat has high bloodwork levels, then one day on IV
fluids is simply not long enough to
decide whether a cat is going to turn the corner or not! Read the rest of
this page, particularly the Cat in
Crisis section, see what problems your cat is experiencing, and do your best to treat
them. I cannot promise that treating your cat is going to work.
But there is a pretty good chance that it will. And even if it doesn't, at
least you would have the peace of mind of knowing that you tried your best.
And remember: it is not the vet's decision to put your cat to sleep, it is
Commonly Seen Symptoms
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This is a short
list of symptoms which may be seen in CKD. Some of these problems, such as constipation, are not
life threatening, but they can make a big difference to how well a cat feels.
Others, such as not eating, can cause severe problems if left untreated.
The classic symptom for a
CKD cat is to vomit
clear foam, which is usually caused by
excess stomach acid. Other
causes of vomiting include
metabolic acidosis, or using certain types of antibiotics. Occasionally vomiting is
caused by constipation,
particularly if your cat vomits immediately after using the litter tray.
If you are giving your cat sub-Q fluids and s/he regularly vomits after
fluids, this may because of the
type of fluids
Excess Stomach Acid
Many CKD cats suffer from excess stomach acid or, in severe
cases, stomach ulcers.
If creatinine and particularly
BUN/urea are elevated, itís quite likely your cat has this problem too.
cat's stomach gurgles a lot, or if your cat has little appetite or vomits
clear foam, or grinds his/her teeth, or rests his/her head over the water
bowl, then you
should suspect that stomach acid is present.
Sometimes the cat will appear to want to eat, but will sniff the food,
then walk away (this may also be a sign of
The toxins produced by the body can cause ulceration.
Mouth ulcers may also be a sign of
metabolic acidosis. You may see ulcers in the cat's mouth if you look
inside, or in severe cases your cat may
vomit blood (which
may also be a sign of bleeding from further down the
Mouth ulcers are painful for the cat and often lead to
of appetite, or a desire to eat coupled with an inability to do so - the
cat may approach the food bowl and sniff the food, then walk away.
Weakness, Especially in the Back Legs
Many CKD cats are
weak at initial diagnosis. This may be because they are dehydrated, or anaemic. Other possible causes include high phosphorus levels, low potassium
levels, metabolic acidosis, constipation and calcium imbalances. If you and
your vet can work out what the cause is and treat it appropriately, you
should find that this symptom improves greatly.
that accompanies CKD may cause constipation. Symptoms - apart from the
obvious one of no poop in the litter tray - may include an ungainly walk,
vomiting after using the litter tray, loss of appetite, pooping outside the
litter tray, and, surprisingly, diarrhoea. Constipation can usually be
treated easily and quickly.
CKD cats often
howl, especially at night.
commonly caused by
pressure. It may also
have other causes such as toxins, deafness,
hyperthyroidism, or occasionally just old age and possibly
dysfunction (senility). Certain medications such as
mirtazapine (Remeron), both appetite stimulants, or anabolic
steroids, can make a cat become vocal.
Refusal to Eat
This is really
common in CKD cats. Common causes include excess stomach acid, high phosphorus
levels, dehydration, constipation, fluid retention and loss of sense of
smell. Many cats refuse to eat the CKD prescription diets in particular.
Treating the cause will usually help, though some CKD cats will always need
encouragement to eat.
This is a
classic sign of anaemia, though it may also occasionally be seen in cats
with calcium imbalances. It should stop once the anaemia is under control.
is relatively common in CKD cats. Causes of twitching include high
phosphorus levels, high or low potassium levels, calcium imbalances
(especially head twitching),
B deficiency. Twitching may also be caused by toxin levels. If your cat only twitches
while you are giving fluids, it is probably caused by either the
type of fluid
used or by
giving cold (room temperature) fluids.
CKD cats go blind, and this may happen suddenly. Look at your cat's pupils
and check whether they are enlarged or very black, even in bright light.
If so, don't panic. The most common cause of blindness in a CKD cat is
hypertension (high blood pressure), but if you start the correct treatment
(a drug called amlodipine -
Norvasc or Istin) as quickly as possible, your cat has a reasonable
chance of regaining his/her vision.
My Cat Has Symptoms Not
If the symptom
you are interested in is not here, check the
lengthy list of possible symptoms on the
Symptoms and Treatments page, together with detailed links to possible
causes and appropriate treatments. And don't panic, you are not going to be
faced with all these problems!
Commonly Used Treatments
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The following is
a list of some of the treatments which you may be offered. If you are in the
UK, I can virtually guarantee that you will only be offered a prescription
diet, Fortekor, and occasionally Renalzin or Ipakitine; but many
of the other treatments are equally, if not more important, depending upon
your cat's condition.
Diet is a popular
way of trying to treat CKD. Your vet may prescribe a prescription diet,
which is a food that is relatively low in protein and phosphorus, and has
other benefits. If your cat will
eat these foods, then by all means feed them, though try to introduce them
gradually, which increases the chances of your cat accepting any new food.
loss of appetite is very common in CKD cats, and these foods can be a little
dry and many cats find them lacking in flavour. Your vet may tell you it is
essential that your cat only eats this food, but cats
who go just a short time (a couple of days or so) without eating are at risk of
hepatic lipidosis (fatty liver disease) where the
liver starts to function abnormally; this can happen after just a day or two
of not eating, and can be life-threatening.
Mar Vista Vet
has more information about this.
So if your cat refuses to eat the prescription food,
don't panic - not eating is far worse for him/her.
If you are in the middle of a crisis, feed whatever
your cat will eat Ė baby food (without onion), Hill's a/d. Anything to
get some nourishment into him/her. See the
Cat To Eat page for tips.
Also try to treat any
possible problems, such as
excess stomach acid, anaemia, etc.,
- once these are under control, you may well find that your catís appetite
You can look into
getting your cat onto a better diet once s/he is more stable, but be sure to
introduce any new food gradually. If you do not succeed, you don't need to
despair: it is still more important that your cat eats than that
he/she eats prescription foods. In fact, the current thinking is that
feeding a low protein diet might not be appropriate for cats in the earlier
stages of CKD (see
Nutritional Requirements). However, once BUN (urea) is consistently over 60-80, most cats
tend to feel better with
less protein in the diet to process.
your cat refuses to eat any prescription foods, aim at least to feed a food
low in phosphorus. There is a lot more information on the
Which Foods to Feed
Cat To Eat pages.
Vitamin B is
a water-soluble vitamin, and is often lacking in CKD cats, who lose much of
their Vitamin B through urination. A lack of vitamin B may be related to a
lack of appetite, or occasionally may cause twitching or itching. Vitamin B
deficiencies are also known to cause non-regenerative anaemia. Your vet may
therefore suggest a supplement in order to avoid these problems. British
vets often give Vitamin B injections, but you can also give Vitamin B
In contrast, additional doses of Vitamins A, C and D are not appropriate for
Nutritional Requirements for more information about
Vomiting, Nausea and Excess Stomach Acid
The most effective treatments
for excess stomach acid are slippery elm
bark, from health food stores (see
Treatments) and/or a drug called famotidine, trade name Pepcid AC (not
With Pepcid AC, you usually start with a quarter of a 10mg
tablet once every other day, but if necessary you can go up to a quarter of
a 10mg tablet twice a day (all with your vet's approval, of course).
In some cases, you will also need anti-nausea medications.
All About Stomach Acid
has more information about excess stomach acid, nausea and vomiting
High Phosphorus Levels
If your cat's
phosphorus level is above 6 mg/dl US or 1.9 mmol/L international, and you are not feeding
a prescription diet, or if the levels are this high despite feeding a
prescription diet for a month, you should ask your vet about using a phosphorus binder.
Phosphorus binders bind with the excess phosphorus in cat food and therefore reduce
the load on the kidneys. They must be given with food in order to bind
ideally an hour or so apart from other medications.
A popular choice is aluminium hydroxide. US vets may
offer this in the form of AlternaGel, but this is peppermint-flavoured,
which most cats hate. Aluminium hydroxide can be obtained in odourless and
flavourless formulations and simply added to the cat's food without the cat
In Europe, you may also be offered a binder called
Renalzin, which is lanthanum carbonate and which seems to be effective.
Unfortunately it was discontinued in late 2014 so is unlikely to be
available from spring 2015 onwards.
You may be
offered other binders such as Ipakitine (Epakitin) or Pronefra. Another common choice
by vets is Alternagel, but this is peppermint-flavoured, which most cats
The All About Phosphorus
page explains more about phosphorus control.
has information on your binder choices.
Hypertension (High Blood Pressure)
This is present in up to two thirds of
CKD cats, so do ask
your vet to monitor your cat's blood pressure; many do not do so routinely. If your cat has
suddenly gone blind, the most common cause is hypertension; and if you act
quickly enough, your cat may be able to regain some or all of his/her sight.
Even if your cat
has not gone blind, if hypertension is present, it must be treated. The
treatment of choice for CKD cats with hypertension is a drug called amlodipine (trade names are
Norvasc or Istin) This is very well tolerated by the majority of cats,
is less likely than some other treatments to cause the opposite problem of
low blood pressure, and is the only treatment which gives your cat a chance of regaining his/her
sight if it has been lost.
You can read
about high blood pressure in more detail on the
All About Hypertension page.
ACE inhibitors: benazepril (Fortekor)
or enalapril (Enacard)
If you are in
any country other than the USA, your vet will almost certainly prescribe a drug called
benazepril (Fortekor, or Lotensin in USA). Occasionally in the USA vets prescribe
a similar medication called enalapril (Enacard).
These drugs are
actually heart medications known as ACE inhibitors. Some recent studies into
the use of benazepril in particular indicate that these drugs may help with
CKD, at least in the early stages, and therefore benazepril is approved in
Europe and Canada for the treatment of chronic renal failure in cats.
There are pros
and cons in using ACE inhibitors to treat CKD. My main concern is that when first used, these
medications may cause an increase in creatinine, which might be enough to
push a cat
with high bloodwork over the edge.
If your cat has hypertension, particularly if s/he has gone blind, ACE inhibitors
are not what you need: a drug called
amlodipine (Norvasc or Istin) is the
drug of choice for CKD cats with hypertension, and may enable your cat to
regain his/her sight.
For more information about using ACE
inhibitors, please see
If you are in the UK and other parts of Europe, you may be offered
steroids. If you are in the USA, most vets do not seem to use steroids
Steroids are intended either as an appetite stimulant or as a general pick
me up, but they do have possible risks. I did find Thomas did better overall
on steroids but he was extremely ill when first diagnosed; cats who are
diagnosed early probably would not benefit particularly. You should
familiarise yourself with the possible risks before deciding whether to use
For more information about using steroids, please see
the Treatments page.
If your cat is
severely dehydrated with high blood values at diagnosis, then regardless of
your location, your vet will probably offer intravenous (IV) fluid therapy
(a drip) to rehydrate your cat.
If your cat has
lower numbers upon diagnosis or following IV treatment, but the creatinine
is over 300 (US: 3.5), you will probably find that he/she does better with
regular subcutaneous fluids (known as sub-cuts in the UK) to help prevent
dehydration. Unfortunately, whilst subcutaneous fluids (sub-Qs) are routinely offered in the USA,
they are very uncommon and hard to obtain in Europe.
receiving sub-Qs need about 100ml a day, no more. Your vet can show you how
to give sub-Qs to your cat yourself at home, and they can really help to
make your cat feel better, although you do need to be sure that your cat
does not have a heart condition before using them.
If your cat has
creatinine below 3-3.5, the chances are that s/he can maintain hydration without
sub-Qs. Sub-Qs are a strain on the kidneys, so there is no point giving them
before the benefits outweigh the risks. If your vet recommends them for a
cat with creatinine below 3-3.5, ask why.
Fluid Therapy for more information.
bark, which as mentioned above can help with stomach acid,
can also be made into a syrup and used to help heal mouth ulcers - this has
been found to be a very effective treatment by many people. See
for more information about slippery elm bark and how to make the syrup.
mouth ulcers, antibiotics may be necessary; while for really
obstinate ulcers, you may need to consider using a treatment called
sucralfate, which forms a protective coating over the ulcers and allows them
to heal. Trade names for this drug include Antepsin in the UK, Carafate in
the USA and Ulcogant in Germany.
has more information about treating mouth ulcers.
Slippery elm bark may also help
with this (see Holistic
Treatments), or you may wish to ask your vet about MiraLAX or Lactulose. See
All About Constipation
for more information.
If your catís
level is 4.0mmol/L (US:
4.0mg/dl) or lower, ask your vet for a potassium supplement Ė the most common one
is Tumil-K. However, do not give potassium supplements without your vet's
knowledge and approval - high potassium levels can be dangerous. See
All About Potassium
for more information.
If your cat's
potassium levels are high, the first thing to do is to run another blood
test because the most common cause of high potassium levels is an error in
the measurement. If your cat really does have high potassium levels, the
All About Potassium
page has more information on how to deal with this.
This means the cat's pH levels are out of balance, causing excess acidity.
If your catís bloodwork contains something called TCO2 or CO2
and this is below 15, ask your vet about using bicarbonate of soda or
potassium citrate to help with this problem. See
for more information.
There are two commonly used appetite stimulants in cats,
cyproheptadine (Periactin) and mirtazapine (Remeron). They are usually very
effective, but may have side effects, such as making the cat agitated,
causing howling etc.
these medications may stimulate your cat to eat, it is better if you can find
the cause of your cat's inappetance and treat it. But appetite stimulants can
certainly be a useful tool for inappetance at initial diagnosis.
Cat To Eat page has more information about
essentially a type of probiotic. Probiotics are commonly used to re-balance
the bacteria in the gut, particularly after using antibiotics - there is
more about them in the
contains strains of three patented types of bacteria, and the
manufacturers of Azodyl claim that their strains of these bacteria have a
particularly high affinity for some of the major uraemic toxins found in
CKD. Azodyl is intended to bind with and reduce the levels of these
uraemic toxins in CKD cats.
I have heard
reports from several people who have used Azodyl. Most people seem to think
it has helped their cats, though one person said that it made his cat vomit,
and some people think it did not make any difference.
currently only available in the USA and Canada, although it can usually be
shipped to other countries if required.
There is more
information about Azodyl in the
not routinely used in CKD, though some vets appear to prescribe them
routinely. However, they may well be necessary for cats with urinary tract
or kidney infections, dental infections or severe mouth ulcers.
section has more information about antibiotics.
If your catís PCV or HCT level
is below 30%
(25% for some laboratories), your cat
has anaemia. Treatment depends upon how severe the anaemia is:
If PCV is between 20% and 30%, an iron supplement, B Vitamins or anabolic
steroids such as Nandoral may be enough to control it.
is below 20%, your cat has severe anaemia and you need to treat it more
aggressively. If this is CKD-related
anaemia, you should consider using erythropoiesis
stimulating agents (ESAs)
which have the trade names of
Procrit, Eprex or NeoRecormon, particularly if your cat's PCV is closer to 15% than to
20%. Many vets are extremely negative about using ESAs, but you need to
understand that severe anaemia will kill your cat before the CKD does. We
began using an ESA (Eprex) for Thomas when his PCV reached 18%. For us, it was a
no-brainer since the alternative was to sit back and watch Thomas die of
anaemia, and we never regretted using it.
treatments take time to take effect. If your cat's anaemia is particularly
severe (PCV below 15%), you may need to consider a blood transfusion to tide
you over until the other treatments kick in.
Please see the Anaemia
Stimulating Agents page for more information.
Meloxicam is a
non-steroidal anti-inflammatory drug (NSAID). It is a very effective
painkiller, but unfortunately when given in too high a dose, in some cases
it may lead to
acute kidney injury. If your cat is taking meloxicam when or
shortly before CKD is diagnosed, ask your vet about stopping it with
immediate effect. There is more information about meloxicam
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It is all very
well knowing about the treatment options available, but that can be very
depressing if money is a factor, as it is for most people. It can be
particularly horrifying if your cat crashes and requires hospitalisation -
some large city hospitals charge a fortune for such services.
The good news is
that you should not need all the treatments described above; and for home
treatments, it is usually possible to purchase most of the supplies you
require cheaply online. For the average cat who needs sub-Q fluids, phosphorus binders
and treatments for excess stomach acid or constipation, it is often possible to spend as little as US$5 a week
treating your cat once s/he is stable. Other treatments, including Epogen
which many vets believe costs up to $300 a vial, can also be obtained
cheaply - a vial of Epogen bought online, if you know where to look, costs
as little as US$30.
Coping with CKD page gives tips on coping with the financial burden and
finding ways of paying for your cat's care, whilst the
Obtaining Supplies Cheaply page gives details of reasonably priced
suppliers in UK, Canada and USA.
Advice for Those New to CKD
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That is your crash course in CKD. Unfortunately I know you are probably still feeling overwhelmed, so
here is some advice for you from Pat, who has been in your shoes. Pat cared for her cat SEM when he
had CKD. In early 2006, she wrote a wonderful message to a person with a
newly diagnosed CKD cat. She says it all so well here, far better than I could,
that I asked her if I could repost her message here.
"I am sorry you have a need to be here but you have come
to a good place. First, I can't think of a single individual who hasn't
landed here in an emotional heap. It seems not to matter the numbers of the
cat or the circumstances of the individual, everyone is devastated.
"So... your sweet cat is exactly the same cat the day
before the diagnosis as the day after. The only thing that has changed is
information in your head. These cats set such very fine examples for us - if
they're feeling well, all is well. If they're not feeling well, they need
some help. My advice is to face the fear squarely, see it for what it is,
and know that it has now moved in with you. But it doesn't require your
attention, let it simmer away on the back burner with the lid on and do as
it will. In the meantime, you can educate yourself by reading the
overwhelming CRF site bit by bit so you can get a jump on anything that
develops. That old stitch in time saves nine :-)
"There is no cure for CRF (at present). And life itself is a terminal
condition. There's simply nothing to be done about that. But there is
something to do about cats and CRF and that something is to learn about
kidneys and their function and what helps and what doesn't and what
shouldn't be done. In the meantime, your girl will not be worrying her
pretty head, she will be doing normal cat things :-)
"Do get a copy of your blood work and post the numbers to the group (with
normal ranges included), and keep copies of all tests and lab reports etc.
It is hard dealing with a chronic condition, which is why I urge you to deal
with the crux of the matter now and set it aside. There's no way to avoid
going up and down emotionally with these cats, that will happen as a matter
of course, but if you can, see your cat as very much alive because she is
and should remain so for a good long time to come with your attention and
love. And her heart is doing the beating, her lungs the breathing, her
tongue the washing up. Life still courses through her. If you go crazy, she
will have lost a loyal and articulate ally. We surely don't want that to
One Last Word
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One last word from me, Helen.
I know CKD is a scary diagnosis - I've been there three
The first time, with Tanya, I was not online and although I tried to help
her, in retrospect there was so much more I could have done to help her.
It is different for you. You have this
website. By all means feel frightened, but then tell yourself you are going
to do your best to help your cat. Read the site. Educate yourself about the basic issues above.
In the vast majority of cases, there is hope. You can do it!
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This page last updated:
06 May 2015
Links on this page last
checked: 06 February 2012