TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

THE IMPORTANCE OF PHOSPHORUS CONTROL

 

ON THIS PAGE:


Why Phosphorus is So Important for CKD Cats


Symptoms of High Phosphorus Levels


Goal for Phosphorus Level in Bloodwork


Ways to Control Phosphorus Levels


All About Phosphorus Binders


Aluminium Hydroxide: The Best Binder


Where to Buy Phosphorus Binders


 

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Home > Key Issues > Phosphorus

 


Overview


  • If your cat's phosphorus level (in blood tests) is over 6 mg/dl (USA) or over 1.9 mmol/L (international), it is too high and you need to get it under control.

  • Doing this should help slow the progression of the CKD, reduce the risk of serious problems (including heart problems) and make your cat feel better.

  • Feeding a food low in phosphorus is the first step. Ideally you want a food with a level below 0.5% phosphorus on a dry matter analysis basis. Prescription kidney foods are really the only foods which meet this criterion.

  • If your cat will not eat the prescription diet, feeding a food as low in phosphorus as possible and adding a phosphorus binder to the food when appropriate can help control your cat's phosphorus levels.


Why Phosphorus is So Important for CKD Cats                                                  Back to Page Index


 

Phosphorus is a mineral essential for good health which is contained in many foods. The body is very good at regulating its phosphorus levels by removing excess phosphorus via the kidneys. However, the kidneys of a CKD cat can no longer efficiently excrete excess phosphorus, so the vast majority of CKD cats will eventually have levels of phosphorus in their blood which are too high: this is known as hyperphosphataemia.

 

In contrast to the protein debate, there is no dispute about the importance of treating hyperphosphataemia because:

  • They can cause a variety of unpleasant symptoms.

  • In Chronic kidney disease in dogs and cats: the pivotal role of phosphorus control (2011) A Presentation to the 63rd CVMA Convention, Dr D Chew states that it is possible for a CKD cat to develop secondary hyperparathyroidism even if phosphorus levels and ionised calcium levels are normal. He explains "In the early stages of chronic kidney disease increased levels of parathyroid hormone (PTH) keep serum phosphorous within the normal range by increasing phosphate excretion into urine. This allows for normalization of serum phosphorous at the expense of hyperparathyroidism." Therefore, even a cat with normal phosphorus levels but with elevated PTH levels would benefit from phosphorus restriction.

  • high phosphorus levels may reduce the cat's response to ESAs, a treatment used for severe anaemia, which is relatively common in CKD cats.

Thus, focusing on phosphorus control is one of the most effective ways to help your CKD cat feel better and live longer. The good news is, it's not usually too difficult or expensive to do either.

 


Symptoms of Hyperphosphataemia                                                                      Back to Page Index


There are a number of different symptoms of high phosphorus levels. You may not see all of these symptoms, and some of them may have other causes as outlined under each symptom, but if you see any of the symptoms described below, please ensure that your cat's phosphorus level is checked (via bloodtests) and is no higher than 6 mg/dl (US) or 1.9 mmol/L (international).

 

Loss of Appetite


High phosphorus levels can make a cat feel bad and lead to a loss of appetite, particularly if secondary hyperparathyroidism develops.

 

Other causes include levels of toxins in the blood which may cause excess stomach acid, anaemia, crashing, metabolic acidosis, mouth ulcers, fluid build-up, the use of antibiotics, constipation or the use of medication for hyperthyroidism. Dental problems may also cause loss of appetite.

 

Cats who do not eat are at risk of developing a potentially life-threatening condition known as hepatic lipidosis; Mar Vista Vet has more information about this. Therefore, it is important to try to find the cause and treat it as quickly as possible.

 

Itching


Itching is fairly common in cats with high phosphorus levels, particularly if the high phosphorus levels go untreated, resulting in secondary hyperparathyroidism.

 

Itching may also be caused by general levels of toxins in the blood. Alternatively itching may indicate a vitamin B deficiency or be a sign of an essential fatty acids deficiency. Itching on the face in particular may be a side effect of the medication for hyperthyroidism. Occasionally itching can be a sign of liver problems; if this is the case, your cat's bloodwork should show elevated liver values.

 

Lack of Co-ordination in the Limbs/Back Leg Weakness


This can be due to high phosphorus levels interfering with the nerve messages that control the limbs, a condition known as neuropathy. Some of the symptoms include "forgetting" where the hind legs are (getting up and leaving without them, for instance, or leaving them in the air after licking them), or stumbling and feet crossing over when walking.

 

Plantigrade Posture


You may also see a plantigrade posture (as demonstrated by Ollie to the left), where the cat walks on his/her hocks instead of his/her feet: this is most common in diabetic cats, but may sometimes be seen in cats with high phosphorus levels, or with neurological problems from other causes. Ollie did this because of low potassium levels. Since Ollie is so fluffy, you may find this photo on 123catworld clearer.

 

Long Beach Animal Hospital has a photograph of a cat with diabetic neuropathy doing this (click on Symptoms). Newman Veterinary has a good before and after photo of a diabetic cat with this problem, scroll down a little to Other Common Consequences, then click on Plantigrade Stance (in red font).

 

University of Chicago Jack Miller Center for Peripheral Neuropathy is a human site which discusses uraemic neuropathy (neuropathy caused by CKD).

 

Teeth Grinding


This may be a sign of "rubber jaw", caused by a condition related to the CKD called secondary hyperparathyroidism.

 

Other more common causes of teeth grinding include excess stomach acid, dental problems and dehydration.

 

Animal Dental Center of Milwaukee and Oshkosh discusses the various courses of teeth grinding in cats.

Youtube has a video of a cat grinding his/her teeth.

 

Knuckling


"Knuckling" may also be seen, where the cat walks on the top of the foot with the toes tucked underneath, appearing almost to be dragging the toes behind. I haven't been able to find a photo of a cat with high phosphorus levels doing this, but there is a video on youtube of a dog with a similar problem (but with a different cause).

 

Weakness


Weakness and muscle wasting may be seen, especially in the back legs. This can be caused by high phosphorus levels leading to secondary hyperparathyroidism

 

Weakness in the back legs is often caused by low potassium levels or occasionally by low magnesium or low calcium levels; while muscle wasting may be caused by metabolic acidosis. General weakness may be caused by anaemia. If your cat no longer jumps, this may be thought to be weakness when in fact it is an unwillingness to jump because of blindness caused by hypertension. An inability to jump or climb may also be caused by arthritis.

 

If your cat suddenly cannot walk properly on one leg, particularly a back leg, and the leg feels cold to the touch, this may indicate a heart-related problem known as a saddle thrombus. This is a medical emergency, and you need to contact your vet as soon as possible.

 

Weight Loss


This may be caused by high phosphorus levels.

 

Other causes include proteinuria or  metabolic acidosis. Weight-loss may also be a symptom of other diseases such as diabetes or hyperthyroidism. Other possible causes include IBD (Inflammatory Bowel Disease) or cancer.

 

Purina has a Body Condition diagram showing how to gauge your cat's physical condition.

 

Nausea


High phosphorus levels and the resulting secondary hyperparathyroidism may cause nausea, which may be manifested as a lack of appetite.

 

Alternatively, vomiting clear foam is a classic symptom for a CKD cat, and is usually caused by high toxin levels, particularly excess stomach acid. Occasionally vomiting is caused by constipation, particularly if your cat vomits before, during or immediately after using the litter tray. Anaemia or metabolic acidosis may also cause nausea. 

 

Twitching, Trembling or Shaking


Twitching may be caused by high phosphorus levels.

 

Other causes of twitching include high or low potassium levels, high blood pressure, calcium imbalances (especially head twitching), hyperthyroidism or vitamin B deficiency. Twitching may also be caused by high 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.

 

Pharaoh's Shakes is a video showing a CKD cat twitching.

Pet MD mentions that twitching may be caused by kidney disease.

 


Goal for Phosphorus Level in Bloodwork                                                             Back to Page Index


 

Your vet can determine if your cat's phosphorus levels are too high by checking your cat's bloodwork for phos, P or Pi (these are all abbreviations for phosphorus). Most vets do this routinely, but if yours doesn't, ask for it to be done.

 

Your cat may have phosphorus levels within normal limits, but many vets forget that the higher limits only apply to growing kittens. In Chronic kidney disease in dogs and cats: the pivotal role of phosphorus control (2011) A Presentation to the 63rd CVMA Convention, Dr D Chew states "Serum phosphate levels are maintained within a narrow range in health. Young growing animals often have higher levels of serum phosphorus than adults. The normal serum phosphorus range of many laboratories includes that of adults and growing animals which may make it difficult to detect early rises in serum phosphorus above normal. The typical normal range for phosphorus in the cat is 2.5-6 mg/dL (0.81 to 1.94 mmol/L)."

 

A few years ago the University of Texas Health Science Center gave the following ranges for healthy cats of differing ages:

Age Phosphorus Range in mg/dl (US) Phosphorus Range in mmol/L (International)
10 days - 2 years 4.5 - 6.7 1.45 - 2.16
2 years - 12 years

4.5 - 5.5

1.45 - 1.80
Over 12 years

2.7 - 4.5

0.90 - 1.45

 

As the table shows, even a healthy older cat should have phosphorus levels in the bottom half of most laboratory ranges. It is even more important for a CKD cat. In Chronic kidney disease in dogs and cats: the pivotal role of phosphorus control (2011) A Presentation to the 63rd CVMA Convention, Dr D Chew states "Cats with 4.7 to 6.8 mg/dl serum phosphorus were at increased risk for shorter renal survival despite the fact that these values were still within the normal reference range."

 

Vets may also forget that, if the cat's phosphorus multiplied by calcium is higher than 70 (US) or 5 (international), the cat is at risk of tissue calcification (see secondary hyperparathyroidism).

 

So if your vet tells you your cat's phosphorus level is fine, don't just take that at face value, ask for the exact level. Chances are it is too high for a CKD cat.

 

Ideally you want to get the level down to 4.0 (US) or 1.3 (international) but as the CKD progresses, this may become more challenging. The tables below give goals for phosphorus control based on the stage of CKD that your cat is in, based on guidelines from the International Renal Interest Society. Don't forget, these stages apply to stable cats; if your cat is dehydrated, for example, the bloodwork will not be accurate.

 

US Values


 

Stage of CKD Creatinine Level in mg/dl Phosphorus Target
IRIS Stage 2

Between 1.6 and 2.8

Below 4.5 mg/dl
IRIS Stage 3

Between 2.9 and 5.0

Below 5.0 mg/dl
IRIS Stage 4

Over 5.0

Below 6.0 mg/dl

 

International Values


 

Stage of CKD Creatinine Level in mmol/L Phosphorus Target
IRIS Stage 2

Between 140 and 249

Below 1.45 mmol/L
IRIS Stage 3

Between 250 and 439

Below 1.60 mmol/L
IRIS Stage 4

Over 440

Below 1.90 mmol/L

 

Summary of Phosphorus Goals


 

USA


  • Take action as soon as your cat's phosphorus level goes above 6 mg/dl.

  • If your cat's level is between 4.5 and 6 mg/dl, but multiplying it by your cat's calcium level gives you a reading of 60-70 or over, take action now.

  • Your aim is to reduce your cat's phosphorus to a level of 4 mg/dl. You may not be able to get it this low if your cat is in IRIS Stage 3 or 4, but aim never to let it go above 6 mg/dl.

  • If your cat's level is above 6 mg/dl, you can read below about ways to reduce the level. Check phosphorus levels every month to see if any adjustments to your treatment plan are necessary.

  • Low phosphorus levels (below 4 mg/dl) are extremely rare in CKD cats, but are generally not considered to be a problem as long as they do not fall below 2.5 mg/dl. I would try not to go below 3 mg/dl. See Diagnosis for more information.

  • If your cat is very young (6-12 months old), then a higher level is appropriate, because kittens need phosphorus for their bones to grow properly. Check out the table above and discuss with your vet what would be an acceptable level.

Rest of the World


  • Take action as soon as phosphorus goes above 1.9 mmol/L.

  • If your cat's level is between 1.45 and 1.9 mmol/L, but multiplying it by your cat's calcium level gives you a reading of 5 or over, take action now.

  • Your aim is to reduce it to a level of 1.3 mmol/L. You may not be able to get it this low if your cat is in IRIS Stage 3 or 4, but aim never to let it go above 1.9 mmol/L.

  • If your cat's level is above 1.9 mmol/L, you can read below about ways to reduce the level. Check phosphorus levels every month to see if any adjustments to your treatment plan are necessary.

  • Low phosphorus levels (below 1.3 mmol/L) are not normally present in CKD cats, but are generally not considered to be a problem as long as they do not fall below 0.8 mmol/L. I would try not to go below 1 mmol/L. See Diagnosis for more information.

  • If your cat is very young (6-12 months old), then a higher level is appropriate, because kittens need phosphorus for their bones to grow properly. Check out the table above and discuss with your vet what would be an acceptable level.

Veterinary References for Phosphorus Goals


If your vet refuses to accept that a phosphorus level above 6 mg/dl (US) or 1.9 mmol/L (international) is too high for your cat, print out and show him/her some of these references:

 

Prof Jonathan Elliott of the Royal Veterinary College states on page 14 that "the goal should be to keep the serum phosphorus concentration at the lower end of the reference range."

Phosphatemia management in the treatment of chronic renal disease: a round table discussion (2006) states "practitioners need to realise that a phosphate in the normal range could still be abnormal in renal patients." Page 6 provides detailed recommendations on phosphorus control.

Dr David Polzin of the College of Veterinary Medicine of St Paul's in Minnesota states that phosphorus binders should be begun "when serum phosphorus concentration exceeds 6.0 mg/dl."

 


Ways to Control High Phosphorus Levels                                                           Back to Page Index


 

There are two main ways to control phosphorus levels, through dietary changes or by using phosphorus binders.

Controlling Phosphorus Levels with Diet


  • The most effective way to control phosphorus levels is by feeding foods low in phosphorus.

  • Retrospective analysis of dietary management of hyperphosphataemia in cats with CKD (2008) Elliott J Veterinary Record 18(2) pp45-47 concludes "This uncontrolled retrospective analysis of cats presenting to the Renal Research Clinics at the Royal Veterinary College demonstrates that feeding of renal clinical diets results in effective control of plasma phosphate concentration in about two thirds of cats presenting in Stage 2 and 3 CKD", with cats eating the renal diet living longer than the cats in the study who ate normal food with no phosphorus binder.

  • People sometimes think that if a food does not mention phosphorus on the label, it must not contain any. This is virtually impossible, especially if the food contains animal-based protein, as most cat foods do. In fact, any American food labelled as an adult maintenance food must contain at least 0.5% phosphorus on a dry matter analysis basis and many foods contain far more than this.

     

  • Most of the prescription kidney diets have phosphorus levels below 0.5%, which is one of the main reasons why these foods were developed (though they also have other attributes, see Which Foods to Feed).

  • If your cat won't eat the prescription foods, you still need your cat to eat. Many people seem to think that a food below 1% phosphorus on a dry matter analysis (DMA) basis is low phosphorus but that's not the case; you want to get as close to prescription food levels as possible.

  • In the USA, the minimum level of phosphorus in a non-prescription adult maintenance food is 0.5%, so you are not going to find a commercial food with phosphorus below this; but if you check the food data tables in the Diet and Nutrition section, you can try to find a food which your cat will eat with a level of phosphorus as close to 0.5% as possible.

  • Although canned foods are generally a better choice for CKD cats than dry foods, since phosphorus control is so important, if I had a cat who was prepared to eat a dry prescription diet, I would feed that rather than feed a non-prescription commercial canned diet with added binders.

  • Even if your cat's phosphorus level is normal, it is wise to feed a CKD cat a food as low in phosphorus as you can, because the less phosphorus your cat eats, the less work there is for the kidneys to do trying to process it; plus phosphorus levels tend to rise as the CKD progresses, and usually it is easier to keep them low rather than have to reduce them.

Controlling Phosphorus Levels with Phosphorus Binders


  • If your cat will not eat a prescription diet, or if his/her phosphorus levels are still too high despite feeding such a diet, products called phosphorus binders are used. These are simply added to the cat's food: they bind with some of the phosphorus in the food in the intestine, thus preventing it from being absorbed and therefore reducing levels of phosphorus in the cat's body.

  • Phosphorus binders are usually used when phosphorus levels are over 6 mg/dl (US) or 1.9 mmol/L (international). Once you start using binders, the goal is to get phosphorus down to a level of around 4 mg/dl (US) or 1.3 mmol/L (international).

  • To be effective, phosphorus binders should be given shortly before or with food. You should start to see a difference in phosphorus levels around 7-10 days after starting binders. There are instructions on how to give binders below.

  • Using binders is not as effective as feeding a low phosphorus diet, because binders cannot bind all the phosphorus in the food, so your cat will still be absorbing some of the phosphorus. Therefore, if you do have to feed a non-prescription diet (because the most important thing is that your cat eats), you should aim to feed the lowest phosphorus food that your cat will eat. Many people seem to think that a food below 1% phosphorus on a dry matter analysis (DMA) basis is low phosphorus but that's not the case, particularly when you consider that most of the prescription renal diets have phosphorus levels below 0.5%. Aim for as low a phosphorus level as you can. The Diet and Nutrition section has links to food data tables for you to check out the phosphorus levels of various cat foods. I'm not recommending any of these foods, this is simply a list in order of phosphorus content.

  • You should not normally need to use binders if your cat is eating a prescription kidney diet, because this should be sufficient to control your cat's phosphorus levels. However, this is not always the case, particularly as the CKD worsens. If your cat's phosphorus levels are over 6 mg/dl (US) or 1.9 mmol/L (international) despite feeding a prescription diet, speak to your vet about adding binders.

  • If your cat isn't eating, there is little point giving phosphorus binders because your cat isn't ingesting any phosphorus in the food that needs binding. However, if you assist feed (as you should if your cat is not eating), you can add binders to the mixture.


All About Phosphorus Binders                                                                               Back to Page Index


 

Phosphorus binders are used if feeding foods lower in phosphorus levels, such as prescription diets, does not keep your cat's blood phosphorus levels in the desired range (see above). They work by binding with some of the phosphorus in the cat's food in the intestine, thus preventing it from being absorbed and therefore reducing levels of phosphorus in the cat's body.

 

Over the counter antacids are commonly used for this purpose, and there are two main types: aluminium-based products and calcium-based products. Recently, branded products have also been released, including Ipakitine/Epakitin (which is calcium-based) and Renalzin (which contains a new type of binder called lanthanum carbonate).

 

The most popular binders are made from aluminium hydroxide. Overall these are the best choice because they are very effective, are available over the counter, are cheap, and have no taste or smell so most cats are prepared to eat them. Therefore these are what I recommend, but I do cover all binder types below.

Letting Other Family Cats Eat Food Containing Binders


If possible, try not to let your non-CKD cats eat food containing phosphorus binders. However, if they eat a small amount occasionally (say once a week or so), this should not be a problem as long as you make sure that most of the food they eat does not contain binders. This is particularly important for kittens, who need twice as much phosphorus each day as a healthy cat because they are still growing.

 


Aluminium-Based Binders                                                                                      Back to Page Index


 

There are three types of aluminium-based binders, but aluminium hydroxide is generally considered to be the best choice.

 

Aluminium Magnesium Hydroxide


These binders, as the name suggests, also contain magnesium. Brand names include Maalox, Mylanta, Milk of Magnesia or Aludrox. Binders containing magnesium are not suitable for CKD cats because they can cause high magnesium levels in the blood, which in turn can sometimes cause urinary tract problems such as stones in some cats.

 

Pet Education states "Do not use magnesium containing products in animals with kidney failure."

 

Sucrose Aluminium Hydroxide


Sucrose aluminium hydroxide is also known as sucralfate or Carafate. It coats the digestive tract, so is commonly used to treat mouth ulcers or gastro-intestinal bleeding. Some British vets also recommend sucralfate as a phosphorus binder. One old study, Changes in serum phosphorus, calcium and alkaline phosphatase due to sucralfate (1986) Vucelić B, Hadzić N, Gragas J, Puretić Z International Journal of Clinical Pharmacology, Therapy and Toxicology 24(2) pp93-6, did find sucralfate was effective as a binder in humans, but it is not usually recommended as a phosphorus binder in cats. If you are unable to obtain aluminium hydroxide, however, it could certainly be worth considering, though I don't know the correct dosage for using it as a phosphorus binder.

 

If you are using sucralfate for mouth ulcers or gastro-intestinal bleeding at the same time as using aluminium hydroxide as a phosphorus binder, you might be able to reduce your dosage of aluminium hydroxide.

 


Aluminium Hydroxide: The Best Binder                                                               Back to Page Index


 

This is the most effective binder and the one I recommend because it is available over the counter (though you may have to use mail order in the USA), cheap, and if you buy the correct type it is odourless and tasteless. Unfortunately many vets are reluctant to prescribe aluminium-based binders because they think cats hate the taste. If they do prescribe them, they often prescribe AlternaGel, a peppermint-flavoured binder which most cats hate, so it then becomes a self-fulfilling prophecy. AlternaGel also contains potassium citrate, which is not a good idea because citrate can increase the absorption of aluminium within the body. 

 

I recommend instead that you look into buying aluminium hydroxide binders which are tasteless and odourless, and which most cats do not seem to notice in their food. See below for information on the various brands and links to mail order suppliers who can ship to UK, USA, Canada and Australia. Contrary to what some vets and pharmacists seem to believe, you do not need a prescription to buy these products.

 

Aluminium Hydroxide Binders Dosage


Please also see the general tips below.

 

Naturally you must seek your vet's advice on the most suitable dosage for your cat; but generally speaking, the appropriate dosage for aluminium hydroxide based binders is as follows:

 

USA

Current Phosphorus Level: mg/dl

Binder Dosage

Between 4.0 and 6.00*

25 mg per lb (0.5kg) of cat per day, divided and given with food.*

Between 6.0 and 8.0

50 mg per lb (0.5kg) of cat per day, divided and given with food.

Between 8.00 and 10.00

100 mg per lb (0.5kg) of cat per day, divided and given with food.**

Over 10.00

Discuss with your vet

 

International 

Current Phosphorus Level: mmol/L

Binder Dosage

Between 1.3 and 1.9*

25 mg per lb (0.5kg) of cat per day, divided and given with food.*

Between 1.9 and 2.6

50 mg per lb (0.5kg) of cat per day, divided and given with food.

Between 2.6 and 3.25

100 mg per lb (0.5kg) of cat per day, divided and given with food.**

Over 3.25

Discuss with your vet

*Not everybody chooses to start binders if phosphorus levels are in this range - most people only start binders once phosphorus levels are over 1.9 (US: 6.0). However, if your cat has previously had high phosphorus levels which you have reduced with binders, or if your cat has high calcium levels, you will probably need to continue to give binders, either at this dosage or even higher, otherwise your cat's values will probably rise over 1.9 (US: 6.0) again.

**I would not give more than 50 mg per lb of cat per day (100 mg per kg of cat per day) without detailed discussions with your vet. It is probably safe, but you need to balance the potential benefits against the possible risks, including the rare possibility of aluminium toxicity - see below. It may be safer to use a smaller amount of aluminium hydroxide together with another binder, such as lanthanum carbonate (Renalzin or Fosrenol).

 

The amounts above are the total daily dose, but the total amount should be divided among as many of your cat's daily meals as possible.

 

Aluminium hydroxide does not have to be measured too precisely, but as a rough guide, if you are using powdered aluminium hydroxide, a loosely packed quarter of a teaspoon of powder contains approximately 300mg of aluminium hydroxide. If you are using a liquid type of binder, as a guide, a teaspoon of AlternaGel contains approximately 600mg of aluminium hydroxide. If you prefer not to guess at a quarter of a teaspoon, Amazon sells a set of measuring spoons which include a quarter and an eighth of a teaspoon for less than USD10. The same set costs £10.61 from Amazon UK.

 

You should see an improvement in your cat's blood phosphorus levels after about two weeks, if not earlier. You may see a difference in your cat's demeanour sooner than this. Check your cat's phosphorus level every two weeks until the level is acceptable, then check it every 2-3 months to see if any adjustments to your treatment plan are necessary.

 

Aluminium Hydroxide Binder Tips


Phosphorus binders must be given with food so they can bind with the phosphorus in it. Aluminium hydroxide binders are usually odourless and tasteless if you choose carefully (see below), but since they are a natural (mined) product, they can sometimes add a bit of a gritty texture to food or make it taste a little drier.

 

See above for recommended dosages. Here are some tips on how to give aluminium hydroxide binders:

 

Using Aluminium Hydroxide Binders with Canned Food


  • tablets can simply be crushed and added to the food.

  • capsules can be opened and the contents mixed with the food. 

  • liquid binders can either be mixed in the food or syringed into your cat's mouth just before eating.

  • one retailer recommends adding a teaspoon of water to the tinned food and binder and letting it stand for ten minutes before serving in order to let the binder mix thoroughly. This may help remove any grittiness.

Using Aluminium Hydroxide Binders with Dry Food


  • try putting the food in a freezer bag together with the crushed or powder binder and leave them to mingle overnight.

  • if you are using a liquid binder, you can syringe it into your cat's mouth just before eating.

Aluminium Hydroxide Cautions and Interactions


Side Effects


Sometimes phosphorus binders may cause constipation, so watch for this when you first start them and be ready to start a suitable treatment if required.

 

Interactions


If you are using potassium citrate (perhaps to treat metabolic acidosis), give this at least two hours apart from phosphorus binders. This is because, as Drugs mentions, products containing citrate may increase the absorption of aluminium, which could increase the risk of aluminium toxicity. Many prescription diets contain potassium citrate,  but apparently these findings have not been replicated in cats. In most cases, you will not need to use phosphorus binders if you are using a prescription diet.

 

According to Plumb's Veterinary Drug Handbook, phosphorus binders should be given two hours apart from Baytril, an antibiotic. It's probably wise to keep binders away from antibiotics generally, particularly those in the same family as Baytril (this includes Zeniquin).

 

Plumb's Veterinary Drug Handbook also advises giving phosphorus binders two hours apart from famotidine (Pepcid AC), which is used to treat excess stomach acid, because it may interfere with the absorption of the treatment, which would make it less effective. However, RX Med states that "concomitant use of aluminum hydroxide/magnesium hydroxide at commonly used doses, does not influence the pharmacodynamics or bioavailability of Pepcid AC."

 

Dr Larry Nagode of Ohio State University has stated that phosphorus binders should be separated from ACE inhibitors such as benazepril (Fortekor) because they may interfere with the absorption of the treatment, which would make it less effective.

 

I would try to err on the side of caution and still separate famotidine from phosphorus binders and ACE inhibitors if you can, but if this is difficult for you, e.g. because of work commitments, just do the best you can.

 

Phosphorus binders should ideally be given separately from iron, because the binders may reduce the absorption of the iron.

 

Medline Plus mentions that vitamin C may interact adversely with products containing aluminium, such as phosphorus binders. Cats do not need Vitamin C supplements anyway, they can manufacture all the Vitamin C they need themselves.

 

I don't know if slippery elm bark would interfere with phosphorus binders, as far as I know this has never been studied, but it might be possible in theory. However, if you are adding Slippery Elm Bark to food once or twice a day, I would still mix binders in with that food in the hope that at least some of the phosphorus would be bound.

 

Aluminium Toxicity


You may have read that there is a risk of aluminium toxicity from the aluminium in aluminium hydroxide medications. This applies in particular to human patients on dialysis, because aluminium is used in the dialysis process. Do oral aluminium phosphate binders cause accumulation of aluminium to toxic levels? (2011) Pepper R, Campbell N, Yaqoob MM, Roberts NB & Fan SLS BMC Nephrology 12 found that even patients on dialysis did not develop aluminium toxicity if changes were made to the dialysis process (during which patients may be exposed to dialysate water which is contaminated with aluminium), but the patients in this study were on relatively low doses of aluminium hydroxide.

 

Since cats are not on dialysis, aluminium toxicity was not thought to be a concern for cats (or dogs), especially since even in humans it takes years before it becomes a problem, and cats and dogs don't live as long as humans. Recently, however, there has been increasing concern about the possible risk of aluminium toxicity in cats using aluminium hydroxide based binders. This is partly because of a study which reported on aluminium toxicity in two dogs on binders, Aluminum toxicity following administration of aluminum-based phosphate binders in 2 dogs with renal failure (2008) Segev G, Bandt C, Francey T & Cowgill LD Journal of Veterinary Internal Medicine 22(6) pp1432-5. There is no abstract available for this study, but Treatment options for hyperphosphataemia in feline CKD: what's out there? (2009) Kidder AC & Chew D Journal of Feline Medicine & Surgery 11(11) pp813-24 reported that the two dogs in question developed "probable aluminum toxicity" after being on binders for only 62 and 65 days. The symptoms seen were "severe neuromuscular abnormalities." The dogs were on dosages of 125mg/kg per day (or 56mg per lb body weight) and 200 mg/kg (or 91mg per lb bodyweight) per day, which are not particularly high doses. However, both these dogs had been on dialysis, though apparently the dialysate water was not contaminated with aluminium.

 

Partly because of this study, vets are becoming increasingly aware of the need for caution and awareness when using aluminium hydroxide binders in cats too, particularly when using large doses.

 

Physical symptoms to watch for include neurological problems, such as stumbling and an awkward gait (although, just to complicate matters, these can actually be signs of uncontrolled phosphorus levels too, see above). One possible 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 potassium citrate (perhaps to treat metabolic acidosis), give this at least two hours apart from phosphorus binders. This is because, as Drugs explains, products containing citrate can in theory increase the absorption of aluminium, which could increase the risk of aluminium toxicity. Many prescription diets contain potassium citrate, but apparently these findings have not been replicated in cats. In most cases, you will not need to use phosphorus binders if you are using a prescription diet.

 

Try not to worry too much. I am only aware of one case in cats to date (this cat was given massive doses of aluminium hydroxide, more than twice as much as she would normally be given based on the table above), and most cases in dogs have occurred in dogs taking over 200 mg/kg. In Updates in feline chronic kidney disease (2008) Dr CL Langston states "Excessive absorption of aluminum can lead to toxicity, including anemia and neurologic symptoms, but this seems uncommon in veterinary practice." In contrast, the dangers of elevated phosphorus control are very real, and very common, and controlling phosphorus is essential for your cat's wellbeing.

 

If your cat has phosphorus levels that require large amounts of aluminium hydroxide, or if you cannot control your cat's phosphorus levels with aluminium hydroxide only, consider adding another phosphorus binder. Most people in this situation use lanthanum carbonate (Renalzin or Fosrenol)See below for suggestions on dosage.

 

If you think your cat may have aluminium toxicity, I would ask for a referral to a vet school or a neurologist if possible. Chelation therapy plus dialysis helped to remove the aluminium from dogs with aluminium toxicity, and indeed following treatment the neurological problems experienced by the dogs in the above study were successfully reversed.

Other Concerns


It does not matter if your non-CKD cats occasionally (say once a week) eat some of your CKD cat's food containing phosphorus binders. However, please make sure that most of the food they eat does not contain binders. This is particularly important for kittens, who need twice as much phosphorus each day as a healthy cat because they are still growing.

 

If you buy aluminium hydroxide gel or powder in the USA, you may see a warning about arsenic which bizarrely supposedly only applies to people living in California. This is to comply with that state's legal requirements. The fact of the matter is that aluminium hydroxide is a naturally occurring product which is mined, and therefore it contains a naturally occurring tiny amount of arsenic of no more than 8 parts per million. This is no more than you might find in soil or in vegetables grown in soil. However, if you want to be on the safe side, you might wish to avoid inhaling the powder.

 

If you buy aluminium hydroxide, you may see an expiration date on it. This is usually to comply with pharmacy laws, but in practice, since aluminium hydroxide is a mineral that is mined from the earth, it cannot really expire, so if you are using a gel or powder form of aluminium hydroxide, I would not worry too much about expiry dates. However, if you are using a suspension of some kind, it may expire because of other ingredients in the mix.


Calcium-Based Binders                                                                                         Back to Page Index


Sometimes your vet will recommend using a calcium-based antacid such as Tums or PhosLo as a phosphorus binder. These are not an ideal choice because:

  • these binders are not as effective as binders containing aluminium hydroxide;

  • they may make your cat's calcium levels rise too high (hypercalcaemia).

 

Hypercalcaemia in cats (2001), a paper by Dr Chew presented to the World Small Animal Veterinary Association World Congress 2001 mentions that using calcium-based binders may cause hypercalcaemia. Thus, if you are using a calcium-based binder, frequent monitoring of blood calcium levels is essential. You should not use a calcium-based binder if your cat is taking calcitriol.

Effects of phosphorus binders in moderate CKD (2012) Block GA, Wheeler DC, Persky MS, Kestenbaum B, Ketteler M, Spiegel DM, Allison MA, Asplin J, Smits G, Hoofnagle AN, Kooienga L, Thadhani R, Mannstadt M, Wolf M & Chertow GM Journal of the American Society of Nephrology 23(8) pp1407-15 found that binders containing calcium acetate, lanthanum carbonate or sevelamer carbonate did reduce phosphorus levels but also caused calcium build up in blood vessels, which can lead to heart problems.

 

Calcium Acetate


The calcium acetates (e.g. PhosLo) bind about three times as much phosphorus as calcium carbonate (e.g. Tums). On the other hand, they are more likely to cause hypercalcaemia.

 

Calcium Carbonate


The risk of hypercalcaemia is lower with calcium carbonate based binders such as Tums, though it still exists. However, in some cases it may be worth considering using a calcium carbonate based binder called Ipakitine (Epakitin in the USA).

 

Ipakitine/Epakitin


Ipakitine (known as Epakitin in the USA) is a combination of a calcium carbonate based phosphorus binder and an oral adsorbent called chitosan. Adsorbents are products that bind with something else, and adsorbents used in the treatment of CKD usually bind with toxins, thus improving wellbeing. Phosphorus binders are an obvious example of an oral adsorbent, but Ipakitine contains another type of adsorbent too, chitosan, which is said to help with uraemic toxins. There is more information about Ipakitine, including its adsorbent properties, on the Treatments page.

 

In the marketing literature, emphasis seems to be placed on Ipakitine's role as a phosphorus binder, but many vets seem to sell it to clients whose cats do not have elevated phosphorus levels, so they are presumably advocating it for its chitosan-related effects. It is only supposed to be given for six months, but I have heard of cats who have been on it for longer with no obvious problems.

 

My own vet in the UK has seen falls in creatinine and BUN (urea) in some cats when using Ipakitine and no other treatments. I did use it myself for Ollie, who did not have very high phosphorus levels, nor were his calcium levels elevated.

 

Ipakitine contains quite a high percentage of lactose, so I would not use it if your cat is lactose intolerant.

 

For a cat with higher phosphorus levels (over 2.25 international, 7 USA), I personally would opt to use an aluminium hydroxide binder instead of Ipakitine. Even for cats with lower phosphorus levels, if the cat's phosphorus multiplied by total calcium is higher than 70 in US values or 5 in international values, the cat is at risk of tissue calcification (see secondary hyperparathyroidism). In such a case, again I would opt for using an aluminium hydroxide binder in order to get the phosphorus levels under control as quickly as possible.

 

Effects of an intestinal phosphorus binder on serum phosphorus and parathyroid hormone concentration in cats with reduced renal function (2008) Brown SA, Rickertson M & Sheldon S International Journal of Applied Research in Veterinary Medicine 6(3) pp155-160 reports on a small randomised placebo-controlled study (partly funded by the manufacturers) of twelve cats without naturally occurring renal failure, which indicated that Epakitin appeared to reduce phosphorus levels in the cats, who were fed a commercial (non-prescription) diet and who were in IRIS Stages 1 and 2.

 

See below for stockists.

 

Renal (by Candioli)


Renal, made by Candioli Pharma in Italy, is a similar product to Ipakitine. It is commonly offered to people in Italy, and also those in Canada, where it is marketed by Aventix Animal Health. Like Ipakitine, it contains calcium carbonate and chitosan, but also contains potassium citrate. Since not every CKD cat needs additional potassium, I think I would give this product a miss.

 


Other Types of Binder                                                                                          Back to Page Index


Lanthanum Carbonate


New binders are coming on the market in which the active ingredient is lanthanum carbonate. This is supposed to bind more effectively with phosphorus than either aluminium or calcium, and is tasteless. Some people are using lanthanum carbonate-based binders in addition to aluminium hydroxide when they cannot control phosphorus levels with aluminium hydroxide alone.

 

See below for dosing if using lanthanum carbonate in addition to aluminium hydroxide because you cannot control phosphorus levels with aluminium hydroxide alone, or if you would prefer not to use really high amounts of aluminium hydroxide.

 

Effects of phosphorus binders in moderate CKD (2012) Block GA, Wheeler DC, Persky MS, Kestenbaum B, Ketteler M, Spiegel DM, Allison MA, Asplin J, Smits G, Hoofnagle AN, Kooienga L, Thadhani R, Mannstadt M, Wolf M & Chertow GM Journal of the American Society of Nephrology 23(8) pp1407-15 found that binders containing calcium acetate, lanthanum carbonate or sevelamer carbonate did reduce phosphorus levels but also caused calcium build up in blood vessels, which can lead to heart problems.

 

Renalzin


In October 2008 a binder containing lanthanum carbonate known as Renalzin was released in Europe for the feline market. Initially it was only available in UK, Germany, Austria and Benelux, but it is now also available in a number of other countries.

 

Renalzin contains Vitamin E and kaolin as well as lanthanum carbonate. The vitamin E is intended to act as an antioxidant, and the kaolin as a "toxin binder", by which I think they mean an oral adsorbent. Kaolin (which is often used to treat diarrhoea) can be constipating, so it seems an unusual choice of ingredient, but I suspect Bayer are jumping on the Ipakitine/Epakitin bandwagon here by wanting to add an oral adsorbent.

 

Renalzin also contains the preservative Methyl 4-hydroxybenzoate (E218). According to the UK Food Guide, this additive is banned in Australia and France. A German site, the Lebensmittel-Lexikon (Food Lexicon), says that it has a high allergic potential and may cause asthma attacks.

Renalzin is produced in pump form and one dose provides 1 ml, which contains 200mg of lanthanum carbonate. It can be sprayed directly onto food, and makes canned food quite creamy. Renalzin is supposed to be odourless and tasteless but one user in Germany has reported that it tasted slightly bitter and mouldy to her.

 

Bayer recommend that two pumps (2ml) a day are used, giving a total dose of 400mg of lanthanum carbonate each day. This compares with the recommended human starting dose for Fosrenol (which also contains lanthanum carbonate) of 750-1500mg a day, so the recommended feline dose seems relatively high. However, veterinary sources have stated that lanthanum carbonate can be dosed in the same way as aluminium hydroxide, in which case 400mg is within normal levels. The product on sale in Germany says that two pumps (2ml) a day should be mixed with dry food or three pumps (3ml) a day with tinned food. I have no idea what you are supposed to do if you are feeding both dry and tinned, perhaps average it out.

 

It is not essential to give Renalzin only twice a day, the total daily dose can be calculated and spread over all meals if required. Phosphorus levels should be checked after 2-4 weeks and the dose adjusted as required. Like Ipakitine/Epakitin, Renalzin is supposed to be given for up to six months only, but most CKD cats have an ongoing requirement for phosphorus control.

 

Renalzin is not absorbed into the digestive tract like aluminium hydroxide-based binders, and therefore should have fewer possible interactions with other treatments. The most common side effects for humans taking lanthanum carbonate are nausea, vomiting and diarrhoea, and I have also heard of CKD cats who developed nausea and vomiting whilst taking Renalzin. The manufacturer confirmed to one person's vet that these were possible side effects.

 

Some people are using Renalzin in addition to aluminium hydroxide when they cannot control phosphorus levels with aluminium hydroxide alone, or if they would prefer not to use really high amounts of aluminium hydroxide. See below for dosing if using Renalzin in this way.

 

See below for stockists.

 

Renalzin is the UK website for Renalzin.

Renalzin: the new innovation for CRF is a video presentation from Bayer about Renalzin.

Safety and efficacy of Lantharenol (Lanthanum carbonate  octahydrate) as a feed additive for cats according to Regulation (EC)  No 1831/2003 is a European Food Safety Authority report on the basis on which Renalzin was approved. This refers to a number of supporting studies but the majority of these have not been published yet.

 

Fosrenol


Although Renalzin is not currently available in the USA, a human version of lanthanum carbonate called Fosrenol has been available in the USA since 2005 which is gradually being used in cats. A prescription is required. Fosrenol comes in the form of extremely expensive tablets which are supposed to be chewed, but in order to use them for cats, most people crush the tablets.

 

Fosrenol dosing is the same as for aluminium hydroxide. So, for example, if you are giving 300mg of aluminium hydroxide a day but want to switch to Fosrenol, you would still need to give 300mg per day.

 

The most common side effects for humans taking lanthanum carbonate are nausea, vomiting and diarrhoea. In September 2011 an Important Drug Warning was issued warning of a risk of faecal impaction when using Fosrenol. The warning advises caution for patients who are constipated, diabetic or using a calcium channel blocker (such as amlodipine, used to treat high blood pressure in CKD cats).

 

See below for stockists.

 

Fosrenol - the manufacturer's (Shire's) website.

Eurek Alert has a press release regarding the approval process for Fosrenol in the USA.

 

Renaltan


Renaltan is a liquid lanthanum carbonate-based phosphorus binder made by Recoactiv (RecoVet) in Germany. 10ml contain 500mg of lanthanum carbonate, together with some B vitamins, essential fatty acids and minerals.

 

The manufacturer claims that this product stimulates the appetite and increases food intake, which I presume is because of the B vitamins. It also claims that by using this product, you can avoid using prescription food in IRIS Stages 1 and 2 because you are controlling phosphorus levels but leaving protein levels untouched. Whilst it is true that it is not necessarily a good idea to reduce protein levels in IRIS Stages 1 and 2 (see Nutritional Requirements), prescription foods do have other attributes (see Which Foods to Feed for information on when and why to use prescription food).

 

I have heard from a few German users who seem to like Renaltan. It is available from the manufacturer's own website (first link above), from Tiernaturprodukte or from Amazon Germany.

 

Using Lanthanum-Based Binders in Addition to Aluminium Hydroxide


If you are having trouble getting phosphorus under control using aluminium hydroxide alone, you can use Fosrenol in addition to the aluminium hydroxide. In such cases, a suitable starting dose might be 50-100mg per kg of cat per day, which equates to 25-50 mg per lb of cat per day. You can go up to 200mg per kg of cat per day (just under 100mg per lb of cat per day) if necessary, but obviously work with your vet on determining the most appropriate dosage for your cat.

 

Renalan


Renalan is another lanthanum-based phosphorus binder which is currently undergoing testing on cats. It is not yet commercially available.

Form 10-K (2007) of Altair Nanotechnologies Inc has information on the testing of Renalan (pages 16-18), and states that the process to seek regulatory approval was to begin in 2008.

 

Sevelamer Hydrochloride: Renagel and Renvela


Renagel (sevelamer hydrochloride) is a relatively new phosphorus binder approved for use in humans, with not much history of use in cats. One possible problem is interference with blood clotting, so it may be necessary also to give your cat Vitamin K. It is also very expensive, but may be worth considering if you cannot use the other types of binders for some reason. Doctor's Guide has information on the approval of Renagel for use in the USA.

 

Renvela (sevelamer carbonate) is the next generation version of Renagel which contains a carbonate buffer. It is intended to help with bicarbonate levels, but in some cases it might actually worsen metabolic acidosis.

 

Effects of phosphorus binders in moderate CKD (2012) Block GA, Wheeler DC, Persky MS, Kestenbaum B, Ketteler M, Spiegel DM, Allison MA, Asplin J, Smits G, Hoofnagle AN, Kooienga L, Thadhani R, Mannstadt M, Wolf M & Chertow GM Journal of the American Society of Nephrology 23(8) pp1407-15 found that binders containing calcium acetate, lanthanum carbonate or sevelamer carbonate did reduce phosphorus levels but also caused calcium build up in blood vessels, which can lead to heart problems.

 


Where to Buy Phosphorus Binders                                                                   Back to Page Index


Please read above about which binder to use and why.

 

If you buy aluminium hydroxide, you may see an expiration date on it. This is usually to comply with pharmacy laws, but in practice, since aluminium hydroxide is a mineral that is mined from the earth, it cannot really expire, so I would not worry too much about expiry dates.

 

Sources - USA


If you buy your binders from your vet, you will often be offered AlternaGel, but this is peppermint flavoured, which most cats hateAlternaGel also contains potassium citrate.

 

Another product which vets sometimes stock, Amphojel, comes in both unflavoured and peppermint flavoured version, so check before you buy that you will be getting the unflavoured one; most vets only seem to stock the peppermint-flavoured version.

 

Most people on Tanya's CKD Support Group use the loose aluminium hydroxide in gel or powder form. This used to be available from a number of online pharmacies, but the only one which definitely still sells it these days is Thriving Pets, though some local compounding pharmacies may be able to order it for you. The loose aluminium hydroxide gel or powder is odourless and tasteless, so is much easier to give than the other formulations in most cases. There are three main generic brands available, Spectrum, Gallipot and PCCA. You may be told that a prescription is required, but this is not correct, the gel and powder formulations are over the counter products. It may take a local pharmacy a few days to obtain it for you; it is fine to wait that long.

 

Aluminium Hydroxide USA


  • Thriving Pets in the USA sells 500g (1.1 lbs) of aluminium hydroxide dry gel for US$39.95 plus shipping. They also sell 1 oz at a time (which costs about US$7 including shipping within the USA), as well as capsule or liquid (oral) formulations (these require a prescription, which the gel formulation does  not) . If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55. Shipping is free for orders over US$55 after the discount.

Fosrenol and Renalzin USA


  • Thriving Pets sells nine Fosrenol 500mg tablets for US$79.95 or ten 1000mg tablets for US$89.95. A prescription is required.

    If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55. Shipping is free for orders over US$55 after the discount.

  • Best Pet Pharmacy in the UK sells Renalzin for £9.35 for 50ml or £24.98 for 150ml. This pharmacy shipped products to me in the USA with no problems.

Epakitin USA


  • Entirely Pets sells Epakitin for US$16.49 (50g), US$43.99 (150g) or US$68.99 (300g).

  • Medi-Vet sells Epakitin for US$22.82 (50g), US$54.99 (150g) or US$76.16 (300g).

Sources - UK


 

Aluminium Hydroxide UK


  • Alucaps are an odourless and flavourless phosphorus binder made by 3M. Members of Tanya's CKD Support Group in the UK have successfully obtained Alucaps from Boots, Lloyds and Superdrug during 2013. In May 2013 they cost from £5-10 for 120 capsules of 475mg aluminium hydroxide from many branches of Boots and other chemists, but since then many people have been asked to pay as much as £16-20. Don't say they are for a cat, or they may ask for a prescription from your vet, whereas if you buy them for your own indigestion, they are over the counter. When I asked for Alucaps in Boots, the pharmacist had never heard of them, but - unbeknownst to her - she did actually have some in stock; so you may need to be persistent or ask for them to be ordered for you. If they need to be ordered, they should only take a couple of days to arrive, and it is fine to wait that long

  • Clear Chemist sells Alu-caps online at £16 for 120. As far as I can see, they do not require a prescription.

  • Lloyds Pharmacy sell Alucaps online for 9p per capsule (so 120 capsules cost £10.80) plus £3.95 delivery, though for some reason they require a prescription if bought this way.

  • Thriving Pets in the USA sells 500g (1.1 lbs) of aluminium hydroxide dry gel  for US$43, and will ship to the UK and elsewhere. They also sell 1 oz at a time, as well as capsule or oral forms. Contact them to obtain a quote for shipping & handling costs. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Renalzin UK


  • Vet UK sells Renalzin for £8.92 for 50g or £18.95 for 150g.

Ipakitine UK


  • Vetscriptions sells Ipakitine for £9.99 for 50g or £23.69 for 150g.

Sources - Canada


 

Aluminium Hydroxide Canada


  • Pet Pharm sells an aluminium hydroxide based binder called Basaljel made by Axcan Pharma Inc. It comes in gelcaps, each containing 500 mg of aluminium hydroxide, and they cost CAN$26.95 for 100. Basaljel is also available over the counter in many Canadian pharmacies.

  • Xenex Laboratories in Canada sells 500g of aluminium hydroxide, you can contact them to check the current price, but for reference in June 2011 one member of Tanya's CKD Support Group paid CAN$66 plus CAN$20 shipping, whilst another paid a total of CAN$78 including shipping (she lived closer).

  • Canada Drugs sell a liquid aluminium hydroxide product called Alugel for CAN$17.65, but unfortunately this is mint-flavoured, which does not appeal to many cats.

  • Thriving Pets in the USA sells 500g (1.1 lbs) of aluminium hydroxide dry gel  for US$43, and will ship to Canada. They also sell 1 oz at a time, as well as capsule or oral forms. Contact them to obtain a quote for shipping & handling costs. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Fosrenol/Renalzin Canada


  • Thriving Pets sells nine Fosrenol 500mg tablets for US$45 or ten 1000mg tablets for US$89.95. A prescription is required. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

  • Best Pet Pharmacy in the UK sells Renalzin for £9.35 for 50ml or £24.98 for 150ml. This pharmacy shipped products to me in the USA with no problems.

Sources - Australia and New Zealand


Alu-Tabs, made by iNova Phamaceuticals, are probably your best bet. They come in 600mg tablets rather than a powder, but I imagine you could crush them. They should be available over the counter in pharmacies, though your pharmacist may not realise they are there. Don't say they are for a cat, or they may ask for a prescription from your vet, whereas if you buy them for your own indigestion, they are over the counter.

 

Home Pharmacy sells 100 Alu-Tabs for AUS$33.99 (I do not know anybody who has used this pharmacy as yet).

 

 

 

 

 

Back to Page Index

This page last updated: 30 November 2013

Links on this page last checked: 19 April 2012

   

 

*****

 

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.

 

*****

Copyright © Tanya's Feline CKD Website 2000-2012. All rights reserved.

 

This site was created using Microsoft software, and therefore it is best viewed in Internet Explorer. I know it doesn't always display too well in other browsers, but I'm not an IT expert so I'm afraid I don't know how to change that. I would love it to display perfectly everywhere, but my focus is on making the information available. When I get time, I'll try to improve how it displays in other browsers.

 

You may print out one copy of each section of this site for your own information and/or one copy to give to your vet, but this site may not otherwise be reproduced or reprinted, on the internet or elsewhere, without the permission of the site owner, who can be contacted via the Contact Me page.

 

This site is a labour of love, from which I do not make a penny. Please do not steal from me by taking credit for my work.

If you wish to link to this site, please feel free to do so. Please make it clear that this is a link and not your own work. I would appreciate being informed of your link.

 

The group is hosted on yahoo!groups, part of yahoo. It has its own address separate from Tanya's website. You can either click here or copy and paste this link into your browser:

 

http://pets.groups.yahoo.com/group/tanyas-ckd-support/

 

If you are already familiar with yahoo!groups, just click on the link and apply to join (and don't forget to complete the short questionnaire you'll be sent), but if you'd like to know more about how the group works, read on.

 

I own and run the group, but I am ably assisted by two moderators, Anne V and Anne A. They help with membership queries, approve messages, and do lots of boring admin stuff behind the scenes to help the group run smoothly for the members.

 

The group has various sections, including a photos section and a realtime chat function but for most people the most important part of the group is its message section. Basically, a member who wants support, vet recommendations, or to hear how others are coping with a particular problem, sends a message to the rest of the group. Other members then respond if they can. All messages sent to the group are stored in a message archive which members can search if they wish.

 

The group is private, i.e. messages sent to it are only visible to members, so people are not posting to the internet at large. The names of group members are also private, so nobody will know you are a member unless you choose to send messages to the group.

 


Joining the Group                                                                                                                        Back to Page Index


 

There are two ways to join the group, via the group's website or via e-mail:

 

How to Join the Group via E-mail


Just send an e-mail to

tanyas-ckd-support-subscribe@yahoogroups.com

You should then receive an e-mail in response asking you to confirm that you definitely want to join the group. Just click Reply and send.

 

If you join the group via e-mail, you will be able to send and receive e-mails to the group, but you will not be able to access the group website and read the message archives or look at the photos. If you wish to do that, you will need to set up a yahoo! ID by visiting the group website.

 

How to Join the Group via the Web


You can visit the group's homepage and follow the instructions. If you do this, yahoo!groups will help you set up your yahoo! ID, which gives you access to the group message archive etc. A yahoo! ID is not the same thing as an e-mail address.

 

Here are the steps to follow. Don't worry, this all sounds far worse than it is! You should find that in practice it all works more smoothly than it sounds when you're trying to explain it in writing:

 

Existing yahoo! ID

  1. Go to the group website: http://pets.groups.yahoo.com/group/tanyas-ckd-support/

  2. Click on the Join this Group button and you'll be taken to a Sign In to Yahoo! page.

  3. Sign in and link Tanya's Support Group to your existing account.

  4. Choose the e-mail address you wish to use for the group (see below).

  5. There is a little box for you to tell me why you would like to join the group. You don't need to be inventive or fancy, it's not a competition, it's just an extra check by yahoo!groups to keep spammers out.

  6. Choose your message delivery options (see below).

  7. Scroll down and click on the blue Join button at the bottom right of the page.

New yahoo! ID

  1. Go to the group website: http://pets.groups.yahoo.com/group/tanyas-ckd-support/

  2. Click on the Join this Group button and you'll be taken to a Sign In to Yahoo! page.

  3. Scroll down a little and click on the Create New Account button.

  4. On the next page you can create your new account. Some people are somewhat inventive in their responses, but in such cases it is important to remember what responses have been given in case the information is needed later to access the account. I can't see any of this stuff, it's entirely private between you and yahoo!groups, so I cannot help in case of later queries. 

  5. Once the account is successfully set up, you'll be taken to a Congratulations! page.

  6. Before you click on the Continue button on the Congratulations! page, untick the box that makes yahoo! your homepage (unless that is what you want).

  7. Also click on the Edit Marketing Preferences link below the Continue button. This takes you to another page where they helpfully opt you in to everything, so go through and set it as you wish.

  8. Then on the same separate page click on Account Info at the top of the page. You will be asked for your password again and taken to the Account Info page. Click on Profile and opt out of the various choices as you wish. The key thing is, you do have choices here, you can make things as public or private as you wish.

  9. Now click on the Continue button on the original page. You will be taken back to the group page to choose your membership settings.

  10. Choose the e-mail address you wish to use for the group (see below).

  11. There is a little box for you to tell me why you would like to join the group. You don't need to be inventive or fancy, it's not a competition, it's just an extra check by yahoo!groups to keep spammers out.

  12. Choose your message delivery options (see below).

  13. Scroll down and click on the blue Join button at the bottom right of the page.


Membership Settings                                                                                          Back to Page Index


 

There are various choices you need to make regarding your membership of the group. The most important are which e-mail address to use, and which way you read messages sent to the group by group members.

 

Membership Settings: Your E-mail Address


You need to decide which e-mail address you wish to use for the group. If you have created a yahoo! ID, yahoo!groups will normally have also set up a free yahoo! e-mail account for you based on your new yahoo ID. You can use this e-mail address to access the group if you wish, but it's not essential, you can use any e-mail address you wish. Since yahoo! is now scanning messages for advertising purposes (similar to gmail), I would recommend not using yahoo! e-mail if possible (though it would probably be better than using your work address for private stuff).

 

If you do not want to use your free yahoo! e-mail address, click on Add e-mail address to add a different one. Be aware, if you don't add a new address here, yahoo! will use the yahoo! e-mail address as a default address. So if you don't receive the membership questionnaire, it may well be because it's gone to your new yahoo! e-mail address.

 

If you ever wish to change the e-mail address you are using for the group, you can do that here:

http://pets.groups.yahoo.com/group/tanyas-ckd-support/join

 

Membership Settings: Message Delivery


This sets up how you will access messages that are sent to the group.

 

This is a pretty active group. If you're looking after your CKD cat, you want support but you probably don't want a full inbox all the time. To help you manage this issue, you have three options for messages, and you can switch between them all as you wish:

  1. Individual E-mails

  2. Daily Digest

  3. Web Only (No e-mail)

Individual E-mails


This is the default setting. If you apply to join the group via e-mail, you will end up with this setting. If you apply to join the group via the group's webpage, if you don't choose one of the other settings, this is the one you will end up with.

 

This setting means that as soon as somebody sends a message to the group, it is sent directly to your inbox. It's a good choice if you might want to know immediately if somebody has responded to you, or if you would like to store some of the group messages for your reference. It's also good for being able to quickly delete messages which don't interest you.

 

The downside is that this is a busy group, averaging 50-100 group messages each day, so your inbox can quickly get full. One solution is to create a folder to use for group messages. All messages sent to the group have a tag in the subject line [tanya-crf] so you can filter all messages from the group to a new folder using this tag if you wish.

 

With both individual e-mail and message digest options, you can also choose the format of messages sent to you (Display Format), either Fully Featured (html, pretty colours etc.) or Traditional (plain text).

 

Message Digest


This means that you receive e-mails from the group, but yahoo!groups waits until there are about 25 messages available and sends them to you all in one go. With this option, you would therefore only receive 2-4 e-mails a day from the group, but it means you have to wait for responses (though you can still check on the group website for messages) and it can be more difficult to find what you are looking for within each digest.

 

With both individual e-mail and message digest options, you can also choose the format of messages sent to you (Display Format), either Fully Featured (html, pretty colours etc.) or Traditional (plain text).

 

Web Only (No Mail)


This means that you receive no messages at all from the group. This is a wise choice if you are using a work e-mail address, or if you cannot cope with the group's message volume. With this system you simply go to the group's website and read the messages that interest you there. Even if this is not your usual choice, it can be helpful to use this option if you are going on holiday.

 

So make your choices, then click the Join button at the bottom right of the page.

 


Important: Membership Questionnaire                                                           Back to Page Index


OK, so you've successfully applied to join the group. However, there is one more thing you need to do in order to join. I want to protect the group members from spammers, so whichever way you apply to join the group, you will receive a short questionnaire asking:

  1. Your first name

  2. The country where you live

  3. Your CKD cat's name and age

You need to respond to this before your membership will be approved.

 

Please don't worry about saying "the right thing." This is not a test to see if you are "good enough" for the group, everybody is welcome here, whoever they are or wherever they come from, as long as they want to help their cat. This questionnaire is basically just to reassure us that you are a real person applying to join rather than somebody trying to sell stuff and spam the group, but it also enables us to tailor our responses to your group messages e.g. if we moderators know where you live, we will not suggest treatments not available there.

 

Please note, only the two Annes and I can see your responses to these questions. The group will not know anything about you unless you choose to introduce yourself.

 

Once you respond to the questionnaire, your membership application should be approved very quickly (most people are approved within two hours or less).

 

Occasionally the questionnaire goes missing. You think we haven't sent it, and we think you haven't responded! If we haven't heard from you five days after you apply to join, we will send you a reminder. Unfortunately, we can only use the address you've used to sign up for the group, so if you've accidentally used your new yahoo e-mail address without realising it (see above), you won't see either the questionnaire or our reminder. If you don't hear from us, please simply write to us at tanyas-ckd-support-owner@yahoogroups.com and let us know. Please respond to the three questions in your response and we will either approve you (if your membership is pending) or send you a personal invitation to join the group (if your membership application has disappeared into a black hole).

 


Messages                                                                                                                                          Back to Page Index


 

Message Options: Sending Messages


You don't have to post, you can just lurk if you prefer.

 

If you wish to change the name that appears on messages you send to the group, Yahoo! explains how you can do that.

 

Starting a Thread


  1. You can simply send an e-mail to ask your question by sending it to tanyas-ckd-support@yahoogroups.com.

  2. You can go to the group website, click on Post Message in the sidebar on the left, and then write your message there.

Replying to an Existing Message


Messages sent in response to another message on the group also go directly to the group, not to the individual to whom you are replying. Therefore if you wish to respond to a message somebody else has sent, you can simply click reply on your e-mail programme. If you reply via the group website, you can click on the message in the group archives, then click reply which is top left above the message.

 

If you're changing the subject, or replying to a Digest (which have the subject line of Digest No. xxx), please change the subject line appropriately to something more meaningful. And please remove everything except that to which you are replying.

 

If you wish to reply privately to somebody, you will need to press reply, then delete the group e-mail address and paste their personal e-mail address into the To: line if you are using e-mail. If you are replying via the group website, you will see a little envelope over on the right under the person's name. If you click on that, your message will go to that person.

 

Message Content


You are welcome to discuss anything relating to care of your CKD cat. We do have a few guidelines we ask people to follow though:

  1. Please do not refer to vets or vet clinics by name for legal reasons. Just say "my vet" or "Dr J".

  2. Please do not ask for money or other donations.

  3. Since this is a very busy group, we ask that condolences are sent privately to the bereaved group member. Certain other messages should also be sent privately e.g. short "me too" messages, off topic posts etc.

  4. Please trim your posts.

Moderation of Messages


When you first join the group, your messages will be moderated for a short while. This means that they will not reach the group immediately, but will first be read and approved by one of the moderators. We do this to ensure that:

  1. you are not a spammer;

  2. you are keeping to other group guidelines (e.g. not naming your vet publicly);

  3. you are trimming your messages appropriately.

If you comply with the group guidelines sent to you when you join the group, you will be taken off moderation quickly. The main reason people stay on moderation is because they do not trim their posts. So please read up on this in the group guidelines. If you get stuck, just ask for help.

 


Leaving the Group                                                                                                Back to Page Index


 

Some people decide to leave the group. Their cat may have died, or they may find the message volume is too much, or they simply decide it's not the place for them. Leaving is fine, but if you're thinking of leaving simply because you cannot cope with message volume, please consider changing your message options first, such as by going no mail. This means your inbox will not be full, but you can still reach out for support quickly when you need it.

 

If you are leaving because your cat has died, please consider joining our sister group, Tanya's Feline Loss Support:

http://pets.groups.yahoo.com/group/tanyas-feline-loss/

 


Conclusion                                                                                                            Back to Page Index


I do hope you've decided to join Tanya's CKD Support Group! It can give you support, it can give you hope. It can make you smile too - where else would people share your thrill at hearing that your constipated cat has pooped? (Believe me, when you've been dealing with CKD for a while, things like this are real triumphs which can absolutely make your day).

 

I personally read every message sent to the group. I don't respond to every post (my priority is running this website) but I do keep an eye on things and post occasionally if I can add to what has already been said.

 


Group Quick Links                                                                                               Back to Page Index


Some of these only work if you are already a member of the group.

 

Weblinks


Group homepage:                                                 http://pets.groups.yahoo.com/group/tanyas-ckd-support/

Managing your membership options:                  http://pets.groups.yahoo.com/group/tanyas-ckd-support/join

Messages archive                                                 http://pets.groups.yahoo.com/group/tanyas-ckd-support/messages

 

E-mail Addresses


Sending a message to the group via e-mail:        tanyas-ckd-support@yahoogroups.com

Group owner e-mail address:                                 tanyas-ckd-support-owner@yahoogroups.com

Joining the group via e-mail:                                   tanyas-ckd-support-subscribe@yahoogroups.com

Leaving the group via e-mail:                                  tanyas-ckd-support-unsubscribe@yahoogroups.com