TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

 
 

POTASSIUM IMBALANCES

 

ON THIS PAGE:


Why Potassium Imbalances are Important


Frequency of Potassium Imbalances


Measuring Potassium Levels


Goal for Potassium Levels in Bloodwork


LOW Potassium Levels: Causes, Symptoms and Treatments


HIGH Potassium Levels: Causes, Symptoms and Treatments


 

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Home > Key Issues > Potassium Imbalances

 


Overview


  • Potassium helps nerves and muscles, including the heart, to function, so it is important to keep levels in the body within a healthy range.

  • Potassium imbalances are common in CKD cats.

  • Low potassium levels (hypokalaemia) occur in around 30% of CKD cats. The most usual treatment is an oral potassium supplement.

  • High potassium levels (hyperkalaemia) occur in around 13% of CKD cats, who usually have more advanced CKD. These are harder to manage, but there are a few possible treatments.


Why Potassium Imbalances Are Important


 

Potassium is an electrolyte (body salt) which acts in concert with sodium within the body. It is used at cellular level, and two of its most important functions are to help muscles function smoothly, and (since the heart is a muscle), to help regulate the heart rhythm.

 

Low potassium levels are known as hypokalaemia. They can damage the kidneys and may make CKD progress more quickly. They may also contribute to the development of both metabolic acidosis and hypertension. If your cat has both low potassium levels and metabolic acidosis, it is very important to treat both conditions because, according to Dr S Ross states in Renal disease/urology (2003), "potassium depletion and metabolic acidosis may promote potentially fatal reductions in plasma taurine concentrations in cats."

 

High potassium levels are known as hyperkalaemia. They may also cause heart problems, which in the worst case could result in heart failure.

 

Therefore it is essential to monitor your cat's potassium levels regularly and to treat any imbalances which may arise. Strangely, however, many laboratories do not seem to measure potassium levels routinely. Check your cat's bloodwork (it may be shown as  potassium, pot or K+) and ask for it to be measured whenever you run routine bloodwork. If your cat has a potassium imbalance, it will need to be measured more regularly (see below) until the imbalance is resolved.

 

Cornell University College of Veterinary Medicine has some information about potassium levels.

Pet Place discusses hypokalaemia in cats.

 


Frequency of Potassium Imbalances


 

Potassium imbalances are quite common in CKD cats. In the earlier stages of CKD, potassium levels are usually too low because potassium is lost in the increased urination and vomiting commonly seen in CKD cats.  One study, Feline renal failure: questions, answers, questions (1992) Lulich JP, Osborne CA, O’Brien TD and Polzin DJ Compendium on Continuing Education for the Practising Veterinarian 14 pp127-153, estimated that approximately 30% of CKD cats have low potassium levels.

 

However, in cats whose CKD is relatively advanced (IRIS stage 4, with creatinine over 5 mg/dl US or over 440 mmol/L international), the opposite problem may occur and potassium levels may become too high. Thomas had this problem towards the end, when his creatinine was over 7 mg/dl (620 mmol/L)for about a month and he did develop extremely high potassium levels during his last few days. Occasionally hyperkalaemia is also seen in cats with less severe CKD. The study mentioned above (Lulich et al., 1992) found that around 13% of CKD cats have hyperkalaemia.

 


Measuring Potassium Levels


 

A blood test will tell your vet if your cat's potassium level is too low or too high. However, sometimes the level may look artificially high or artificially low:

  • If the sample is haemolysed (the blood cells in the sample have ruptured), the potassium level may look higher than it actually is, though occasionally it will look lower than it actually is.

  • If the sample has sat around for a while before being tested, the potassium level may look artificially high.

  • A cat with a very high white blood cell count, perhaps because of infection, may have artificially low potassium levels.

  • In a cat with metabolic acidosis, the potassium level may appear normal or high in blood tests, but may subsequently fall after the metabolic acidosis is treated.

Potassium levels may sometimes appear to be normal in blood tests when in fact there is a potassium deficiency in the body. Dr D Polzin states in Chronic kidney disease (2007) Delaware Valley Academy of Veterinary Medicine "muscle potassium content decreased in normokalemic cats with spontaneous CKD, indicating that a total-body deficit of potassium may develop well before the onset of hypokalemia." This is because, although potassium is used in the body's cells, the regulatory mechanism of the body is actually set to maintain a certain level of potassium in the blood, not the cells. Thus, when potassium levels drop, as they tend to do in early stage CKD, the cat's body will try to maintain levels of potassium in the blood by taking potassium from the cells. This means that at the intra-cellular level where the potassium is really needed, potassium levels are too low, even though the blood levels of potassium may appear to be normal.

 

There are a number of tests available for humans to test potassium at the intracellular level. One is the Exa Test, which requires a buccal sample (from the cheek inside the mouth). I only know of one person who has had potassium checked at the intracellular level, but unfortunately he cannot remember which company his vet used.

 


Goal for Potassium Level in Bloodwork


Potassium is usually measured in either mEq/l (USA) or mmol/l (international). However, in practice the numbers are the same value for potassium, e.g. 4 mEq/l is the same as 4 mmol/l.

 

Although laboratories vary, most have a range around 3.5 to 5.5. Ideally though, you want your cat's potassium level to be firmly in the middle, at around 4.4, but definitely above 4.

 

What is too low a level? Hyperaldosteronism in cats (2011) Schaer M NAVC Clinician's Brief Nov 2011 says "Serum potassium values of less than 3.0 mEq/L may have adverse effects on the skeletal and cardiac muscles", though you may certainly see symptoms before the potassium level falls that low. Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 says "a concentration of less than 2.0 mEq/L may be life threatening." Fortunately it is extremely rare for a CKD cat to have such a low potassium level.

 

What is too high a level? Ideally you do not want it to go above 6.0 according to 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats (2013) Davis H, Jensen T, Johnson A, Knowles P, Meyer R, Rucinsky R & Shafford H Journal of the American Animal Hospital Association 49(3) pp149-159, which talks about treatment when "life-threatening hyperkalemia is either suspected or present (K 6 mmol/L)." Above 6.5 is definitely a problem, considering that high potassium levels may cause seizures and even a heart attack.

 


All About Low Potassium Levels (Hypokalaemia)



Causes of Low Potassium Levels


 

Most CKD cats with potassium imbalances have low potassium levels because potassium is lost from the body via the increased urination and vomiting commonly seen in CKD. Not eating may worsen hypokalaemia because the cat is not taking in potassium that could help offset that lost via urination.

 

There are some other possible causes or risk factors, as follows:

 

Metabolic Acidosis


Cats with low potassium levels are prone to metabolic acidosis, but metabolic acidosis also increases the chances of developing low potassium levels. Chronic kidney disease (2007) Polzin D Delaware Valley Academy of Veterinary Medicine states "acidosis is a major risk factor for the development of hypokalemia."

 

Hyperthyroidism


Cats with hyperthyroidism may have low potassium levels.

 

Diabetes


Cats with diabetes may have low potassium levels.

 

Amlodipine


Another possible cause for CKD cats is amlodipine, which is commonly used for hypertension. Chronic kidney disease (2007) Polzin D Delaware Valley Academy of Veterinary Medicine says "amlodipine may promote hypokalemia in cats with chronic renal insufficiency/failure."

 

Hyperaldosteronism


Very occasionally, low potassium levels may be caused by a condition known as hyperaldosteronism. This may make the CKD progress faster, so it is important to treat it if present. It is more common in cats with hyperthyroidism.

 

Aldosterone is a hormone which regulates sodium and potassium levels in the blood. In cats with hyperaldosteronism, too much aldosterone is produced, usually because of a benign tumour on the adrenal glands (in which case it is known as Conn's disease). The excess aldosterone production means the cat develops low potassium levels and high sodium levels which eventually lead to hypertension (high blood pressure). If your cat has low potassium levels and low magnesium levels, and the potassium does not rise even after treating the low magnesium levels, ask your vet to rule out hyperaldosteronism, especially if your cat has hypertension. An ultrasound of the adrenal glands may assist with diagnosis.

 

Treatment is the same as for CKD cats with these problems, i.e. potassium supplements and medication to control the high blood pressure, though surgery to remove the affected adrenal gland is also an option in some cases, and may completely resolve the problem for some cats. Occasionally a diuretic called spironolactone is used but diuretics can be tricky for CKD cats, who are already prone to increased urination.

 

Primary hyperaldosteronism in the cat: a series of 13 cases (2005) Ash RA, Harvey AM & Tasker S Journal of Feline Medicine & Surgery 7(3) pp173-82 states that "it is recommended that primary hyperaldosteronism should be considered as a differential diagnosis in middle-aged and older cats with hypokalaemic polymyopathy and/or systemic hypertension and should no longer be considered a rare condition."

 

Best treatment for hyperaldosteronism in cats? (2011) ME Peterson Insights Into Veterinary Endocrinology discusses the pros and cons of surgery for this problem.

 

Feline hyperaldosteronism: recognition and diagnosis (2012) Bruyette DS & Bisignano J Veterinary Medicine discusses how to recognise and diagnose hyperaldosteronism.

 

Feline hyperaldosteronism: treatment and prognosis (2012) Bruyette DS & Bisignano J Veterinary Medicine discusses the treatment of hyperaldosteronism.

 

Primary hyperaldosteronism in cats - an underdiagnosed disorder (2010) Kooistra HS Presentation to the World Small Animal Veterinary Association World Congress explains more about diagnosis and treatment.

 

Hyperaldosteronism in cats (2011) Schaer M NAVC Clinician's Brief Nov 2011 pp59-61 has a good overview of hyperaldosteronism.

 

Inappetance and lethargy in a cat (2015) Little S Clinician's Brief Jan 2015 pp77-79 discusses the case of a cat with aldosteronism.

 

Hyperaldosteronism case report: reviving a senior cat's verve (2012) Bruyette DS Veterinary Medicine discusses a case of aldosteronism.

 

Less common feline endocrinopathies (2004) is a presentation by BR Jones to the World Small Animal Association World Congress 2004. Scroll to the last section for information on hyperaldosteronism.

 

Inherited Hypokalaemia


Pet Place mentions that Burmese cats may develop an inherited form of low potassium levels. This appears to occur in Burmese cats outside the USA. First WNK4-hypokalemia animal model identified by genome-wide association in Burmese cats (2012) Gandolfi B, Gruffydd-Jones TJ, Malik R, Cortes A, Jones BR, Helps CR, Prinzenberg EM, Erhardt G &  Lyons LA Public Library of Science One 7(12) e53173 found the gene which seems to cause this problem.

 

Langford Veterinary Services in the UK (owned by the University of Bristol which participated in the above research into this problem) can perform a genetic test from a mouth swab to test for this condition.

 


Symptoms of Low Potassium Levels


 

Here are the most common symptoms of low potassium levels. Rather confusingly, two of them (twitching and lethargy) may also be symptoms of high potassium levels.

 

As you can see, since potassium is important for nerve and muscle function, the symptoms seen usually affect nerves or muscles. When the muscles are severely affected, it is known as hypokalaemic polymyopathy.

Twitching, Trembling or Shaking


Low potassium levels can cause twitching, trembling or shaking. Other possible causes include high potassium levels, high blood pressure, high phosphorus levels, 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.

 

Weakness, Especially in the Back Legs


Weakness may be seen in the back legs. This is a common symptom of low potassium levels. You may also see a plantigrade posture, where the cat walks on his/her hocks instead of his/her feet, like Ollie to the left. His back half also seemed to sway when he walked. This photo was taken a  day after he came to live with us, a week before his 16th birthday.

 

Ollie saw the vet that day and since his potassium level was at the very bottom of the range (3.5 mmol/L), she started him on a potassium supplement - he had his first dose just after this photo was taken. There was improvement within 24 hours, and within 48 hours he was walking normally again.

 

A plantigrade stance can have other causes. It is most likely to occur in diabetic cats, caused by diabetic neuropathy. 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).

 

Back leg weakness and/or a plantigrade stance may also be caused by high phosphorus levels which interfere with the nerve messages that control the limbs, a condition known as peripheral neuropathy. Occasionally the cause is low magnesium or low calcium levels.

 

General weakness may be caused by anaemia, or because the cat is simply not eating enough. It is essential that cats eat, because if they do not eat, they are at risk of developing a potentially life-threatening condition called 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.

 

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.

 

Stilted Gait in the Front Legs


This is usually a sign of low potassium levels.

 

Stiff Neck or Inability to Hold Up Head (Ventroflexion)


The cat may be unable to raise his or her head properly - in most CKD cats, this is a symptom of potassium deficiency. Very occasionally, this may be a sign of vitamin B1 (thiamine) deficiency, which is sometimes seen in cats fed too much fish.

 

Long Beach Animal Hospital has a photograph of a cat with this problem - scroll down to find the photograph.

 

Stilted Gait in the Front Legs


This is usually a sign of low potassium levels.

 

Hoarseness


This can be caused by low potassium levels adversely affecting the vocal chords. Alternatively, this is sometimes a sign of excess stomach acid. If accompanied by coughing, consider the possibilities of fluid build-up and/or heart problems.

 

Trouble Breathing


This can be a sign of low potassium levels or metabolic acidosis. Other possible causes include fluid build-up, heart problems or anaemia.

 

Increased Night-time Urination


One peculiarity which you may see is nocturia, or excessive urination during the night, which may be caused by low potassium levels. Another possible cause is calcitriol. If you only give your cat sub-Qs late at night, this might also be the cause.

 

Constipation


This may be a sign of low potassium levels. It may also be caused by dehydration or high calcium levels.

 

Lethargy


This may be a sign of low or high potassium levels, anaemia or hypertension. Lethargy may sometimes be a sign of heart problems, especially if it appears after giving fluids.

 

Loss of Appetite


Low potassium levels may be a factor in a cat having a poor appetite.

 


Treating Low Potassium Levels


 

Managing fluid and electrolyte disorders in renal failure  (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 says "Because normalization of hypokalemia can improve renal function and decrease clinical signs, treatment of hypokalemia should not be overlooked."

 

When to Start Treatment


When do you need to consider treatment? In 11 guidelines for conservatively treating chronic kidney disease (2007) Polzin D, Veterinary Medicine December 2007, Dr Polzin states "Intervention to manage serum potassium concentrations is indicated in dogs and cats when the concentrations fall outside the target range of 3.5 to 5.5 mEq/L, regardless of the chronic kidney disease stage."

 

It may in fact be appropriate to treat when your cat's potassium level falls below the middle of the normal range. For most laboratories, this would mean treatment for cats whose potassium level is below 4.0 mEq/L US or 4.0 mmol/l international. The reason for this is that if it is impossible to keep potassium levels in the blood at the middle of the normal range, it must be because the cells are depleted to such an extent that they cannot release any more potassium into the blood. Since hypokalaemia may damage the kidneys and make the CKD progress more quickly, as well as contribute to the development of both metabolic acidosis and hypertension, it is wise to be proactive when faced with low potassium levels.

 

I have personal experience of this. My Ollie had a potassium level of 3.5 mmol/l at diagnosis, which was technically within range, so initially my vet felt he did not require supplementation. However, he could barely walk (see the photo above). My vet started him on a potassium supplement and within two days he could walk normally again.

Therefore I personally would want to supplement any cat with potassium below 4. It is not only I who favours treating cats whose potassium level falls below the middle of the normal range. In Chronic renal failure in the cat (2006) Sparkes A Presentation to the World Small Animal Veterinary Association World Congress, Dr Sparkes states "Potassium concentrations should be monitored regularly in cats with CKD and if they fall below 4 mmol/l, supplementation with potassium salts is recommended." Finding the right balance: medical management of renal patients (2014) Vaden SL Eukanuba Veterinary Diets Clinical Symposium, Norway says "Potassium supplementation should be considered in cats that do not maintain a serum potassium >4.0 mEq/L while consuming a renal  diet."

 

Discuss the best approach for your cat with your vet.

 

See above for your potassium goal.

 

Here are the main treatments for low potassium levels:

Diet


Therapeutic kidney diet foods contain additional potassium. For mild hypokalaemia, this may be enough to resolve the problem.

 

Fluid Therapy


Some types of sub-Q fluids also contain additional potassium, e.g. lactated ringers solution (LRS). This may be sufficient to help cats with mild hypokalaemia.

 

For cats with a severe potassium deficiency, intravenous fluids, which are given in hospital to severely dehydrated cats, may be necessary. If required, additional potassium can be added to intravenous fluids by the vet. This type of treatment can improve potassium levels quite quickly. Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 has a table indicating how much potassium should be supplemented depending upon the severity of the hypokalaemia.

 

If your cat is placed on intravenous fluids with added potassium, do not panic if the potassium level falls further when treatment is first begun. Dr Langston also states "Serum potassium concentration may decrease during initial fluid therapy despite supplementation because of extracellular fluid volume expansion, increased distal renal tubular flow, and cellular uptake."

 


Potassium Supplements


If additional treatment is necessary, a potassium supplement may also be given. These are usually given at home on an ongoing basis. They may be given orally, or as an injectable into the sub-Q fluids bag, though this can make the fluids sting. Please see above for when to start.

How to Give Potassium Supplements


Unfortunately, oral potassium supplements can make some cats vomit more - after all, potassium is a type of salt, and salt would give anyone a stomach upset if taken neat. Supplements may also cause diarrhoea in some cats.

 

The first thing to do is to try to spread the daily dose out over several meals and to mix it in with foods if possible.

 

The formulation you use can also make a difference. Most people find the powder form or crushed pills easiest to use, because the daily dose can be spread over several meals. I hear a lot of complaints about cats loathing the gel form of potassium, so I would avoid that if you can.

 

If the problem persists, consider changing the brand you are using in case that helps.

 

Alternatively, if you are giving your cat sub-Qs each day, ask your vet about using injectable potassium (which must be injected into the fluid bag, not directly into the cat), but fluids with added potassium can sting the cat.

 

Potassium Supplements Effectiveness


Giving potassium supplements when appropriate can make a real difference to your cat's wellbeing. My Ollie could barely walk when his potassium levels were low (see the photo above). My vet started him on a potassium supplement and within two days he could walk normally again.

 

The speed of Ollie's response is not uncommon because potassium supplements do usually take effect quickly. Chronic kidney disease (2007) Polzin D Delaware Valley Academy of Veterinary Medicine says "If muscle weakness is present, it usually resolves within 1 to 5 days after initiating parenteral or oral potassium supplements."

 

If your cat does not seem to be responding to potassium supplements, ask your vet to check your cat's magnesium levels. Although low magnesium levels are rare in CKD cats, you are unlikely to be able to raise potassium to an acceptable level if low magnesium levels are also present. Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 says "If hypokalemia persists after standard supplementation, hypomagnesemia may be present and magnesium supplementation may be necessary."

 

Your vet should also consider the possibility of hyperaldosteronism if your cat has persistently low levels of magnesium and potassium, especially if hypertension is also present. 

 

Monitoring


If your cat is in hospital, your vet will make regular checks on your cat's potassium level.

 

Dr D Polzin recommends in Chronic kidney disease (2007) Delaware Valley Academy of Veterinary Medicine that cats with severe symptoms (such as multiple muscle weakness) should be monitored every 24-48 hours when first beginning a supplement, and that all cats should be checked every 7-14 days until the appropriate maintenance dose is established.

 

This advice is echoed by Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697, which says "During potassium repletion on an outpatient basis, monitoring every 7 to 14 days is recommended until a stable maintenance dose is determined."

 

Potassium Supplements Interactions


ACE inhibitors such as benazepril (Fortekor) may cause potassium levels to rise; so if you are using one of these treatments, your vet should monitor potassium levels carefully and adjust the dose as appropriate.

 

Cyproheptadine is a medication often used as an appetite stimulant in CKD cats. Disposition of cyproheptadine in cats after intravenous or oral administration of a single dose (1998) Norris CR, Boothe DM, Esparza T, Gray C, Ragsdale M American Journal of Veterinary Research 59(1) pp79-81 found that when cyproheptadine is used at the same time as oral potassium citrate or oral potassium chloride in solid form, it may increase the risk of the potassium irritating the stomach. Drugs has more information on this. As far as I can tell, this does not seem to apply to potassium gluconate.

 

When Not to Use Potassium Supplements


Never administer potassium supplements without your vet's approval - an overdose of potassium can cause heart failure.

 

11 guidelines for conservatively treating chronic kidney disease (2007) Polzin D, Veterinary Medicine December 2007, Dr Polzin states "Intervention to manage serum potassium concentrations is indicated in dogs and cats when the concentrations fall outside the target range of 3.5 to 5.5 mEq/L, regardless of the chronic kidney disease stage." It is unlikely that you would need to give a potassium supplement to a cat whose potassium level is over 5.5.

 

You should not give potassium to a cat with a high creatinine level (above 6mg/dl USA or 500 mmol/L international) without the cat being monitored closely by a heart specialist. Most cats with creatinine at this level will probably have high potassium levels and would therefore not require a potassium supplement.

 

Potassium should never be given to a cat who cannot urinate.

 

Types of Potassium Supplement


There are three main types of potassium supplement:

Do not supplement potassium without your vet's knowledge and approval, because not all CKD cats have low potassium levels, and giving potassium to a cat who does not need it can be very dangerous. Potassium should never be given to a cat who cannot urinate.

 


Potassium Gluconate


 

This is the supplement most people use. It is given orally. Chronic kidney disease (2007) Polzin D Delaware Valley Academy of Veterinary Medicine says "Oral replacement is the safest and preferred route for administering potassium." Gold standard management of chronic kidney disease (2014) Caney S Eukanuba Veterinary Diets Clinical Symposium, Norway says "potassium gluconate is the preferred oral supplement as it is the least gastric irritant."

 

Drugs has some information about potassium gluconate.

Dosage


Potassium is usually measured in either mEq/l (USA) or mmol/l (international). However, in practice the numbers are the same value for potassium, i.e. 4 mEq/l is the same as 4 mmol/l, etc.

 

Chronic kidney disease (2007) Polzin D Delaware Valley Academy of Veterinary Medicine states "Depending on the size of the cat and severity of hypokalemia, potassium gluconate is given initially at a dose of 2 to 6 mEq per cat per day."

 

Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 recommends "Once oral intake is possible, potassium gluconate can be administered. A dose of 5 to 10 mEq/d divided into two to three doses is used to replenish potassium, followed by 2 to 4 mEq/d for maintenance."

 

Potassium disorders in cats: myths and facts (2009) de Morais HA Presentation to the World Small Animal Veterinary Association World Congress states "Potassium gluconate usually is recommended for oral supplementation. In cats, the initial dose is 5-8 mEq/day divided BID or TID, followed by a maintenance dose of 2-4 mEq/day."

 

Gold standard management of chronic kidney disease (2014) Caney S Eukanuba Veterinary Diets Clinical Symposium, Norway says "a dose of 1-4 mmol twice daily."

 

Taken together, then, you are looking at a range of 2-6 a day, divided over several meals, for the maintenance dose which you will give at home.

 

Most people seem to start by giving their cats 2 mEq twice a day (or 4 mEq a day in total, if they are dividing it over several meals in one day). This is actually the dose recommended for a 10 lb cat by the manufacturers of veterinary potassium supplements. This dosage seems to work well for most cats, including my Ollie, though some cats need more or less than this, and you might want to start with a lower dose if your cat is small. Be guided by your vet.

 

Dosage Calculation


It can be rather tricky calculating potassium doses because there is a difference between the form of potassium being used (in this case, potassium gluconate) and elemental potassium, which is the active amount of potassium and what dosages are based on.

 

Why don't we just give elemental potassium? Elemental potassium is chemically unstable by itself, so it has to be bound to other chemicals to stabilise it. So let's crunch a few numbers:

  • Plumb's Veterinary Drug Handbook (7th Edition) states that 1 gram (1000mg) of potassium gluconate contains approximately 168 mg of elemental potassium. In other words, potassium gluconate consists largely of the gluconate and only 16.8% of it is actually potassium.

  • The elemental weight of potassium divided by its atomic weight gives you the  meQ equivalent.

  • The atomic weight of potassium is 39.

  • So you divide the 168 mg of elemental potassium by the atomic weight of 39, and the result is 4.3 mEq.

 

As explained above, most people seem to give 2 mEq (or mmol/l) twice a day, for a total of 4 mEq a day. Let's do the calculation on that basis:

  • Multiply the 2 mEq by the atomic weight of 39

  • This gives you a total of 78 mg of elemental potassium.

  • This is only 16.8% of the total weight of potassium gluconate

  • Divide 78 by 16.8%

  • This gives a total of 465 mg of potassium gluconate

  • This amount would normally be given twice a day.

Has your brain seized up? Mine has. Fortunately veterinary products are usually formulated to provide 2 mEq per dose, but products designed for humans can also be used in cats if you are careful to check and adjust the dose as necessary (and ensure the product does not contain any additional ingredients unsuitable for cats). To make things a bit easier, I have created a table comparing some of the popular potassium gluconate supplements below.

 

Potassium Gluconate Commonly Used Brands


There are a number of brands available, some of which are available in many different countries. Most people use veterinary brands but some human brands are also suitable, as long as you check the ingredients and dosage carefully and your vet agrees. The safest thing is to check with your vet about the product and dosage you plan to use. Please read above for how to give.

Potassium Gluconate Veterinary Brands


These are the main veterinary brands:

Tumil-K


Tumil-K is a veterinary formula available in powder, caplet or gel form that is usually stocked by many vets. It is rather expensive, but is a good choice because it does not contain phosphorus. It comes in powder, caplet or gel form. Drugs has some information about it. See below for dosage.

 

I used Tumil-K for Ollie on my vet's advice and Ollie's symptoms improved within two days

 

Unfortunately, as at August 2016 Tumil-K has been out of stock worldwide for well over a year and I do not know when it will be back in stock. I am leaving stockist details below in case things change.

 

USA

Thriving Pets

sell Tumil-K in tablet, gel or powder form at prices ranging from US$24.95 - US$34.95. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.

 

KV Vet Supply

sells 100 Tumil-K tablets for US$29.95.

 

UK

Vetscriptions

in the UK sells 113g of Tumil-K powder for £32.99.

 

Chemist Direct

sells 100 Tumil-K tablets for £34.09.

 

RenaKare


RenaKare

 is another veterinary version of potassium gluconate. It is pork-flavoured and comes in tablet, powder or gel form. See below for dosage.

 

Drs Foster & Smith have a video about RenaKare.

 

USA

Drs Foster & Smith sell 30 RenaKare tablets for US$9.90.

 

Thriving Pets sells RenaKare in tablet, gel or powder form at prices ranging from US$24.95 - US$34.95. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.

 

Potassa-Chew


Potassa-Chew is a chewable form of potassium gluconate. The manufacturers claim over 60% of cats will eat this willingly as a type of treat. See below for dosage.

 

California Veterinary Supply sells 100 chews for US$6.79.

 

Renal K+, Amino B & K and Kaminox


These products contain both potassium gluconate and B vitamins, though whether the amounts of vitamin B are enough to be of any real benefit is debatable. Personally I would use separate potassium and B vitamins products, which should also work out cheaper. See below for dosage.

 

Renal K+


This product is made by Vetoquinol and comes in gel and powder versions. The ingredients in both versions can be found here but the precise composition of the products is unknown, though I am trying to work out why maple flavour (found in the gel) might be appealing to cats.

 

Thriving Pets

sells 100g of Renal K+ in powder form for US$19.95. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.

 

Thriving Pets

sells a 5 oz tube of Renal K+ for US$18.95.

 

Amino B+K


Made by Rx Vitamins for Pets, this US product has liver and bacon flavouring. It also contains a small amount of iron, which should not be given to cats with infections (see Anaemia). Drugs has some information about Amino B+K.

 

Amazon

sells 120 capsules for US$20.48

 

Kaminox


This UK product is also a combination of B vitamins, iron and potassium gluconate. Alfamedic provides a list of the ingredients. You should not give iron to a cat with an infection.

 

Vet UK

sells Kaminox for £20.64 for 120ml, with free UK shipping.

 

Vetscriptions

sells Kaminox for £21.99 for 120ml or £14.99 for 60ml. Search for Kaminox.

 

Thriving Pets sells a 200g jar of potassium gluconate powder for US$19.95. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.

 

Potassium Gluconate Human Brands


Potassium supplements for humans are widely available in pill form and occasionally in powder form in health food shops without prescription, often very cheaply (around US$6-10 for 100 pills), so many people use these with their vet's approval. The powder can be mixed with food as it is, the pills can simply be crushed first before adding to the cat's food in appropriate quantities.

 

Be very careful about the dosage if you do this, because human potassium supplements are stronger than most veterinary supplements. If you are in the USA:

  • The amount of elemental potassium in an over the counter capsule or pill in the USA cannot exceed 99mg.

  • In practice therefore most potassium gluconate tablets for humans contain around 590mg of potassium gluconate.

  • This means they contain 99mg of elemental potassium.

  • Dividing this by the atomic weight for potassium of 39 gives 2.53 mEq. 

  • this is a bit stronger than veterinary products such as Tumil-K, which contain 2 mEq of elemental potassium.

  • Thus 0.79% of a 590mg tablet contains the same amount of elemental potassium as a veterinary product.

  • Therefore to obtain 2 mEq you would in theory give three quarters of a potassium tablet made for the human market.

  • The regulations do not apply to powdered potassium, so be sure to check the strength if you buy a powdered product.

NOW


Now makes two types of potassium gluconate, pills and powder.

 

NOW powdered potassium gluconate is popular on Tanya's CKD Support Group. Be sure to check the strength of the product when you purchase it because its strength was reduced in 2015 but some retailers may still be selling the older, stronger formulation:

 

New Formulation

  • The new formulation states that half a level teaspoon contains 175 mg of elemental potassium.

  • The elemental weight of potassium divided by its atomic weight gives you the  meQ equivalent.

  • The atomic weight of potassium is 39.

  • Divide the 175 mg of elemental potassium by the atomic weight of 39, and the result is 4.49 mEq.

Old Formulation

  • The old formulation stated that half a level teaspoon contained 270 mg of elemental potassium.

  • The elemental weight of potassium divided by its atomic weight gives you the  meQ equivalent.

  • The atomic weight of potassium is 39.

  • Divide the 270 mg of elemental potassium by the atomic weight of 39, and the result is 6.92 mEq.

See below for dosage.

 

Lucky Vitamin

sells the NOW brand in powder form for US$10.16 for 1 lb with flat rate shipping. They will ship internationally.

 

Amazon

sells the NOW brand in powder form for US$27.07 for 1 lb.

 

Potassium Gluconate Dosage Table


Since it can be confusing working out how much to give, I have created this table showing how much you need to give, depending upon which potassium gluconate product you are using.

 

Most of the manufacturers of veterinary potassium gluconate products recommend giving 2 mEq twice a day to a 10lb (4.5kg) cat, so the cat receives a total of 4 mEq a day. The amount given should ideally be divided between several meals if possible, but twice a day is acceptable.

 

As per my vet's recommendation I used this dosage even for Ollie, who was very small (5.3lbs) with no problems, but Ollie's potassium level was very low (3.5) and he had severe hypokalaemic symptoms. Be guided by your vet on the optimum dosage for your cat.

 

Please read above for how to give and how to monitor.

 
Oral Potassium Gluconate Supplements
Brand Potassium Gluconate mg Elemental Potassium mEq Amount Containing 2 mEq
 
Veterinary Brands
Tumil-K 468 78 2

One capsule

Half a teaspoonful of gel

Quarter of a level teaspoon  (0.65g) of powder

 
RenaKare 468 78 2

1 tablet

Half a teaspoon of gel
 Quarter of a level teaspoon (0.65g) of powder
 
Potassa-Chew 200 34 0.87 Two and a quarter chews
 
Renal K+ 468 78 2 Half a teaspoon of gel
1 level scoop of powder
 
Amino B+K 468 78 2 2ml of the liquid
 
Kaminox 468 78 2 2ml of the liquid
 
Human Brands
NOW! Powder 525 87.5 2.25 A little under a quarter of a level teaspoon
 
NOW! Tablets 593 99 2.53 Fifth of a teaspoon

 

Most veterinary products come with a scoop or spoon to help you measure what you need. Some members of Tanya's CKD Support Group, especially those using human products, like to use mini measuring spoons, such as those mentioned here.


Potassium Citrate


 

This is the form of potassium that is commonly found in therapeutic kidney diets. This is probably because it is a good choice for cats who also have metabolic acidosis. In fact, Dr D Polzin says in Chronic kidney disease (2007) Delaware Valley Academy of Veterinary Medicine that other treatments for metabolic acidosis in cats who also have low potassium levels may only be of limited use.

 

Dr Polzin recommends Polycitra-K in syrup form. He states that a common starting dose is 40 to 60 mg per kg of cat per day (18 to 27 mg per pound of cat) divided into 2 or 3 doses.

 

Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 recommends "Potassium citrate (40–60 mg/kg/d divided into two to three doses) is an alternative to potassium gluconate that also helps to correct acidosis."

 

Therefore a 10lb (4.5kg) cat would receive 180-270 mg per day, divided into 2-3 doses.

 

Potassium citrate must be given at least two hours apart from any phosphorus binders containing aluminium, because citrate may increase the absorption of aluminium.

 

Potassium citrate is not recommended for use in cats who are prone to forming struvite crystals in the urine. However, this means it may be suitable for cats with calcium oxalate stones.

 

Drugs has some information about potassium citrate.

 

Thriving Pets

sell Urocit-K 1080mg tablets for US$1.95 each, or 100 generic potassium citrate 540mg for US$150. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.

 


Potassium Chloride


 

Some vets recommend potassium chloride because it is cheaper. Few people use potassium chloride in the oral form because it may contribute to metabolic acidosis, but if you want to give potassium by adding it to your cat's sub-Q fluids, this is the type you would use. Slow-K is one brand.

 

Injectable potassium chloride is available in a 2 mEq/ml strength, in either 10ml or 20 ml vials. If your vet adds the 10ml strength vial to your bag of 1000ml sub-Q fluid (it must be added to the bag, not injected into the line), the bag now contains 20 mEq of potassium. If you are giving 100ml a day of fluids, you are giving 2 mEq of potassium each day, or the equivalent of one Tumil-K tablet a day.

 

 If your vet adds the 20ml strength vial to your bag of 1000ml sub-Q fluid, the bag now contains 40 mEq of potassium. If you are giving 100ml a day of fluids, you are giving 4 mEq of potassium each day, or the equivalent of two Tumil-K tablets a day.

 

If you give potassium in this way, be aware that it can sting.

 

Drugs has some information about potassium chloride.

 

Thriving Pets

sell a 10 ml vial of the 2 mEq/ml strength for US$3. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.

 

Thriving Pets

sell a 20ml vial of the 2 mEq/ml strength for US$6.95. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$100. Shipping is free for orders over US$100 after the discount.


High Potassium Levels (Hyperkalaemia)


 

It is important to understand that not all CKD cats need potassium supplements. Feline renal failure: questions, answers, questions (1992) Lulich JP, Osborne CA, O’Brien TD and Polzin DJ Compendium on Continuing Education for the Practising Veterinarian 14 pp127-153) found that around 13% of CKD cats have high potassium levels. Therefore you should not supplement potassium without a blood test and your vet's approval.

 

Some cats never have low potassium levels, particularly if their CKD is relatively advanced (IRIS stage 4, creatinine over 5 mg/dl USA or 440 mmol/L international). Thomas's creatinine was not that high until near the end of his CKD battle, yet he never needed potassium supplementation even when his creatinine was 3.47 mg/dl. Other cats may have normal or even low potassium levels, but go on to develop high potassium levels, either because the CKD has progressed or because of a crisis, e.g. a cat who cannot urinate, perhaps because of kidney stones, will develop high potassium levels.

 

When are Potassium Levels Too High?


What is too high a level? Management of potassium disorders (2014) Odunayo A Clinician's Brief March 2014 pp69-72 states "Hyperkalemia, a serum potassium concentration greater than 5.5 mEq/L (although reference ranges can vary), is considered life threatening at concentrations greater than 7.5 mEq/L; however, an individual animal may have life-threatening clinical signs at higher or lower concentrations."

 

Ideally you do not want potassium to go above 6.0 according to 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats (2013) Davis H, Jensen T, Johnson A, Knowles P, Meyer R, Rucinsky R & Shafford H Journal of the American Animal Hospital Association 49(3) pp149-159, which talks about treatment when "life-threatening hyperkalemia is either suspected or present (K 6 mmol/L)." Above 6.5 is definitely a problem, considering that high potassium levels may cause seizures and even a heart attack. Management of potassium disorders (2014) Odunayo A Clinician's Brief March 2014 pp69-72 says "Although there is no consensus for treatment of hyperkalemia, veterinary patients with acute serum potassium concentrations greater than 6.5 mEq/L or with ECG changes suggestive of hyperkalemia are typically treated."

 


Causes of High Potassium Levels


 

Haemolysis


Firstly, don't panic, because in many cases an apparently high potassium level is in fact nothing of the sort. Quite often bloodwork may indicate high potassium levels when it is actually an error caused by a haemolysed blood sample or by leaving the blood for a while before testing it. Therefore the first thing to do is to re-run the test to be sure that you really are dealing with high potassium levels.

 

Metabolic Acidosis


If a cat has metabolic acidosis, potassium levels may appear high in blood tests, but may subsequently fall after the metabolic acidosis is treated.

 

ACE Inhibitors


Using ACE inhibitors such as  benazepril (Fortekor) may increase potassium levels. If you start using one, ensure your vet checks your cat's kidney values and potassium levels 7-10 days later. If your cat's potassium levels have fallen too far, discuss using a potassium supplement with your vet. If you need to stop using an ACE inhibitor, you should never do so abruptly, but taper off the dose.

 

Reduced or No Urination, Particularly Kidney Stones or Acute Kidney Injury


Since the kidneys flush excess potassium out of the body, anything that stops this happening can lead to high potassium levels in the body. An inability to urinate or reduced urination in particular can lead to hyperkalaemia, and are often caused by kidney stones or acute kidney injury.

 


Symptoms of High Potassium Levels


 

These are the usual symptoms of high potassium levels. Rather confusingly, two of them (twitching and lethargy) may also be symptoms of low potassium levels.

Lethargy and Weakness


This may be a sign of high or low potassium levels, anaemia or hypertension. Lethargy may sometimes be a sign of heart problems, especially if it appears after giving fluids.

 

Twitching, Trembling or Shaking


Twitching may be related to potassium levels in the body. In early CKD, it is likely to be due to potassium levels being too low, but in cats with more advanced CKD, potassium levels may rise and cause twitching as happened to Thomas on his last day.

 

Other possible causes include low potassium levels, high blood pressure, high phosphorus levels, 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.

 

Seizures


When potassium levels are very high, heart problems can arise, and short seizures may also occur, especially in end stage kidney disease.

 

Seizures may take a number of different forms. There may be the classic jerking and loss of consciousness, but being "spaced out" or mentally absent or staring into space may also be a type of seizure. Harpsie' s website has more information on what seizures may look like.

 

Seizures can also be a sign of high blood pressure, high levels of toxins, metabolic acidosis or of calcium imbalances. The use of Reglan (metoclopramide) for stomach problems or Advantage for fleas may lower the seizure threshold. Other possible causes of seizures include epilepsy or a brain tumour, but the causes mentioned above are far more likely in a CKD cat and should therefore be considered first.

 


Treatment of High Potassium Levels


 

If your cat does indeed have high potassium levels (see above), which is more likely in cats with creatinine over 5 mg/dl USA or 440 mmol/L international, it is important to try to reduce them. If they are only a little elevated, don't panic, you should be able to get them down to a safe level.

 

Whether the hyperkalaemia is acute (has come on suddenly) or is chronic can also make a difference. If it has come on suddenly and you can find and treat the cause, it should be possible to get things under control.

 

Unfortunately it is not always easy to control severe hyperkalaemia, particularly if your cat is no longer urinating much or at all. Some of the treatments below only reduce potassium levels temporarily, but this may be sufficient to stabilise your cat if, for example, urination begins again. Your vet can advise you and provide hospital treatment as appropriate.

 

Stop Potassium Supplementation


The first thing to do, of course, is to stop all potassium supplements. This will include oral supplements, and if you are giving sub-Qs, you may need to change the type of fluid you are giving, since some types (such as LRS) contain potassium.

 

Correct Metabolic Acidosis


If a cat has metabolic acidosis, potassium levels may appear high in blood tests, but may subsequently fall after the metabolic acidosis is treated.

 

Reduce or Stop ACE Inhibitors


Using ACE inhibitors such as  benazepril (Fortekor) may increase potassium levels, so you may need to reduce or stop this treatment, although Managing fluid and electrolyte disorders in renal failure (2008) Langston C Veterinary Clinics Small Animal Practice 38 pp677–697 says "Mild hyperkalemia is relatively common in stable patients being treated with angiotensin-converting enzyme inhibitors. My experience is that most patients on angiotensin-converting enzyme inhibitors do not develop serum potassium concentrations in excess of 6.5 mEq/L, and the clinical relevance of mild hyperkalemia in these patients is uncertain."

 

If your vet feels you should stop using ACE inhibitors, you normally need to reduce the drug gradually rather than suddenly. 

 

Fluid Therapy


If you are giving sub-Qs at home, your vet may wish you to increase the amount you are giving. Your vet may also ask you to use saline fluid rather than lactated ringers solution, which contains potassium, though Management of potassium disorders (2014) Odunayo A Clinician's Brief March 2014 pp69-72 says "Fluid therapy may also correct mild hyperkalemia. Traditionally recommended for patients with hyperkalemia, 0.9% sodium chloride contains no potassium. However, potassium-containing fluids (lactated Ringer's solution; PlasmaLyte A; Normosol-R) can be safe in patients with hyperkalemia if the underlying cause has been identified and is being treated (e.g., cats with urinary obstruction)."

 

In severe cases, the fluid therapy will need to be performed in a hospital setting. 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats (2013) Davis H, Jensen T, Johnson A, Knowles P, Meyer R, Rucinsky R & Shafford H Journal of the American Animal Hospital Association 49(3) pp149-159 state "If life-threatening hyperkalemia is either suspected or present (K 6 mmol/L), begin fluid therapy immediately along with medical therapy for hyperkalemia."

 

Potassium disorders in cats: myths and facts (2009) de Morais HA Presentation to the World Small Animal Veterinary Association World Congress says that it is important to consider whether the hyperkalaemia is acute or chronic: "Treatment of hyperkalemia will depend on the magnitude and rapidity of onset of the hyperkalemia. Patients with symptomatic hyperkalemia or ECG abnormalities should be treated. Mild chronic hyperkalemia (K < 6,5 mEq/L) may not require immediate therapy. Asymptomatic, non-oliguric patient: The underlying disease process should be treated and any source of potassium intake or drugs that cause potassium retention should be discontinued, if possible. Fluid therapy with potassium-free solutions ameliorates mild hyperkalemia by improving renal perfusion, enhancing urinary excretion of potassium, and by diluting the potassium in ECF."

 

Insulin


For really high potassium levels, sometimes insulin may be administered in conjunction with dextrose or sodium bicarbonate, which work together to move potassium intracellularly.

 

Doyle Medical has information on the use of these drugs in human emergency medicine, scroll down to Treatment of Hyperkalaemia Using Insulin.

 

Diuretics


If your cat has oliguria (reduced urination), diuretics such as Lasix (furosemide) may be suggested by your vet in an attempt to get urine flowing again.

 

Bronchodilators


Pet Place reports that albuterol, a bronchodilator commonly used to help open the airways during asthma attacks, has also been used in treating hyperkalaemia associated with CKD.

 

Potassium Exchange Resin


In extreme cases, your vet may choose to use a potassium exchange resin: I heard from one person who successfully used a human drug called sodium polystyrene sulfonate (potassium kayexolate) which has apparently been used to a limited extent in dogs but I do not know of anybody else who has used this for a cat. Potassium levels need to be monitored daily when using this treatment.  

 


Links


Pet MD discusses high potassium levels.

Cornell University College of Veterinary Medicine has some information about potassium levels.

Medline discusses high potassium in humans, but the basic principles are similar for cats.

Medscape is a human site with information on hyperkalaemia.

Endocrine Emergencies is a presentation by Dr MS Wallace to the Atlantic Coast Veterinary Conference 2001.

 

 

Back to Page Index

This page last updated: 18 August 2016

Links on this page last checked: 18 August 2016

   

 

*****

 

TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

 

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

 

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

 

*****

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