Tanya's Comprehensive Guide to Feline Chronic Kidney Disease

If you are in the UK, I can virtually guarantee that the only treatments you will be offered are prescription food and Fortekor (benazepril), an ACE inhibitor which is licensed in Europe and Australia for the treatment of renal insufficiency in cats.

If you are in the USA, you will probably be offered prescription food, sub-Q fluids and possibly a phosphorus binder.

For some cats, these treatments will be sufficient, but there are many others which can also help. However, it can be difficult to know which treatments to use and when, particularly if funds are limited.
This page aims to explain which treatments are crucial, depending upon your cat's particular problems.
It also explains which problems you are most likely to be faced with at the different stages of CKD.

Purposes of Treatment Back to Page Index

There are two main purposes of treatment:

To help the cat feel better
To tackle problems that may make the CKD progress faster

There are so many treatments available that people sometimes get confused about which are essential for these purposes, which are optional and which are a waste of time. They also may not know which treatments to use first. I therefore include information about these issues on this page.

Which Treatments To Use When Back to Page Index

These days many vets place CKD into one of four stages according to the International Renal Interest Society's guidelines. You can read about the different stages here.

Nutritional management of feline chronic kidney disease (2008) Elliott J, Elliott D Veterinary Focus 18(2) pp39-44 recommends different treatments based on which stage your cat is in, as follows:

Stage 2 and early Stage 3

Creatinine between 2.1 and 4.5 mg/dl or 185 mmol/L and 400 mmol/L international

The goal is to slow progression using the following:

Management of high phosphorus levels through dietary phosphate restriction
Management of proteinuria
Management of hypokalemia (low potassium levels)
Management of hypertension (high blood pressure)

Late Stage 3 and Stage 4

Creatinine over 4.5 mg/dl US or 400 mmol/L

The goal is to control imbalances that lead to higher toxin levels and therefore affect quality of life, as follows:

Minimise azotemia (elevated BUN and creatinine levels)
Limit hyperphosphatemia by dietary restriction and intestinal phosphate binders
Fight against anorexia to maintain sufficient energy intake
Manage metabolic acidosis

What This Means in Practice Back to Page Index

Most people read this page shortly after diagnosis when they are feeling overwhelmed. The technical jargon means nothing to them, but they are desperate to help their cat and are vulnerable to the marketing hype found on some websites. Therefore below I have divided treatments into categories, explaining which treatments are essential, which are optional and which are appropriate in some circumstances.

The main ways of telling whether a treatment is appropriate are firstly, by checking for symptoms of a problem (e.g. eating litter is often a sign of anaemia) and secondly by seeing what is out of range in test results, then discussing your concerns with your vet.

In practice, most people with cats in the early stages of CKD will have to use treatments for nausea and vomiting (which are often caused by excess stomach acid in CKD cats) and something for phosphorus control. Later on, they may also need to use subcutaneous fluids in order to prevent dehydration, and a potassium supplement if their cat's potassium levels are too low. In due course, they may need to treat hypertension, anaemia and metabolic acidosis. In all cases, any infections should be dealt with promptly.

If money is a concern, as it is for most people, you'll be relieved to hear that the most commonly needed treatments only cost about US$5 a week. It is only when you need to treat severe anaemia using erythropoiesis stimulating agents (ESAs), such as Epogen, Aranesp, Procrit, Eprex or NeoRecormon, that the cost will be higher, but even these products can be obtained relatively cheaply (I give sources for a vial of Epogen costing around US$30); and the frequency of use reduces after a few weeks, which reduces the price further.

Try to be proactive - keep a close eye out for symptoms and start treating any that arise as soon as possible. At the same time, you may find that some treatments are too stressful for your cat - they all are individuals, and some cope better than others. Even if you decide not to use some treatments, you should be able to use others, so just do the best you can, and check the Tips on Medicating Your Cat page for tips on how to make medicating your cat easier for both of you.

Don't give up hope. Merck's Veterinary Manual states "With appropriate therapy, animals can survive for long periods with only a small fraction of functional renal tissue, perhaps 5-8% in dogs and cats."

How to speak for Spot by Dr Nancy Kay is about how to decide which treatments would be the best choice for your dog in your particular circumstances but the principles apply to cats too.

Essential Treatments

Food

The one essential treatment for all cats is food. Although a prescription renal food can be helpful, if your cat won't eat it, it's not helpful at all.

If your cat hasn't eaten for a couple of day, s/he needs food now. Cats who don't eat can develop a lifethreatening liver condition called hepatic lipidosis, which can happen after just a day or two of not eating. The site will help you identify possible causes of inappetance and how to treat them, but right now, this minute, if your cat hasn't eaten today, I want you to stop reading and go and get some food into your cat. Try any cat food you have in the house - at this point, anything is better than nothing. If your cat won't eat what you have in stock and you are in the USA, pop out to the supermarket and buy some Gerbers Stage 2 meat-based baby foods and some Fancy Feast Classic pate-style foods. You can check on what you need to buy here and here. If you're near a pharmacy, also buy some Pepcid AC regular (not Complete or Extra Strength, you want the 10mg size). You are going to ask your vet if you can use the Pepcid AC for your cat.

Once your cat has eaten, you can read up on how to get your cat to eat, how to get your cat to eat the prescription food, what to do if you don't succeed and the nutritional requirements of CKD cats in the Diet and Nutrition section.

Essential Treatments in Some Circumstances

These problems are all explained in more detail in the Key Issues section. Don't worry, it is highly unlikely that you will have to deal with all of them - remember, they are only appropriate in some cases.

Blood Pressure Control

If your cat's blood pressure is consisently over 160, s/he has hypertension. In order to avoid blindness, heart problems and strokes, you need to ask your vet about starting a medication for hypertension called amlodipine (Norvasc or Istin). As a bonus, once your cat's blood pressure is under control, you should see an improvement in your cat's wellbeing (if your cat has already gone blind, s/he may even regain some vision), and you may also see improved blood test results. See All About Hypertension for more information.

Phosphorus Control

Many CKD cats have elevated phosphorus levels, which make the cat feel lousy and may make the CKD progress faster. If your cat's phosphorus level is over 6 (USA) or 1.9 (international), your cat would benefit from a phosphorus binder. See Phosphorus Control for more information.

Vomiting, Nausea and Excess Stomach Acid

Most CKD cats have one or more of these problems. One common symptom is vomiting, especially white foam. There are some simple, quick, free or cheap treatments that work well for some cats. Other cats need treatments that block the production of excess stomach acid, such as famotidine (Pepcid AC). Other medications to help prevent vomiting, such as ondansetron or maropitant (Cerenia) are also appropriate in some cases. See Nausea, Vomiting, Appetite Loss and Excess Stomach Acid for more information.

Fluid Therapy

Most CKD cats eventually become dehydrated. If this is an acute situation, the cat will need intravenous fluids (IV fluids, or a drip). Even cats who are not in crisis will eventually need treatment to avoid a crisis developing. In most cases, this will be when creatinine levels are consistently over 3.5 (USA) or 300 (international) and the treatment is subcutaneous fluids. See Maintaining Hydration for more information.

Anaemia

Anaemia is relatively common in CKD cats. If your cat's PCV or HCT measurement is below normal, ask your vet about using a Vitamin B supplement. If your cat's PCV or HCT level is below 20%, you will need to consider using a type of treatment known as an erythropoiesis stimulating agent (ESA), such as Epogen, Aranesp, Procrit, Eprex or NeoRecormon. See All About Anaemia for more information.

Potassium

Many (but not all) CKD cats have low potassium levels, which can cause weakness (especially in the back legs) and other problems. If your cat's level is below 4, ask your vet about using a potassium supplement. See Potassium Imbalances for more information.

Metabolic Acidosis

This means that the acid levels in the body are out of balance. It is not the same thing as stomach acid. It is more common in more advanced CKD. See Metabolic Acidosis for more information.

Optional Treatments

Most of these treatments (except benazepril and calcitriol) are not used for a specific purpose, but are attempts to help the cat feel better and perhaps slow the progression of the CKD.

B vitamins

B vitamins can help with appetite, energy levels and anaemia. Any excess is peed out so they are usually a very safe treatment. Although they are optional, I think they are a good choice for any CKD cat, because they may help and should not harm. See The B Vitamins for more information.

Azodyl

Azodyl is a type of probiotic specially developed to help with renal toxins. Virtually everybody I've heard of who uses it thinks it helps their cat feel better, but it's expensive, not available outside the USA (though I've found possible sources), and needs to be shipped cold. It's also a very large capsule, which some cats don't like to take, but again, there are ways around this. See Treatments for more information.

If you can afford and obtain Azodyl, I'd definitely use it. If not, don't worry too much.

Astro's CRF Oil

This is an essential fatty acid treatment. Some people find their cats seem to do better overall when taking this, but some cats don't like the taste. If you can get your cat to take it, I think it's fine, but if you can't, I wouldn't worry about it. See Treatments for more information.

Benazepril (Fortekor)

This is approved in Europe, Australia and Canada for the treatment of CKD in cats. If you are in the UK, I virtually guarantee you left the vet's clutching a tin of prescription food and some Fortekor.

Benazepril is actually a heart medication, and the evidence for its use in CKD is not particularly strong; plus in some cases, it may worsen bloodwork, at least initially. It can, however, be effective in treating a problem sometimes seen in CKD cats known as proteinuria (where protein leaks into the urine). Personally, I would use it in a cat with proteinuria, and I would probably use it for additional blood pressure control if amlodipine (mentioned above) was not sufficient, but I probably wouldn't bother with it otherwise. See Treatments for more information.

Calcitriol

This is a treatment used for a condition known as secondary hyperparathyroidism, which is common in CKD cats. The first step in reducing the risk of secondary hyperparathyroidism is to control phosphorus levels (see above). See Treatments for more information.

Save Your Money

Tripsy

This contains ingredients inappropriate for CKD cats. Don't bother. See Holistic Treatments for more information.

RenAvast

I can't tell you if this contains ingredients inappropriate for a CKD cat, because the manufacturer doesn't actually divulge what is in it. It has an aggressive viral marketing campaign, which contains no real information. I wouldn't buy it. See Holistic Treatments for more information.

Obtaining Medications Back to Page Index

The Obtaining Supplies Cheaply page has tips on obtaining medications at reasonable prices in the UK, USA and Canada. The Medicating Your Cat page has information on how best to medicate your cat with the least stress for both of you. It also has tips on possible drug interactions.

DO NOT GIVE YOUR CAT ANY MEDICATION WITHOUT FIRST OBTAINING YOUR VET'S APPROVAL.

This page last updated: 06 February 2012

Links on this page last checked: 06 February 2012