The toxins of CKD can cause problems in all these areas. This important topic now has its own page here.

Fluid Therapy                                                                                                        Back to Page Index

Fluid therapy is intended to prevent dehydration, not to flush out toxins in any way. Therefore you should only give enough to maintain hydration rather than giving lots of unnecessary fluid. However, if your cat is or becomes dehydrated, the toxins will build up in the cat's body. Therefore giving sufficient fluids to maintain hydration may help with minimising toxins. 

Mouth Ulcers And Gastro-Intestinal Bleeding                                               Back to Page Index

Mouth ulcers can be very painful, so treating them is important for your cat's wellbeing. Gastro-intestinal bleeding can cause anaemia and is potentially very serious, so getting it under control is extremely important.

Mouth Ulcers

Slippery elm bark, which as mentioned above can help with mouth ulcers, may also help with some milder cases of gastro-intestinal bleeding.

Sucralfate may be helpful for both mouth ulcers and gastro-intestinal bleeding. It forms a protective coating over the ulcerated areas of the stomach and allows them to heal. 

Diarrhoea                                                                                                                   Back to Page Index

Bad breath will often improve as dehydration is treated and the toxin levels in the body are controlled. If your cat's breath does not improve, ensure your vet rules out dental problems.

Itching

Howling (Particularly at Night)

Probiotics and Prebiotics                                                                                   Back to Page Index

• What are probiotics?
• What are prebiotics?
• Using probiotics and prebiotics in CKD
• Azodyl
• Astro's Nitrogen Scrub

Probiotics are colonising microorganisms (bacteria or flora) which are sometimes referred to as "friendly bacteria" or "good bacteria." Bacteria live in the lower gastro-intestinal tract, and are essential to gut health. Probiotics are commonly given orally to re-balance the bacteria in the gut, particularly after using antibiotics. The National Institutes for Health explains more about probiotics.

Probiotics and Prebiotics (2010) S Perea Natura Pet Technical Information Series 2(9) is a helpful overview.

The Use of Probiotics and Prebiotics in CKD

Some people have taken these concepts further and aim to use these products as a means of diverting toxins from the kidneys, in order to reduce their workload.

Most of the urea produced by the body is excreted via the kidneys, but the remainder is excreted via the large intestine. In CKD, the kidneys may struggle to cope with excreting urea, leading to it building up in the cat's body. The use of fermentable fibre in CKD is aimed at diverting more of the urea to the large intestine/faecal route, thus relieving the workload imposed on the kidneys. This process is sometimes referred to as "nitrogen trapping." Recent studies indicate that it may be possible to use probiotics in a similar manner.

Azodyl                                                                                                                      Back to Page Index

• What is Azodyl?
• Does Azodyl work?
• Availability
• How to give azodyl
• Suppliers

What is Azodyl?

Azodyl is a probiotic designed to be such a treatment for CKD by reducing the workload of the kidneys. It contains strains of three particular probiotics, Streptococcus thermophilus (KB19), Lactobacillus acidophilus (KB27) and Bifidobacterium longum (KB31), along with a prebiotic, psyllium, a type of fibre commonly used to control constipation. The manufacturers of Azodyl claim that their strains of these bacteria have a particularly high affinity for some of the major uraemic toxins found in CKD. Similar to the "nitrogen trapping" use of fermentable fibre in CKD, Azodyl is intended to bind with and reduce the levels of these uraemic toxins in CKD cats, hence its name, which is a play on azotaemia and dialysis.

Kibow Biotech, who make Kibow Biotics, the human version of Azodyl, call this "enteric dialysis". Azodyl also seems to have some similarities to oral adsorbents such as Ipakitine/Epakitin (also manufactured by Vetoquinol), which also bind with uraemic toxins.

Kibow Biotech explains more about the principles behind the product.

Does Azodyl Work?

Since Azodyl is classified as a dietary or nutritional supplement, clinical trials are not required by the American Food & Drug Administration. However, Probiotic amelioration of azotemia in 5-6th nephrectomized Sprague Dawley rats (2005) Ranganathan N, Patel B, Ranganathan P, Marczely J, Dheer R, Chordia T, Dunn SR, Friedman EA Scientific World Journal 24;5 pp652-60 is a study on rats who were treated with probiotics, including probiotics provided by Kibow Biotech (which did not appear to be identical to Azodyl). The study seemed to show that Bacillus pasteurii and Sporolac (Lactobacillus sporogenes) were particularly effective. Sporolac is produced by Sankyo Co Ltd in India, where it is commonly used in farm animals. I have not been able to find a source for it in Europe or North America. 

The manufacturers of Azodyl state that Azodyl is not a true probiotic and does not change the bacteria in the gastro-intestinal tract. This is why Azodyl needs to be given every day. It is debatable whether Azodyl truly improves kidney function, but if it reduces BUN levels, it may at least help cats feel a little better.

I have heard from a number of people who have used Azodyl. Most people seem to think it has helped their cats, though some people find that it can make a cat vomit, and others could not see any discernible difference. It may take up to a month before you see any benefit from using Azodyl, though apparently some people see results (usually in the form of better appetite) within two weeks.

Azodyl appears to be a safe product and I would be happy to try it myself, but it is not essential, so don't get stressed if you can't find it or afford it, or if you find it too difficult to give (see below).

Kibow Biotech explains more about the reasoning behind Azodyl.

Kibow Biotech reports on its studies into the use of probiotics.

A preliminary clinical evaluation of Kibow Biotics, a probiotic agent, on feline azotemia (2006) Palmquist R Journal of the American Holistic Veterinary Medical Association reports on a trial conducted at a veterinary practice in California.

Azodyl Availability

Azodyl is widely available in the USA and Canada but can be difficult to obtain elsewhere.

Azodyl was created by Kibow Biotech, and was introduced to the US and Canadian markets in July 2006 by Vetoquinol, the manufacturers of Ipakitine/Epakitin. Many vets stock it and it is also available from online pet pharmacies.

Vetoquinol may purchase the manufacturing and marketing rights for Azodyl for the rest of the world in due course, but as at 2011 there were no plans to introduce the product in Europe because Vetoquinol do not wish to go through the necessary registration process. The human version of Azodyl (which contains twice as many bacteria as Azodyl but which is safe to use in cats) is already available in some other markets under the name of Kibow Biotics. Kibow Biotics is not yet available in Europe but the manufacturers have told me they expect to have a distribution channel in place for it within Europe some time during 2012 (this date has slipped from 2011)..

In theory you can import Azodyl into Europe from the USA, and suppliers who are prepared to ship to Europe are below. Since the product has to be kept chilled at all times, you are taking a bit of a risk because it may not be usable if it gets held up by Customs or en route for any reason, but some people have imported it with no problems. 

How to Give Azodyl

Giving Azodyl to cats may be problematic. Firstly, the required dosage is quite high: a cat weighing 5-9 lbs would require two capsules a day according to a table provided by Vetoquinol which shows dosage requirements according to weight.

Secondly, Azodyl is enteric-coated, which means it is intended to release its contents in the intestines rather than the stomach. For this reason the capsules are intended to be given whole; however, since the product was originally developed for use in humans, the capsules are size 1, which is rather large for many cats; this may be one reason why some cats throw up the entire capsule, sometimes several hours after it has been given. The manufacturers are aware of this problem following complaints from many users, and are currently working on trying to produce a smaller capsule which can still hold the correct quantities of bacteria. They hoped to launch the smaller size capsule in the second half of 2011, but that has not happened. With luck it will arrive early in 2012.

The Veterinary Information Network has run a trial into Azodyl to investigate whether opening the capsules and sprinkling them on the cat's food will affect the product's effectiveness. Unfortunately, the study, Azodyl, a synbiotic, fails to alter azotemia in cats with chronic kidney disease when sprinkled onto food (2011) Rishniw M & Wynn SG Journal of Feline Medicine and Surgery 13(6) pp 405-9, found that giving Azodyl by opening the capsule and sprinkling its contents onto food or mixing it into a slurry had no effect on BUN or creatinine levels.

I have discussed the results of this trial with the manufacturer, who have told me that in the above study the capsule contents were mixed into a full meal. However, they recommend opening the capsule and mixing the contents with a small amount (about a teaspoonful) of fatty food, such as cream cheese, cream, full fat yoghurt or a pat of butter. This should then be given on an empty stomach one hour before feeding a full meal, in order to give the probiotics the right environment to work properly. It should not be mixed with liquids as this will activate the bacteria in the product too early, making it less effective.

In the Palmquist study mentioned above, Kibow Biotics, the human version of Azodyl, was found to be effective even when mixed with meals. This could be because Kibow Biotics contains twice as many bacteria as Azodyl, so more bacteria survived. One member of Tanya's CRF Support Group is successfully using this product mixed directly with meals. So if you wish to continue mixing the product into meals, you might wish to use Kibow Biotics instead (for suppliers, see below).

For those using Azodyl itself, in practice most people seem to give Azodyl first thing in the morning mixed with a little butter or cream, and then wait an hour before giving their cat breakfast. Members of Tanya's CRF Support Group are generally positive about Azodyl when given in this way.

One person had the bright idea of opening the capsule and decanting the contents into two smaller capsules, which she then gives in Pill Pockets.

Azodyl should not be given at the same time as antibiotics; separate them by 2-3 hours.

Azodyl should be kept in the fridge, otherwise the bacteria may die. They can probably survive for some time in normal weather (up to three days according to the manufacturers), so if you leave Azodyl out overnight there is unlikely to be cause for concern, but if you buy online it is safest to have Azodyl shipped chilled, because there is no guarantee that it was shipped chilled to the retailer.

Azodyl Suppliers

Azodyl is widely available from vets in USA and Canada, but can often be purchased more cheaply online - see below.

If you live in Europe, Azodyl is not available and the only way to buy it is to order it from a US supplier. You can also order the stronger human version, Kibow Biotics, from a US supplier, but it should be available within Europe sometime in 2012. Kibow Biotics is as safe to use in cats as Azodyl.

I understand that it is not currently possible to import Azodyl into Australia, but that it may be permitted in due course (possibly during 2012).

Wherever you live, if you buy Azodyl online, it must be shipped cold, otherwise the bacteria can die and the product will not be effective. I would try to order early in the morning so it should be shipped to you on the same day; if you order after midday, it might well be packed that day but not actually shipped until the next day.

USA

Entirely Pets sells 60 Azodyl capsules for US$24.99 plus shipping or 180 capsules for US$73.99. Shipping is free on orders over US$85. I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled.

Thriving Pets sells 60 Azodyl capsules for US$31.95, plus shipping. Shipping is free on orders over US$85. I used Thriving Pets within the USA myself for other items with no problems. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Thriving Pets also sells Kibow Biotics, the human version of Azodyl. 90 capsules cost US$44.95 plus shipping, so it actually costs slightly less than Azodyl but the product is twice the strength, which may be helpful if you wish to mix it with your cat's meals. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Kibow Biotech sells three bottles of Kibow Biotics for US$121.50 including a new customer discount (normal price is US$135) plus shipping costs of US$12.95.

Amazon sells Azodyl via a variety of suppliers at various prices. Make sure they will use chilled shipping.

Canada

Petpharm sell Azodyl in Canada.

Entirely Pets sells 60 Azodyl capsules for US$24.99 plus shipping or 180 capsules for US$73.99. Shipping is free on orders over US$85. I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled. They will ship to Canada. I have heard from two UK residents whose orders arrived after only two days (ordered on a Monday, arrived on a Wednesday) and were still nicely chilled.

Thriving Pets sells 60 Azodyl capsules for US$31.95, plus shipping. Shipping is free on orders over US$85. I used Thriving Pets within the USA myself for other items with no problems. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Thriving Pets also sells Kibow Biotics, the human version of Azodyl. 90 capsules cost US$44.95 plus shipping, so it actually costs slightly less than Azodyl but the product is twice the strength, which may be helpful if you wish to mix it with your cat's meals. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Kibow Biotech gives contact details for the Canadian distributor of Kibow Biotics.

Europe

Entirely Pets sells 60 Azodyl capsules for US$24.99 plus shipping or 180 capsules for US$73.99. They will ship to UK. I have heard from two UK residents whose orders arrived after only two days (ordered on a Monday, arrived on a Wednesday) and were still nicely chilled.

Thriving Pets sells 60 Azodyl capsules for US$31.95, plus shipping, and will ship to some European countries. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Thriving Pets also sells Kibow Biotics, the human version of Azodyl. 90 capsules cost US$44.95 plus shipping, so it actually costs slightly less than Azodyl but the product is twice the strength, which may be helpful if you wish to mix it with your cat's meals. If you enter the word "tanya" (without the ") in the promotional code box, you will receive a 10% discount on orders over US$55.

Kibow Biotech sells three bottles of Kibow Biotics for US$121.50 including a new customer discount (normal price is US$135) plus shipping costs. They have told me they are happy to ship to Europe until the product becomes available in Europe (which is expected before the end of 2011).

Astro's Nitrogen Scrub                                                                                        Back to Page Index

The manufacturer of Astro's CRF Oil also makes a product called Astro's Nitrogen Scrub, although it is not mentioned on the manufacturer's website. This product is a "highly refined glycoprotein powder" made from acacia gum powder (gum arabic) and appears to be a type of prebiotic. It is supposed to be mixed with a probiotic such as kefir (available from health food stores) or live yoghurt, so I'm not sure how you are supposed to know if it is the Astro product or the probiotic which is working, but the manufacturer claims that in tests the Nitrogen Scrub alone produced reductions in BUN and creatinine of as much as 20% when dosed at 0.5g/kg of bodyweight.

The product is apparently designed in this manner so as to make it easier to ship without the risk of killing off the live bacteria, as is the case with probiotics. It is in powder form so you can control the dose. Some people simply mix it into food rather than adding it to kefir. Astro's Nitrogen Scrub costs US$22.95 for a 140 gm jar and can be ordered by emailing the manufacturer.

Scientific opinion on the substantiation of health claims related to acacia gum (gum Arabic) and decreasing potentially pathogenic gastro-intestinal microorganisms (ID758), changes in short chain fatty acid (SCFA) production and pH in the gastro-intestinal tract (ID759), changes in bowel ffunction (ID759), reduction of gastro-intestinal discomfort (ID759), maintenance of faecal nitrogen content and/or normal blood urea concentrations (ID840, 1975) and maintenance of normal blood LDL cholesterol concentrations (ID841) pursuant to Article 13(1) og Regulation (EC) No 1924/2006 (2011) EFSA Panel on Dietetic Products, Nutrition and Allergies European Food Safety Authority Journal 9(4) p2022-40 found that "a cause and effect relationship has not been established between the consumption of acacia gum and a beneficial physiological effect related to the maintenance of faecal nitrogen content and/or normal blood urea concentrations." The research focused on healthy people, not those with CKD.

I don't know many people who have used the scrub, but I've heard from one person has used it for a year and thinks that it probably has helped overall. Others felt it helped with appetite. Please check with your vet before using.

Antioxidants                                                                                                            Back to Page Index

Oxidative stress and chronic kidney disease (2008) Brown SA The Veterinary Clinics of North America. Small Animal Practice 38(1) pp157-66 concludes that "newer data indicate that dietary supplementation with specific antioxidants is an important consideration for limiting renal oxidant stress and progression of CKD."

Vitamin E

Vitamin E is one of the ingredients in Astro's CRF Oil.

Dietary supplements of vitamins E and C and beta-carotene reduce oxidative stress in cats with renal insufficiency (2006) Yu S, Paetau-Robinson I Veterinary Research Communications 30(4) p403-13 found that using these vitamins as antioxidants appeared to be effective.

The Winn Feline Foundation gave a grant to Colorado State University in 2010 for a study into the use of  "Vitamin E as a Novel Treatment for the Anemia of Feline Chronic Renal Failure." Vitamin E was selected for its antioxidant properties. As at October 2011 the study is still ongoing and is open to new participants. You can read more about it here, and your cat may be eligible to participate, see the Research Participation page. I will report on its findings once it is completed. In the meantime, please do not supplement Vitamin E without your vet's approval.

Co-enzyme Q10 (Ubiquinone or Ubiquinol)

Co-enzyme Q10 (CoQ10), also known as ubiquinone or ubiquinol, is an antioxidant that is used by the body in energy production. It is important for heart function, and is sometimes used in people and cats with heart disease for that reason (see Heart Problems). It is one of the ingredients in Astro's CRF Oil.

A human trial, Randomised double-blind placebo-contolled trial of co-enzyme Q10 in patients with end stage renal failure (this link often doesn't work properly, you may need to search for this study on this site) (2003) Singh R, Kumar A, Niaz MA, Singh RG, Gujrati S, Singh VP, Singh M, Singh UP, Taneja C, Rastog SS Journal of Nutritional and Environmental Medicine 13 (1) pp 13-22, indicated that CoQ10 may reduce creatinine and BUN levels in some patients. I am not aware of any studies into using CoQ10 in CKD cats, but I have heard from a few people who think it has done the same for their CKD cats.

Renal preservation effect of ubiquinol, the reduced form of coenzyme Q10 (2011) Ishikawa A, Kawarazaki H, Ando K, Fujita M, Fujita T & Homma Y Clinical and Experimental Nephrology 15(1) pp30-3 found that ubiquinol appears to support renal function in rats who had had a kidney surgically removed.

Effect of topical application of coenzyme Q10 on adult periodontitis (1994) Hanioka T, Tanaka M, Ojima M, Shizukuishi S & Folkers K Molecular aspects of medicine 15 Suppl pp241-8 found that the topical application of CoQ10 appeared to improve periodontitis in humans. Sugano, N, et al. There were similar findings in more recent research by Nihon University School of Dentistry presented to The 63rd Meeting of the Vitamin Society of Japan, Hiroshima, Japan on 4th and 5th June 2011.

Generally speaking CoQ10 is normally considered to be a safe supplement with few side effects, though please do not give it without your vet's approval. It may lower blood glucose levels, so extra care should be taken if you and your vet decide to use it in a diabetic cat.

CoQ10 is available from health food stores. If you decide to use it, it should be given with fat or oil, so it is normally given with food. A possible starting level would be 10mg a day for a 15 lb cat, though some people give higher amounts. Holisticat recommends 30mg a day for cats with heart disease, though some people find their cats have stomach upsets and diarrhoea at this level, so you might want to start lower and increase the dose gradually.

If you do decide to try CoQ10 with your vet's agreement, please do not stop using it suddenly. There have been several cases of humans and one cat with heart disease who were using CoQ10 relapsing after it was stopped suddenly. This might not be such a risk with cats with CKD rather than heart disease, but if you do decide to stop using it, it would probably be safer to do so gradually.

Long-term coenzyme Q10 therapy: a major advance in the management of resistant myocardial failure (1985) Mortensen SA, Vadhanavikit S, Baandrup U, Folkers K Drugs under Experimental and Clinical Research 11(8) pp581-93 found that "preliminary CoQ10 withdrawal results showed severe clinical relapse with subsequent improvement on CoQ10 reinstatement."

Response of patients in classes III and IV of cardiomyopathy to therapy in a blind and crossover trial with coenzyme Q10 (1985) Langsjoen PH, Vadhanavikit S & Folkers K Proceedings of the National Academy of Sciences of the United States of America 82 pp4240-44 concluded that "CoQ10 deficiency might be a major if not the sole cause of cardiomyopathy and that CoQ10 is likely a lifetime therapy for the cardiac patient."

University of Maryland Medical Center is a human site with information about CoQ10.

The Mayo Clinic reports that "there is initial data from one small trial [in humans] to support the use of CoQ10 in the treatment of kidney failure. More research is needed before a recommendation can be made."

Astro's CRF Oil                                                                                                      Back to Page Index

Astro's CRF Oil was created by a human doctor to treat his own CKD cat, and has been on the market since January 2007. The manufacturer states that the product was tested on an informal basis on 18 CKD cats in the Montreal area over a period of about eight months. This product is basically a combination of essential fatty acids, Vitamin E and CoQ10 (ubiquinon), both antioxidants, but in a concentrated formula.

Astro's CRF Oil contains approximately 565mg EPA, 340 mg DHA, 15mg of Ubiquinon (CoQ10) and 200 IU of natural Vitamin E (D-tocopherol) per 1.5ml dose. It is claimed that combining these ingredients creates a synergistic effect. The intention is for the product to have a strong anti-inflammatory effect, which it is hoped will help the kidneys. Astro's CRF Oil is only available from the creator's website (link above). A 60 ml bottle costs US$29.95 and you give 1.5 ml a day so it lasts about 40 days.

Essential fatty acids do have an anti-inflammatory effect. However, one kidney specialist vet has informed me that oversupplementation can throw off the correct ratio of Omega-3s to Omega-6s, and might be detrimental in some cases. Having said that, many people on Tanya's CRF Support Group use the product and most people seem to like it, reporting that their cats seem "better", albeit in some unmeasurable way. A small percentage found that it made their cats vomit more though, so they stopped using it.

Almost everyone I have heard from has mentioned that their cat hates the taste and smell of Astro's CRF Oil. Ideally you want to mix it with food, in which case it might may help to build up to the full dose gradually. You can also mix it with a small amount of food and syringe it in - if you do this,  be sure to give it at the side of the mouth. If your cat doesn't like Astro's CRF Oil, you can consider giving essential fatty acids and antioxidants separately instead.

I don't consider Astro's CRF Oil to be an essential product, but it is probably worth a try if you can obtain it where you live and your cat tolerates it. If you do use it, please see the advice about not stopping products containing CoQ10 here.

The product's website states that using this product may enable you to stop other treatments such as sub-Qs, but I cannot see why an anti-inflammatory product might help prevent dehydration. I certainly would not recommend stopping any of your cat's current treatments, particularly sub-Qs, without your vet's knowledge and approval.

Effects of a dietary chitosan and calcium supplement on calcium and phosphorus metabolism in cats (2004) Wagner E, Schwendenwein I, Zentek J Berliner und Münchener tierärztliche Wochenschrift 117 pp310-315 found that Ipakitine reduced phosphorus and BUN (urea) levels in the CKD cats in the trial.