Controlling Nausea, Vomiting, Appetite Loss and Excess Stomach Acid

Fluid Therapy

Mouth Ulcers and Gastro-Intestinal Bleeding (Including Sucralfate)


Bad Breath, Itching or Howling

Probiotics and Prebiotics, Including: Azodyl and Astro's Nitrogen Scrub

Antioxidants: Vitamin E, CoQ10, Astro's CRF Oil

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Fluid and Urinary Issues (Fluid Retention, Infections, Incontinence, Proteinuria)

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Home > Treatments > The Regulation Of Waste Products in the Body



  • Controlling toxins can help your CKD cat feel much better.

  • This page discusses treatments for specific problems, such as mouth ulcers.

  • It also discusses treatments which are intended to help generally with the CKD toxin load rather than treat specific problems, such as Azodyl and Astro's CRF Oil.

Controlling Nausea, Vomiting, Appetite Loss and Excess Stomach Acid

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


Fluid Therapy

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 Gastrointestinal Bleeding


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

Mouth Ulcers

 If you want to try holistic methods, slippery elm bark can be made into a syrup and used to help heal mouth ulcers - this has been found to be a very effective treatment by many people on Tanya's CKD Support Group. See Holistic Treatments for more information about slippery elm bark and how to make the syrup.

Another natural remedy for mouth ulcers is to mix white cheddar cheese with water to make a paste and spread it on the gums. The enzymes in the white cheddar cheese are supposed to eat the bacteria and help alleviate the infection, though I have not tried this myself and would not recommend it for dental problems other than mouth ulcers (see Related Diseases for more information on dealing with dental problems generally). I did try eel serum homeopathic remedy for Tanya, and I would say it did help, though perhaps not as much as the slippery elm bark might have done.


For severe mouth ulcers, antibiotics may be necessary.


For really obstinate ulcers, particularly in End Stage Renal Disease, you should consider using a treatment called sucralfate, which forms a protective coating over the ulcers and allows them to heal. 

Do not use Bonjela to treat mouth ulcers. It contains salicylate, which is toxic to cats.

It can be hard to get a cat with mouth ulcers to eat because they hurt so much. One possible short-term solution is baby food - this is runny so your cat may be able to lap it up with his/her tongue, avoiding the ulcers. Alternatively you can use pureed food. See Persuading Your Cat to Eat for more tips.


Gastrointestinal Bleeding

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


More serious cases will need sucralfate. If the bleeding has caused severe anaemia, your cat might also need a blood transfusion to tide him or her over the crisis.

Sucralfate (Carafate, Antepsin)

Sucralfate is sucrose aluminium hydroxide. It used to be used as a phosphorus binder but is not overly effective for that purpose. However, it is very good at forming a protective coating over ulcerated areas of the digestive tract including the mouth, which allows the  ulceration to heal. Members of my support group who have used it find it helpful for both mouth ulcers and gastrointestinal bleeding.


Trade names for this drug include Carafate in the USA, Antepsin in the UK and Ulcogant in Germany.


Sucralfate is widely available but unfortunately it is out of stock in the UK at the moment (June 2017) due to manufacturing problems and, according to this statement from the Pharmaceutical Services Negotiating Committee, it is not known when it will be back in stock (it has been out of stock for eighteen months already). One member of Tanya's CKD Support Group was able to source sucralfate via her vet from Idis Pharma, the details of which are in the statement above; it was not cheap.

Sucralfate is sold in 1g (1000mg) tablets and in a 1g/10ml suspension. In the USA there is also a veterinary brand called Feline Mucosalfate which comes in paste form for use on mouth ulcers.


A common dose is - (0.25-0.5) g three to four times a day (the Mucosalfate paste has its own dosing at outlined here). Most people mix the suspension form of sucralfate with water, draw the mixture into a syringe and give it that way. If you buy sucralfate in tablet form, it dissolves easily in water. You can make the mixture relatively thick if you are applying it to mouth ulcers, or into more of a slurry if it is for stomach ulcers. 

You should give sucralfate on an empty stomach in order for it to work properly. I used to recommend giving sucralfate at least two hours apart from famotidine (Pepcid AC), because, according to Plumb's Veterinary Drug Handbook, sucralfate could bind with the famotidine and thereby reduce its effectiveness. However, the most recent edition of Plumb's does not mention this requirement, so it appears that you do not need to separate sucralfate from these other medications after all. Plumb's Veterinary Drug Handbook does still recommend separating sucralfate from ranitidine (Zantac 75) or cimetidine (Tagamet).

Mar Vista Vet has information about sucralfate.

Pet Place has some information about sucralfate, including dosage suggestions (no need to register to read the article, just click on Close at the bottom of the irritating pop-up).


In many cases, diarrhoea will only last for a day. However, if it goes on any longer, or stops and then starts again, I'd recommend a trip to the vet because the cat may become quickly dehydrated (which does not only mean water loss, the cat may also be losing potassium).

Slippery elm bark appears to be able to help with both diarrhoea and constipation. It soothes the lining of the gut and gives the digestive system time to heal. Psyllium may also help firm up the stool.

Occasionally a cat may appear to have diarrhoea, but it is in fact constipation with a small amount of liquid squeezing around the hard stool. This requires treatment for constipation.


If the diarrhoea is a result of changing food too suddenly, stop feeding the new food and go back to your cat's old food until the problem is under control. Then gradually re-introduce the new food as described in Which Foods to Feed.


If your vet agrees, you can try a medication containing pectin and kaolin for a few days. However, be sure you use a formulation suitable for cats; kaopectate used to be suitable, but as the American Medical Veterinary Association explains, the formulation has changed and is no longer safe for cats. Pet Pectillin is a brand of pectin and kaolin which is safe for cats, available from Arcata Pet.


Although loperamide (Imodium) is available without a prescription, please do not use it without your vet's knowledge and approval. According to Pet Place, it is a controversial treatment for animals, and can cause side effects in some cats, particularly those suffering from certain conditions including kidney disease. It is also hard to work out a cat-sized dose. Other treatments outlined here are much safer.


East meets west: integrative veterinary medicine (2007) Silver RJ has some suggestions for a short-term rice water-based diet suitable for a cat with diarrhoea (it is about halfway down the page). Check with your vet before using this.


Diarrhoea and Probiotics

If the diarrhoea is caused by antibiotics, you may need to re-balance the bacteria in the gut with probiotics. A small amount of natural, unflavoured yoghurt may help, but since many cats are lactose intolerant, there is a risk that this might actually make the diarrhoea worse. You may therefore find it easier to buy a commercial product in capsule form instead. There are a number of different types available. East meets west: integrative veterinary medicine (2007) Silver RJ recommends using a product with 1-10 billion CFU units per day (scroll down to Probiotic Cultures near the bottom of the page). Consumer Lab has a report on what probiotics do and how to choose one. Here are some to consider:

  • Acidophilus is a good choice for rebalancing gut bacteria - Pet Education discusses this. Effects of lactobacillus acidophilus DSM13241 as a probiotic in healthy adult cats (2006) Marshall-Jones ZV, Baillon M-LA,Croft JM & Butterwick RF American Journal of Veterinary Research 67(6) pp1005-1012 concluded that "administration of this probiotic results in beneficial systemic and immunomodulatory effects in cats."

  • Culturelle contains lactobacillus. A typical feline dose is half a capsule in the morning and half a capsule in the evening while the cat is on antibiotics, but check with your vet.

  • Benebac is designed especially for pets, and is available from Revival Animal Health among others.

  • FortiFlora is a nutritional supplement for cats which contains a probiotic, though it also contains vitamins, amino acids and iron. I therefore think it is perhaps not the best choice of probiotic, but some cats love it, so it may be helpful if added in small quantities to make food or pills more tempting. It is available from Entirely Pets.

Probiotics are currently being considered as a treatment for CKD in their own right; see below for more information.


Other Problems


Bad Breath

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.


Treating the uraemia will usually reduce the toxin levels and stop the itching. If your cat has high phosphorus levels, reducing these can also help. Occasionally itching may be related to low levels of Vitamin B6, in which case you should discuss supplementation with your vet.

Howling (Particularly at Night)

If this is caused by high toxin levels, it should decrease in frequency and volume as you get the toxins under control.

Howling is often a sign of hypertension, so ask your vet to rule this out. It may also be caused by deafness, hyperthyroidism, or occasionally just old age and possibly cognitive dysfunction (senility).


Certain medications such as periactin (Cyproheptadine) or mirtazapine (Remeron), both appetite stimulants, or anabolic steroids can make a cat become vocal. Metoclopramide (Reglan), used for stomach problems, may also have this effect.


Probiotics and Prebiotics

What are Probiotics?

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. Many commercial diets contain probiotics but Bacteriological evaluation of dog and cat diets that claim to contain probiotics (2003) Weese JS & Arroyo L Canadian Veterinary Journal 44 pp212215 concluded that "Overall, commercial pet foods that claim to contain probiotics appear to contain very low numbers of viable organisms, and often do not contain the species listed on the label... Results of this study indicate that these commercial diets are not good sources of probiotics."


This is not necessarily a problem because we all contain gut bacteria naturally, but some people choose to give probiotics orally as well. I am not aware that this is essential for most cats, but it can be helpful to re-balance the bacteria in the gut after using antibiotics, which cause diarrhoea in some cats. There is also some research indicating that probiotics may help with CKD, see below.


The National Institute for Health explains more about probiotics.

Probiotics {2013) Ridgway MD Clinician's Brief pp21-23 discusses the use of probiotics in animals.

Science-based Medicine (2009) is an article about the pros and cons of probiotics.

Probiotics and GI health (2010) Steiner JM CVC in Baltimore Proceedings explains more about probiotics.


What are Prebiotics?

Prebiotics encourage the intestinal bacteria (or flora) to grow. They are commonly fermentable fibre, particularly a type of fermentable fibre called fructooligosaccharides (FOS). Fermentable fibre provides a source of nutrients for the gastro-intestinal bacteria, i.e. essentially they are food for probiotics.


Prebiotics, probiotics and intestinal health (2011) Tremayne J Veterinary Practice News discusses prebiotics and 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

There is some research into the use of 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 (or prebiotics) 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."


One member of Tanya's CKD Support Group has, with her vet's approval, been giving her cat a tiny amount of locust bean gum (a prebiotic) mixed with water and added to canned food every day as a dietary supplement and thinks it has helped her cat and improved his bloodwork. She used a heaped 1/8th of a teaspoon of locust bean gum, mixed with 2 tablespoons of water, and added to a 3 oz can of wet food. It must be mixed with water before being added to the wet food because otherwise it can swell and cause choking. Do not try to mix it with dry food. If you wish to do something similar, please discuss it with your vet and remember, more is not always better. Please check fermentable fibre for the pros and cons of using fibre.  



Recent studies indicate that it may be possible to use probiotics to reduce toxins in a similar manner. Pilot study of probiotic dietary supplementation for promoting healthy kidney function in patients with chronic kidney disease (2010) Ranganathan N, Ranganathan P, Friedman EA, Joseph A, Delano B, Goldfarb DS, Tam P, Venketeshwer Rao A, Anteyi E & Musso CG Advances in Therapy 27(9) pp634-647 investigated the use of probiotics in human patients with CKD and found "The main outcomes of this preliminary trial include a significant reduction of BUN, enhanced well-being, and absence of serious adverse effects, thus supporting the use of the chosen probiotic formulation for bowel-based toxic solute extraction."


Can the bowel substitute for the kidney in advanced renal failure? (2008) Friedman EA Current Medical Research and Opinion 25(8) pp1912-8 has an excellent overview of the various ways of reducing toxins in CKD, including what it calls "bacterial enzyme nitrogen recycling within the gut."



What is Azodyl?

Azodyl is a product designed to help cats with CKD by reducing the workload of the kidneys. It contains a prebiotic, psyllium, a type of fibre commonly used to control constipation, together with strains of three particular probiotics:

  • Enterococcus (Streptococcus) thermophilus (KB19)

  • Lactobacillus acidophilus (KB27); and

  • Bifidobacterium longum (KB31)

These probiotics are not unique, but these particular strains are. The manufacturers claim that their strains of these bacteria, which they have patented, have a particularly high affinity for some of the major uraemic toxins found in CKD. Azodyl is intended to bind with and reduce the levels of these uraemic toxins in CKD cats (rather like the "nitrogen trapping" use of fermentable fibre in CKD), hence its name, which is a play on azotaemia and dialysis.


Kibow Biotech, which makes Renadyl (previously known as Kibow Biotics), the human version of Azodyl, calls this "enteric dialysis". Azodyl also seems to have some similarities to oral adsorbents such as Ipakitine/Epakitin, which also bind with uraemic toxins.


I have been asked why I think Azodyl and Renadyl are the same when Azodyl contains Enterococcus thermophilus, whereas Renadyl contains Streptococcus thermophilus. It is my understanding that they are actually the same - The regulatory environment (c. 1997) Pendleton B Direct-fed Microbial, Enzyme & Forage Additive Compendium says in the table on the bottom of the first page that Enterococcus thermophilus was formerly catalogued as Streptococcus thermophilus, but I am awaiting confirmation of this from the manufacturer.


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 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.


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 for ways to give it, and information on whether the way it is administered affects its effectiveness).


Azodyl FAQs answer a number of commonly raised questions about Azodyl.

Kibow Biotech explains more about the reasoning behind Azodyl.

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

Pilot study of probiotic dietary supplementation for promoting healthy kidney function in patients with chronic kidney disease (2010) Ranganathan N, Ranganathan P, Friedman EA, Joseph A, Delano B, Goldfarb DS, Tam P, Venketeshwer Rao A, Anteyi E & Musso CG Advances in Therapy 27(9) pp634-647 reports on a trial of Renadyl, the human version of Azodyl, on human patients in four locations. BUN levels fell and the patients felt better.

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 2012 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 (30 billion) as Azodyl (15 billion), and which is safe to use in cats, is already available in some other markets under the name of Renadyl. Renadyl 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 at some point.


In theory you can import Azodyl into Europe from the USA, and some suppliers who are prepared to ship to Europe are below. Since the product should ideally be kept chilled, 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, and the manufacturer has stated that the bacteria can survive for up to fourteen days at temperatures of 25 Celsius, 77 Fahrenheit.


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 (this is so the bacteria are not killed off by stomach acid). For this reason the capsules are intended to be given whole; however, since the product was originally developed for use in humans, the capsules were 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.


Therefore some people opened the capsules and gave the contents separately, often mixing them with food. The Veterinary Information Network ran a trial into Azodyl to investigate whether giving Azodyl in this way affected 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 discussed the results of this trial with the manufacturer, who 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. Given in this way, the Azodyl should still be about 80% effective. It should not be mixed with liquids as this will activate the bacteria in the product too early, making it less effective.


Following complaints from many users about the difficulty in giving Azodyl in the intended, optimal manner, the manufacturers launched a smaller capsule in April 2012 under the name of Azodyl Small Caps, which can still hold the correct number of bacteria (15 billion) but which is smaller because it has less filler. Azodyl Small Caps are sold in 90 per container versus 60 per container for standard Azodyl. To the left is a photo from Virginia and Jellybean of the two Azodyl capsule types together with a quarter, to give you an idea of the difference in sizes.


Many people find it easier to give Azodyl intact in the Small Caps form, but some still prefer to open the capsules. In these cases, 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 CKD Support Group are generally positive about Azodyl when given in this way.




In the Palmquist study mentioned above, Renadyl, the human version of Azodyl, was found to be effective even when mixed with meals. This could be because Renadyl contains twice as many bacteria as Azodyl, so more bacteria survived. One member of Tanya's CKD 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 Renadyl instead (for suppliers, see below).


The Compendium of Veterinary Products has an information sheet from Vetoquinol Canada which states that Azodyl should not be used in diabetic cats.


Azodyl should not be given at the same time as antibiotics; separate them by 6 hours.


Azodyl Storage

Azodyl should be kept in the fridge, otherwise the bacteria may die. They can probably survive for some time in normal weather (up to fourteen days at temperatures of 25 Celsius, 77 Fahrenheit, 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, especially if you live in a hot climate, because there is no guarantee that it was shipped chilled to the retailer. 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.


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, Renadyl, from a US supplier, but it may be available within Europe at some indeterminate time. Renadyl 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.



  • Entirely Pets sells 60 Azodyl capsules for US$29.99 plus shipping of US$29.95 or 180 capsules for US$87.99. Shipping is free on orders over US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled.

  • Entirely Pets sells 90 Azodyl Small Caps capsules for US$43.99 (normally US$57.99) plus shipping. Shipping is free on orders over US$85 (may not apply for the required chilled shipping). 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$39.95, plus chilled shipping. I used Thriving Pets within the USA myself for other items with no problems.

  • Thriving Pets sells 90 Azodyl Small Caps capsules for US$54.95 plus chilled shipping. I used Thriving Pets within the USA myself for other items with no problems.

  • Thriving Pets also sells Renadyl, the human version of Azodyl. 90 capsules cost US$49.95 plus chilled 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.

  • Kibow Biotech sells three bottles of Renadyl for US$135 plus ground shipping costs of US$14.95.

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


  • Entirely Pets sells 60 Azodyl capsules for US$29.99 plus shipping of US$29.95 or 180 capsules for US$87.99. Shipping is free on orders over US$85 (may not apply for the required chilled shipping). 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.

  • Entirely Pets sells 90 Azodyl Small Caps capsules for US$43.99 (normally US$57.99) plus shipping. Shipping is free on orders over US$85 (may not apply for the required chilled shipping). 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$55 (may not apply for the required chilled shipping). 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 sells 90 Azodyl Small Caps capsules for US$39.95 plus shipping. Shipping is free on orders over US$55 (may not apply for the required chilled shipping). 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 Renadyl, 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 Renadyl.


If you import Azodyl into the UK from the USA, it may sometimes be delayed because if Customs decide you need to pay duty, Parcelforce write to tell you this and do not deliver until you have paid, rather than simply delivering the parcel and asking you to pay at that time (which is what UPS do). If you have a tracking number, follow it and try calling Parcelforce once you think they have your parcel so you can pay over the phone or go and collect your parcel personally. It is better to order on a Monday, so your parcel does not end up sitting in Customs all weekend.

  • Allivet sells 60 Azodyl capsules for US$30.99 plus shipping of around US$35-45. One member of Tanya's CKD Support Group in Hong Kong ordered from this supplier and the Azodyl was still chilled when it arrived.

  • Entirely Pets sells 60 Azodyl capsules for US$29.99 plus shipping of US$29.95 or 180 capsules for US$87.99. Shipping is free on orders over US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled. 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.

  • Entirely Pets sells 90 Azodyl Small Caps capsules for US$43.99 (normally US$57.99) plus shipping. Shipping is free on orders over US$85 (may not apply for the required chilled shipping). I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled. 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$55 (may not apply for the required chilled shipping). 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 sells 90 Azodyl Small Caps capsules for US$39.95 plus shipping. Shipping is free on orders over US$55 (may not apply for the required chilled shipping). 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 Renadyl, 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 Renadyl for US$135 plus shipping costs. Unfortunately, following the change of name from Kibow Biotics to Renadyl, international shipping costs a ridiculous US$150. I guess they have to recoup the costs of the name change somehow.

Astro's Nitrogen Scrub


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 function (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 help combat inflammation by mopping up free radicals which can cause damage to cells and are associated with aging and disease. Research Participation Opportunities offers the chance to participate into a trial investigating oxidative stress in CKD cats.


Using antioxidants in dogs and cats is an article from Pet Education which explains more about them.

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

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. Hill's Evidence Based Clinical Nutrition has more information on this study.


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. This study was completed in 2013 but Winn Feline Foundation reported that "administration of vitamin E did not appear to affect the clinical presentation, degree of oxidative stress, or level of anemia in cats with chronic kidney disease."


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


See Nutritional Requirements for more information on vitamin E.


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. 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 may not be appropriate if your cat is on blood thinners such as aspirin or clopidogrel. University of Maryland Medical Center says "There have been reports that CoQ10 may make medications such as warfarin (Coumadin) or clopidigrel (Plavix) less effective at thinning the blood. If you take blood thinners, ask your provider before taking CoQ10."



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


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 is in the previous paragraph). 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 CKD 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. Some people put it in a gelcap. 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.


Oral Adsorbents


Adsorbents are products that bind with something else, and adsorbents used in the treatment of CKD usually bind with toxins, thus improving wellbeing. Phosphorus binders are an obvious example of an oral adsorbent, but this section focuses on newer types of adsorbents.


Almost all of the research into the use of these newer products has taken place in Japan, and some of these adsorbents seem to be routinely used in Japan when treating human CKD patients; therefore, if you are in Japan, you may also be offered these treatments for your cat. However, one such treatment, Ipakitine, was developed in Germany.

Can the bowel substitute for the kidney in advanced renal failure? (2008) Friedman EA Current Medical Research and Opinion 25(8) pp1912-8 has an excellent overview of the various ways of reducing toxins in CKD, including reference to Kremezin.




Ipakitine has been available in the UK since December 2002 and in the rest of Europe for even longer. Ipakitine was introduced into the USA in 2005, under the slightly different name of Epakitin.

What is Ipakitine

Ipakitine is partly a phosphorus binder, containing calcium carbonate. However, it also contains an adsorbent called chitosan, which is said to help with uraemic toxins.


How Does Ipakitine Work?

Phosphorus Binders explains more about phosphorus binders and calcium-based phosphorus binders in particular.


Chitosan is a polysaccharide similar to cellulose and is obtained from the shells of crustaceans (shell fish such as crabs). 


When protein is eaten and digested, an amino acid in the food called tryptophan is converted into indoxyl, which in turn is converted by the body into indoxyl sulphate, a type of uraemic toxin. Chitosan is said to bind with the indoxyl, so it cannot be converted to indoxyl sulphate, thus reducing toxin levels, which helps the cat to feel better. Chitosan is also said by the manufacturer to help reduce BUN/urea levels, and indirectly to reduce creatinine levels. The manufacturer appears to be basing these claims largely on the results of human trials (see clinical trials).


Chitosan may also reduce cholesterol levels, but high cholesterol levels are not normally a concern for cats as they are for humans; it is also said to increase levels of haemoglobin. 


Web MD has some information about chitosan.


When and How is Ipakitine Used

In the USA, Epakitin is marketed as both a "nutraceutical" and a "nutritional supplement". In the marketing literature, emphasis seems to be placed on its role as a phosphorus binder, but many vets seem to sell it to clients whose cats do not have elevated phosphorus levels, so they are presumably advocating it for its chitosan-related effects.


From my discussions with German users of Ipakitine, it seems to be commonly prescribed in Germany for cats who refuse to eat a prescription diet; I presume this is both for its phosphorus-binding effects and for its toxin-binding effects (since higher levels of protein in the diet may cause increased BUN levels).


My own vet in the UK has seen falls in creatinine and urea in some cats when using Ipakitine and no other treatments. I used it myself for Ollie who did not have very high phosphorus levels, and to whom none of the cautions below applied. It did appear to reduce his phosphorus levels.


Ipakitine comes in powder form, and is apparently tasteless. It is sprinkled on the cats food for a period of up to six months, although it may be used for longer if your vet agrees. Dosage is weight-related, and phosphorus levels do not appear to be taken into account when determining how much to give.


Ipakitine Clinical Trials

Effects of an intestinal phosphorus binder on serum phosphorus and parathyroid hormone concentration in cats with reduced renal function (2008) Brown SA, Rickertson M & Sheldon S International Journal of Applied Research in Veterinary Medicine 6(3) pp155-160 reports on a small randomised placebo-controlled study of twelve cats at the University of Georgia College of Veterinary Medicine (partly funded by the manufacturers) which indicated that Epakitin reduced phosphorus levels in the cats, who were fed a commercial (non-prescription) diet and who were in IRIS Stages 1 and 2. The study did not find that Ipakitine reduced BUN or creatinine levels in this study, however the cats in this study did not have naturally occurring kidney disease, which the cats in the 2004 study below did.

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

Effect of iron (III) chitosan intake on the reduction of serum phosphorus levels in rats (2000) Baxter J, Shimizu F, Takiguchi Y, Wada M, Yamaguchi T The Journal of Pharmacy and Pharmacology 52 pp863-74 indicated that a compound of iron and chitosan might be a more effective phosphorus binder than the commonly used binders. This is, however, not the same product as Ipakitine, and cats are not rats.

Effect of chitosan on renal function in patients with chronic renal failure (1997) Jing SB, Li L, Ji D, Takiguchi Y, Yamaguchi T The Journal of Pharmacy and  Pharmacology 49 pp721-23 describes a human trial into the effects of chitosan on 80 patients undergoing long term haemodialyis in Japan. The patients' cholesterol levels reduced and their haemoglobin levels increased, and their appetites improved; reductions in BUN/urea and creatinine were also seen after four weeks of treatment. 


Ipakitine Cautions

According to the manufacturer, Ipakitine contains a high (70-90) percentage of lactose, so I would not use it if your cat is lactose intolerant.


Products containing calcium are not normally suitable for cats with high calcium levels (hypercalcaemia). The risk of hypercalcaemia is lower with calcium carbonate-based binders (which is what Ipakitine contains) than with other calcium-based binders, but if your cat is taking Ipakitine, it would probably be wise to monitor his/her calcium levels. Ipakitine should not be used in cats taking calcitriol.

Calcium-based phosphorus binders are not as effective as aluminium hydroxide based binders, and the type of calcium contained in Ipakitine (calcium carbonate) is the least effective type of calcium-based binder: calcium acetate type binders bind 2-3 times as much phosphorus as calcium carbonate based ones. There is more information on these issues on the Phosphorus Binders page.

Indoxyl sulphate is only one of a number of uraemic toxins, so Ipakitine alone may not be sufficient to deal with problems such as stomach acid.

Ipakitine Suppliers



  • Entirely Pets sells Epakitin for US$16.49 (50g). Other sizes are available.

  • Medi-Vet sells Epakitin for US$19.04 (50g), US$47.89 (150g) or US$68.89 (300g).


Kremezin (AST-120)

Kremezin (AST-120) is an oral adsorbent based on charcoal which has been used to treat human CKD patients in Japan since 1991. It has been tested on humans (these trials continue) and on rats with surgically-induced kidney disease, but not on cats as far as I am aware.


Kremezin was developed by Kureha Chemical Industries and has been marketed in Japan for the treatment of feline CKD by Sankyo Lifetech under the trade name of Covalzin. I have heard from a couple of Japanese people who have used it on their cats without any problems, and they thought it might have helped their cats.


This part of Sankyo Lifetech's business was sold to Novartis in 2007. I assumed they planned to introduce Covalzin into Western markets but they haven't done so as yet. The human version of Kremezin has not been made commercially available in the USA to date, although JCN Network reports that Kureha Chemical Industries introduced Kremezin in South Korea in 2005.


A multi-center, randomized, double-blind, placebo-controlled, dose-ranging study of AST-120 (Kremezin) in patients with moderate to severe CKD (2006) Schulman G, Agarwal R, Acharya M, Berl T, Blumenthal S, Kopyt N American Journal of Kidney Disease 47(4) pp565-577 is a study of human CKD patients in the USA. The study found that AST-120 did not reduce creatinine levels, but it did appear to help the patients feel better ("significant improvements in malaise were observed").


Combination therapy with benazepril and oral adsorbent ameliorates progressive renal fibrosis in uraemic rats (2002) Aoyama I, Shimokata K, Niwa T Nephron 90 pp 297-312 - this study of a very small group of rats with surgically-induced kidney disease indicated that rats treated with both medications did better than rats treated with neither or with only the benazepril.


Indoxyl sulfate and progression of renal failure: effects of a low protein diet and oral sorbent on indoxyl sylfate production in uremic rats and undialysed uremic patients (1997) Niwa T, Tsukushi S, Ise M, Miyazaki T, Tsubakihara Y, Owada A, Shiigai T Mineral and Electrolyte Metabolism 23 pp179-184 suggests that the use of Kremezin may reduce levels of indoxyl sulphate, as does a low protein diet. 


Oral charcoal adsorbent (AST-120) prevents progression of cardiac damage in chronic kidney disease through suppression of oxidative stress (2009) Fujii H, Nishijima F, Goto S, Sugano M, Yamato H, Kitazawa R, Kitazawa S & Fukagawa M Nephrology Dialysis Transplantation 24(7) pp2089-95 found that Kremezin reduced heart damage in human CKD patients.



I have heard from a couple of people using activated charcoal, which has a similar mechanism to Kremezin. Activated charcoal is used to treat human overdoses by absorbing toxins. I have no knowledge of appropriate doses for CKD cats. Please do not use this without your vet's knowledge and approval. Charcoal may darken stools.


Combination of oral activated charcoal plus low protein diet as a new alternative for handling in the old end-stage renal disease patients (2010) Musso CG, Michelangelo H, Reynaldi J, Martinez B, Vidal F, Quevedo M, Parot M, Waisman G & Algranati L Saudi Journal of  Kidney Disease & Transplantation 21(1) pp102-4 reports on the use of charcoal and a low protein diet in elderly (over 80) patients who had declined dialysis. It found that BUN and creatinine levels fell significantly and none of the patients experienced a crisis.




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This page last updated: 22 November 2016


Links on this page last checked: 24 April 2012







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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