Tanya

 

TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

 

TREATMENTS:

 

THE REGULATION OF WASTE PRODUCTS (URAEMIA)

 

ON THIS PAGE:


What is Uraemia?


Appetite Loss, Nausea and Vomiting Treatments


Gastrointestinal Treatments: Mouth Ulcers, Gastrointestinal Bleeding, Diarrhoea


Sucralfate


General Toxin Reduction


General Toxin Reduction: Fluid Therapy


General Toxin Reduction: Use of the Gastrointestinal Tract


Probiotics


Prebiotics, Including Astro's Nitrogen Scrub


Azodyl and Renadyl


Oral Adsorbents: Chitosan, Including  Ipakitine/Epakitin, Yucca, Charcoal (Kremezin), Porus One


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


 

 

HOME


Site Overview


Just Diagnosed? What You Need to Know First


Search This Site


 

WHAT IS CKD?


What Happens in CKD


Causes of CKD


How Bad is It?


Is There Any Hope?


Acute Kidney Injury


 

KEY ISSUES: PROLONGING LIFE


Phosphorus Control


Hypertension

(High Blood Pressure)


Proteinuria


Anaemia


Potassium Imbalances


Pyelonephritis (Kidney Infections) and Urinary Tract Infections NEW


Metabolic Acidosis


Kidney Stones


 

KEY ISSUES: HELPING YOUR CAT FEEL BETTER


Nausea, Vomiting, Appetite Loss and Excess Stomach Acid


Maintaining Hydration


The B Vitamins (Including Methylcobalamin)


Constipation


 

CAT FOOD DATA


Ways of Assessing Food Content, Including What is Dry Matter Analysis


How to Use the Food Data Tables


USA Canned Food Data


USA Dry Food Data


USA Cat Food Brands: Helpfulness Ratings


USA Cat Food Brands: Contact Details


USA Food Data Book


UK Canned Food Data


UK Dry Food Data


UK Cat Food Brands: Helpfulness Ratings


UK Cat Food Brands:

Contact Details


 

SUPPORT


Coping with CKD


Tanya's Support Group


Success Stories


 

SYMPTOMS


Important: Crashing


Alphabetical List of Symptoms and Treatments


Fluid and Urinary  Imbalances (Dehydration, Overhydration and Urinary Issues)


Waste Product Regulation Imbalances (Vomiting, Appetite Loss, Excess Stomach Acid, Gastro-intestinal Problems, Mouth Ulcers Etc.)


Phosphorus and Calcium Imbalances


Miscellaneous Symptoms (Pain, Hiding Etc.)


 

DIAGNOSIS: WHAT DO ALL THE TEST RESULTS MEAN?


Early Detection


Blood Chemistry: Kidney Function, Potassium, Other Tests (ALT, Amylase, (Cholesterol, Etc.)


Calcium, Phosphorus, Parathyroid Hormone (PTH) and Secondary Hyperparathyroidism


Complete Blood Count (CBC): Red and White Blood Cells: Anaemia and Infection


Urinalysis (Urine Tests)


Other Tests: Ultrasound, Biopsy, X-rays etc.


Renomegaly (Enlarged Kidneys)


Which Tests to Have and Frequency of Testing


Factors that Affect Test Results


Normal Ranges


International and US Measuring Systems


 

TREATMENTS


Which Treatments are Essential


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


Waste Product Regulation (Mouth Ulcers, GI Bleeding, Antioxidants, Adsorbents, Azodyl, Astro's CRF Oil)


Phosphorus, Calcium and Secondary Hyperparathyroidism (Calcitriol)


Phosphorus Binders


Steroids, Stem Cell Transplants and Kidney Transplants


Antibiotics and Painkillers


Holistic Treatments (Including Slippery Elm Bark)


ESAs (Aranesp, Epogen etc.) for Severe Anaemia


General Health Issues in a CKD Cat: Fleas, Arthritis, Dementia, Vaccinations


Tips on Medicating Your Cat


Obtaining Supplies Cheaply in the UK, USA and Canada


Working with Your Vet and Recordkeeping


 

DIET & NUTRITION


Nutritional Requirements of CKD Cats


The B Vitamins (Including Methylcobalamin)


What to Feed (and What to Avoid)


Persuading Your Cat to Eat


2007 Food Recall USA


 

FLUID THERAPY


Oral Fluids


Intravenous Fluids


Subcutaneous Fluids


Tips on Giving Subcutaneous Fluids


How to Give Subcutaneous Fluids with a Giving Set


How to Give Subcutaneous Fluids with a Syringe


Subcutaneous Fluids - Winning Your Vet's Support


Dialysis


 

RELATED DISEASES


Heart Problems


Hyperthyroidism


Diabetes


Polycystic Kidney Disease (PKD)


Pancreatitis


Dental Problems


Anaesthesia


 

OBTAINING SUPPLIES CHEAPLY


UK


USA Online


USA Local (Fluids)


Canada


 

SAYING GOODBYE


The Final Hours


Other People's Losses


Coping with Your Loss


 

MISCELLANEOUS


Prevention


Feline CKD Research, Including Participation Opportunities


CKD Research in Other Species


Share This Site: A Notice for Your Vet's Bulletin Board or Your Local Pet Shop


Canine Kidney Disease


Other Illnesses (Cancer, Liver) and Behavioural Problems


Diese Webseite auf Deutsch


 

SITEOWNER (HELEN)


My Three CKD Cats: Tanya, Thomas and Ollie


My Multi Ailment Cat, Harpsie


Find Me on Facebook


Follow Me on Twitter


Contact Me


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

 


Overview


  • As the kidneys gradually lose their ability to regulate and remove waste products effectively, these waste products build up in the blood. This is called uraemia and can make a cat feel very unwell.

  • Generally speaking, cats with creatinine over 3 mg/dl (US) or 265 µmol/L (international), will have problems with uraemia.

  • Controlling the CKD should help your cat feel a lot 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.


What is Uraemia?


 

One of the main roles of the kidneys is filtering the blood to regulate and remove waste products or toxins. Kidneys damaged by CKD gradually lose their ability to do this properly, so these waste products build up in the blood: this is called azotaemia. This can make a cat feel very unwell, and the clinical signs and symptoms that azotaemia causes are collectively known as uraemia.

 

The uraemic toxins which the cat's damaged kidneys are unable to filter properly include parathyroid hormone. Contrary to popular opinion, BUN and creatinine are not toxins themselves. However, BUN levels correlate with uraemic toxin levels, i.e. if BUN is elevated, it is highly likely that uraemic toxins (which are less easy to measure) are also elevated.

 

Generally speaking, you will probably start seeing signs of uraemia in cats who are properly hydrated but whose creatinine is over 3 mg/dl (US) or 265 µmol/L (international).

 

University of Georgia College of Veterinary Medicine has some information about uraemia.

 


Appetite Loss, Nausea and Vomiting


 

These are extremely common problems in CKD cats, so there is a page devoted to the subject here.

 


Gastrointestinal Problems


 

Gastrointestinal problems that may sometimes be seen in CKD cats are:


Mouth Ulcers


 

Mouth ulcers can be very painful, so treating them is important for your cat's wellbeing.

 

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

 

Mouth Ulcers: Holistic Treatments


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

 

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 tried 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.

 

Mouth Ulcers: Other Treatments


For really obstinate ulcers, talk to your vet about using sucralfate, which forms a protective coating over the ulcers and allows them to heal. Sucralfate is discussed below.

 

For severe mouth ulcers, antibiotics may be necessary.

 

Mouth Ulcers: Eating


It can be hard to get a cat with mouth ulcers to eat because the ulcers 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.

 

If the ulcers are really severe, you may have to consider a feeding tube.

 

See Persuading Your Cat to Eat for more tips.

 


Gastrointestinal Bleeding


 

If uraemia is severe, the cat may occasionally develop gastrointestinal bleeding. Nutritional management of chronic renal disease Fascetti AJ & Delaney S University of California at Davis says "The waste products may also enhance blood loss by leading to the formation of gastrointestinal ulcers and a reduction in blood clotting ability."

 

Gastrointestinal bleeding can cause anaemia and is potentially very serious, so getting it under control is extremely important, but unfortunately it is not always apparent, though one possible symptom is diarrhoea. Renal Disease (2006) Polzin DJ Delaware Valley Academy of Veterinary Medicine says "Uremic enterocolitis, manifested as diarrhea, may occur in dogs and cats with severe uremia, but it is typically less dramatic and less common than uremic gastritis. Owners of 80 cats with spontaneous CKD did not report diarrhea. However, when present, uremic enterocolitis is often hemorrhagic. Considerable gastrointestinal hemorrhage may initially escape clinical detection."

 

See Symptoms for more information on possible symptoms and Diagnosis for more information on how to test for gastrointestinal bleeding.

 

Gastrointestinal Bleeding: Holistic Treatments


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

 

Yunnan baiyao is a herb which is used in humans to control bleeding. Angell Animal Medical Center has also used it in animals for many years. Yunnan baiyao, to use or not to use? (2017) Whelan M Angell Animal Medical Center explains more about the use of yunnan baiyao and says that it "currently appears safe since there have been no reported adverse effects."

 

Yunnan baiyao for patients with hemorrhage, neoplasia (2017) McKenzie B Veterinary Practice News reports on the use of yunnan baiyao and states that there is very little supporting research into its use. I am not aware of any studies in cats.

 

Members of Tanya's CKD Support Group have used yunnan baiyao in their cats with gastrointestinal bleeding and many have found it helpful. As ever though, do not use it without talking to your vet first.

 

Gastrointestinal Bleeding: Other Treatments


Proton pump inhibitors appear to help some human patients with gastrointestinal bleeding. Approach to acute upper gastrointestinal bleeding in adults (2018) Saltzmann JR UpToDate talks about gastrointestinal bleeding in humans before and after endoscopy and says "acid suppressive therapy with H2 receptor antagonists has not been shown to significantly lower the rate of ulcer rebleeding. By contrast, high dose antisecretory therapy with an intravenous infusion of a PPI significantly reduces the rate of rebleeding compared with standard treatment in patients with bleeding ulcers." It also says "PPIs may also promote hemostasis in patients with lesions other than ulcers. This likely occurs because neutralization of gastric acid leads to the stabilization of blood clots."

 

I do not know if the same applies to cats with gastrointestinal bleeding, who have not usually undergone an endoscopy, and the PPI in the above scenario was given intravenously, not orally, but it might be worth talking to your vet about using a PPI such as omeprazole.

 

More serious gastrointestinal bleeding 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.

 


Diarrhoea


 

There are a number of possible causes of diarrhoea in CKD cats, which are discussed in the Symptoms chapter. Depending upon the cause, diarrhoea may only last for a day. However, if it goes on any longer, or stops and then starts again, I would recommend a trip to the vet because cats with diarrhoea may become dehydrated (which does not only mean water loss, the cat may also be losing potassium).

 

Although it is not overly common, in CKD cats uraemia may be a cause of diarrhoea, and this in turn may be a sign of gastrointestinal bleeding. Renal Disease (2006) Polzin DJ Delaware Valley Academy of Veterinary Medicine says "Uremic enterocolitis, manifested as diarrhea, may occur in dogs and cats with severe uremia, but it is typically less dramatic and less common than uremic gastritis. Owners of 80 cats with spontaneous CKD did not report diarrhea. However, when present, uremic enterocolitis is often hemorrhagic. Considerable gastrointestinal hemorrhage may initially escape clinical detection."

 

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.

 

International Cat Care discusses diarrhoea treatments.

 

Diarrhoea: Diet


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.

 

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.

 

East meets west: integrative veterinary medicine (2007) Silver RJ Delaware Valley Academy of Veterinary Medicine 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.

 

If your cat has chronic digestive problems, your vet may recommend a therapeutic food such as Hill's i/d, which has protein and phosphorus levels acceptable for most CKD cats (40.6% and 0.80% respectively for the canned food).

 

Diarrhoea: Holistic Treatments


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.

 

Some people also find pumpkin or similar types of fibre, traditionally used to treat constipation, may also help with diarrhoea, because they may help rebalance the gut bacteria (see probiotics below).

 

Diarrhoea: Kaolin and Pectin


Another possible option is to use a medication containing kaolin and pectin for a few days, with your vet's approval.

 

Kaolin is a kind of clay. Drugs explains "When given orally, kaolin, especially light kaolin, adsorbs substances from the GI tract and increases the bulk of feces. Kaolin improves stool consistency within 24 to 48 hours; however, it does not decrease the number of stools passed or reduce the amount of fluids lost."

 

Pectin is a kind of fibre, found in many plants and fruits. Drugs says "Pectin has been used in the management of diarrhea for many years. Pectin supplementation was as effective as green bananas in the management of persistent diarrhea in children. Both pectin and banana reduced the volume of stool, improved stool quality, decreased the amount of oral replacement solutions and intravenous fluids for hydration needed, and shortened the duration of illness. In a study of 44 critically ill, tube-fed adults receiving antibiotics, there was a trend toward decreased diarrhea in those receiving fiber and pectin. Pectin stimulates epithelial growth in the colon, thus reducing diarrhea. Additional suggested mechanisms of action in the GI tract include the effect of peptic oligosaccharides on the intestinal microflora."

 

It is difficult to find products combining both kaolin and pectin in the USA because, as Web MD explains about human products, "Kaolin has been used for years in combination with pectin (Kaopectate) for diarrhea. However in April 2003, the U.S. Food and Drug Administration (FDA) found that there wasn't enough scientific support for kaolin's use in treating diarrhea. Since April 2004, drug manufacturers have not been allowed to put kaolin in diarrhea medicine."

 

A human product called kaopectate was a popular choice for cats, but as a result of the FDA's directive, the formulation has changed and is no longer safe for cats, as explained by the American Veterinary Medical Association.

 

Pet Pectillin is a brand of pectin and kaolin which is safe for cats. Drugs has some information about it. It is available from a number of suppliers, including Drs Foster and Smith and Arcata Pet.

 

Pro Pectalin is another product containing kaolin and pectin available in both gel and tablet form, though it also contains a probiotic called E. faecium. It is available from Chewy and Amazon  among others.

 

You can also buy kaolin, and then buy pectin separately. The apple pectin product sold by some supermarkets for making preserves usually contains additives, so is not suitable for this purpose. Twinlabs apple pectin tablets are available in many health stores and also from Affordable Natural Supplements.

 

Drugs recommends giving kaolin at least three hours apart from other medications.

 

Diarrhoea: Probiotics


Probiotics ("good" bacteria). may help with diarrhoea, particularly when a cat is receiving antibiotics. Antibiotics aim to eradicate the bacteria causing an infection. However, they will also eradicate "good" bacteria which normally protect the body from infection, and in some cases this can lead to diarrhoea.

 

Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis (2012) Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, Johnsen B & Shekelle PG Journal of the American Medical Association 307(8) pp1959-69 found that giving probiotics may help with this type of diarrhoea, though further studies are needed to determine which probiotics work best with which antibiotic.

 

See below for more on probiotics and which may help with diarrhoea.

 

Diarrhoea: Loperamide (Imodium)


Loperamide (Imodium) is a mild narcotic that also has an effect on diarrhoea by slowing down gastrointestinal contractions.

 

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. Plumb's Veterinary Drug Handbook says "Not commonly used in cats and its use is controversial; cats may react with excitatory behavior." It also advises against the use of loperamide in patients with severe renal insufficiency.

 

It can be hard to work out and measure a cat-sized dose of loperamide. Plumb's Veterinary Drug Handbook says "a) For Diarrhea: Using the suspension 0.04 -- 0.06 mg/kg PO twice daily (Tams 1999). b) 0.08--0.16 mg/kg PO q12h (Willard 2003)." How to manage feline chronic diarrhea Part-II:treatment (2010) Cook AK & Purcell S Veterinary Medicine  says on page 8 "0.04 to 0.06 mg/kg orally every 12 hours."

 

How to manage feline chronic diarrhea Part-II:treatment (2010) Cook AK & Purcell S Veterinary Medicine  also says on page 8 "we think that these drugs are rarely appropriate in feline patients and can cause adverse reactions, including respiratory depression and excitatory behavior."

 

Other treatments outlined here are much safer, but your vet might occasionally prescribe loperamide for short-term use for intractable diarrhoea. Loperamide is available without a prescription, but please do not use it without your vet's knowledge and approval.

 


Sucralfate (Carafate, Antepsin)


 

Sucralfate is sucrose aluminium hydroxide. It has previously been 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 ulceration to heal. Members of my support group who have used sucralfate have found it very helpful for both mouth ulcers and gastrointestinal bleeding.

 

Trade names include Carafate in the USA, Antepsin in the UK and Ulcogant in Germany. There is also a feline version called  Mucosalfate, see formulations below.

 

11 guidelines for conservatively treating chronic kidney disease (2007) Polzin D, Veterinary Medicine Dec 2007 recommends (page 5) "Providing mucosal protection with sucralfate" and adds "Sucralfate is added when gastrointestinal ulcers and hemorrhage are suspected."

 

Sucralfate is widely available but unfortunately may be difficult to obtain in the UK where it has been out of stock since 2014 due to manufacturing problems. The manufacturer explains more about this. It may be back in stock by the time you read this, but if you are struggling to find it, 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 manufacturer's statement above; it was not cheap (more than Ł100).

 

Mar Vista Vet has information about sucralfate.

 

Pet Place has some information about sucralfate, including dosage suggestions.

 

Sucralfate Formulations


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.

 

Sucralfate Dosage


A common dose is Ľ-˝ (0.25-0.5) a gram three to four times a day. This is the same as 250-500mg three to four times a day.

 

Plumb's Veterinary Drugs Handbook (7th Ed.) says "It is empirically dosed at Ľ-˝ of a 1 gram tablet (250 – 500 mg) for toy breed dogs and cats."

 

The Mucosalfate paste has its own dosing as outlined here.

 

Sucralfate How To Give


Most people mix the suspension form of sucralfate with water, draw the mixture into a syringe and give it that way. Plumb's Veterinary Drugs Handbook (7th Ed.) says "May be crushed and suspended in water or compounded into a suspension (see Compatibility/Compounding Considerations) and used within 14 days."

 

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.

 

Sucralfate Side Effects


 

Plumb's Veterinary Drugs Handbook (7th Ed.) mentions that vomiting may be seen in cats.

 

Sucralfate Interactions


Sucralfate must be give separately (two hours apart) from antibiotics in the fluoroquinolone family because it may reduce the effectiveness of the antibiotics. This includes enrofloxacin (Baytril), marbofloxacin (Marbocyl), pradofloxacin (Veraflox) and orbifloxacin (Orbax). Drugs has some information about this.

 

Plumb's Veterinary Drug Handbook used to recommend giving sucralfate at least two hours apart from famotidine (Pepcid AC), because the 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 and famotidine after all.

 

Plumb's Veterinary Drug Handbook (7th Ed.)  does still recommend separating sucralfate from ranitidine (Zantac 75) or cimetidine (Tagamet).

 


Toxin Reduction


 

In CKD, the kidneys may struggle to cope with the excretion of urea and uraemic toxins, leading to these toxins building up in the cat's body and making the cat feel unwell.

 

The treatments described above relate to specific problems linked to uraemia. The rest of this page focuses on general treatments that may help with uraemia, including these possible symptoms:

 

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.

 

Itching


Treating the uraemia will usually reduce the toxin levels and stop the itching.

 

If your cat continues to itch and scratch, you need to consider other possible causes, such as high phosphorus levels

 

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 may have other causes such as:

 

I would recommend always having blood pressure checked in a howling cat.

 


Toxin Reduction: Fluid Therapy


 

People often refer to fluid therapy as removing the toxins from the body, often by flushing

 

Dialysis certainly removes toxins; however, it is extremely expensive, so rarely used in cats in practice.

 

Intravenous fluids are sometimes used in CKD cats to flush through the kidneys to correct severe dehydration and any resulting electrolyte imbalances, and to remove toxins from the blood. Flushing the kidneys in this way is known as diuresis. It is usually reserved for cats with high bloodwork values, i.e. creatinine over around 6-7 mg/dl (US) or 550-650 µmol/l (international). IV fluids are also used for cats who have suffered an acute insult to the kidneys (acute kidney injury), such as a kidney infection or kidney stones. In some cases, IV fluids may succeed in flushing out kidney stones.

 

Subcutaneous fluids are intended to maintain your cat's hydration levels, so you are unlikely to be giving enough fluid to flush out toxins. This is intentional - you should not increase the amount you give. Maintaining your cat's hydration levels should minimise the risk of toxins building up.

 


Toxin Reduction: Using the Gastrointestinal Tract (Probiotics and Prebiotics)


 

There has long been interest in whether other bodily mechanisms might be useful for relieving the load on damaged CKD kidneys. Most of the urea produced by the body is excreted via the kidneys, but the remainder is excreted via the large intestine, so some researchers have looked at whether it is possible to use the gastrointestinal tract to help remove uraemic toxins. Reducing the load on the kidneys by diverting the excretion of urea from the kidneys to the gastrointestinal tract is sometimes referred to as "nitrogen trapping."

 

Bowel as a substitute in renal failure (1996) EA Friedman American Journal of Kidney Diseases 28(6) pp943-50 states "Extraction, modification, or recycling of nitrogenous wastes by the gastrointestinal tract is a potentially low-cost means of substituting for missing renal function. Multiple approaches to the bowel as a substitute kidney have been attempted."

 

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."  

 

One way of doing this is through the use of probiotics and/or prebiotics. The manufacturer of Renadyl, a product containing both prebiotics and probiotics, has trademarked the term "enteric dialysis" to describe the mechanism of its product. Nutritional management of renal disease: an evidence-based approach (2014) Sanderson SL Today's Veterinary Practice 4(1) pp51-56 explains the theory behind enteric dialysis.

 

How helpful this can be is debatable, because BUN and creatinine are not toxins themselves. However, BUN levels correlate with uraemic toxin levels, i.e. if BUN is elevated, it is likely that uraemic toxins (which are less easy to measure) are also elevated. However, it is not known whether these mechanisms do reduce levels of uraemic toxins.

 

Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge Symposium pp18-20 says "Oral probiotics operate as “enteric dialyzers,” relying on the intestinal tract to eliminate wastes normally excreted by the kidneys. Live bacteria can catabolize urea and other uremic toxins, effectively trapping them within the lumen of the bowel to be excreted in the feces. Bacteria that have been used for this purpose include Streptococcus thermophilus, Lactobacillus acidophilus, and Bifidobacteria species. These bacteria are generally regarded as safe and are not known to have any adverse or disease-inducing effects in normal or uremic dogs or cats. Preliminary studies in rats and Gottingen mini pigs with induced CKD suggest that oral probiotic supplementation may moderate azotemia, consequently slowing the progress of disease and prolonging survival. Observational studies of cats and dogs with spontaneous CKD have also shown decreases in blood urea nitrogen and serum creatinine levels after initiation of probiotic therapy. Reductions in these surrogate markers alone, however, do not prove that probiotics remove the essential uremic toxins. Further studies are needed to determine the usefulness of “enteric dialysis” in managing CKD in domestic animals."

 


Probiotics


Probiotics: What Are They?


Probiotics are colonising microorganisms (live bacteria). Some people worry when they see the word "bacteria" because they associate it with bacterial infections, but there are many bacteria which are beneficial to health, sometimes referred to as "friendly bacteria" or "good bacteria."

 

Many of these bacteria live in the lower gastrointestinal tract, and are essential to gut health. They used to be called the intestinal flora but the preferred term these days is the microbiome.

 

Commercial diets often contain probiotics but Bacteriological evaluation of dog and cat diets that claim to contain probiotics (2003) Weese JS & Arroyo L Canadian Veterinary Journal 44 pp212–215 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. Adding probiotics to the diet is therefore not usually necessary for healthy cats, though Use of probiotics in small animal veterinary medicine (2017) Jugan MC, Rudinsky AJ, Parker VJ & Gilor C Journal of the American Veterinary Medical Association 250(5) pp519-528 says that doing so is unlikely to do any harm.

 

However, probiotics may be helpful to help cats with diarrhoea, particularly for cats who develop diarrhoea after using antibiotics to help re-balance the bacteria in the gut. There is also some research indicating that probiotics may help with CKD, see below.

 

Sometimes probiotics are combined with prebiotics, in which case they may be referred to as synbiotics.

 

The National Institute for Health explains more about probiotics.

 

Literature review: probiotics (2011) Lefebvre S Banfield Applied Research and Knowledge Team Aug 2011 pp1-12 has an excellent overview of the use of probiotics in cats and dogs.

 

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

 

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

 

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.

 

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

 

Probiotics: Use in CKD


There is some research into the use of probiotics to help CKD patients. 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."

 

Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge Symposium pp18-20 says "Oral probiotics operate as “enteric dialyzers,” relying on the intestinal tract to eliminate wastes normally excreted by the kidneys. Live bacteria can catabolize urea and other uremic toxins, effectively trapping them within the lumen of the bowel to be excreted in the feces. Bacteria that have been used for this purpose include Streptococcus thermophilus, Lactobacillus acidophilus, and Bifidobacteria species. These bacteria are generally regarded as safe and are not known to have any adverse or disease-inducing effects in normal or uremic dogs or cats. Preliminary studies in rats and Gottingen mini pigs with induced CKD suggest that oral probiotic supplementation may moderate azotemia, consequently slowing the progress of disease and prolonging survival. Observational studies of cats and dogs with spontaneous CKD have also shown decreases in blood urea nitrogen and serum creatinine levels after initiation of probiotic therapy. Reductions in these surrogate markers alone, however, do not prove that probiotics remove the essential uremic toxins. Further studies are needed to determine the usefulness of “enteric dialysis” in managing CKD in domestic animals."

 

Probiotics: Species and Strains


There are many species and strains of bacteria. We all have a unique mix of bacteria in our gastrointestinal tracts, but cats have different strains to other species such as dogs or humans, and an individual cat will have completely different species and strains to another cat. Bacteria commonly found in cats include:

Bifidobacterium


Bifidobacterium is found mainly in the gastrointestinal tract, and may be helpful for gastrointestinal problems such as constipation and diarrhoea. MedlinePlus US National Library of Medicine has some information about it.

 

Pet MD says "Bifidobacterium tends to live in the small intestine, whereas Enterococcus generally resides in the colon (large intestine). So each strain could have a different function when it comes to promoting health. Bifidobacterium is more involved with digestion and the Enterococcus aids with the formation of normal feces and helping to maintain colonic health."

 

Lactobacillus


Lactobacillus is found in the gastrointestinal and urinary tracts. MedLinePlus US National Library of Medicine has some information about it.

 

Lactobacillus is useful for many different health concerns. In cats, a type called Lactobacillus acidophilus (L. acidophilus) is a good choice for rebalancing gut bacteria and therefore may be helpful for diarrhoea. 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."

 

Enterococcus


Enterococcus is commonly found in the gastrointestinal tract, usually in the colon. Pet MD says "Bifidobacterium tends to live in the small intestine, whereas Enterococcus generally resides in the colon (large intestine). So each strain could have a different function when it comes to promoting health. Bifidobacterium is more involved with digestion and the Enterococcus aids with the formation of normal feces and helping to maintain colonic health."

 

It has been known for some time that enterococcus appears to be more likely to develop antibiotic resistance than some other species. Bacteriological evaluation of dog and cat diets that claim to contain probiotics (2003) Weese JS & Arroyo L Canadian Veterinary Journal 44 pp212–215 states “concern has been expressed over the use of enterococci, because they can be opportunistic pathogens and probiotic strains of enterococci are able to transfer the vanA gene: the gene responsible for Vacomycin resistance.” This is referring to Probiotic enterococcus faecium strain is a possible recipient of the vanA gene cluster (2001) Lund B Clinical Infectious Diseases 32(9) pp1384–1385, which says "Although enterococci generally have low pathogenicity, they increasingly are a cause of nosocomial [occurring in hospital] infection in the United States and Europe, especially in immunocompromised patients. This might be explained in part by the intrinsic tolerance of these enterococci against several antimicrobial agents and to harsh conditions, and their tendency to gain antibiotic resistance. The nature of E. faecium has led to discussions regarding the safety of using E. faecium as a food supplement."

 

Antibiotic susceptibility analysis of Enterococcus spp. isolated from urine (2004) Rudy M, Nowakowska M, Wiechuła B, Zientara M & Radosz-Komoniewska H Przeglad Lekarski 61(5) pp473-6 says "Recently increase of enterococcal infections has been observed. These bacteria, mainly Enterococcus faecalis and Enterococcus faecium are members of the normal flora of gastrointestinal tract but also are typical opportunistic pathogens. Enterococci are characterized by natural resistance to numerous antibiotics (among them cephalosporins), and also by easy acquired resistance to antibiotics. Infections caused by multiresistant strains are difficult in treatment, chronic, recurrent and sometimes fatal are described. Enterococcal infections are caused often by E. faecalis, rarely by E. faecium."

 

The genus Enterococcus as probiotic: safely concerns (2013) Ferreira Araújo T & de Luces Fortes Ferreira CL Brazilian Archives of Biology and Technology 56(3) has an overview of the safety concerns.

 

Don't feed foods containing enterococcus (2009) Weinberg S believes there may be a connection between feeding foods containing Enterococcus bacteria and cats developing urinary tract infections involving enterococcus bacteria. Therefore some people are reluctant to use enterococcus in their cats.

 

However, one strain of enterococcus, Enterococcus faecium SF68, was developed not to have the problem with resistance, and has been widely used and studied in cats. Enterococcus faecium (SF68) is now being added to some cat foods and is present in a number of probiotics for cats. Research indicates that it appears to be safe to use in healthy kittens. It can be very effective for diarrhoea. Pilot study to evaluate the effect of oral supplementation of Enterococcus faecium SF68 on cats with latent feline herpesvirus 1 (2009) Lappin MR, Veir JK, Satyaraj E & Czarnecki-Maulden G Journal of Feline Medicine and Surgery 11(8) pp650-654 found it also appeared to be helpful for cats with feline herpes (cat flu). Research and clinical experience with probiotics (2012) Lappin MR Nestlé Purina Companion Animal Nutrition Summit: The Gastrointestinal Tract in Health and Disease pp46-51 provides an overview of the research into the SF68 strain.

 

Probiotics: Choices


Your choice of probiotic depends partly on why you are giving it. If you are trying to help with diarrhoea, there are several proven probiotics. If you are interested in using probiotics to help with uraemic toxins, Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge Symposium pp18-20 says "Oral probiotics operate as “enteric dialyzers,” relying on the intestinal tract to eliminate wastes normally excreted by the kidneys. Live bacteria can catabolize urea and other uremic toxins, effectively trapping them within the lumen of the bowel to be excreted in the feces. Bacteria that have been used for this purpose include Streptococcus thermophilus, Lactobacillus acidophilus, and Bifidobacteria species. These bacteria are generally regarded as safe and are not known to have any adverse or disease-inducing effects in normal or uremic dogs or cats."

 

When choosing a probiotic for your cat, ideally you need a product that contains several different strains, but not too many. I would aim for a product containing around six different strains.

 

It is also important to choose a product with live, viable bacteria. As discussed above, adding probiotics to commercial cat food is hit and miss, and even in supplement form many probiotics fail to deliver on their promises. It is therefore essential to choose your product carefully.

 

Probiotics need to reach the intestines alive in order to be effective, which can be tricky because stomach acid may kill many of them. Some products use a process called "microencapsulation" to protect the probiotics, whilst others use an enteric coating. Ideally you would give them on an empty stomach, but if you give with food, you may need to give a higher dose.

 

East meets west: integrative veterinary medicine (2007) Silver RJ Delaware Valley Academy of Veterinary Medicine recommends using a product with 1-10 billion CFU units per day (scroll down to Probiotic Cultures near the bottom of the page).

 

Whether to choose a product marketed for cats is much debated. There are few regulations regarding probiotics for cats in most countries (though the EU has banned the use of the word "probiotics" from marketing literature generally), so many probiotic supplements may not be effective for your cat, even those marketed for cats. Assessment of commercial probiotic bacterial contents and label accuracy (2011) Weese JS & Martin H Canadian Veterinary Journal 52(1) pp43-46 examined probiotics targeted for animal use and found "Only 4/15 (27%) products that had specific claims of viable organisms met or exceeded their label claim. Only 2 of these also had an acceptable label, which properly described the contents. Deficiencies in veterinary probiotic quality remain. Veterinarians and owners should scrutinize commercial probiotics and demand evidence of quality control and efficacy." The two products which were found to meet their label claims were FortiFlora (see below) and Prostora (which is for dogs).

 

Consumer Lab has a report on what probiotics do and how to choose one.

 

If you are giving probiotics and find them helpful, you will have to keep giving them if you wish to continue to see a benefit.

 

Here are some products to consider:

 

Proviable


Proviable DC (for dogs and cats) is a veterinary product which contains seven strains as follows:

  • Bifidobacterium bifidum

  • Enterococcus faecium

  • Lactobacillus acidophilus

  • Lactobacillus bulgaricus

  • Lactobacillus casei

  • Lactobacillus plantarum

  • Streptococcus thermophilus

Some people are uncomfortable using enterococcus-based probiotics (see above).

 

Each capsule contains 5 billion CFU units, and the recommended dose is one capsule sprinkled on food daily.

 

Open-label trial of a multi-strain synbiotic in cats with chronic diarrhoea (2012) Hart ML, Suchodolski JS, Steiner JM & Webb CB Journal of Feline Medicine and Surgery 14(4) pp240-245 found that 72% of people thought a 21 day course of Proviable DC seemed to help with their cats' diarrhoea.

 

Proviable also contains prebiotics in the form of FOS, which may lead to an increase in calcium levels (see below). It may therefore be better not to give Proviable longer-term. It also contains yucca, an adsorbent.

 

VSL#3


VSL#3 is a prescription-only human probiotic which contains eight strains as follows:

  • Streptococcus thermophilus

  • Bifidobacterium breve

  • Bifidobacterium longum

  • Bifidobacterium infantis

  • Lactobacillus paracasei

  • Lactobacillus acidophilus

  • Lactobacillus delbrueckii subsp. Bulgaricus

  • Lactobacillus plantarum

Each sachet contains 450 billion CFU units. The recommended human dose is 1-2 sachets per day. For cats, a tenth of a sachet once a day might be a suitable dose, but be guided by your vet.

 

Prebiotics, probiotics and intestinal health (2012) Tremayne J Veterinary Practice News says ""Veterinary probiotics are less regulated than drugs," says Joseph Bartges, DVM, PhD, Dipl. ACVIM, Dipl. ACVN, professor of medicine and nutrition at the University of Tennessee in Knoxville. "There's less confidence that you are getting what the label claims. I believe in using probiotics in animals but I prefer to use one called VSL#3 marketed for human use because it contains 450 billion live bacteria per packet. This probiotic is manufactured by VSL Pharmaceuticals Inc.""

 

Comparison of microbiological, histological and immunomodulatory parameters in response to treatment with either combination therapy with prednisone and metronidazole or probiotic VSL#3 strains in dogs with idiopathic inflammatory bowel disease (2014) Rossi G, Pengo G, Caldin M, Palumbo Piccionello A, Steiner JM, Cohen ND, Jergens AE & Suchodolski JS Plos ONE 9(4) pp1-13 found that this probiotic helped dogs with IBD, concluding that "A protective effect of VSL#3 strains was observed in dogs with IBD, with a significant decrease in clinical and histological scores," and that this effect was not seen in the dogs receiving prednisone and metronidazole.

 

FortiFlora


FortiFlora is made by Purina, and only contains one probiotic, enterococcus faecium (SF68). It also contains vitamins, amino acids and iron. Some people are uncomfortable using enterococcus-based probiotics (see above), and some do not like the fact that FortiFlora contains animal digest (which I understand is hydrolysed pork). Most cats do not agree with their humans, finding FortiFlora very yummy.

 

Although FortiFlora only contains one probiotic, it has been tested and amongst other things, it has been found to be effective in treating shelter cats with diarrhoea. Research and clinical experience with probiotics (2012) Lappin MR Nestlé Purina Companion Animal Nutrition Summit: The Gastrointestinal Tract in Health and Disease pp46-51 provides an overview of the research into the SF68 strain.

 

It is also one of only two products in the above study which were found to found to meet their label claims (the other product was a canine product).

 

Many people use and like FortiFlora, and find it particularly effective for diarrhoea. As mentioned earlier, most cats love the taste of it too, so it can be helpful to make pills or food more tempting. Discuss with your vet.

 

It is available from Entirely Pets, amongst others.

 

Culturelle


Culturelle is a human product which also only contains one probiotic, Lactobacillus rhamnosus GG. Some members of Tanya's CKD Group use it when their cat is receiving antibiotics.

 

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.

 

Probiotics: Side Effects and Interactions


Side effects are usually mild and gastrointestinal, such as vomiting or wind. Starting with a low dose and increasing gradually may help if you see such side effects.

 

Do not give probiotics at the same time as antibiotics, separate them by 3-4 hours.

 

There is some debate as to whether probiotics are appropriate for patients with pancreatitis. There is more about this on the Pancreatitis page.

 


Prebiotics


Prebiotics: What are They?


Prebiotics encourage the gastrointestinal bacteria (or flora) to grow by providing a source of nutrients for them, i.e. essentially prebiotics are food for probiotics. They are commonly fermentable fibre, particularly a type of fermentable fibre called fructooligosaccharides (FOS).

 

Inulin, which is found in Renadyl, is a prebiotic. So is psyllium, which is found in both Azodyl and Renadyl (see below).

 

Sometimes prebiotics are combined with probiotics, in which case they may be referred to as synbiotics.

 

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.

 

Prebiotics: Use in CKD


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.

 

There has long been interest in whether other bodily mechanisms might be useful for relieving the load on damaged CKD kidneys. Most of the urea produced by the body is excreted via the kidneys, but the remainder is excreted via the large intestine, so some researchers have looked at whether it is possible to use the gastrointestinal tract to help remove uraemic toxins. See above for more on this.

 

Prebiotics (fermentable fibre) provide a source of carbohydrate for the bacteria in the gut. These bacteria increase in number when provided with additional fermentable fibre, and the more bacteria there are, the more nitrogen is excreted in the faeces.

 

A 1999 study, Role of fermentable carbohydrate supplements with a low-protein diet in the course of chronic renal failure: experimental bases Younes H, Alphonse JC, Behr SR, Demigné C, & Rémésy C American Journal of Kidney Disease 33(4) pp633-46 indicated that the use of fermentable fibre may help reduce BUN levels. Fermentable carbohydrate supplementation alters nitrogen excretion in chronic renal failure (2006) Younes H, Egret N, Hadj-Abdelkader M, Remesy C, Demigne C, Gueret C, Deteix P, Alphonse JC Journal of Renal Nutrition 16(1) pp67-74  suggests that this method appears to have similar benefits to protein restriction without the drawbacks of protein restriction.

 

Therapeutic kidney diets contain fermentable fibre, because some is always needed to feed the gut bacteria. Iams has patented a Nitrogen Trap Fiber System containing beet fibre for use in their therapeutic kidney diets. Hill's uses both beet fibre and locust bean gum. Pet Education (link currently down) discusses beet pulp.

 

Nutritional management of feline chronic kidney disease (2008) Elliott J, Elliott D Veterinary Focus 18(2) pp39-44 states "classic uremic toxins, unlike urea nitrogen, are medium sized molecules, too large to easily pass through the membrane barrier. It is therefore unlikely that these toxins may be used by the bacteria to cater for their nitrogen needs. Conversely, the beneficial effects of fermentable fibers can help to regulate the digestive disorders that accompany CKD."

 

Prebiotics: Side Effects and Interactions


Some forms of fibre, such as fructooligosaccharides (FOS), may also bind calcium in the small intestine and lead to an increase in calcium levels in the body (hypercalcaemia). This is not  good for cats with high calcium levels. Inulin (found in Renadyl) and guar gum may do this, as may slippery elm bark and lactulose, two treatments commonly used for constipation in CKD cats. The effects of gum arabic oral treatment on the metabolic profile of chronic renal failure patients under regular haemodialysis in Central Sudan (2008) Ali AA, Ali KE, Fadlalla AE & Khalid KE Natural Product Research 22(1) p12-21 found that patients given gum arabic for three months had lower BUN, creatinine and phosphorus levels, but calcium levels increased significantly.

 

Too much fibre may also prevent your cat from absorbing sufficient nutrients or calories from his/her food. Fibre may also affect taurine levels in some foods. I would therefore recommend discussing additional fibre with your vet before adding it, and avoiding its use in a cat who already has high calcium levels.

 

Kibow Biotech has recently (2018) released a new product called Fortis which contains six prebiotic fibres. The manufacturer suggests using it in conjunction with Azodyl or Renadyl.

 

Prebiotics: Locust Bean Gum


One member of Tanya's CKD Support Group, with her vet's approval, gave 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. She believed it 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.  

 

Prebiotics: Acacia Gum (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.

 

The manufacturer claims that in unpublished tests the Scrub produced reductions in BUN and creatinine of as much as 20% when dosed at 0.5g/kg of bodyweight. 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.

 

Originally the Scrub was supposed to be mixed with a probiotic such as kefir (available from health food stores) or live yoghurt. The Scrub was apparently designed in this manner so as to make it easier to ship without the risk of killing off the live bacteria contained in a probiotic, which may happen when you ship probiotics without chilled shipping. The manufacturer apparently now states that you no longer need to mix it with a probiotic.

 

The Scrub is in powder form so you can control the dose. Some people simply mix it into their cat's food. A typical dose might be half a teaspoon per 7 lbs of cat once a day but it is recommended that you start lower and build up to this level. Do not exceed 2 g per day because this could apparently increase your cat's calcium levels. It should not be given at the same time as slippery elm bark or antibiotics.

 

Astro's Nitrogen Scrub costs US$22.95 for a 140 gm jar and can be ordered by emailing the manufacturer.

 

I don't know many people who have used the scrub, but I've heard from one person has used it for a couple of years and she thinks that it probably has helped overall. Others felt it helped with appetite. Personally, I wouldn't bother with it, but if you do decide to try it, please check with your vet before using.

 


Probiotics and Prebiotics: Azodyl or Renadyl


Azodyl/Renadyl: What Are They?


Azodyl and Renadyl are products which are intended to help cats with CKD by reducing the workload of the kidneys. They are not identical but the main ingredients in both are probiotics and prebiotics, so you may see them referred to as synbiotics, the term for a product containing both probiotics and prebiotics.

 

Azodyl


Azodyl is designed for the veterinary market and is sold by Vetoquinol. Azodyl's name is a play on azotaemia and dialysis. It contains:

  • psyllium, a type of fibre commonly used to control constipation and also a prebiotic

  • strains of three particular probiotic species:

    • Enterococcus thermophilus (KB19)

    • Lactobacillus acidophilus (KB27); and

    • Bifidobacterium longum (KB31)

In terms of probiotics, it contains 15 billion CFUs (colony forming units, see above) per capsule.

 

Renadyl


Renadyl is designed for the human market and sold by Kibow Biotech. Some people use it in their cats. It contains:

  • inulin, a prebiotic

  • psyllium, a type of fibre commonly used to control constipation and also a prebiotic

  • strains of three particular probiotics:

    • Streptococcus thermophilus (KB19)

    • Lactobacillus acidophilus (KB27); and

    • Bifidobacterium longum (KB31)

In terms of probiotics, it contains 45 billion CFUs (colony forming units, see above) per capsule, so one Renadyl capsule is three times as strong as an Azodyl capsule.

 

Product information sheet has an overview of Renadyl.

 

Azodyl versus Renadyl


Although Azodyl and Renadyl are not exactly the same, they do contain the same probiotics. I am sometimes asked about this, because Azodyl contains Enterococcus thermophilus, whereas Renadyl contains Streptococcus thermophilus. However, 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.

 

Azodyl/Renadyl Mechanism


The probiotics contained in these products are not unique, but these particular strains are, in fact they are  patented.

 

The manufacturers claim that these strains have a particularly high affinity for some of the major uraemic toxins found in CKD. The idea is that Azodyl and Renadyl should bind with and thus reduce the levels of these uraemic toxins in CKD cats, which the manufacturer of Renadyl calls enteric dialysis (a term it has trademarked).

 

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

 

Kibow Biotech explains more about the reasoning behind Azodyl.

 

Azodyl/Renadyl Research


Since Azodyl and Renadyl are classified as dietary or nutritional supplements, the American Food and Drug Administration does not require them to undergo clinical trials. Therefore there are only limited studies available, though in October 2017 Kibow Biotech, the manufacturer of Renadyl, announced a placebo-controlled large scale clinical trial into the use of Renadyl in human patients (the Hope Study) in the USA.

 

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 of 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.

 

Intestinal bacterial microflora - a potential source of chronic inflammation in patients with chronic kidney disease (2006) Kotanko P Nephrology Dialysis Transplantation 21(8) pp2057-2060 concludes "Intestinal bacteria contribute to the uraemic syndrome by the production of uraemic toxins. Additional evidence suggests that translocation of bacteria and endotoxins from the gut to the blood takes place in kidney failure. Consequently, it is plausible to assume that the gut contributes to the chronic inflammatory state in dialysis patients. The availability of iron in the intestinal lumen may increase growth and virulence of intestinal bacteria and affect the intestinal barrier adversely. Oral iron chelation may be beneficial in reducing the intestinal iron load. Basic research and clinical studies are needed to further define the significance of intestinal bacteria and their products in uraemia. Interventions aimed at restoring and maintaining the physiological intestinal microflora in dialysis patients should be tested rigorously in clinical trials."

 

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 an informal trial conducted at a veterinary practice in California which found that creatinine reduced in 86% (6/7) of cats who were given Renadyl.

 

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 in human patients in four locations. BUN levels fell and the patients felt better.

 

Probiotic Therapy of Chronic Kidney Disease. ACVIM Forum (2011) Polzin DJ found that the BUN and creatinine levels of four dogs on dialysis receiving Azodyl did not improve.

 

A study in the same year, The effects of a probiotic on blood urea nitrogen and creatinine concentrations in large felids (2011) McCain S, Allender MC, Schumacher J & Ramsay E Journal of Zoo and Wildlife Medicine 42(3) pp426-429, looked at the effects of Azodyl on tigers, lions, cougars and a leopard, all of whom had BUN over 35 mg/dl and creatinine over 3 mg/dl. It found "creatinine but not BUN significantly decreased over time." The decrease occurred mainly between two and six months after starting the supplement.

 

Dose escalation, safety and impact of a strain-specific probiotic (Renadyl) on stages III and IV chronic kidney disease patients (2013) Ranganathan N, Pechenyak B, Vyas U, Ranganathan P, DeLoach S, Falkner B, Weinberg A, Saggi SJ & Friedman EA Journal of Nephrology and Therapeutics 3(3) found that giving Renadyl to human CKD patients for four months appeared to lead to "statistically significant improvements in creatinine."

 

Metabolic profiling of a chronic kidney disease cohort reveals metabolic phenotype more likely to benefit from a probiotic (2017) Saggi SJ, Mercier K, Gooding JR, Friedman E, Vyas U, Ranganathan N. McRitchie S & Sumner S International Journal of Probiotics & Prebiotics 12(1) pp43-54 considers why BUN fell in some patients in the previous study but rose in others.

 

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

 

Azodyl/Renadyl Concerns


One concern is that using enteric dialysis may lead to an artificial reduction in creatinine and BUN levels, making the CKD look less severe than it actually is. Chronic progressive renal disease in the cat: recognition and management (Proceedings) (2009) Wolf AM CVC in Kansas City Proceedings quotes Dr Larry Nagode (formerly at Ohio State University College of Veterinary Medicine, now deceased): "I feel both Epakitin and Azodyl are best considered as masterpieces of marketing of possibly questionable real use in therapy of CRF in dogs and cats—although veterinary users through a profit sharing arrangement with Vetoquinol involving a retail "markup" can turn a tidy profit by prescribing them for clients. I say this in part because of lack of data I am aware of that Azodyl removes "real" uremic toxins from patients guts and "word of mouth" I have heard that this perturbation of the normal intestinal bacterial flora in these patients has often led to significant diarrheal and other intestinal "upset" problems—how often this has been so I have no idea. Vetoquinol marketed Epakitin first and Azodyl more recently so that the "urea and creatinine lowering" capacity originally being part of the justification for use of Epakitin is now the rationale for added use of Azodyl. Why sell clients one product when you can sell them two??. My cynicism with respect to these products may well be misplaced and they may well be outstanding wonderful products for our dogs and cats—but until I can find data that solidly supports this view I remain skeptical."

 

Enteric dialysis: does it work? (2009) Polzin DJ Bayer Cutting Edge Symposium pp18-20 says "Preliminary studies in rats and Gottingen mini pigs with induced CKD suggest that oral probiotic supplementation may moderate azotemia, consequently slowing the progress of disease and prolonging survival. Observational studies of cats and dogs with spontaneous CKD have also shown decreases in blood urea nitrogen and serum creatinine levels after initiation of probiotic therapy. Reductions in these surrogate markers alone, however, do not prove that probiotics remove the essential uremic toxins. Further studies are needed to determine the usefulness of “enteric dialysis” in managing CKD in domestic animals."

 

Azodyl FAQs respond to these concerns as follows: "AZODYL reduces the BUN and Creatinine values. This occurs because the bacteria consume non-protein nitrogen molecules found in the gut. BUN and Creatinine are the markers used for evaluation of renal function. Uremic toxins build up during renal failure as the kidneys are unable to remove them. It does stand to reason that if we reduce the levels of BUN and Creatinine we may develop a false sense of increased renal function. BUT, does anything improve renal function? NO, once we lose the nephron (the functional element of the kidney) it is not replaced. Early on, a compensatory mechanism occurs whereby the remaining nephrons “pick-up the slack”. Soon they “burn themselves out”. This compensatory mechanism is detrimental. We recommend administration of AZODYL once the kidneys display signs of Azotemia. We define azotemia as persistent increases in BUN and creatinine. Clinically, azotemia is an indication that we have lost 75% of the functional nephrons. With 25% or less of the nephrons remaining we know we are on the downward slide. We can continue to monitor the decreased renal function as the BUN and Creatinine rise and offer no systemic support to the animal or we can try to improve the quality of life. We have opted to improve the quality of life. If we remove these uremic toxins we help to minimize or possibly prevent the effects of a uremic crisis. With all that said let’s look at it another way. In human medicine we offer dialysis. This procedure eliminates toxins that build up in the body, thereby improving the quality of life. Without the elevation of these toxins and the markers of renal function we could assume the kidneys are doing better. NOT THE CASE. We already know that renal function is so compromised that the animal (or human) will suffer the effects from a uremic crisis. We can prevent that by reducing the effects of the uremic toxin build up."

 

Azodyl and Renadyl cannot reverse kidney disease but if they reduce BUN levels, they 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 cause vomiting, and others could not see any discernible difference. There may or may not be a difference in bloodwork.

 

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/Renadyl Side Effects and Interactions


The most commonly reported side effects are vomiting and occasionally diarrhoea.

 

Renadyl and Azodyl contain psyllium, and Renadyl also contains inulin, and there is some debate as to whether these might increase calcium absorption, which could mean they are not suitable for cats with high calcium levels. See below for more on this.

 

Drugs is the Canadian version of information on Azodyl and states "not for use in diabetic animals." This is thought to be because Azodyl contains psyllium, a type of fibre (carbohydrate), and Canadian laws require that this be mentioned in case it affects the cat's blood glucose levels. Apparently the manufacturer has not received any reports of Azodyl having any adverse effects on diabetic cats.

 

How to Give Azodyl/Renadyl


 

Giving 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 Vetoquinol.

 

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.

 

The previous version of Azodyl was only available in large capsule form (size 1), which is rather large for many cats; this may be one reason why some cats threw up the entire capsule, sometimes several hours after it had been given.

 

The manufacturer therefore switched to a smaller capsule. 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 (though the larger Azodyl capsule size is no longer commercially available, so in practice you will only be offered the small capsule).

 

 

 

 

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, investigated whether opening the capsule and sprinkling the contents on to food affected the product's efficacy. Unfortunately, the study 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 study 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.

 

From what I hear, 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; they then give the second Azodyl dose about an hour before dinner in the same way. Members of Tanya's CKD Support Group are generally positive about Azodyl when given in this way, and it apparently has very little taste, so most cats do not notice it in their treat.

 

Giving Renadyl


In the Palmquist study mentioned above, Renadyl was found to be effective even when mixed with meals.

 

Renadyl says "The gel cap product is more efficacious when taken immediately after each meal." This could be because Renadyl contains three times as many bacteria as Azodyl, so more bacteria survived. One member of Tanya's CKD Support Group has successfully used this product mixed directly with meals after apparently being told this would reduce the efficacy of the product but not remove it completely.

 

Renadyl states "Probiotic supplements should be taken 4 hours after the antibiotics."

 

Azodyl/Renadyl 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 there are currently no plans to introduce the product in Europe because Vetoquinol does not wish to go through the necessary registration process.

 

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 or Renadyl 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.

 

Azodyl and Renadyl Storage and Shipping


People are often confused as to how best to have Azodyl or Renadyl shipped to them and how to store it once it has  arrived. This is because the manufacturers of the two products offer conflicting advice:

 

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 Azodyl FAQs), so if you leave Azodyl out overnight there is unlikely to be cause for concern. However, 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.

 

Kibow Biotech, the manufacturer of Renadyl, says Renadyl is "fully stable without refrigeration for at least 2 weeks," so it can be shipped without chilling. It does recommend that it is kept in the fridge upon receipt.

 

Azodyl/Renadyl 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 or the UK, Azodyl and Renadyl are not available and the only way to buy them is by ordering from a US supplier. This also applies to Asia, although a deal was struck with a distributor in India in 2018, so Renadyl may become available locally.

 

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

 

USA


Entirely Pets

An authorised Azodyl seller, sells 90 Azodyl capsules for US$68.44 plus shipping. I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled.

 

Allivet

Sells 60 Azodyl capsules for US$62.99 plus cold shipping of around US$29.99.

 

Thriving Pets

Sells 90 Azodyl capsules for US$64.95 plus shipping. I used Thriving Pets within the USA myself for other items with no problems. The tanya discount code mentioned elsewhere on my website does not apply if your basket includes Azodyl.

 

Kibow Biotech

The manufacturer sells three bottles of Renadyl for US$148.50 with free shipping without ice packs.

 

Thriving Pets

Sells 60 Renadyl capsules for US$49.50 plus shipping. I used Thriving Pets within the USA myself for other items with no problems. You can choose whether to ship with or without a cold pack (which costs an extra US$5). The tanya discount code mentioned elsewhere on this site does not apply if your basket includes Renadyl.

 

Canada


Pets Drug Mart

Sells 60 Azodyl capsules for CAN$54.45 plus shipping.

 

Entirely Pets

An authorised Azodyl seller, sells 90 Azodyl capsules for US$68.44 plus shipping. They will ship to Canada, click here for more information. I have used Entirely Pets myself to buy Azodyl within the USA with no problems, it arrived chilled.

 

Thriving Pets

Sells 90 Azodyl capsules for US$64.95 plus shipping. I used Thriving Pets within the USA myself for other items with no problems. The tanya discount code mentioned elsewhere on my website does not apply if your basket includes Azodyl.

 

Kibow Biotech

The manufacturer sells three bottles of Renadyl for US$148.50 with free shipping without ice packs.

 

Thriving Pets

Sells 60 Renadyl capsules for US$49.50 plus shipping. I used Thriving Pets within the USA myself for other items with no problems. You can choose whether to ship with or without a cold pack. The tanya discount code mentioned elsewhere on my website does not apply if your basket includes Renadyl.

 

Europe


Entirely Pets

An authorised Azodyl seller, sells 90 Azodyl capsules for US$68.44 plus 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 90 Azodyl capsules for US$64.95 plus shipping. I used Thriving Pets within the USA myself for other items with no problems. The tanya discount code mentioned elsewhere on my website does not apply if your basket includes Azodyl.

 

Kibow Biotech

The manufacturer sells three bottles of Renadyl for US$148.50 with free shipping without ice packs. I have thus far heard of successful shipments to the UK, Italy. Shipping to Europe costs around US$50.

 

Thriving Pets

Sells 60 Renadyl capsules for US$49.50 plus shipping. I used Thriving Pets within the USA myself for other items with no problems. You can choose whether to ship with or without a cold pack. The tanya discount code mentioned elsewhere on my website does not apply if your basket includes Renadyl.

 

If you import Azodyl or Renadyl into the UK from the USA and duty is due, it may sometimes be delayed depending upon which delivery company is delivering it. UPS simply deliver your parcel and ask you to pay at that time. Unfortunately, Parcelforce write to tell you duty is due and do not deliver until you have paid, and in the meantime your parcel will be sitting in Customs. 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.

 

Asia


ET Healthworld reports that in 2018 Kibow Biotech entered into an alliance with Centaur Pharma that will enable Centaur Pharma to market Renadyl in India.

 


Oral Adsorbents


 

Adsorbents are products that bind with something else. The most commonly used adsorbent in the treatment of CKD in cats is phosphorus binders, which are so important that they have their own page here.

 

This section focuses on other adsorbents which are intended to bind with some of the uraemic toxins seen in CKD and thus improve wellbeing.

 

Can the bowel substitute for the kidney in advanced renal failure? (2009) Friedman EA Current Medical Research and Opinion 25(8) pp1912-8 has an excellent overview of the various ways of trying to reduce toxins in CKD, including reference to AST-120 (see below).

 

There is ongoing research into whether oral adsorbents might not only help CKD patients feel better, but might also reduce damage to the kidneys and slow the progression of kidney disease. Much of the research into the use of these products has taken place in Japan, and at least one of these adsorbents is routinely used in Japan when treating human CKD patients. However, one treatment, Ipakitine/Epakitin, was developed in Germany.

 

Unlike the strong evidence for phosphorus control delaying the progression of CKD, there is currently little evidence that these products do the same. Oral adsorbents for preventing or delaying the progression of chronic kidney disease (2014) Wu HM, Sun HJ, Wang F, Yang M, Dong BR & Liu GJ The Cochrane Database of Systematic Reviews 15(10) reviewed the results of fifteen research studies from Japan, China and the USA. It concludes "there is evidence of limited quality that AST-120, Ai Xi Te and Niaoduqing granules may have positive effects on delaying the decline of kidney function. There were no serious adverse events for any of the interventions in patients with CKD. Given the lack of information for our primary outcomes, the low methodological quality of most studies, and the small sample sizes, there is no strong evidence on the effectiveness of these oral adsorbents."


Calcium Carbonate-Based Phosphorus Binders With Added Adsorbents


 

There are a number of calcium carbonate-based phosphorus binders on the market. Basic calcium carbonate is available very cheaply and without a prescription from any pharmacy, so, presumably to justify their high prices, the manufacturers of branded products add other ingredients, and in some cases these are adsorbents.

 

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

 


Adsorbents: Chitosan


 

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

 

Chitosan Mechanism


When protein is eaten and digested, an amino acid in the food called tryptophan is converted into indole. Indole is then converted into indoxyl, which in turn is converted by the body into indoxyl sulphate, a type of uraemic toxin. AST-120 for the management of progression of chronic kidney disease (2014) Schulman G, Vanholder T & Niwa T International Journal of Nephrology and Renovascular Disease 7 pp49–56 says "Uremic toxins such as indoxyl sulfate contribute to the pathogenesis of chronic kidney disease (CKD) by promoting glomerulosclerosis and interstitial fibrosis with loss of nephrons and vascular damage."

 

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.

 

Indoxyl sulphate is only one of a number of uraemic toxins, so products containing it are unlikely to be sufficient to help your cat feel better in isolation.

 

Chitosan is also said to help reduce BUN/urea levels, and indirectly to reduce creatinine levels. These claims appear to be based largely on the results of human trials (see clinical trials).

 

Web MD has some information about chitosan.

 

Chitosan Research


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 examined the effects of chitosan on 80 human patients undergoing long term haemodialysis 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. 

 

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 states 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 calcium-based phosphorus binders, and cats are not rats.

 

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 manufacturer of Epakitin) which indicated that Epakitin reduced phosphorus levels in the cats, who were fed a commercial non-therapeutic diet and who were in IRIS Stages 1 and 2. The study did not find that Ipakitine reduced BUN or creatinine levels, 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 Münchener tierärztliche Wochenschrift 117 pp310-315 found that Ipakitine reduced phosphorus and BUN (urea) levels in the CKD cats in the trial.

 

Adsorbents Containing Chitosan


There are a number of calcium carbonate-based phosphorus binders on the market. Basic calcium carbonate is available very cheaply and without a prescription from any pharmacy, so, presumably to justify their high prices, the manufacturers of branded products add other ingredients, and in many cases these are adsorbents.

 

Ipakitine/Epakitin, Pronefra, and Renal (also known as Aventi KP) all contain:

  • calcium carbonate, commonly used as a phosphorus binder.

  • chitosan, commonly used as an adsorbent, which is said to help with uraemic toxins.

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

 


Adsorbents: Yucca Schidigera


 

Yucca schidigera is a plant found largely in Mexico which is thought to have anti-inflammatory properties. It is sometimes used to help with arthritis. There is very little research into the use of yucca in cats, but it appears to be safe in small amounts.

 

Yucca schidigera extract is often added to cat foods in order to reduce the odour levels of the cat's stools. The effect of Yucca schidigera extract on canine and feline faecal volatiles occurring concurrently with faecal aroma amelioration (1997) Lowe JA, Kershaw SJ, Taylor AJ & Linforth RS Research in Veterinary Science 63(1) pp67-71 reports on this.

 

Yucca does this by binding to ammonia. Actual and potential applications of Yucca schidigera and Quillaja saponaria in humans and animal nutrition (2001) Cheeke PR Recent Advances in Animal Nutrition in Australia 13 pp115-126 refers to studies in rats and states that yucca "may alter kidney function to increase the rate of urea clearance, thus lowering blood urea and ammonia concentrations."

 

Adsorbents Containing Yucca Schidigera


There are a number of calcium carbonate-based phosphorus binders on the market. Basic calcium carbonate is available very cheaply and without a prescription from any pharmacy, so, presumably to justify their high prices, the manufacturers of branded products add other ingredients, and in many cases these are adsorbents.

 

Easypill Kidney Support Cat is a calcium carbonate-based phosphorus binder made by Vetinnov in France and available in a number of European countries. As the name suggests, this product is intended to offer high palatability. The product contains:

Rather strangely for a phosphorus binder, Easypill Kidney Support Cat contains 1.19% phosphorus on a dry matter analysis basis. I was told this is because chicken hydrolysate, which is used to make the product palatable to cats, contains phosphorus.

 

The recommended dose is one 2mg pellet per day for three months.

 

I have not heard from anybody who has used this product as yet.

 

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

 


Adsorbents: Charcoal


 

Charcoal has been used as an adsorbent for many years. In human and animal medicine, it is used to treat overdoses by absorbing toxins.

Activated Charcoal


Activated charcoal is the form used to treat human overdoses. Like chitosan, its mechanism is related to its effect on indoxyl sulfate (see below for more on this).

 

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) human patients who had declined dialysis. It found that BUN and creatinine levels fell significantly and none of the patients experienced a crisis.

 

The effect of activated charcoal on adenine-induced chronic renal failure in rats (2014) Ali BH, Alza'abi M, Ramkumar A, Al-Lawati I, Waly MI, Beegam S, Nemmar A, Brand S & Schupp N Food and Chemical Toxicology 65 pp321-8 looked at the effects of activated charcoal on rats with artificially induced renal failure. It concludes "The results suggest that charcoal is a useful sorbent agent in dietary adenine-induced CRF in rats and that its usability as a nephroprotective agent in human kidney disease should be studied."

 

I have heard from a couple of people using activated charcoal, and they felt it seemed to help their cats feel a bit better. I have no knowledge of appropriate doses for CKD cats. Please do not use this without your vet's knowledge and approval.

 

Possible side effects include nausea, vomiting and constipation. Charcoal may darken stools.

 

AST-120: Covalzin (Kremezin)


AST-120 is an oral adsorbent developed by Kureha Chemical Industries which is based on activated charcoal, though according to AST-120 for the management of progression of chronic kidney disease (2014) Schulman G, Vanholder T & Niwa T International Journal of Nephrology and Renovascular Disease 7 pp49–56, "It differs from activated charcoal in its uniform composition, and it has a lower adsorption ability for amylase, pepsin, lipase, and chymotrypsin than charcoal."

 

AST-120 Mechanism


When protein is eaten and digested, an amino acid in the food called tryptophan is converted into indole, which is then converted into indoxyl, which in turn is converted by the body into indoxyl sulphate, a type of uraemic toxin. AST-120 for the management of progression of chronic kidney disease (2014) Schulman G, Vanholder T & Niwa T International Journal of Nephrology and Renovascular Disease 7 pp49–56 states "elevated indoxyl sulfate levels were associated with increased mortality, even after adjustment for multiple variables."

 

AST-120 binds with the indole, so it cannot be converted to indoxyl and then into indoxyl sulphate, thus reducing toxin levels, which helps the cat feel better. AST-120 for the management of progression of chronic kidney disease (2014) Schulman G, Vanholder T & Niwa T International Journal of Nephrology and Renovascular Disease 7 pp49–56 also says "Uremic toxins such as indoxyl sulfate contribute to the pathogenesis of chronic kidney disease (CKD) by promoting glomerulosclerosis and interstitial fibrosis with loss of nephrons and vascular damage. AST-120, an orally administered intestinal sorbent, adsorbs indole, a precursor of indoxyl sulfate, thereby reducing serum and urinary concentrations of indoxyl sulfate."

 

This is similar to the mechanism for products containing chitosan, but it takes place one stage earlier than chitosan (which binds with indoxyl, not indole).

 

Indoxyl sulphate is only one of a number of uraemic toxins, so AST-120 alone is unlikely to be sufficient to help your cat feel better.

 

AST-120 Availability


AST-120 is marketed under the name of Kremezin for the treatment of human CKD patients in Japan, where it has been used for this purpose since 1991. It is also available in South Korea and the Philippines. It is not currently commercially available in the USA or Europe, though trials have taken place in the USA and Europe.

 

AST-120 is also marketed under the trade name of Covalzin for the treatment of feline CKD. It is available in Japan, and I have also heard from people in South Korea and Hong Kong who have used it. In 2018 one person obtained it in the USA and will keep me posted on his progress with it.

 

I have heard from a couple of Japanese people who have used Covalzin on their cats without any problems, and they thought it might have helped their cats.

 

AST-120 Research


AST-120 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.

 

An early study, Indoxyl sulfate and progression of renal failure: effects of a low protein diet and oral sorbent on indoxyl sulfate 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 suggested that AST-120 may reduce levels of indoxyl sulphate, as does a reduced protein diet.

 

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 is a study of a very small group of rats with surgically-induced kidney disease, which found that rats treated with both medications did better than rats treated with neither or with benazepril only.

 

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 looked at the effects of AST-120 on 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").

 

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 AST-120 reduced heart damage in human CKD patients.

 

Randomized placebo-controlled EPPIC trials of AST-130 in CKD (2015) Schulman G, Berl T, Beck GJ, Remuzzi G, Ritz E, Arita IK, Kato A & Shimizu M Journal of the American Society of Nephrology 26(7) pp1732–1746 reports on two trials into the use of AST-120 in human CKD patients in the USA and Europe and found that it did not appear to slow the progression of CKD, in contrast to the results seen in similar patients in Japan. It states "In conclusion, the benefit of adding AST-120 to standard therapy in patients with moderate to severe CKD was not supported by the data from these trials."

 

AST-120 How to Give


A box of Covalzin contains 90 small sachets, each containing 400mg in small pieces. The typical dosage for a cat is one sachet a day, which can be mixed into food or given in gelcaps. It should be given one hour apart from other medications or supplements.

 

AST-120 Side Effects


Possible side effects in humans are usually gastrointestinal, such as constipation, diarrhoea or nausea, according to AST-120 for the management of progression of chronic kidney disease (2014) Schulman G, Vanholder T & Niwa T International Journal of Nephrology and Renovascular Disease 7 pp49–56. If your cat develops constipation while using Covalzin, speak to your vet about whether stop the Covalzin until you have the constipation under control.

 


Adsorbents: Renaltec


 

Porus One is a new adsorbent manufactured in Germany that was released in German-speaking countries (Germany, Austria and Switzerland) in February 2018. Its active ingredient is called renaltec, which apparently is a form of carbon. I have not been able to find any information about the exact composition of renaltec as yet.

 

Porus One is provided in 500mg sachets which are sprinkled on the cat's food and mixed in. It is given once daily. There are 30 sachets in a pack, and a pack costs around 30 Euro.

 

I will report further on Porus One as and when I receive feedback about it.

 


Antioxidants


 

Antioxidants help combat inflammation by mopping up free radicals which can cause damage to cells and are associated with aging and disease.

 

In humans, it is known that the degree of oxidative stress reflects the stage of CKD, and it is thought that antioxidants may help reduce levels of oxidative stress and slow the progression of CKD in cats. 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." The Research page has some information on a study of oxidative stress in CKD cats.

 

Using antioxidants in dogs and cats is an article from Pet Education which explains more about antioxidants (this page is currently down).

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. However, a more recent study, Vitamin E supplementation fails to impact measures of oxidative stress or the anaemia of chronic kidney disease (2016) Timmons RM & Webb CB Veterinary Medicine and Science 2(2) pp117–124 found that "Daily supplementation with 30 IU of vitamin E did not affect the measures of oxidative stress or the anaemia seen in cats with CKD."

 

Vitamin E is one of the ingredients in Astro's CRF Oil (see below).

 

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. 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."

 

Ubiquinone is converted in the body into ubiquinol. Some people therefore prefer to give ubiquinol, believing it to be more bio-available.

 

CoQ10 is one of the ingredients in Astro's CRF Oil (see below).

 

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

 

Co-enzyme Q10: Research


A human trial, Randomized double-blind placebo-controlled trial of co-enzyme Q10 in patients with end stage renal failure (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.

 

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 appeared to support renal function in rats who had had a kidney surgically removed.

 

Randomized double-blind placebo-controlled trial of coenzyme Q10 in chronic renal failure: discovery of a new role (2009) Singh RB, Khanna HK & Niaz MA Journal of Nutritional and Environmental Medicine 10(4) pp 281-288 looked at the effect of CoQ10 on human patients, some of whom were receiving dialysis. It concludes "Treatment with coenzyme Q10 improves renal function in patients with chronic renal failure and decreases the need for dialysis in patients on chronic dialysis. Long-term follow-up in a large number of patients would be necessary to confirm these results."

 

Coenzyme Q10 dose-escalation study in hemodialysis patients: safety, tolerability and effect on oxidative stress (2015) Yeung CK, Billings FT, Claessens AJ, Roshanravan B, Linke L, Sundell MB, Ahmad S, Shao B, Shen DD, Ikizler TA & Himmelfarb J BMC Nephrology 16 looked at the use of CoQ10 in human patients on dialysis and concluded "In summary, CoQ10 appears to be safe and well tolerated in subjects receiving MHD and may reduce oxidative stress by improving mitochondrial function. Further studies are needed to investigate the potential metabolic and clinical benefits associated with longer term CoQ10 supplementation."

 

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.

 

I am not aware of any studies into the use of CoQ10 in cats, CKD or otherwise, but I have heard from a few people who think it helps their CKD cats feel better overall.

 

Co-enzyme Q10: Dosage


If you decide to use CoQ10 with your vet's approval, 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.

 

CoQ10 is available from health food stores. It is also available from Amazon and Amazon UK.

 

Co-enzyme Q10: Side Effects and Interactions


Possible side effects include nausea or abdominal discomfort, though starting with a low dose and only increasing gradually may help minimise the chance of these occurring.

 

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 clopidogrel (Plavix) less effective at thinning the blood. If you take blood thinners, ask your provider before taking CoQ10."

 

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.

 

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. cat. I would not stop it suddenly, see the next paragraph.

 

Co-enzyme Q10: Stopping Suddenly


If you do decide to try CoQ10 with your vet's agreement, please do not stop using it suddenly, particularly if your cat has heart disease. There have been several cases of humans and one cat with heart disease who were using CoQ10 relapsing after it was stopped suddenly. 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."

 

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.

 

Antioxidants: 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.

 

Each 1.5ml dose of Astro's CRF Oil contains approximately:

Therefore this product is basically a combination of essential fatty acids, and two antioxidants. 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.

 

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 Astro's CRF Oil and most people seem to like it, reporting that their cats seem "better", albeit in some immeasurable way. A small percentage found that it made their cats vomit more though, so they stopped using it.

 

Astro's CRF Oil is only available from the creator's website (link is in the first paragraph). A 60 ml bottle costs US$29.95 and you give 1.5 ml a day so it lasts about 40 days.

 

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 unlikely to do any harm. If you do use it, please see the advice about not stopping products containing CoQ10 suddenly 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 maintain hydration. I certainly would not recommend stopping any of your cat's current treatments, particularly sub-Qs, without your vet's knowledge and approval.

 

 

 

Back to Page Index

 

This page last updated: 27 March 2018

 

Links on this page last checked: 26 March 2018

 

   

*****

 

TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

 

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

 

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

 

*****

Copyright © Tanya's Feline CKD Website 2000-2018. All rights reserved.

 

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

 

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

 

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

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

 

 

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

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