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Kidney Failure and Disease
Kidney failure with no symptoms
Kidney Failure
Renal Amyloidosis
Kidney problems and dry vs wet cat food
Kidney problems in cats
Kidney failure - daily fluid treatment
Kidney failure
Kidney problems and cyproheptadine
Acute Kidney failure - feline
Kidney failure and methimazole (Trapazole)
Kidney failure - diuresis
Kidney failure
Feline Kidney Failure
Kidney failure - heart failure
Kidney failure
Kidney transplants
Kidney dialysis and transplantation
also see Renal failure
also see Urinary
also see CRF Treatment
also see Liver Disease
also see Hepatic Lipidosisalso see this excellent site on feline renal failure - http://www.felinecrf.com
Kidney Failure with no symptomsQuestion: Hi Doc:
I brought my 18-20 year old cat, Romeo (male, neutered) in for a check up
last week and we ran a blood profile because of his age. His BUN was 103,
his CREAT 8.4. GLOB was 5.14. All else normal (alb, alkp, alt, amyl, ca,
chol, glu, phos, tp).Obviously, results are very troubling and indicative
of kidney insufficiency.Romeo has NO symptoms of kidney insufficiency. He is active, a good eater,
fun-loving, coat shiny,not lethargic, happy. The only symptom I have noted
is drinking a lot of water and outputing it too.My questions are....does this seem right? That he would show NO symptoms
and still be that sick? Could it be something other than kidney?What else should I do? Hemocrit was almost normal as was urinanalysis. I
put him on KD which he DOES NOT like and that is a problem as he is eating
much less than normal (it is mixed with his old food).HELP....I love this cat, and as you know, just had to send Snowflake,
another of my senior cats to heaven in August. I don't know if I can go
through this again so soon.Thanks in advance. Ellen
Answer: Ellen
We see some older cats whose kidneys have apparently been failing for some
time who act normal despite very high BUN and creatinine levels. With the
levels being this high, you either need to confirm that the bloodwork was
correct (we have had three or four instances in our practice of lab work
that was submitted incorrectly (our fault) or reported incorrectly (lab's
fault) so it is worth rechecking lab work when it doesn't seem to fit the
clinical picture. Drinking a lot and urinating a lot are signs of kidney
disease, though. Diabetes is the other strong possibility but the lab work
should have shown increases in the glucose levels if that was the case.It is much more important that Romeo eat well than that he eat a diet made
for kidney disease. Please let your vet know that he is not tolerating the
diet well. There are other alternatives he might like better (Purina NF
(tm), Waltham's moderate protein, low phosphorous diet). If he doesn't like
any of the specialized diets it would be better, in my opinion, to let him
eat what he wants -- but please discuss this with your vet, too. Using a
phosphate binder with his usual diet would help a lot, if a specialized
diet is not possible.I would strongly advocate subcutaneous fluid therapy for a patient with
these BUN and creatinine values, even if he or she didn't seem bothered by
them. It is better to get these to reasonable levels before he notices that
he is sick, if possible. It is often possible to maintain cats with
insufficient kidney function for very long time periods using a judicious
mix of diet, medications and fluid therapy.There is a link to a good web site on chronic renal failure in cats on our
links page.Mike Richards, DVM
1/22/2001
Question: Dr. Mike. My cat, Emily, 16 this month has CRD. Her symptoms only became
evident 1 1/2 wk ago. I have several questions about her treatment. She is
on KD diet and Tumil-K gel. My vet mentioned sub Q fluids may be needed in
the future. I apologize for not having the levels of her tests for you, but
my head from spinning from the news that this is a fatal disease and I just
stopped writing things down trying to digest the hard facts. As I have always
been so diligent with her health/diet I really expected to have her w/me
19-20 yrs. Eight yrs. ago Em was rushed to an emergency clinic. After a
diagnosis of urinary tract infection the vet said quite casually that she had
chronic kidney disease. I asked what that meant and he said it meant her
kidneys were very small for a cat. I told him I had her on a diet of Hills
Scientific and he said that was good for her and that was the end of it. I
was never told that this was a fatal disease or offered any advice on
treatment. As Em seemed fine after that, and he seemed to casual I did not
consider her condition a problem. 1st question...was the disease unknown to
be fatal then, or chould the vet, considering her age, overall health and very
chubby physic have thought it was really nothing to worry about at that time?My second question is my concern over my vet not putting her on fluids
immediately. I will ask him this question Mon. but I would like your opinion
also. He has been our vet for 8 yrs. now and I trust his judgement but as I
knew nothing about the disease before I have been doing alot of research and
this seems like a very common approach. As I said, I do not have figures to
give you but I can tell you her condition. She is lethargic, not eating, was
drinking tons of water (but that seems to have decreased), moving away from
me and clearly uncomfortable. She is weak to the point of being unsteady on
her feet. She ate the KD, diluted w/her regular food the 1st day but has not
since. I have mixed it w/tuna water, warmed it but no go. For 2 days she
would eat nothing, even her regular. Today she ate from my finger, a very
diluted mixture of her food w/KD. My last question, with this diet and the
supplements how long should it take to see any improvement or sign that this
is even helping her? Am I being too impatient? Sorry for this very long
letter, I visit your site often and find it so helpful as I work for a rescue
group and often need ideas/help. I will be asking my vet these questions but
would really appreciate your input, my absolute concern is to be able to care
for Em the best I can, she's been my joy for many years and I must do right
for her. Thanks, CindiAnswer: Cindi-
I think that it is best to give subcutaneous, or intravenous, fluids in
patients who have clinical signs of illness resulting from deficiencies in
kidney function. It is a much harder choice when we discover signs of
kidney insufficiency on a routine examination of an otherwise healthy cat,
or in blood work that turns up another illness that seems to be the current
problem. In these patients we often try dietary modifications such as
changing to diets that are helpful in kidney insufficiency, supplementing
potassium, using calcitriol or phosphate binders and closer monitoring of
the cat's health. Usually, there is some improvement in activity levels,
attitude or other behaviors indicating that this approach is helping,
within a few weeks. If not, it would be best to consider additional therapy.I am pretty sure that most cats over ten years of age have some degree of
compromise in kidney function. Most of these cats will do fine, without
treatment, for several years. At some point, one of the functions of the
kidney will become deficient enough to cause problems. For some cats this
will be potassium regulation problems, for others azotemia (inability to
detoxify the blood adequately), weight loss or other sigs of kidneys that
are just not functioning well enough. Veterinarians, including me, tend to
refer to this condition as kidney failure when it really is more accurately
described as kidney insufficiency. The kidneys need help to do their usual
jobs and if they get the help, they will continue to meet the body's needs
for a long time. Our personal record for a cat that came in to the office
in a crisis situation from kidney insufficiency was eight years of good
quality life after this initial episode. We have had a number of patients
in which we discovered kidney insufficiency by accident who lived much
longer than this after the initial realization that there was going to be a
chronic problem with kidney insufficiency.The things that help the kidneys are these: 1) control phosphorous levels
in the diet, through the use of low phosphorous diets, calcitriol
supplementation and/or phosphate binding agents, 2) moderate protein levels
in the diet, 3) supplement potassium, 4) use anti-hypertensive agents (we
like amlodipine (Norvasc Rx) as a first choice but use enalapril (Enacard
Rx) in some patients), 5) do what you can to get more liquid into the diet
by switching to canned foods, encouraging water intake with a source of
running or moving water, 6) when it is apparent that a cat can not maintain
adequate hydration, or needs enough fluids to induce diuresis, use
subcutaneous fluid administration. I strongly prefer that my clients learn
to do this at home, so that it can be done daily when necessary and so that
it is less stressful to the cat, but if intermittent therapy at our office
is all that can be done, we use that approach, 7) when anemia becomes a
problem, consider using erythropoietin supplementation. This should be put
off until absolutely necessary, unless a cat origin source of
erythropoietin becomes available, which may happen. The present products
are human origin and cause antibody formation against this hormone in some
cats, which is a really serious complication of therapy. 8) for younger
cats, kidney transplant is possible, although it is expensive and does not
always work out well.Eventually kidney insufficiency will lead to a situation in which the
kidney have truly failed and this condition becomes fatal. However, this
decline in function may take a very long time, if you help the kidneys out,
allowing them to do less work and making it possible for them to meet the
body's needs in this manner.I think it is still reasonable to hope for Emily to live 19 to 20 years.
There is no guarantee but there is also no reason to give up and passively
accept a poorer prognosis for longevity, either.Mike Richards, DVM
11/26/2000
Renal amyloidosis in Abyssinian
Question: Dr. Mike:
I have an Abysinian cat named Bobby. He was born late February of this year,
he has just been diagnosed with kidney failure. He had bloodwork and most
recently an ultrasound which somehow confirmed he was only able to utilize
33% of his kindeys.
(His urine is not concentrated..)My question has to do with treatment. My vet says just wait and re-test. I
want to be more aggressive. What do you think? Have you ever heard of this
in such a young cat? Is it a breed thing?My girlfriend owns two of his litter mates and has offered a kidney for a
transplant. We live in No. California and I understand UC Davis does perform
this procedure. I also read some of your online articles?
What are the risks to both kittens? What about food? I've been feeding
Bobby 4-5 times a day really small bites to help in processing - what else?
I love Bobby and want him to be around...Thank you.
Answer: J-
Renal amyloidosis occurs in Abyssinian cats as a congenital disease. In
Siamese cats this disease is thought to follow family lines and is
therefore suspected to be genetic in origin but I do not know if this is
the case in Abyssinians. This is a disorder in which excessive production
of amyloid occurs somewhere in the body and it damages the kidneys as they
try to filter it. This disorder can occur due to infections, such as feline
leukemia virus (FeLV) or feline infectious peritonitis (FIP), so looking
for a primary cause is a good idea. If amyloidosis is present, a kidney
transplant is not going to help much over the long term, because the
production of amyloid continues to occur and the new kidney will become
damaged over time, as well.There are other potential problems that may have lead to the current state
where the kidney function is insufficient. Trauma to the kidneys, blood
clots that damage the kidneys, congenital disorders other than amyloidosis,
glomerulonephritis, infections of the kidneys, and other problems can all
lead to damage to the kidneys at an early age. It is possible for Bobby to
compensate for a one-time insult to the kidneys, even if it damaged a major
portion of the kidneys, and to live a pretty normal life. It would be a
good idea to try to rule out viral causes like FeLV and FIP and to look for
any other treatable underlying cause at this time.The first step in the process of deciding what to do is to try to identify
the underlying cause of the kidney failure. I think that it would be best
to ask for referral to the veterinary school, or at least an internal
medicine specialist, as this stage. Identification of the underlying
problem may require biopsy of the kidney at some point, but there are other
tests to consider first. A protein:creatinine ratio (done with urine) helps
to confirm that protein is spilling into the urine, which is a strong
indicator that glomerulonephritis or amyloidosis is present. Ruling out
possible causes can be done by physical exam and testing for things like
FeLV. If this does not provide an answer, then kidney biopsy would be
helpful, because glomerulonephritis tends to respond to treatment (the
progress of the disease can be slowed) and cats with this condition may do
well with a kidney transplant. Amyloidosis tends not to respond to
treatment and cats with this condition are not good candidates for a kidney
transplant. Getting to the point where you know which problem is present
allows a better decision making process.There is not enough research to tell you the best diet for cats with
glomerulonephritis and amyloidosis but the prevailing opinion among kidney
specialists seems to be that moderate protein restriction and low salt
content in diets are good goals. The diets made for kidney failure, such as
Purina's NF, Hill's k/d and others are satisfactory to meet these goals. As
kidney failure progresses, the low phosphorous content of these diets is
also helpful.Controlling hypertension (high blood pressure) is a good idea, since many
cats with kidney insufficiency, particularly with glomerulonephritis, will
have high blood pressure. Fluid therapy is often helpful.There is a good link on our link page for cats with chronic renal failure.
I really do think that it is best to be more aggressive about finding out
what is going on and then in treating the problem, so do consider asking
for a referral to an internal medicine specialist or the vet school at UCD.Good luck with this.
Mike Richards, DVM
11/6/2000
Kidney problems and dry vs wet cat food
Question: Dear Dr. Richards,
Your publications are very informative and your website has helped me w/questions regarding one of
my cat's skin problems.We adopted two Malaysian stray cats while living in Kuala Lumpur who are now almost 7 years old.
My question regards the merits of dry food over wet. Our vet here in Singapore (a Canadian trained in
Canada) suggested feeding only dry food when we moved here almost 3 years ago and recommended
ANF and MaxCat. I am feeding a mixture of both of these plus some wet (canned food) in the
morning. My friend (from Belgium) brought her two cats from Belgium and adopted 2 Singaporean
strays which stay mostly outside. We use the same vet and she has been feeding her cats mostly
dry food. She recently had to have her female Singaporean cat put down due to kidney problems and I
think she blames the vet for recommending only dry food. (She told me that the Belgium vets
recommend only wet food - no dry for cats there).Both ANF and MaxCat claim they are formulated for optimum kidney health. I hope the dry
combination plus wet food (and having water available all the time) that I have been feeding my cats is
good for them. (They also get treats of cooked chicken and fish and my male loves honeydew melon).
Do you have an opinion? - I don't want my cats to have kidney problems.Thanks, Cecelia
Answer: Cecelia-
I am not aware of any studies suggesting that dry cat foods cause kidney problems, nor does this
seem to be the case based on our patients. However, there are studies that suggest that feeding wet
food can help in reducing the rate of deterioration in cats that do have kidney insufficiency/failure
problems. The reason for this appears to be an increased intake of water in the food, since the
moisture is not removed, as it is in dry foods. It seems logical that at least some cats would benefit
from eating wet foods rather than dry foods, from the standpoint of kidney disease. But like most
nutritional things, it is probably true that wet food can lead to some other problem, balancing out the
beneficial effect in kidney disease. An example of this is an early indication that cats fed canned food
are more prone to hyperthyroidism, for instance.In all honesty, I do not think we know enough about the nutritional effects of these products to
declare a clear advantage to either product. Like you, I feed my cats a mixture of dry and canned
wet foods.Mike Richards, DVM
10/9/2000
Question: Dr. Richards,
I have a mixed breed cat, Genny, she is neutered and a strictly inside pet. I
have had her for approximately 12 years and when I took her in for yearly
check up my vet ran some bloodwork on her since he was going to clean her
teeth; we have never had blood work done before on this cat so I have no
other test to compare her results with. My vet has advised me that the test
came back showing my cat has kidney disease and he feels that we have caught
it early. My vet is trying to reassure me that we'll be able to control the
disease with special food (I think it is Hill's Prescription Diet) and if
this food does not work there is another food that is a bit stronger (I'm
sorry I do not know the name of it.) He also said I will need to bring her in
for frequent check ups.My questions/concerns are:
1. Is this a curable disease?
2. If not, can my cat continue to live a long life with this condition?
3. If the food is the only option I have right now, how long before we will
see improvements in her bloodwork?
4. How often should any testing be done to monitor her kidneys?
5. Is the blood test the only testing that should be done to diagnose and/or
monitor the kidney disease?
6. Is there anything I can do to stop further damage to her kidneys?
7. Is there anything I should watching for - for example: changes in her
drinking, urinating, any body changes or reactions, etc.?
8. Is there anything else that I can give her to "build up" her kidneys?
9. If the food does not work do I have any other options (for example:
medications)?Dr. Richards, I appreciate your time and any information that you can provide
me, for I am trying not to over react, but I am quite worried and want to do
whatever I have to keep my kitty healthy and happy!Sincerely, Dianne
Answer: Diane-
As cats age many of them develop renal insufficiency, which is a decrease
in the function of the kidneys to the point that they are not able to
adequately do their job. This happens because kidney cells die and are not
replaced. To compensate, the remaining kidney cells learn to do their job
better. Fortunately, it is possible to slow the rate of cell death and to
encourage the other kidney cells to function better, making it possible to
slow the progress of the disease. Still, the disease is incurable and will
eventually lead to the death of the patient over time. We have managed cats
with renal insufficiency for as long as ten years before that happened,
though. Although that is an exceptional case, many cats live several years
with good quality of life.If the signs are very mild, we will sometimes rely on diet alone. When we
do this, we ask owners to let us check lab values after 2 weeks to one
month and then every three to six months. We are not really looking for
improvement, we are trying to make sure we catch any deterioration in
kidney function quickly. Many cats do actually show improvement in the
kidney related blood work with dietary control alone, often by the time we
do the initial blood work.The things that help prevent loss of kidney function are adequate
hydration. Feeding canned food is preferable to dry food due to this and I
think that going to subcutaneous administration of fluids early in the
disease process is beneficial. Medications to control blood pressure are
sometimes necessary and may be helpful even when increases in blood
pressure can not be documented. Potassium supplementation is helpful in
many cats. While its use is controversial, calcitriol administration seems
to make many cats feel better. Phosphate binding agents (such as Amphogel
tm) are helpful but less necessary when using a low protein/low phosphorous
diet. Figuring out when to add each of these medications is difficult
because each patient is different but all may be necessary at some point.Making sure that complicating diseases are not present is a good idea, too.
The most common one is hyperthyroidism, which should be tested for if there
is weight loss, especially if it is accompanied by an increase in appetite.Monitoring urine specific gravity is helpful. I like this test a lot when
it is easy to get urine, because it helps to determine how well the kidneys
can concentrate urine. Keeping track of Genny's weight helps a great deal,
too. Weight loss can actually be good for patients with kidney problems but
if it is occurring too fast it can be a sign that additional therapy is
necessary.It is critical for cats with kidney problems to drink water on a regular
basis. A great increase in thirst often indicates that the kidney
situation is becoming unstable again and when cats with kidney disease stop
drinking they need to be checked to see if the kidney disease is getting
worse suddenly.I don't know of any food supplements other than those mentioned above that
are helpful. Potassium administration seems to help even when potassium
levels are in the normal range, so if it isn't too much trouble (some cats
hate the potassium preparations) it would be worth considering
supplementing potassium.There is a very good web site for chronic renal failure
at http://www.felinecrf.comHope this helps some.
Mike Richards, DVM
7/24/2000
Kidney Failure - daily fluid treatment
Q: Doctor,
Please advise. My friend has a 9-year-old female cat (Tiga) who has
recently been diagnosed with kidney failure.Her "mom" gives her fluid IVs on a daily basis. Tiga seems to be happy,
sometimes playful, although her weight is still low.Is there an average life span for a cat once it begins fluid therapy for
kidney failure? I would welcome any advice or thoughts you have re this
condition.Thank you,
B. G.A: B-
I think that daily fluids is very helpful for cats with compromised renal
function. I don't think I can give you an average lifespan for cats once
fluid therapy is necessary but I can give you some idea of our experiences
with this. We have had several cats who lived for longer than 5 years with
frequent, or daily, fluid therapy. Right now we have four or five cats in
the practice who are nearing this timer period or are over it. On the other
hand, we have cats who live less than a year. I suspect that most of our
patients live between 1 and 3 years after the decision is made to go to
frequent fluid therapy administered at home.There are a lot of additional therapeutic measures that help in controlling
the progression of kidney failure in cats. Low protein/low phosphorous
diets are very helpful. Calcitriol administration seems to help a lot of
cats. Hypotensive agents such as amlodipine (Norvasc Rx) and enalapril
(Enacard Rx) seem to be helpful. We have better luck with Norvasc but have
had some success with both medications. Phosphate binders like Amphogel
(tm) are also helpful, more so if calcitriol isn't used. Appetite
stimulation is sometimes necessary. Fluid therapy is the mainstay of
treatment but these other options can help, too.The longest a patient has lived after having severe elevations in renal
values (creatinine >5, BUN > 150) was eight years. We used almost all of
the above products in that particular patient, except the Amphogel.Hope this helps. There is a link to a good site on feline renal failure on
our link page.Mike Richards, DVM
10/9/99
Q: Dear Dr. Richards,
I am a subscriber to Vetinfo digest.
My 17 year old cat, Tigger Alice, has been having progressively
worsening kidney failure. I have a wonderful vet here in NYC, but
I always get nervous when I go and don't ask all the questions I have.Tigger Alice is now on fluids that I inject every other day. I just
started two days ago and today will be my second injection. My doctor
wanted me to give her fluids once a day, but I bargained for every three
days and we settled on every other because I really hate sticking her. I
think it must hurt. But I would do anything to keep her healthy. We will
be going to the vet in a month for a follow-up check up. Tigger also takes
tapazole every day for her thyroid.My question is (finally!); should I have injected her every day? I
don't know anything about this "creatinine level" thing other than what I've read
at Vetinfo. My vet said her level is 3.5 and that normal is 2.5. With that
3.5 level, is every other day of fluids going to be ok or did I make a
mistake?
Does the constant puncturing hurt Tigger Alice? Is there any other
method of getting the needed fluids into my cat?
I actually didn't mind injecting her. I thought it would be horrible
and I built it up to be so awful in my mind that it wasn't bad at all. It's
just that I'm afraid of hurting my cat after many punctures in the future. But,
if this is all there is, this is what I have to do.Also, any suggestions on how to get her to eat more? She's 7 pounds now
and the vet would like her to be 8 and1/2. I leave out food all the time;
both wet and dry.
Thank you for your time. I think it's incredible that you do this
service for people. I find the online information at Vetinfo so helpful,
too.L
A: L
There isn't a clear answer to your question. We have cats on all sorts of
intervals of fluid therapy, ranging from people who give fluids at the
first sign of problems, such as inappetance, but not routinely, to people
who give fluids every day. In general, I think that people are pretty good
at evaluating their cat's need for fluid therapy based on their assessment
of their cat's attitude. If Tigger Alice seems to feel better on fluid days
than on non-fluid days, I'd go to giving it everyday. If she doesn't show
much difference in her attitude then the longer spacing is probably OK. It
is unlikely that you would cause any long term harm by starting out with
fluids at intervals of 48 hours and then deciding later they needed to be
given daily.I am pretty sure that the needle punctures do hurt. I think that there are
cats who appear to learn that the fluids make them feel better, though. We
have had several clients who really felt that their cats would seek them
out for fluid therapy when it was necessary. Of course, there is no way of
being sure of that. In any case, sometimes it is necessary to cause some
discomfort in order to get a greater level of overall comfort and quality
of life. Thinking of it that way can make it easier when it does seem like
you hurt Tigger Alice making the injection.You could try adding a little oil to her food. A teaspoonful of oil has a
lot of calories in it and the higher fat doesn't seem to hurt the kidneys.
I don't usually worry much about weight if the cat feels good but it is
reassuring when they begin to gain weight back so I can understand the
desire to see this.It is a big commitment to go to at home fluid therapy but it is usually
worth the effort.Mike Richards, DVM
9/1/99
Kidney Problems and cyproheptadine (Periactin Rx) in Himalayan
Q: Dear Dr. Richards,
I have a Himalayan cat, approx. 11-12 years old. He was diagnosed
with kidney problems back in Sept. of 98. I had noticed that he was
drinking a lot of water and his appetite was poor, along with frequent
urination. I was told to try to get him to drink as much water as possible
every day and to have him eat mostly canned foods. I have been giving him
water mixed with a couple of teaspoons of turkey or chicken baby food to be
sure he drinks enough. Because of his poor appetite, I am also giving him
"Periactin" to stimulate his appetite. The dosage is 2 mg., 2x a day, as
needed. I usually only give him 1 dose per day. Do you feel it is safe
for him to take this medication for a long period of time, even for the
rest of his life? I get worried that I use it too much but when I skip a
day or two, he definitely doesn't eat as well. Even with the medicine, he
doesn't eat as much as I'd like; maybe a half of a 6 oz. can of food, if
I'm lucky, and an eighth of a cup of "Rx" dry food, but he does seem to be
maintaining his weight. I recently had to put my other cat to sleep and I
am very heartbroken so I just want to be extra certain that I am doing the
right thing for this cat so that he is with me for a long time to come.Thanks in advance, Julieann
A: Julieann-
I can not find any information that suggests there is a problem with long
term use of cyproheptadine (Periactin Rx). It is sometimes used for asthma
in cats on a long term basis, so if there was a major problem with it I
think that there would be reports of the problem.It may be a good idea to consider more aggressive therapy for the renal
disease, though. There have been several recent articles that say that cats
given calcitriol when they have renal failure feel a lot better and eat
better. It sometimes helps to use an ACE (angiotensin converting enzyme)
inhibitor like enalapril, too -- at least according to reports. We have
used amlodipine (Norvasc Rx) and feel that it has worked well enough for us
that we haven't had as much experience with enalapril. So it is another
option, too. We have usually waited until there were signs of hypertension
(high blood pressure) in the past before starting one of these last two
medications but newer reports seem to indicate that it is worthwhile to
consider them before there are clinical signs of hypertension since so many
cats with renal failure that develop high blood pressure.We use subcutaneous fluids when there is a drop in appetite in cats we know
have renal failure. This really seems to help in our practice.Keep working with your vet and let him or her know that you are interested
in aggressively caring for your Himalayan (if you think you can give more
than one medication a day and if you want to).Good luck with this.
Mike Richards, DVM
4/16/99Q: Dear Dr. Richards
I would like your advice on how best to keep my persian cat who has been
diagnosed with acute kidney failure.Perhaps I should start with the beginning:
In early May 1998, my 8 1/2 year old Persian cat who has never been sick
before refuse to eat or drink. I took her to my usual vet, who gave her
a Vitamin B injetion and some appertiser but by the second day, she
still refuse to drink or eat and look really sick. I rush her to the
vet again and she said that she was dehydrated and needed to be
hospitalized. I rush her to the only animal hospital we have in
Singapore, where the vet felt a lump in her abdomen. He took an x-ray
and on looking at the result diagnose that it could be a fur-ball or a
tumour but needed to run further test. However, as she was badly
dehydrated, he suggested that she be put on a drip and kept overnight.
In the morning, the resident vet said that he had to operate as the lump
felt quite large. He warned me that if it was a tumour it would be
pointless to let the cat live but if it were a fur-ball, he would remove
and then see what happens. He also warn me that the anasthetic could be
dangerous for the cat and that it had adverse effects on various cat.
Luckily, when he operated he found that it was fur-ball trapped in her
stomach. After the surgery, Bluey, my cat was in critical condition for
3 days and I nearly lost her. However, on the 4th day, her condition
stablized and the vet began feeding her liquid food. The vet had
inserted a tube directly to her throat to allow her to be fed by liquid
food. After a week, Bluey, still look bad, however, the vet felt she
would be better off in the home environment. The family took turns to
feed her 4 times a day according to the vet's instructions. We also
gave a vitamin, liver tonic as well as glucose water. She was 3.5 lbs
when she left the clinic. She slowly recovered but it took almost 8
weeks before we could remove the feeding tube. After that she began to
eat on her own. The vet suggest that I don't bring her to the clinic
too often to eliminate the stress she is put through. I initially fed
her with her usual cat food, Friskies and also introduce Hills KD diet
but she didn't like it much and sometime when hungry. So I decided to
change the cat food to IAMs mixed with the KD. She gained weight and by
the time I visited the vet in August 98, she was an almost 8 lb. cat.
The vet was very pleased but when he did the blood test and found that
her creatnine level when up from 3.2 to 3.5, he suggested that I put her
on a Hills KD diet again. Bluey doesn't like the KD Diet and I
alternate it with the IAMs cat food, she would refuse to eat and rather
starve.In January this year, I took her to the vet and her blood test shows
that the creatnine has gone up to 4.3. Bluey just refuses to eat the KD
diet, and by February, she was ill again refusing to eat and her weight
when down to 6.5 lbs. I took her back to the vet, he gave her some
vitamins and antibiotics which I had to administer daily. The blood
test indicated that creatnine had gone up to 4.6. I am now giving her
on a daily basis a vitamin/appetizer call VAL Syrup given by the vet and
a laxative 2 times a week to take care of the fur ball. I have put her
on a diet of fresh boiled fish alternating with Hills Low Magnesium
Liver & Chicken as well as Eukanuba Veterinary Diets, Moderate pH/0.
Bluey seems to like the Eukanuba cat food and laps it up. She initially
use to urinate very little at a time but after the completion of the
antibiotics, she now urinates quite a bit. She still drinks quite
frequently and likes running tap water. She has gain weight and is
around 7.5 lbs. She is now 9 1/2 years old. I also occasionally give
her some Cat barley green.I would like to know what I can do to stabalize her condition. I still
think she is a young cat and if given the proper care, she could live
comfortably for another year or two. Do you have any recommendation on
diet or supplements that I can give my cat.Am I doing the right by giving her food that she enjoys? Your advice
would be greatly appreciated.I have visited the site on Kidney illness and have taken some advise but
I would like to hear from you.Regards
Margarita H
A: Margarita-
Persian cats should be examined for polycystic kidney disease when renal
failure starts at an early age (I think that your cat still qualifies).
This is best done by ultrasound exam, if that is possible for you to arrange.A good website for information on polycystic kidney disease is:
<http://www.indyweb.net/~lucky/Stats.htmlIf this disease is present, the progression of the renal disease will
probably be faster than if it is not present but otherwise the treatment is
roughly the same.At present, the only thing that I can add to the information we have online
concerning kidney failure maintenance therapy is that many vets feel that
angiotensin converting enzyme (ACE) inhibitors seem to help slow the
progression of renal disease. Enalapril (Enacard Rx) is the one most
commonly recommended in the United States.Fluid therapy, usually given subcutaneously, is the mainstay of treatment
for renal disease, otherwise. It helps a lot if you can learn to administer
the fluids at home so they can be given frequently and to minimize stress
for the cat.Calcitriol is also advocated by many veterinarians at this time to help
keep phosphorous levels low and provide a better level of overall health. I
do not think that there is a commercially available calcitriol product. As
far as I know, it is made by compounding pharmacies for the vets using it.
Usually calcitriol is started at dosages approximating 2.4 ng/kg of body
weight but when creatinine is already pretty high it may be necessary to
start at a higher dose to get a good effect. I am not sure what references
might be available to your vet but there is a good article on using
calcitriol in the November 1996 issue of the Clinics of North America.The effect of diet on kidney disease is still being debated in veterinary
journals by researchers on the subject. At this time I still think it is
important for cats to eat so I don't try to starve them to get them to eat
a special food. If a cat will eat a mixture of 1/2 k/d or Purina NF and 1/2
its favorite food, that is a good compromise.Hope this helps some.
Mike Richards, DVM
3/29/99
Feline kidney failure and methimazole (Tapazole Rx)
Q: Dr. Richards,
I'm glad I found your website and only wish I had sooner. I'd like your
opinion regarding my cat Bing. Bing is sixteen or seventeen years old, I
inherited her when she was about eight or so (am not sure of her real
birthdate) and she's been a member of the family ever since. She is a
longhair calico and has been relatively healthy except for a few urinary
tract infections. She has always been a small cat (about 7 pounds) since I
got her. She was tested for and diagnosed with a hyperthyroid problem
about four months ago after I noticed her acting a little unusual and
losing a bit of weight. Her T4 measured at 11 so she was put on 10mg/day
of tapazole. After a followup blood test I was told her T4 levels were in
the normal range and she was kept on 10mg/day. She developed a urinary
tract infection about a month ago, was put on Clavamox and a followup
urinalysis showed her specific gravity at 1.018. There was a question of
her kidney function although I know Clavamox makes her very thirsty and
wondered if it could have affected her spec. gravity. At this point she had
also been on tapazole for about 3 months. I told my vet I wanted to get a
blood test to check her kidney function and recheck her T4 levels.
When the results came back, I was told Bing was in the early stages of
kidney failure and anemic. Also her T4 was low at 0.4. It turns out no one
checked her baseline kidney function or hemoglobin prior to putting her on
tapazole so I don't know what if any negative effect the medication might
be having on her.
The tapazole has been reduced to 5mg/day and Bing seems to have more
of an appetite. She was also put on an iron/vitamin supplement
(Petinic) to help with the anemia and stimulate her appetite.
Her blood values were as follows:
BUN 51
Creatinine 4.3
Alk Phosphatase 3
Amylase 1225
Hemoglobin 6.0
Hematocrit 17.4
RBC 3.58In spite of all this Bing doesn't look bad. She seems pretty alert, has
a decent appetite (the Petinic also seems to be helping) and doesn't seem
uncomfortable. At this point I'm not quite sure what to do. Does she need
to be on fluid therapy; knowing her I'm not sure if she'd let me do that to
her? But I'm in the medical field, do venipunctures and set up IVs on
people so I probably would'nt be too uncomfortable with doing it if she let
me. I assume the tapazole probably isn't helping with the kidney problem
and wonder if its also affecting her hemoglobin levels or if that's just
being affected by a decrease in Erythropoeitin. I wonder whether I should
have her thyroid irradiated to get her off the tapazole, or wait to get
another blood test in a month or so to see if the decrease in tapazole and
iron supplement helps. I'm reluctant to blood test an anemic kitty too
often. I know you probably see cats much worse off with CRF than Bing but
other than knowing her blood levels are abnormal I don't know what to
expect in terms of how quickly she will get much worse. I know no one can
predict in any one case, and at this point my vet doesn't seem to be
superconcerned but they suggested fluid therapy anyway. I'm sure you know
how emotionally wrenching this all can be. Any suggestions or advice would
be greatly appreciated.Thanks and sorry for the long letter,
Dennis
A: Dennis
Based on nothing other than my clinical experiences I think that
methimazole (Tapazole Rx) is very very likely to be the cause of the
anemia. This is the complication of its use that we have experienced most
frequently in our practice. Fortunately, almost all cats have responded to
lowering the dose or using alternative treatments such as surgical excision
of the affected thyroid gland or radioactive iodine therapy.Kidney failure does cause anemia as well, for exactly the reason you point
out in your note. The kidneys produce the hormone erythropoetin, which is
responsible for stimulating the bone marrow to produce red blood cells. So
it can't be ruled out as a cause, especially if withdrawal of Tapazole
doesn't resolve the anemia.It would be a good idea to find out what her phosphorous and potassium
values are, too. Keeping serum phosphorous levels down is helpful in
slowing the damage during chronic renal failure and potassium levels often
fall with kidney failure and this affects muscle function, possibly
appetite and possibly even the progression of the renal disease.The relationship between renal failure and hyperthyroidism is very complex
and it can be difficult to decide what to do when patients have both
problems. The high blood pressure induced by hyperthyroidism causes more
blood flow to the kidneys which MAY help them function better. When cats
that have kidney failure are treated for hyperthyroidism the reduction in
blood flow to the kidneys as the high blood pressure from hyperthyroidism
drops may cause worsening of the kidney failure. This effect is worse when
hypothyroidism results from treatment for hyperthyroidism. So in some cats,
adjustment of the Tapazole dose so that there are reasonable thyroid
hormone levels or even addition of thyroxine by oral supplementation may be
necessary.The bottom line is that it is often necessary to aggressively treat chronic
renal failure during treatment for hyperthyroidism. This may be very
important to do if it is necessary to give up on Tapazole due to
complications associated with its use and to have surgery or radioactive
iodine therapy.It is hard to decide what to do but I think that your vet is probably
following the safest course at this time -- reducing the methimizole dosage
to try to determine which problems are due to methimazole and which to
renal failure a good first step. Instituting aggressive therapy for the
renal failure may also be a good idea. It would be a good idea to talk with
your vet and try to determine the best way to do this since your vet will
have a better idea of how your cat may react to the various treatment
options.Good luck with all of this.
Mike Richards, DVM
Q: I have an almost 18 year old female Siamese cat who has been diagnosed with degenerative kidney disease. She is VERY skinny, although her drinking, eating and litter habits appear to be fairly normal. We started off giving her medication, then came to the conclusion that, except for feeding her a low protein diet, it would be better for her if we just left her alone. This is fine to a point...we just want to make sure that she doesn't suffer unnecessarily and we've reached the point where we have to give her wet food in order to get her to eat. She hasn't been to the vet recently as we prefer not to cause her stress if we don't have to. So, bearing all this in mind (grin), how do we tell when she's reaching the last stages? What are the last stages? Obviously, we'd like to keep her as long as possible, but we'd like to end things for her before she begins to suffer. Thank you for your time. Michelle
A: Michelle- It is very difficult to slow the degeneration in chronic kidney failure without using fluids to diuresis the patient. This can be done at home and many cats tolerate it quite well. I mention this because it sounds like your cat is at the stage where you have to choose to use fluid therapy and possibly medications for appetite stimulation, potassium supplementation and possibly other secondary problems. When cats lose their appetite for "normal" foods it often indicates that the level of toxins in their bloodstream has exceeded the level they can tolerate. Without diuresis or dialysis, it is much less likely that a cat will be able to stabilize the kidney function and get back to a state of "compensated" kidney failure. In most cases, the relief afforded by the use of fluid therapy and medications is worth the stress of the trips to the vet. From a medical standpoint there isn't much question in my mind that the trade-off is clearly in favor of treatment, in this condition.
I know that many cats do not tolerate medications well and for many people, administering fluids subcutaneously at home is not an acceptable option. When this is the case, letting go is necessary when obvious signs of distress occur, such as several days of refusing to eat, difficulty moving or extreme depression.
Talk to your vet about this too. He or she will know you and your cat well enough to give you better advice about when the time is right to consider euthanasia in your particular situation.
Mike Richards, DVM
Q: My cat, last year was diagnosed with chronic kidney failure, the vet ran alot of tests, and wanted him to come in every day, twice a day,for sq fluids, his creat eas 3.02, his bun was 38.8, his alt was 29, they said he didnt have long to live, later I took him back for a check up, that vet said he had a gallop heart rythem, and a thyroid nodule that was cancerous. Generally saying, he's dying. In sheer panic I took him to a homopathic vet, she prescribed catalyn 2140, renafood 7115, fbiotic, also put him on a homopathic diet, after giving him the pills he had a seizure, we took him to the emergency room, 3 doctors saw him there, who also have private practices, he stayed there for 3 days, while they ran up bills, with more tests. He never had a seizure since. They suggested taking him to a specialist, I did. They ran up alot of bills too. That all started last year june 20th. I said to hell with the vets. From all the stuff I read, the homopathic vet made me od the cat on vitamins, no other vets will admit it. What do you think? We found a new vet, that we like, who is honest, and intelligent. WeeWee is still alive, his creat is 3.1, it went down, three months ago it was 3.3. Can you explain, why this cat is still alive, that year he was suppose to be dead, and needed alot of tests, sqfluids, and so on? I'm puzzled, is there any kind of vet board, in Texas to report these so called vets to? WeeWee celebrated his 13th birthday, April 22nd. He's going fine. And still alive. Do you have any advice? Patricia
A: Patricia- It does not surprise me that your cat is still alive today. Kidney failure in cats tends to be a long drawn out process. It is important to monitor certain lab values over the course of the kidney failure, in particular the blood (or serum) urea nitrogen (BUN), creatinine, potassium (K+) and phosphorous. These values give an indication of the progression of the disease. Your cat may also have hyperthyroidism based on the history of a thyroid nodule. This can make kidney failure worse -- although sometimes if hyperthyroidism is treated the kidneys will recover. The high blood pressure often associated with hyperthyroidism seems to give the kidneys difficulty but to be a reversible change.
The standard therapy for kidney failure in veterinary medicine is diuresis using subcutaneous fluids on a long-term basis or sporadically as necessary. In addition to this, it may be necessary to supplement potassium, use phosphate binders, appetite stimulants or medications to reduce high blood pressure that often accompanies kidney failure. Calcitriol has been advocated recently for use in kidney failure. It requires monitoring the lab values a little more closely since it shouldn't be used when the phosphorous levels are very high. As long as it is used carefully it seems to be beneficial. Dialysis and kidney transplants are available in some areas of the country for treatment of renal failure but these are costly treatments.
I am not familiar enough with homeopathic remedy names to give you an opinion on this aspect of the treatment. In general homeopathic medicines are safe but their efficacy is questionable. Vitamin therapy is not likely to cause much problem if the dosages are reasonable.
The standard treatments for hyperthyroidism are radioactive iodine therapy, surgical removal of the affected gland or medical suppression of thyroxine release using methimazole (Tapazole Rx). Doing enough testing to confirm whether or not this is really a problem would be a good idea -- but may have already been done. If it is present, treatment may resolve all of the clinical signs or you may still have to treat for kidney failure. You always have the option of asking your state veterinary board to review a veterinarian's treatment of your pet. I think that all states have a veterinary board. I can't find a phone number or address for the Texas board in the AVMA directory, though. I'm sure that your vet can supply this information.
It is possible to manage chronic renal failure in cats for a long time. It takes close cooperation between you and your veterinarian. It is somewhat costly but the costs tend to be spread out over time.
Good luck with this.
Mike Richards, DVM
Q: Dr. Richards, Thank you very much for your reply and helpful advice. As a testament to your expertise, my cat (since I wrote you my letter on May 15th) was diagnosed with kidney disease and put on (as you suggested) Norvasc immediately. Within just a few days her pupils began dialating and contracting normally again and now it appears (through her actions and ability to follow my hands) that she has regained a significant amount of sight. It's very rewarding to be able to look your animal in the eyes and recognize that it is looking back at, and acknowledging, you. With regards to her kidney problems (I believe after the blood test she registered a 6.2 with 2.0 being normal) the vet simply suggested that I try to switch to Hill's low protein food. This the vet said could give my animal an estimated two years or so left in her life span. Since you were so accurate in your last assessment, I was wondering how this diagnosis strikes you and what else I might be able to do (medicines, etc.) to help out the situation. Thanks a lot for your time. Mr. R
A: Mr. R- There is a very good site for chronic renal failure support and information on cats that you should check out: http://www.felinecrf.com
We have a link to it on our page on urinary problems as well.
There are several medications commonly used for chronic kidney failure complications in cats. Low protein/low phosphorous diets and subcutaneous fluid therapy are the mainstays of treatment. Fluid therapy may not be a good idea until the blood pressure problem is under control, though. If high blood pressure is a complication (as it is in your cat) then Norvasc (Rx) can be helpful. Some cats are constipated from the tendency towards being slightly dehydrated and stool softeners such as lactulose are helpful in those cases. Phosphate binding medications may help lower the high phosphorous levels associated with kidney failure. Appetite stimulants are necessary for many cats at least at times. The two most commonly used ones are diazepam (Valium Rx) and cyproheptadene (Periactin Rx). Many cats with renal failure also need potassium supplementation.
It is also a good idea to make sure that there is not concurrent hyperthyroidism since both of these problems are common in older cats.
Many cats will need some of the above medications but few cats need all of them. You have to work closely with your vet to do what is best for your cat.
Mike Richards, DVM
Kidney failure - heart failure
Q: Dear Dr. Mike, My cat was euthanized one day ago. My cat Sam (15 yrs) had been diagnosed in January with kidney disease. After he was in doctors care for 1 week, we took him home to care for him. His bun was brought down from the 120 range to the mid 40 range. His creatnine levels were reduced from mid 7 to normal range. However, by March, these levels were up again. Bun was 90's. Reading on the web about sub-q fluids, I started administering to him 100cc daily. A further check up one month later, still showed a high bun of 120. I proceeded to double the dosage and was giving 200 cc daily, 100cc morning and 100cc night. He seemed to be in fairly good spirits, up until a week ago, when we noticed he was not eating or drinking. Then two days ago he was breathing harder. We took him to an emergency clinic (Memorial Day) and was told he was suffering from respiratory failure. They put him in an oxygen tent overnight and were giving him diuretics to remove the fluid that was found by x-ray to be around the lung cavity as well as inside the lung. They hoped that thru the night he would urinate, which he did, and that he would breathe without the need for oxygen. Unfortunately, he was not able to leave the oxygen tent without gasping for air. At that point the following morning, we made the decision to end his suffering.
My question to you, since we did not have our regular vet available due to the holidays, is the congested heart failure, usually an end result to renal failure? I had been ,up until a month ago, giving him epogen shots, because he had anemia. Once that was under control, the vet said I did not need to give them to Sam, until the next visit, which we were coming up against almost one month later. Could the lack of epogen have caused his sudden heart problems? The vet said his heart was enlarged at the time we brought him into the emergency clinic. I am wondering if this could have been prevented, in any way. I know he was old, but if I could have prolonged his life without suffering I would have done it.I am very saddened by my loss. Thank you for your help and advice in this matter. Faye
A: Faye- It sounds like you and your vet were making the best possible effort to care for Sam. Epogen (Rx) is used to treat the anemia associated with chronic kidney failure. Discontinuing use of it should not have caused cardiomyopathy, to the best of my knowledge. The most common cause of cardiomyopathy in older cats is probably hyperthyroidism. Unless there were clinical signs of this, it seems unlikely that it would have been advanced to the stage where it would affect his heart, though. Heart enlargement is not always due to cardiomyopathy in cats. Sometimes heart failure occurs for other reasons and still results in an increase in the size of the heart. It really does sound to me like you and your vet were providing Sam with good medical care. Please don't make yourself feel guilty unnecessarily. Sometimes, the best we can do is not good enough.
Mike Richards, DVM
Q: My cat, Blackie, had a dramatic weight loss this week. I took him to the vet for some blood work. They determined that his kidneys are failing, and they gave me a number of 9. I don't know what that means, but they said he is pretty bad-off. Also, they suggested a couple of temporary treatments, but they were not optimistic. Is there anything I can do for him that will make him better? I don't want to put him to sleep. He has been my best friend for 15 years! Please help!
A: Chip- The number you are referring to is probably the creatinine level. This is very high but many cats with creatinine values in this range can live for some time with aggressive medical therapy -- several years in some instances. There is a link to a good site on chronic renal failure in cats on our links page and they have a lot of advice on this condition.
In brief, fluid therapy (usually subcutaneously administered), blood pressure medications if necessary, checking to be sure there isn't a concurrent problem with hyperthyroidism or diabetes, appetite stimulants if necessary, calcitriol administration, potassium administration and use of phosphate binders may all be helpful in kidney failure. Let your vet know you want to do the best you can in treating this condition and work with him or her to do so. This is a condition for which you may have to act as a strong advocate for your cat with your vet to ensure that the best possible care is given -- care is time-consuming and expensive and many vets think most clients don't want to do it for these reasons.
Mike Richards, DVM
Q: Hi Dr. Mike, I am the proud mother of a 5 year old Siamese Seal Point Neutered Male. He was diagnosed December 28th 1996 with Chronic Renal Failure. My husband and I are truely devastated. We have thoroughly checked out the http://www.felinecrf.com and were able to get so much information. They provide a lot of information about Kidney Transplants but I don't see any reference to the health condition of the cat prior to surgery. My cat at top health weighed only 9.5 lbs. When diagnosed, he only weighed 4.5 lbs. We have only been able to get his weight up to 6.25 lbs. at present. With weight being such an important factor after surgery, I would imagine he would have to have a stable weight or not have lost as much weight as my cat has. Can you enlighten me?
What condition should the cat be in, to be considered for such a surgery? The life expectancy of a cat with CRF is 0-2 years correct? With the Transplant surgery I am looking at 0-6? Is that correct? And if all goes well, he will be on anti-rejection meds the entire life just no more sub Q's (just initially). That is if everything goes well... My cats bun and creatine levels were at 6 and 178 at diagnosis, they were only able to bring them down to 4 and 154 which is a significant improvement but still considered high. He is on sub Q-s daily and Tagament for nausea. The Vet is surprised with his levels being so high that he appears as well as he does. He almost looks normal (with the exception of the extremely thin area below the belly), as far as clear eyes etc, compared to other cats with his levels. Also, interesting to note, pedialyte (for babies with diarrhea, electorlytes) works wonderful on my cat with the Sub-Q's. It supplements the fluid therapy and helps him retain his fluids. Any information you can provide would be greatly appreciated.
A: We see cats with chronic renal failure that live longer than two years but it is a condition that continually worsens in most cases so I hate to quibble over that one point.
Kidney transplant is not yet a common occurrence at veterinary hospitals, even as a referral surgery, and I do not have much information on the preoperative care. I do know that the surgeons much prefer to have some stabilization of the cat's condition if possible. It is surprising how well some cats do despite very high BUN and creatinine levels. This is a good thing since it gives you a little time to make arrangements for treatment.
If you are considering this option it is best to contact a referral center that is doing these procedures as early as possible in the course of disease and to get their help and advice. The kidney transplant site has the names of several facilities performing this surgery, I think.
If you wish to correspond with someone who has been through this procedure, I think that clients of ours who have a cat with a donated kidney would be willing to talk with you. Let me know and I will give them your email address.
If you elect to go with long term medical care there are a number of things that can help, including appetite stimulation, control of blood pressure (tends to rise as the disease progresses), low phosphorous diets, phosphate binders, cholecalciferol, gastrointestinal protectants and of course, fluid administration. Given your cat's problems at so young an age, it does seem like a transplant might be best if it is financially feasible for you.
Mike Richards, DVM
Kidney dialysis and transplatation
Q: any information or opinion on kidney dialysis and transplatation?
A: I have not personally had any experience with kidney dialysis in my patients but I do have one patient who has had a kidney transplant and seems to be doing very well with it. There is a very good web page on chronic renal failure in cats that you should visit. There is a link on our links page or the URL is:
http://www.felinecrf.com
They have a lot of current information on renal failure in cats.If you have the financial resources to choose either of these options, both of them are probably good options for a cat with chronic renal failure.
We have had a good success using fluid adminstration to cause diuresis, coupled with dietary control and medications to treat secondary problems, such as appetite stimulators and blood pressure medications where appropriate. Recently the use of calcitriol has been advocated and also seems to be helpful. These are not as directly beneficial as dialysis or kidney transplant but they are more within the budget of many cat owners who can not afford more definitive treatment.
Mike Richards, DVM
Last edited 07/01/05
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