Treating Chronic Renal Disease
CRD is a degenerative disease that does result in death in the end. You can though do many, many things to help ensure that your cat is in the best health possible – and can live for years after the diagnosis… to more probably die of other causes!
Some treatments should be started as soon as possible; others will help depending on specific symptoms that your cat is dealing with.
Primary CRD Treatments
There are a number of important medications and therapies that you should start as soon as you learn your cat has been diagnosed with CRD. Others
The list of the important therapy to start immediately is:
• ACE Inhibitors
• Fluid Therapy
• B12 Injections
• Digestive Aids/Antacids
• Phosphorous binders if your cat has high phosphorous levels
- ACE inhibitors – Benazepril:
Use of ACE inhibitors is widely accepted in Europe and is usually the first therapy recommended. US vets are a bit more reticent, and you may need to insist a bit to get the prescription needed. Benazpril is the medication that is usually used. It is available under the brand name Fortekor in Europe and Lotesin in the US. Benazapril inhibits the hormone that constricts blood vessels, relaxing them and helping to increase blood flow through the kidneys.
- Fluid Therapy
One of if not THE most important thing that you can do is to keep your cat well hydrated – most CRD cats are dehydrated. Giving Sub-Q fluids can truly make a very big difference. If you can dose your cat insulin you are more than capable of giving Sub-Q fluids!
Please see our article about giving Sub-Q fluids in the Knowledge Centre for complete information: Sub-Q Fluids
- B12 Injections
CRD cats lose B12 due to increased urination. Supplementing is a great help for them. The best way to do that is to inject B12 – your vet will need to give you a prescription for that. If for some reason your vet will not give you the injectable B12 prescription, supplementing simply with Vitamin B complex can help. B12 is better and will help more.
CRD cats will often suffer from gastric problems due to the build of of toxins and the change in blood pH which can lead to ulcers. Helping your cat with the pain and acid will make a huge difference in his or hers daily life!
Slippery Elm Bark
• Slippery Elm Bark is a natural remedy that really helps with gastric problems (for people as well as cats!). It is good to try this first – the medications that can be used – PepidAC or Ranitidne (see after) can have certain side effects.
• Slipper elm coats the stomach and intestines. Because of that it is very important to give it 2 hours before or after any other supplements or medications. If not, it can interfere with their absorption.
• PepsidAC is available in North America. It is no longer available in Europe. Pepsidac is an antacid. You need to make certain to use only regular PepsidAC and not the extra strength formula. The dose is a ¼ tab twice a day. In severe cases of nausea it can be increased to ½ tab twice a day for two weeks maximum.
• The active ingredient in PepsidAC is famotidine. Famotidine does exist in Europe (under prescription). However, unlike PepsidAC, which is 10mg famotidine, generic famatodine tablets are 20mg. It is impossible to cut those into1/8ths to dose the correct amount. They can be used (cut into 1/4ths) if the higher dose is needed.
• PepsidAC/Famotidine can be poorly tolerated by cats with high Creatinine levels, leading to increased vomiting and decreased appetite. It also can make any existing heart murmur problems worse.
• It can interfere with B12 absorption, so supplementation is recommended.
• It also may interfere with ACE inhibitors and phosphorous binders (Aluminium Hydroxide in particular), so it is best to give it a few hours before or after those.
• Ranatidine (the generic) / Zantac (brand name) is available in most countries, if it will require a prescription in many.
• Like PepsidAC, it is an antacid.
• The usual dose is 0.25 – 1.00mg per pound / 0.5 – 2.00mg per kg, and is usually given twice a day.
• As is the case for Pepsidac/Famotidine, it may interfere with B12 absorption and ACE inhibitors. It is recommended that Rantidine be given several hours earlier or later than B12 supplementation or ACE inhibitors.
• If your cat is vomiting despite the above, your vet may prescribe a specific anti-vomitive such as Cerenia. It is important to control vomiting as it leads to more dehydration.
- Phosphorous Binders
If your cat’s Phosphorous levels are over 6 mg/dl (US) or 1.9 mmo/L (International), the use of phosphorous binders is needed.
High phosphorous levels not only increase the progression of CRD, they also lead to a number of side effects that more than affect the well-being of your cat: nausea, lack of coordination, tremors, a plantigrade posture (walking on the hocks) and loss of appetite and weight are just some that may occur.
Several types of phosphorous binders exist – Calcium and Aluminium-based are the most common:
o Calcium based
o “Others”, including Lanthanum and Sevelmer-based
Calcium Based Binders
There are two forms of calcium binders: Calcium Acetate and Calcium Carbonate.
While Calcium Acetate is a stronger binder than Calcium Carbonate, it is also more likely to lead to high blood calcium levels. Calcium Carbonate is therefore preferable.
Both forms help more at the beginning, with lower phosphorous levels. A stronger binder may be necessary as your cat’s disease progresses.
Epakitin (US/Canada) or Ipakitine (rest of the world) combines Calcium Carbonate with chitosan, which is derived from crab and shrimp shells. Both short and long-term studies have shown that adding it to a normal diet result in significantly reduced phosphorous levels¹. Epakitin/Ipakitine also may help bind toxins and reduce Creatinine and BUN/Urea.
Epakitin/Ipakitine is a very good binder to start with, if again, a stronger than calcium-based binder may be necessary in the latter phases of the disease.
Aluminium Based Binders
Several types of Aluminium Binders exist. Aluminium Hydroxide is the most adapted to cats, and the one most often prescribed. It is a very effective phosphorous binder; however, there are some concerns about using an aluminium based medication over the long term with cats. Alumunium has been linked to neurological problems and can be toxic to kidneys in humans (no safe levels of aliminium salts have been established for humans). There has also been research showing it can cause neurological problems in dogs.
It therefore is best to start with another type of binder such as Epakitin/Ipakitine if possible, and to only switch to Aluminium Hydroxide as the disease progresses and stronger binders are needed.
Aluminium Hydroxide should be given several hours away from the following treatments:
o Potassium Citrate (if you are feeding your cat a food containing Potassium citrate, as is the case for several Renal formulations, it is better to use a different type of binder)
o Baytril and antibiotics in the same family (such as Zeniquin); in general it is better to separate for any antibiotics
o ACE inhibitors
One important note: cats should NOT be given Aluminium Magnesium Hydroxide (Mylanta, Milk of Magnesia….). Magnesium can be harmful to cats, and in particular CRD cats, as it can lead to the development of urinary tract issues such as kidney stones.
Two main other types of Binders exist: Lanthanum Carbonate and Sevelamer-based.
While Lanthanum was showing very promising results, similar to those for Aluminium Hydroxide, the vet feline form (released only in Europe) has now unfortunately been discontinued.
A human form exists in the US: Fosrenol.
It has been used with cats, but is very expensive. The same list of “dose at least two hours away” exists as for Aluminium Hydroxide, with the only exception of ACE inhibitors, which are not mentioned.
Two Sevelamer Hydrochloride binders are Renagel and Renvela :
– Renagal is quite new and a binder approved for humans; there is not much information available on how it works yet on cats.
– Renvela is a second generation binder.
Little information is available on their effect on cats, and both are very expensive.
Phosphorous Binders In Summary
Given the potential side effects of aluminium salts, it is better to start with Epakitin/Ipakitine as a phosphorous binder. It is very effective at lower levels of phosphorous and also can help with uremic toxins.
Should/when you need a more powerful binder, given the high costs of the alternatives (if available), Aluminium Hydroxide is today the recommended binder to move to.
Additional standard treatments
Additional treatments depending on your cat’s individual condition include:
- Anaemia: Iron, Vitamin B complex or ESA if severe (erethropoiesis stimulating agent)
- Constipation: slippery Elm or Miralax (Restoralax in Canada, Movicol in many European countries and Australia)
- Poor appetite/not eating: Periactin (Cyproheptadine) or Mirtazapine. Periactin should be used in preference. Mirtazapine can have some bad side effects and is long lasting (for several days).
- Hypertension: Amlodipine (brand names Norvasc or Istin)
- Potassium imbalances: Potassium supplements alone or added to subQ fluids
- Metabloic Acidosis: Bicarbonate of Soda or Potassium Citrate
Your vet may suggest other treatment based on your cat’s individual situation.
Two final treatments are available in a few specialised centres: Dialysis and kidney transplants.
Neither are performed regularly on cats, and not very much information about them or long-term results are available. Both treatments are very expensive.
A final message….
Hearing that your cat has Chronic Renal Disease – or Chronic Renal Failure if your vet still uses that terminology – is frightening. Yes, CRD will ultimately lead to death – if your cat lives long enough to die from that! Given the right care, your cat can live for years with CRD…. And may well end up dying for other reasons.
You CAN treat CRD.
You CAN improve your cat’s health and give him or her a happy and good life.
Please do post on the forum for more information and help: Senior Members have dealt with CRD personally and have much to offer on the subject!
Additional Reading & Resources:
- Feline Nutrition Foundation: Kidney disease and phosphorous
- Feline Nutrition Foundation: Feeding for Urinary and Kidney Health
General CRD Information:
Note: the following often mention restrictive, low protein diets as treatment. As stated above, this is not the best choice for any cat and in particular a cat also suffering from Feline Diabetes. The other details provided are very informative and interesting:
- Tanya’s Comprehensive Guide to Feline Chronic Kidney Disease: probably the most informative and detailed resource available on the subject, covering all aspects of the disease and its treatment
- Idexx Protenuria and Renal Disease Roundtable Discussion
- IRIS International Renal Interest Society
- Dr. Becker Chronic Renal Disease in Pets
- Long Beach Hospital CRD: Very detailed medical information about CRD
- Epakitin/Ipakitine studies
¹ DC Chew, “Chronic Kidney Disease (CKD) in Dogs & Cats – Staging and Management Strategies,” Virginia Veterinary Conference Presentation, Virginia Veterinary Medical Association, 2015
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