Chronic Kidney Disease

By Cheryl Craig

TREATING IBD AND CRF
If you have found your way to this website, you probably already have some idea of how difficult it can be to care for an IBD kitty. When there are other medical conditions as well, it can seem especially overwhelming, as there may be conflicting treatments, diets and advice coming from all directions. Since our bodies are designed to work synergistically it makes sense that when one organ or body part is diseased and not functioning properly, other organs may be affected.  Chronic Kidney Disease (CKD) is a very common disease in cats, and like IBD there is no cure at the present time. However with early detection and proper treatment many cats can enjoy a good quality of life for many years.

WHAT EXACTLY IS CHRONIC KIDNEY DISEASE
Chronic Kidney Disease (CKD), also known as Chronic Renal Failure (CRF), is a gradual and irreversible deterioration of the kidneys. Most older cats have some degree of CKD, and certain breeds are more susceptible. The kidneys are made up of thousands of microscopic nephrons which serve to filter and reabsorb fluids. In young healthy cats there is such a surplus of nephrons that some are held in reserve. As the cat ages or has damage to the kidneys, some nephrons stop working and the ones in reserve take their place. When all the nephrons in reserve are depleted, signs of kidney disease will begin to appear. It is because of this reserve system that indicators of kidney disease do not show up until there is significant loss of kidney function. At that point, the kidneys are unable to conserve water, and significant amounts of dilute urine are passed.

Because the filtraton system is no longer working the way it should, toxins build up in the system. The kidneys also regulate the amount of water in the blood and maintain a healthy blood pressure by regulating sodium levels. Calcium and vitamin D are also regulated by the kidneys. In addition, the kidneys also secrete a hormone called erythropoieton which stimulates the bone marrow to produce red blood cells. With so many functions performed by the kidneys, symptoms can vary widely between cats and progress slowly or come on quite suddenly. It also means that kidney disease carries the potential of other related diseases including hypertension, anemia, diabetes and hyperthyroidism.

WHAT CAUSES KIDNEY DISEASE
It is rare that an exact cause of CKD is found. It can be congenital at birth, chronic bacterial infections of the kidneys or urinary obstructions, exposure to toxins, immune system disorders, and certain drugs, such as NSAIDS and some antibiotics. A steady diet of dry and over processed low quality protein puts an additional load on the kidneys. This does not happen overnight, but has a cumulative effect that is not apparent until significant damage has been done.

DIAGNOSIS
IBD is a difficult disease to diagnose, and is only definitive with a surgical biopsy. Many choose not to take this route when a kitty is already very ill and weak to begin with, so a diagnosis is made based on symptoms, other diagnostics and ruling out other possible issues. With CKD a proper diagnosis can be made with a full blood panel and urinalysis, but usually not until 66% of kidney function has been lost. There is, however, a new test, SDMA, that may help detect a problem earlier. https://www.idexx.com/files/small-animal-health/solutions/articles/intro-kidney-test-sdma.pdf.

So a large part of early detection of CKD falls on the pet parent in getting regular blood work done (especially in older kitties), and monitoring the water bowl and litter box. If you have an IBD kitty, you are probably already spending more time than you ever imagined peering in the litterbox. Copious amounts of urine can be a clue. As can excessive drinking, although steroids can also cause increased thirst too. Nausea and inappetance can be a sign, but that can also be caused by IBD. So getting regular blood work is really the best way to determine if something else is going on. There can be dramatic changes in as little as six months. With CKD, a urinalysis is also important. Early indicators may require additional testing.

CKD is usually staged according to the IRIS system from 1-4, with stage one being the earliest stage. But don’t despair. Blood work in the earliest stages can be influenced by dehydration and other factors that often make things look worse than they are. And many kitties can do surprisingly well with as little as 10% kidney function with proper treatment. As always, treat the cat, not the numbers.

Another issue that is common to both IBD and CKD are the formation of kidney stones. Kidney stones can form as a result of minerals (generally calcium and oxalate) binding in the kidneys. Urine that is too acidic is more likely to cause these stones to form. Cats with bowel disease and malabsorbtion issues as well as cats with kidney disease tend to have more acidic urine. Foods labeled “for urinary tract health” ironically tend to acidify the urine and should be avoided, as well as anything containing cranberry. Foods containing high oxalate ingredients including spinach, chard, soy and cereals can add to the risk of stone formation. Sometimes a vitamin B6 deficiency can cause the problem. Often kidney stones are left untreated if they are small and inactive, but should be monitored regularly. Signs may include blood in the urine or frequent kidney infections. If your kitty stops urinating or exhibits signs of straining or discomfort, it is time to go straight to the vet, as a blockage is a medical emergency and must be treated immediately. http://www.litholink.com/downloads/stone_lowoxalatediet.pdf

If it is confirmed that your kitty has kidney disease as well as IBD, then what’s next? Well, the good news is that there are many similar issues and treatments, so you may well already have a few of these things under your belt. So take a deep breath. You can do this!

HYDRATION
This is a crucial treatment in managing CKD, and many IBD kitties as well. Cats with CKD become dehydrated because their kidneys are not able to conserve water. They tend to drink a lot and urinate a lot. Despite that, their kidneys are also having a hard time filtering toxins and can benefit from help flushing them out. IBD kitties are prone to diarrhea and/or vomiting which can also lead to dehydration. Adding a couple of tablespoons of water to their food,  feeding home made broth (without onions, garlic or salt), and if necessary giving Sub Q fluids can help your kitty feel much better, and help prevent the progression of the disease. Dry foods are dehydrating, so avoid them unless it is the only thing your cat will eat.

NUTRITION
This may be the single most important treatment in both IBD and CKD kitties. IBD kitties may have sensitivities to certain proteins or ingredients in commercial cat foods such as thickeners and gums. The “old school” thinking (which many vets still preach) is that CKD cats need a low protein, low phosphorous diet. New research is questioning whether a low protein diet does any good in preventing further kidney damage, and that it may even do more damage in causing muscle wasting since cats rely heavily on protein for their health. http://www.felinecrf.org/nutritional_requirements.htm

The issue is more about providing good quality (human grade) easily digestible protein, which is not easily found in commercial foods. The culprit is phosphorous, which is in all meat, but can be reduced by limiting bone and using some egg whites as a protein source and eggshell as a calcium source. http://ibdkitties.net/tips-tricks/ Tip #3: Cats with CKD often do very well on raw diets without bone, and home cooked human grade food with proper supplementation and eggshell as the calcium source. The same can be said for IBD kitties and the advantage is that you can use whatever protein source your cat can tolerate and eliminate possible irritants in commercial foods. If that is not possible, aim for commercial canned foods with high quality protein, as few additives as possible and lower phosphorous. A list of commercial foods by phosphorous level is available here. http://www.felinecrf.org/food_data_tables.htm. Please note that this table does not factor in additives. Dry food is not recommended as it is dehydrating in itself. If your kitty will not tolerate low phosphorous foods, a binder can be added, such as Epakitin or Aluminum Hydroxide. If your cat’s phosphorous level is 6 mg. or higher, you need to use a binder http://www.felinecrf.org/phosphorus.htm.

MEDICATIONS
One of the biggest challenges of both IBD and CKD kitties are the plethora of medications that are sometimes needed to maintain their health and a good quality of life. Many of these are the same for both, but there a few additional cautions with CKD cats, since many medications are processed through the kidneys and can cause problems, since CKD cats suffer from a build up of toxins in their systems to begin with. Nausea is a common problem in both IBD and CKD kitties. In CKD kitties, stomach acid is frequently the culprit. Sometimes feeding smaller and more frequent meals can be enough to help. Slippery Elm Bark Syrup is effective and has the added advantage of adding fiber and helping to regulate the stools and help prevent hairballs. http://ibdkitties.net/tips-tricks/ (Natural Remedies #1). Pepcid AC or generic famotidine can be used (1/4 of a 10 mg. tablet) given 30 minutes before feeding can usually solve the problem. If vomiting is more of a problem, Cerenia works well for both IBD and CKD kitties. Miralax can be used for constipation if Slippery Elm Bark or pumpkin doesn’t help. A probiotic called S. Boulardi is often effective for diarrhea. http://ibdkitties.net/probiotics/ See “emergency stop diarrhea” instructions. Other cautions for CKD cats regarding antibiotics and painkillers can be found here. http://www.felinecrf.org/treatments_antibiotics_painkillers.htm Please check with your vet before using any medications, even if they are available without prescriptions.

SUPPLEMENTS
Most cats with IBD and/or CRF can benefit from a vitamin B12 supplement, given by injection under the skin. It will help with nutrient absorption and can increase appetite.  These can be done at home, limiting stress to your kitty and reducing costs. Your vet can show you how to do it, and there are many videos on youtube that demonstrate it as well. Probiotics are essential for ANY cat, and there is promising research to show help in treating both IBD and CRF. http://www.ncbi.nlm.nih.gov/m/pubmed/24212182/?i=5&from=%2F26462363%2Frelated We recommend human grade probiotics that have higher potency and more strains. There is not enough research to target specific strains and the microbiome is very complex, so the more strains the better. http://ibdkitties.net/probiotics/. Plant based digestive enzymes act as prebiotics and can help with the absorption of nutrients, which is helpful for both IBD and CRF. Omega 3 fatty acids are extremely beneficial to all kitties, and research continues to support the benefits for both IBD and CKD kitties. These are the basics, but there are additional supplements for specific needs.

There is ongoing research relating to the importance of Omega 3 fatty acids in helping to manage CKD and many other diseases, in addition to helping skin and coat issues. Krill and sardine oil, or other purified oils are recommended.
http://www.cliniciansbrief.com/sites/default/files/attachments/Top%205_Therapeutic%20Uses%20of%20Omega-3%20Fatty%20Acids.pdf
http://www.ncbi.nlm.nih.gov/pubmed/16100367

DISEASES RELATED TO CKD
There are other issues that can occur with CKD that you should be aware of:

Hyperthyroid
High Blood Pressure
Diabetes
Heart Disease
Anemia
Mouth Sores
Potassium imbalances

This is not to alarm you, as they may never happen, but it’s always a good idea to have these checked with your vet.

IN CONCLUSION
Managing multiple health issues is challenging, but it can be done. The goal is to provide you and your kitty the most quality time together you can have. Once you have a diagnosis, be proactive in their care. Most vets have busy practices and various species, medical issues and drug information to keep up with. You only need to be concerned with your beloved pets and their specific needs. Do research and work with your vet. Keep a journal or log of medications, responses, behaviors, etc. It’s easy to forget when you are dealing with multiple pets, health issues and medications and the more accurate you are the better your vet can help. He/she only sees your kitty for a limited amount of time, so you have to provide the info you observe in their daily routines. Ask questions and know we are here to help and support. We’re all in this together!

Other References:
http://healthypets.mercola.com/sites/healthypets/archive/2012/08/06/kidney-disease-in-cats.aspx

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