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CLINICAL

Long-term care of cats


with renal disease
Sarah M A Caney BVSc PhD DSAM(Feline) MRCVS
www.catprofessional.com

Chronic kidney disease (CKD) is one of the most common diagnoses made in
clinical practice. In recent years, there have been many advances in treatment
options and long-term home care can be very rewarding for all involved.
Treatment aims to help the patient to compensate for their renal disease allowing
them to live for as long as possible with as good a quality of life as possible. The
most proven treatment is feeding a prescription renal diet but there are many
other measures that can be helpful to individual patients.

Kidneys perform many complex encourage acceptance by the cat and all
Sarah M A Caney functions and, therefore, a range of efforts should be concentrated on
BVSc PhD DSAM(Feline) MRCVS complications can be seen in patients persuading the cat to eat the food – even
with CKD (Table 1). Treatment should be if it takes months to achieve this aim!
Sarah is a 1993 graduate of the focussed on:
University of Bristol. She is an ● identifying and treating any Maintaining normal
RCVS Specialist in Feline Medicine underlying cause of the disease, such hydration status
and loves both first opinion and as bacterial pyelonephritis
referral feline medicine. In 2007, ● ‘proven’ general therapies for CKD, Dehydration is associated with reduced
she founded Cat Professional, such as prescribing renal diets and renal perfusion, which causes a
which aims to provide cat owners ensuring that the cat maintains normal worsening in renal function. Acutely
and veterinary professionals with hydration, as far as possible decompensated cats require intravenous
the highest quality information, ● additional treatments according to the fluid therapy, but maintaining adequate
advice, training and consultancy
individual’s specific needs. fluid intake at home is of prime
services.
importance. Cats with CKD should be
The Cat Professional has
Prescription renal diets encouraged to drink as much as possible
through tactics that include feeding moist
published three books Caring for a
Cat with Kidney Failure, Caring for Prescription renal diets are the single rather than dry foods, adding water to
a Blind Cat and Caring for a Cat most beneficial proven treatment for cats the food, using water fountains and
with Lower Urinary Tract Disease with renal disease. Several studies have offering flavoured water (prawns
which are all available as ‘soft now shown, emphatically, that cats with liquidised in water, for example).
backs’ and electronic books via renal failure that will eat these diets will
her website live much longer, healthier lives. The diet With cats that fail to maintain adequate
should be introduced gradually to voluntary fluid intake, some owners may

TABLE 1 Normal kidney function and dysfunction in CKD


Healthy Kidney Potential complication in CKD
Excretion of protein breakdown products including urea Azotaemia
and creatinine
Excretion of drugs, toxins and hormones Accumulation of drugs and toxins can cause adverse effects;
accumulation of gastrin (the hormone which regulates
gastric acidity) can cause gastritis and gastric ulceration
Regulation of acid-base status Metabolic acidosis
Regulation of normal hydration status Dehydration
Regulation of normal electrolyte status Hyperphosphataemia and hypokalaemia are the most
common electrolyte disturbances
Regulation of normal systemic blood pressure Systemic hypertension
Production and activation of various hormones, including Reduced erythropoietin can result in anaemia
rennin, erythropoietin, vitamin D (Calcitriol) Reduced production of calcitriol is a contributory factor to
development of renal secondary hyperparathyroidism

Veterinary Nursing Journal • VOL 25 • No9 • September 2010 • Page 39


CLINICAL
 Figure 1: Home subcutaneous fluid this in the bowel and hence limiting the cent of cats with CKD. The cardinal sign of
therapy is helpful in maintaining hydration amount of phosphate that can be severe hypokalaemia is polymyopathy,
in those cats vulnerable to dehydration absorbed by the body. It may take several with generalised muscle weakness and
months for the total body excess ventroflexion of the neck (Figure 3).
phosphate levels and hence blood However, more mildly affected cats will
phosphate levels to normalise. only suffer from non-specific signs, such
as lethargy, weakness and loss of appetite.
The International Renal Interest Society
(IRIS) has devised guidelines for Hypokalaemia is not only a cause of
treatment of cats with CKD and clinical signs but it also adversely affects
recommends that blood phosphate levels renal function. Potassium gluconate is the
are kept at the bottom of the reference preferred oral supplement as it is the least
range (1 – 1.2 mmol/l) as far as possible. gastric irritant. Renal diets which are
supplemented with potassium – but that
Managing poor appetite, are also non-acidifying and low in protein
 Figure 2: Hand feeding and general nausea and vomiting – help to maintain normal serum
nursing tactics can help to encourage
potassium concentrations.
acceptance of renal prescription diets
Many cats with CKD suffer from uraemic
gastritis, contributing significantly to Managing systemic hypertension
their inappetence and weight loss.
General nursing techniques, such as Systemic hypertension affects at least one
feeding warm food by hand, may help in five CKD patients. It can have serious
(Figure 2). In other cases, it is worth consequences including blindness,
trying antacids (H2-antagonists, such as neurological signs (such as seizures),
famotidine) anti-emetics and/or appetite cardiac changes (most commonly, a
stimulants (cyproheptadine, mirtazipine). systolic heart murmur resulting from
cardiac remodelling) and renal damage.
In those cats that are bright and relatively
well but where appetite remains poor, one Blood pressure should be evaluated as a
long-term possibility includes placing a routine part of all check-ups of CKD cats
feeding tube such as an oesophagostomy and anti-hypertensive therapy prescribed
be willing to administer subcutaneous or gastrostomy tube. to those where the mean systolic blood
fluids at home (Figure 1). Subcutaneous pressure readings, taken with the cat
fluid therapy is indicated in those cats Managing hypokalaemia in a calm state, are persistently above
suffering from recurrent episodes of 170 mmHg, or where there is evidence
dehydration. The sole aim of this therapy Hypokalaemia (potassium < 4 mmol/l), of hypertensive retinopathy. Ocular
is to maintain normal hydration status caused by inappropriate loss of potassium manifestations of systemic hypertension
and prevent dehydration. in the urine and inadequate intake owing include retinal oedema, haemorrhage and
to inappetence, is present in around 25 per detachment.
Managing hyperphosphataemia
 Figure 3: Severe hypokalaemia is associated with muscle weakness. One manifestation
is ventroflexion of the neck, illustrated here
Hyperphosphataemia is present in
around two thirds of CKD cats and is a
major trigger for the development of
renal secondary hyperparathyroidism
(R2HP). R2HP is a cause of clinical signs
of CKD and also contributes to the
progression of the disease.

Renal prescription diets and/or phosphate


binders – such as Renalzin and Ipakitine
– are recommended in cats with CKD.
Phosphate restriction is believed to be
a key reason why cats eating renal diets
live so much longer. In cats that won’t
eat a renal diet, phosphate binders are
especially important to help treat/prevent
hyperphosphataemia.

Oral phosphate binders should be mixed


with the food – they work by binding to
phosphate present in the diet, retaining

Page 40 • VOL 25 • No9 • September 2010 • Veterinary Nursing Journal


CLINICAL
 Figure 4: Pallor can be an indication of anaemia – a complication seen in around
35% of cats with CKD
may be considered include iron
supplementation, anabolic steroids and
recombinant human erythropoietin.

Check-ups

Monitoring visits are very important


to ensure that owners are supported
and that clinical problems are identified
and treated promptly. The required
frequency of check-ups varies according
to the patient’s needs, but should
initially be at least once a month. All
check-ups should include weighing the
patient and assessing for clinical
problems, such as dehydration.

Blood pressure and laboratory


monitoring should be checked
according to the patient’s needs and
owner’s concerns – I measure blood
pressure every three to six months and
reassess blood and urine tests every six to
12 months, depending on the individual
patient’s needs.
The most commonly used drugs for Unfortunately, in many cases the bacterial
treatment of feline hypertension are the infection does not cause any clinical signs The long-term outlook for cats with CKD
calcium channel blocker, amlodipine of cystitis – in other words, the infection is very variable ranging from a few weeks
besylate and the ACE inhibitor, is clinically ‘silent’. A course of antibiotics, post diagnosis to many years.
benazepril. In general, amlodipine is ideally chosen on the basis of bacterial
more effective in lowering blood pressure culture and sensitivity results, is often For many cats, once stabilised, their care
than the ACE inhibitors. In some cats, a needed for several weeks or months in is not difficult, time-consuming or
combination of these drugs may be order to successfully eliminate the stressful and it is possible to provide a
required to achieve adequate control. bacterial infection. good quality of life for months or years. vnj

Managing proteinuria Managing metabolic acidosis Useful resources


Caring for a cat with kidney failure by Dr Sarah
Proteinuria is common in cats with CKD Metabolic acidosis is commonly Caney. Available through www.catprofessional.com
and is associated with a worse prognosis. encountered in patients with CKD and and a variety of online bookstores.
ACE inhibitors, such as benazepril, are may contribute to a number of clinical Free downloads are available on the Cat Professional
indicated in cats with a urine protein : signs including anorexia, vomiting and website,
creatinine ratio persistently greater than weight loss. Feeding a renal diet helps to http://www.catprofessional.com/free_downloads.html
0.4, where pre- and post-renal causes of reduce the incidence of acidosis, although on a number of relevant topics including:
proteinuria have been excluded. a small number of cats may require ● potassium supplementation
further treatment with oral sodium ● pyelonephritis
ACE inhibitors should only be used in bicarbonate. ● Doppler blood pressure measurement
clinically stable, normally hydrated cats. ● ocular manifestations of systemic hypertension
If the cat is receiving a urinary acidifying ● giving subcutaneous fluids
Managing urinary tract diet, this should be stopped and, ideally, ● encouraging your cat to take in more fluids.
infections a low-protein diet instituted. www.iris-kidney.com for guidelines and information
from the International Renal Interest Society (IRIS).
Around 25 per cent of cats with CKD Managing anaemia http://www.fabcats.org/kidney.html
suffer from a bacterial cystitis at some http://www.felinecrf.com/
point in the course of their disease – Progressive anaemia is common in CKD
probably since the urine they are and can contribute to lethargy, Disclaimer
producing is so dilute. Bacterial cystitis inappetence, weakness and weight loss. In Some treatments mentioned in this article are not
may pose a risk of ascending infection some cats, iron deficiency can contribute licensed in the UK. All medication should be used
and pyelonephritis or may represent to the anaemia both through inadequate according to the cascade recommendations.
bacterial seeding of the urine from pre- dietary intake and gastro-intestinal blood http://www.noahcompendium.co.uk/Compendium/Ov
existing pyelonephritis. loss (Figure 4). Treatment options which erview/-45043.html

Veterinary Nursing Journal • VOL 25 • No9 • September 2010 • Page 41