How is chronic kidney disease managed?
If a specific cause for the CKD is identified (eg, bacterial infection of the kidneys), treatment may be possible to arrest the progression of the disease. In most cases though, treatment is symptomatic and supportive. Some cats may require initial intravenous fluid therapy to correct dehydration (and perhaps electrolyte abnormalities), but once stable, treatment is aimed at supporting kidney function and minimising the complications of CKD. Despite therapy, CKD cannot be reversed and in most cases will also progress over time.
Optimal management of renal
failure usually requires repeat investigations at regular intervals (including
blood pressure assessment, blood and urine tests) to identify treatable
complications as they arise, eg, anaemia, low potassium, high phosphate,
urinary infections, and hypertension. Dietary modification is important in cats
with CKD to improve quality of life and slow progression of disease, but a variety
of other treatments may be valuable also, depending on individual needs.
Sometimes multiple drug therapies may be needed, but if it is difficult to
administer medications to your cat, these may need to be prioritised.
Diet and the management of CKD
Dietary management is critical in cats with CKD, and there are three main aspects to this:
Water intake
Cats with CKD are more likely to
become dehydrated (due to the reduced ability of the kidneys to conserve
water). Maintaining a good fluid intake is therefore very important, and may
help to slow progression of CKD. As cats obtain much of their water intake from
their food, whenever possible, cats with CKD should be fed tinned (or sachet)
foods rather than dry foods.
Protein content
An ideal diet for a cat with
renal failure should have a restricted protein content. Many of the toxic
products that accumulate in the blood in CKD are a result of protein breakdown,
and feeding a reduced protein diet will help to minimise this and improve
quality of life. Protein restriction has to be performed with care though as
too little protein can be extremely detrimental to general health.
Low phosphate content
Restricting the phosphate content
of the diet appears very beneficial in protecting the kidneys from further damage
in cats with CKD. While restricting protein in the diet helps maintain quality
of life, restricting phosphate thus appears to prolong the life of cats with
CKD. Studies suggest this effect may be quite dramatic in cats. If blood
phosphate concentrations remain high despite being on a low phosphate diet,
further treatment with drugs known as 'phosphate binders' to reduce the amount
of phosphate absorbed from the intestine may also be indicated.
Other dietary measures
Other aspects of the diet may
also have an important role to play in helping manage cats with CKD. These
include the addition of anti-oxidants to try to protect the kidneys against
further damage, essential fatty acids to help maintain blood flow through the
kidneys and reduce inflammation, added potassium to prevent hypokalaemia (low
blood potassium), and added bicarbonate (or similar) to help prevent acidosis
(a build up of acid in the body which can also occur in CKD).
All these measures may help and
have a role to play in keeping cats with CKD as healthy as possible for as long
as possible. Because of the exacting nutritional demands in cats with CKD,
feeding a specific veterinary therapeutic diet designed to manage all these
aspects is strongly recommended. These diets are only available through your
vet, but have a vital role to play in managing the disease.
Managing the change to a new diet
Cats will often develop a strong
preference for particular diets, and low protein diets tend to be less
palatable. This means that changing cats with CKD to an appropriate therapeutic
diet can sometimes be difficult. These
tips may help:
·
Always make a change
in diet gradual - per several days at least and sometimes over a few weeks if
your cat is quite fussy
·
Start by mixing
a very small
amount of the new food with your cats old food, and make sure it is well mixed
·
Only increase the
amount of the new food slowly, once your cat is happy to eat the old mixture.
Make each step where you replace old food with a greater amount of new food
slow
·
Warming the food to
body temperature (around 30C) may help increase the palatability
·
If necessary, talk to
your vet about using drugs to increase the appetite to make the transition
easier
In most cases with sufficient
care and time, cats can be very successfully transitioned to a new diet, and as
this is such an important part of managing CKD it is worth taking the time to
do this properly. If cats absolutely refuse to eat any of a new diet, it is
important that they eat something, so keep offering their old diet in this
situation and contact your vet for further advice.
Managing dehydration
Using a wet rather than dry diet
is important to increase water intake in cats with CKD, but they still
sometimes do not consume enough water to compensate for what is being lost in
the urine. In these cases, additional measures may need to be taken. These may include:
·
Making sure a good
supply of fresh water is always available, and cats should be encouraged to
drink by offering water from different bowls, etc.
·
Using flavoured waters
(chicken or tuna, for example) or water fountains to encourage drinking
·
Adding further water
to the food (if tolerated without affecting the appetite)
·
Using intermittent
intravenous fluid therapy at your vet clinic
·
Using intermittent
sub-cutaneous fluid therapy which can be given at your vet clinic or sometime
in the home environment
Phosphate binders
If, despite using a low phosphate
diet, blood phosphate levels remain high, using a phosphate binder added to the
diet (such as lanthanum or calcium acetate) may be valuable. This is important
as controlling blood phosphate levels appears to have a good protective effect
on the kidneys in cats with CKD.
Potassium supplementation
Some cats with CKD develop low
blood potassium levels. This can cause muscle weakness, can contribute to
inappetence, and itself can worsen CKD. Where this is identified, potassium
supplementation (usually potassium gluconate in the form of tablets, gel or
powder added to the diet) is important.
Controlling blood pressure
Cats with CKD are at risk of
developing high blood pressure (hypertension). This can have a number of
damaging effects, potentially including blindness and worsening of the CKD.
Blood pressure should ideally be monitored in all cats with CKD and where
hypertension is found it should be treated. This is usually achieved with a
group of drugs known as 'vasodilators'. In cats a drug called amlodipine is
particularly effective, but other drugs may also be used.
Treatment of anaemia
In advanced CKD in particular,
anaemia is quite common. This may be due to lack of production of a hormone by
the kidneys (erythropoietin or EPO) that stimulates production of red blood
cells in the bone marrow, but can also be due to other factors (such as loss of
blood in the intestines). More severe anaemia can cause lethargy and weakness
and a poor quality of life. Depending on its cause and severity, a number of
treatment options may be available to manage anaemia including anabolic
steroids, iron supplementation, management of any gastrointestinal ulcers and
in some cases supplementation with EPO.
Treatment of nausea and vomiting
Nausea and vomiting are more
common in advanced CKD and can cause inappetence and significantly affect the
quality of life. Various drugs can be used to control these signs including
maropitant, famotidine and ranitidine.
Use of 'ACE inhibitors' and ARBs
Blocking activation of a hormone
known as angiotensin may be of benefit in CKD. This can be achieved by using so
called 'ACE-inhibitors' (angiotensin converting enzyme inhibitors) such as
benazepril or enalapril, or using angiotensin receptor blockers (ARBs) such as
telmisartan.
These drugs are vasodilators
(dilate blood vessels) and help to support blood flow through the kidneys, and
may help to lower blood pressure in cats, and also significantly reduce protein
loss through the kidneys. Elevated loss of protein through the kidneys in CKD
is a risk factor for progression of CKD, and it is possible that lowering
protein loss (with ACE-inhibitors or ARBs) may improve survival in some cats
with CKD.
Kidney transplants
In some countries, kidney
transplants are offered by some specialist veterinary centres as a means of
treating cats with CKD. Although this can be a successful approach, it raises a
number of ethical questions including where and how a donor kidney is sourced.
Additionally, the procedure is not invariably successful and cats receiving a
new kidney may not necessarily survive any longer than cats managed with good
medical supportive care.
What is the prognosis for cats with CKD?
Once sufficient damage has been
done to the kidneys to cause CKD, the compensatory changes and adaptations that
occur to try to maintain normal kidney function usually eventually fail and
progressive kidney damage occurs. The disease is usually therefore progressive
over time and will eventually lead to the need for euthanasia. However the
rate of progression of renal disease varies considerably between individuals
and appropriate support and treatment can both increase the quality of life of
affected cats and also potentially slow down the progression of the disease.
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