Living with Chronic Renal Failure (CRF) - Consolidated

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Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:27am PST 
I consolidated all the information in this thread so it’s easier to navigate. You can read through the original CRF thread here. One common theme that came through in the old thread is that many furts had CRF for years so don’t panic if you’ve just been diagnosed.

If you have just been diagnosed with chronic renal failure (CRF) and trying to find information and advice this is a great place to start and be able to ask questions of other furts with CRF. If furts with CRF see anything missing or want to give advice about how to manage it, food or treatments that have worked for you just jump on in.

Here are some other good information sites and support groups to check out:
Catster CRF Support Group
Tanya’s Feline CRF Info Centre
Feline CRF Info Centre
• Yahoo’s Feline CRF Info Group & Feline CRF Support Group. The Yahoo groups are both very high volume so make sure to sign up for web only or digests or you’ll get 100+ emails a day

Furts gave some recommendations for finding low cost places to get the supplies and meds you need
Tanya’s CRF site has lots of good tips for reducing costs.
Scooter's Mail Order Supplies for CRF has lots of great info and links to sources to buy CRF supplies
• Generally getting your meds at a pharmacy like Walgreens or Walmart will be cheaper than at your vet and many of the meds you are on are human meds.
NDC numbers for fluids which are identifier numbers for manufactured drug products and will help you order the right thing.

Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:28am PST 
How your kidneys work and the basics of CRF and treatment

Your blood goes through your kidneys about 20-25 times a day (that’s for humans and is probably more for cats as our heart rate is faster). Each time the blood goes through about 20% of it get "scrubbed" by the kidneys so your blood gets completely scrubbed about 4-5 times a day.

Your kidneys get rid of waste products and keep all the ingredients in your blood at the right levels. They work by filtering your blood and then making sure the right stuff either goes back into your blood stream or into your urine/pee. When you pee this gets rid of waste products.

When blood flows into the kidney it is filtered. All the big stuff like blood cells stays in your blood and the rest (water, ions like calcium, sugars and small proteins) go into tiny tubes in the kidney (called nephrons). Inside the kidney this stuff is either reabsorbed and but back into the blood (water, glucose, proteins, ions) or excreted and put into urine (some water, waste products/excess ions).

Your kidneys also help control your blood pressure. They manage the volume of your blood (by adjusting the concentration of salt in your blood) and produce a hormone that tells your blood vessels to constrict.

Your kidneys can lose about 75% of their function before they are unable to keep everything in balance and you start to see the symptoms of kidney disease.

CRF (chronic renal failure) happens gradually over time. As you age the filters and tiny tubes in your kidneys gradually get damaged and stop working and this can happen faster if you have high blood pressure which puts them under pressure or diabetes which makes them brittle.

The symptoms of CRF result from the failure of the processes above. The kidneys leak if the filters don't work properly and you'll start to see proteins in your urine. The kidneys can't filter out all the waste products in your blood so you'll see higher levels or waste products - for instance your blood tests will show high BUN and creatinine which are waste products of protein. The kidneys can't reabsorb/excrete ions properly and you'll have too high/low levels of ions like calcium, bicarbonate, phosphorus.

Treatment of CRF has 3 main components and they can help you live a lot longer.
1) Keep you hydrated so that your kidneys can work as well as possible to filter out waste products. This includes sub-Q fluids, making sure you drink water using fountains etc and eating wet food if possible.
2) Modifying your diet so that there are fewer waste products put into your blood that the kidneys need to filter. This is usually done with special cat food with low protein, low phosphorus levels etc.
3) Medicines to replace the functions of the kidneys. This includes things to get stuff out of your blood like meds to reduce phosphorus levels, to add stuff to your blood like bicarbonate or blood pressure meds.

Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:29am PST 
How to read your lab tests and questions to ask your vet if numbers are too high/low

Once you are diagnosed with CRF it is a good idea to have more frequent tests to monitor how you are doing and identify issues requiring treatment quickly. If you have mild CRF having your blood checked every 6 months is a good idea. As your CRF progresses you’ll need to test more often and your vet can help you decide what frequency is best depending on your symptoms.

Make sure you always get copies of your blood/urine tests and track the results in a notebook or spreadsheet. Being able to see trends and how quickly things are changing can help anticipate problems e.g. if your bicarbonate or potassium levels are still in the normal range but trending down you can start supplements before you suffer from symptoms.

BUN (blood urea nitrogen) and creatinine levels are higher than normal in cats with CRF as your kidneys don’t filter them out as efficiency. The creatinine level probably gives a better measure of kidney function as it is less affected by dehydration or food eaten than BUN is.

The usual ratio of BUN divided by creatinine is 10-20. If only one number is higher than normal ask your vet why as there are some other diseases can also affect BUN/creatinine levels. E.g. a stomach ulcer can cause high BUN / creatinine ratio; liver disease can cause a lower BUN / creatinine ratio.

If your BUN and/or creatinine increase suddenly that can be a sign of high blood pressure or an infection so make sure your vet checks for those too if you see this.

Low potassium levels are common in CRF cats and can cause muscle weakness and constipation. You can have a “normal” blood test reading even when the level of potassium in your cells is low so often vets will treat with potassium supplements if yours is below the mid-point of the normal range. If you have a weak rear end or constipation as your vet whether potassium supplements are something you should try. Some CRF patients have high potassium levels and then taking supplements is dangerous so make sure to talk to your vet first. If you have high potassium levels and are on Lactated Ringer’s fluids they contain potassium so ask your vet whether you should switch to saline solution.

Phosphorus levels can get too high as your kidneys aren’t able to remove as much anymore. High phosphorus levels can speed up the decline of your kidneys, make you feel crappy and nauseous and also mess up your calcium levels. Many vets will start you on phosphorus binders to reduce your phosphorus levels as soon as your phosphorus gets into the high normal range. So if your levels are rising and starting to get high ask your vet about phosphorus binders as using them can really help extend your life.

Low bicarbonate or TCO2 levels can be a sign of metabolic acidosis where acidic waste products start to build up in the blood. If your bicarbonate levels start to drop ask the vet about a supplement.

If you feel crappy and have a blood test to check what’s wrong make sure the vet includes a CBC (complete blood count) to check for infections and anemia.

If you have high white blood cells (WBC) and absolute neutrophils that is a sign of an infection. A urinary tract infection or kidney infection can knock you for six as your already weak kidneys will get even worse while they fight the infection and your BUN etc will often also get worse. The vet should give you antibiotics and may also suggest a urine culture. The culture will help confirm the type of bacteria and confirm that it is not resistant to the antibiotics you are on.

Your kidneys produce a hormone that tells your bone marrow to produce red blood cells and with CRF you may not produce enough and will become anemic. HCT (Heamatocrit) is the main number to watch and if it is low you are anemic. If your HCT is dropping ask your vet about taking an iron supplement or if the values keep declining ask about epogen which is the hormone that tells your bone marrow to produce red blood cells.

Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:30am PST 
Other common illnesses/side effects linked to CRF to watch out for:

High Blood Pressure:Your kidneys help control blood pressure so CRF kitties tend to get high blood pressure more than normal and high blood pressure can accelerate damage to your kidneys. So it’s worth getting your blood pressure checked regularly as part of your regular check-ups. If you become yowly or start to lose your hearing or eyesight that can also be a sign of high blood pressure that you should get checked out right away.

Constipation: This is no fun and CRF kitties are prone to it if they are dehydrated or have elevated calcium levels. If your stools are getting hard and dry or you are starting to strain when you go it is time to take action before you get blocked up. This may be a sign of dehydration and getting properly hydrated (see below) can help. Eating a little bit of canned pumpkin (100% pumpkin not pumpkin pie mix) adds some natural fibre and helps bulk up your stool and stop it getting dried out. Many cats like the taste of canned pumpkin and a teaspoon a day will help with constipation. If better hydration and pumpkin don’t help your vet can give you a stronger laxative like lactulose.

Metabolic Acidosis: This is caused when the kidneys are unable to make enough bicarbonate to balance the acidic waste products like uric acid. Your blood becomes too acidic and this can cause muscle wasting and weakness, mouth sores and nausea. You need a blood test/renal panel to confirm if you have this as other things like low potassium levels or diabetes have very similar symptoms. Taking a bicarbonate supplement can help. Your vet can prescribe you bicarbonate pills or you can also put a pinch of baking soda (sodium bicarbonate) in your food/water. Lactated Ringer’s sub-Q fluids can help mild acidosis because they help flush out the uric acid and the lactate is converted to carbonate by your body.

Nausea & Loss of Appetite: With CRF there are several things that can cause you to lose your appetite or feel nauseous. If you are eating less, licking your lips or vomiting that’s all a sign that one of these things is wrong. CRF kitties tend to get acid stomach, especially overnight on an empty stomach. Raising your food dish and taking pepcid (famotidine) each day will help. High phosphorus levels will make you feel crappy so if your levels are getting towards the high end of normal ask your vet about starting phosphorus binders. CRF kitties can be knocked for six by UTI/kidney infections and you may not show the normal symptoms of frequent peeing. The infection can make your kidneys work even worse than normal and if you suddenly lose your appetite and seem down consult the vet asap and ask them about checking for infections and starting antibiotics ASAP. Chronic dehydration can also make you lose your appetite as your body needs water to digest food. There’s more on dehydration in the next section and there are lots of good tips in the Picky Eating & Nausea thread. If pepcid alone is not enough to deal with your nausea ask your vet about Reglan and Ondansetron which work in different ways and may be more effective for you.

Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:31am PST 

The kidneys of CRF kitties aren’t able to concentrate urine properly and the urine is more dilute. This means that you pee more and you need to take in more water to balance things out. Cats don’t naturally drink much water and it is easy to become dehydrated especially if your CRF is advanced and you are producing large volumes of urine/pee.

Dehydration is bad for a couple of reasons. Firstly it makes you feel generally crappy and if your blood values of BUN, phosphorus etc are already too high then dehydration will just make them worse. Secondly, your kidneys don’t work as well when they are dehydrated. This doesn’t matter much in healthy cat but if you have CRF you need your kidneys to work as well as possible or your blood values will get even worse. So if you are dehydrated its worth discussing with your vet as getting you better hydrated can make you feel better and improve how well your kidneys work.

Here’s how your mum/dad can tell if you are dehydrated. To tell what a normal hydrated cat should feel like use one of your brothers/sisters as a reference. Pull the skin of your scruff away from your body and let go – if you are well hydrated it will snap back fast – if you are dehydrated it will go back more slowly. Your gums should feel moist and slippery – if they feel tacky or dryer then you are dehydrated. If you are drinking more than normal or if you feel generally tired and crappy that can be a sign of dehydration.

There are two main ways to deal with dehydration, either getting you to take in more water through your food and drink or using subcutaneous fluids.

How to take in more water through food and drink

Eating wet/canned food rather than dry food can make a big difference. So if you like wet food just eat that and you can get even more water by adding a little water or broth to make a cat food soup. You may also like broth to drink. Watch out for canned/boxed broth that contains onions or garlic which are poisonous for cats. The best way is to make your own which is really easy. All your mum needs to do is get some meat or bones and cook them in water which will make a lovely weak broth that you will love. A chicken back can make a pint of stock and you’ll get some meat picked off the bones when its done.

Other tips to encourage you to drink more are using multiple water bowls, spring water, adding ice cubes during summer and/or a Drinkwell Pet Fountain or similar water fountain.

Subcutaneous Fluids
Subcutaneous means under the skin so you don’t have to worry about getting the needle into a vein. With most cats it is pretty easy to do and usually you can do it yourself at home after the vet shows you how. These videos show you how to set up the sub-Q fluids equipment and how to give fluids to your cat. Tanya’s CRF site also shows how to give fluids and includes a couple of different methods and includes some good tips.

Furts recommend using Terumo needles. They are sharper (less pain) and thinner walled, so you can get away with a smaller needle without adding a whole lot of time to the sub-q process. This site has good information about different types of needles and their size and flow rates.

Warming the fluids bag to body temperature in warm water for a few minutes is a good way to make giving fluids more comfortable. Make sure you run the fluids through the line until it comes out warm or you’ll get a cold jolt to start with which isn’t pleasant.

Some cats will happily sit on your lap while getting fluids but others will wriggle so much you have to restrain them. Usually cats relax once they are wrapped up and you can leave the scruff of their neck clear to put the needle in. You can use the kitty burrito method and wrap your cat in a big bath towel or you can get a special bag similar to the Klaw Kontrol Bag that zips up around your cat. Our vet will let you rent a restraint bag for a couple of dollars a week so you can try it out and get the right size before you have to buy one so check if your vet does this too.

Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:32am PST 

The golden rule of feeding CRF cats is that it is better for you to eat something you like rather than ignore or pick at food that is better for your kidneys. Weight loss is bad news and will weaken any cat if they are not eating properly and CRF cats often have problems maintaining weight and muscle mass to start with. If you only want to eat dry food or non-prescription food, do it and you can always work with your vet to adjust meds or fluids to offset the impact of the food they are eating.

There are two schools of thought about food for CRF cats. The first is that a low protein diet is best as this will put less protein waste products into the blood and cause less work for the kidneys and most prescription foods follow this direction. More recently people have argued that a higher protein diet based on meat protein is better as the proteins are more easily digested this helps you maintain weight and avoid issues like anemia. Higher protein food with meat protein typically contains more phosphorus but phosphorus binders can be used to offset that. Tanya’s CRF Site gives a good descriptions of the reasoning for both approaches. For cats in the early stages of CRF it looks like both methods can work well. For cats with advanced CRF it’s usually necessary to move to a low protein food if the BUN levels get high enough to cause nausea (Tanya’s site recommends that once BUN is in the 60-80 range you should switch).

If you like it wet food is better than dry as there is more moisture in that. If you have always eaten dry you may be able to use baby food (Gerber stage 2 meat food with no onion or spices is good) to tempt you and gradually mix in more canned cat food. Mixing wet food with warmed broth (with no onions or garlic) makes it very tasty and irresistible.

Furts also suggested prescription kidney foods that they liked. Purina NF, Royal Canin LP, MediCal (Canada) and Science Diet KD were all mentioned as being tasty. Most vets will provide sampler packs of all the food they do so that you can try them out to see which ones that you like before you buy them. Wysong Geriatrix is a good non-prescription food with moderate protein levels and organic ingredients that is designed for older cats.

These tables give good information on the protein, phosphorus and calorie levels in canned food and dry food so that you can do some research on foods that you are eating or considering.

CRF kitties often suffer from nausea and may need help to keep eating and maintaining their weight. If this happens to you check out the Weight loss, Picky Eating & Nausea thread or the Yahoo Feline assisted feeding group while you work with your vet to figure out the underlying issues.

Minxy- (1987-2008)

Queen of the- Rainbow Bridge
Purred: Fri Nov 27, '09 12:33am PST 

With CRF it’s almost inevitable that you will eventually have to take some kind of meds. Here we’ll focus on the common ones and some alternative treatments that furts wanted to highlight. Tanya’s Feline CRF Info Centre gives lots of great advice on pretty much every treatment out there so I recommend everyone reads through that and checks out the symptoms and treatments to see if there is anything they should consider.

If you don’t like taking your meds check out the
Getting the Medicine Down: Compounded Medications & Other Useful Tips thread.

Pepcid AC (Famotidine) is a good way to deal with nausea caused by acid stomach. Avoid the chewable version or ones with similar names like Pepcid Complete that have other ingredients added to them. Pepcid should be given a couple of hours before/after other meds. Pepcid is best at night before bed so it can help with acid production on your empty stomach overnight and reduce morning vomiting of foam.

High phosphorus levels can be reduced with low phosphorus foods and/or using phosphorus binders. Treatment is usually started when the phosphorus level reaches 6 which is high normal and the goal is to try to get it down to 4 which is the mid range of normal. Phosphorus binders should be given with food so they can actually bind with the phosphorus in it. One potential side effect is constipation so watch out for that. Aluminium Hydroxide powder is a tasteless and odorless powder and is the active ingredient in Amphagel or Alternagel. An alternative is PhosLo (Calcium Acetate) but that has to be double gel capped as it is very bitter and can cause vomiting and it should also be avoided if your calcium levels are too high.

Low potassium causes nausea, weakness, muscle spasms and neurological issue. If you need a potassium supplement Renal K Powder was recommended as being cheaper and more palatable than the gel in a tube. You have to mix it with food.

Appetite stimulants like cyproheptadine can help you if your blood levels are off and you don’t feel like eating. Mum noticed that my appetite improved for 2-3 days after I had my acupuncture sessions so she asked my vet about which points improve appetite and this is what she found out. You don't need to use needles just get your mum to massage the spots. You can do it as often as you like.
1st point = where the skin part of your nose meets the fur part. On the top right in the middle.
2nd area = there are multiple points along either side of your spine. The ones that will help your appetite are between your shoulder blades and the end of your ribs. Also the ones between the bottom of your ribs and your tail are good for arthritis and stiffness so doing the whole length of your spine is good for us olde furts.

Cats can’t get dialysis like humans can but there is a process called enteric dialysis which takes the waste products out through your gut that cats can try. There is a type of probiotic called Azodyl that eats the kidney waste products and if you establish them in your guts it helps draw in the waste products from your blood, consumes them and then you poop out what's left. You have to take a capsule with the probiotic in it every day and it takes about a month to build up to a critical mass where you'll start seeing results.

Tanya’s CRF site provides info on other holistic treatments

Misha Angel

Misha Mouse- snuggle muffin
Purred: Thu Jan 28, '10 7:12am PST 
Bumping for Maxwell and his friend who needs info.

Maxwell- Sweet Angel

Patience pays- off
Purred: Thu Jan 28, '10 7:13am PST 
Thank you, Misha!

Freckles- (1993-2011)

My beautiful old- lady!
Purred: Thu Jan 28, '10 10:31am PST 
Maxwell, I hope this thread gives you lots of info that will be useful. Tripsy may be OK for some urinary tract issues but it is a diuretic and isn't recommended for CRF cats as they already pee a lot and ar eprone to dehydration.

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