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Chronic Kidney Disease in Cats: Treatment (Part 2)

This is part 2 of a two-part series written by Veterinary Nurse Candice Drew. Part 1 addressed the role of the kidneys, a discussion of the signs and effects of CKD and how veterinarians diagnose this condition.

Part 2 will describe management of CKD, the role of a “renal diet”, the importance of ongoing monitoring by the veterinarian and by owners at home, and brief case studies of two of her own cats with CKD.

How can I help my cat with CKD?

If you've read Part 1 of this article and it all sounded a bit complicated and scary, the first thing to remember is that whilst CKD cannot be cured, there is a lot you can do to help! 
Your role is vital in helping your cat to enjoy as good a quality of life as possible

Feeding a prescription renal diet, keeping a diary of your cat’s dietary and fluid intake, toileting (how many times a day), vomiting or signs of nausea, mood and activity levels, will help you to recognise what is normal for your cat and if any changes occur. 

You know your cat better than anyone else and this daily record is something your vet cannot witness themselves but will find very useful when they review your cat.

Ideally, your veterinary professionals will develop a plan with you and provide the informational and support you need to help your cat “feline fine” for as long as possible, and to prevent you from becoming overwhelmed.

The single most important aspect of treatment is providing a diet which will reduce the workload on your cat’s kidneys. Cats need protein in their diet because they are carnivores, however once the body utilises this protein the by-products of metabolism need to be excreted by the kidneys. 

The role of a renal diet is to provide your cat with enough high-quality protein to meet his/her dietary needs, without causing unnecessary strain on the kidneys

✔️ Renal diets also have restricted phosphate levels (restricting phosphate is crucial in CKD), restricted sodium (salt) to help control blood pressure, and increased levels of nutrients that are commonly lost in CKD, due to increased urination or vomiting, such as potassium and B vitamins. 

✔️ Renal diets also generally contain antioxidants, essential fatty acids and vitamin D to help manage some complications of reduced renal function.

A prescription renal diet should only be utilised if your veterinarian has recommended this for your cat, and your cat needs ongoing veterinary monitoring when a prescription diet is fed, just like the monitoring that is needed for other prescription medications.

Ensuring your cat maintains an adequate fluid intake is crucial in preventing dehydration. Ways to increase fluid intake include:

✔️ Feeding wet foods such as cans and pouches

Wet food has a much higher water content than dry food, and if your cat is eating well this is one way to maintain their fluid levels. 

Because of this increased water level, your cat will need to eat more wet food to reach their required calorie levels compared with dry food.

✔️ Providing a water fountain, because many cats like to drink from a running water supply (hence the cat who sits in the sink drinking from the dripping tap!)

✔️ Adding a small amount of warm water to dry food to form a gruel

✔️ Adding the spring water (not brine or oil) from a low-salt can of tuna to food. These can also improve palatability for cats who are reluctant to eat.

But my cat won’t eat the renal diet...

Cats with renal disease can be affected by changes in smell and taste, causing them to suddenly “go off” a particular food that they previously liked. Food texture is also important to cats. Your cat might well accept a rejected food again at a later time, so stock a variety of renal diets (dry, mince, pate, chunks in gravy, different flavours). 

Try warming food prior to serving, especially if refrigerated, and offer something new if your cat decides it’s time for a change.

A very important aspect of feeding is to not force your cat into eating a renal diet while they are feeling unwell. Vets usually will not introduce a renal diet to hospitalised cats with newly diagnosed renal disease because they might be feeling nauseous and scared, and they might develop an aversion to any new diet (i.e. they associate the new diet with the vet clinic or with feeling anxious or unwell). 

It’s preferable to let your cat feel better and enjoy being home again before gradually introducing the renal diet over 7-10 days. For example:
  • days 1-3 = 25% new diet / 75% old diet
  • days 4-6 = 50% old and new diets
  • days 7-9 = 75% new diet / 25% old diet
  • day 10 = 100% new diet
This guide is just an example; some cats will take longer to accept a new diet and that’s okay. 

If at any stage your cat stops eating their food during this transition, return to the previous step for a few days and then try again to increase the new diet. Because diet is the most beneficial treatment in slowing the progression of renal disease, it is very important to put as much effort as possible into ensuring your cat accepts the renal diet, most of which are quite palatable (so my own cat tells me!) 

However, eating a non-renal diet is better than not eating at all; if your cat really will not eat any of the prescribed diet foods, just keep trying to introduce them periodically.

Nausea, caused by the build-up of toxins in the blood stream, can also reduce a cat’s food intake. Signs of nausea include:

✔️ salivating
✔️ lip licking
✔️ vomiting
✔️ loss of appetite

Tell your vet if you think your cat might be nauseous because there are medications to help with this.

If your cat is prescribed any medications, it is better to dose them separately than to hide them in food, because they can alter the taste and are another potential cause of food aversion (imagine finding something unpleasant in your own food).

How else can I help my cat?

Another important way you can help your cat is to provide a stress-free, predictable and loving home environment which ensures your cat has everything they need, adjusted to their requirements, such as accessible litter trays, food and water and sleeping areas

Play and interaction with family members are also important in improving their quality of life.

As the disease progresses, it might become necessary to provide your cat with fluids directly into their blood stream (intravenous) or under their skin (subcutaneous) if they are unable to take in enough fluids orally. This is often done by your vet, but some owners can give subcutaneous fluids at home, avoiding the need for additional stressful vet visits. Your veterinary and nursing team can show you how and support you to do this, if you would prefer this option.

Subcutaneous fluid administration - Credit:

Another option for delivering enough nutrition to anorexic cats is for your vet to place an oesophogeal feeding tube, which can remain in place medium-long term and your veterinary team can show you how to manage this at home. 

For this option, your cat must be stable enough to undergo a short general anaesthetic, and must otherwise maintain a good quality of life (feeding tubes are not designed to keep an animal alive if it results in prolonged suffering). 

Most cats tolerate oesophogeal feeding tubes very well and they can still eat normally with this tube in place. The advantage of this tube is if your cat is eating a little but not enough, you can make up the difference with the feeding tube. If this is an option for your cat, your vet will discuss it with you in more detail.

Regular vet check-ups are essential:

Although we don’t want to be taking our cats to the vet unnecessarily and causing additional stress, it is crucial that your cat receives ongoing monitoring

Some aspects of your cat’s health your vet needs to monitor include:

✔️ blood pressure. If hypertension (high blood pressure) occurs and is left untreated, it can cause retinal damage and blindness. It can also worsen renal disease. If your cat’s blood pressure is high over a period of time, your vet might prescribe medication to help control it. Your vet can also assess your cat’s retinas for damage during a normal consultation (see photos of Maggie)

✔️ blood and urine checks. These help to determine your cat’s hydration status, red and white blood cells, levels of toxins (urea and creatinine) and electrolytes in the blood and whether your cat is concentrating its urine adequately or if protein is being lost in the urine

✔️ bodyweight, body condition score and muscle condition score. These ensure your cat is maintaining a healthy bodyweight and not losing muscle mass; these are associated with increased longevity

Cats with renal disease also need to continue receiving the same monitoring and preventative care as non-renal cats. Other age-related diseases which are common in cats include hyperthyroidism, cancer, osteoarthritis, obesity, heart disease and dental disease. Taking a holistic approach will ensure your cat’s treatment meets their individualised needs, which change over time.

It’s important to consider that veterinary care has progressed substantially in recent years and we should never assume that our pets’ health problems are just part of getting old and there’s nothing we can do about them. 

There is so much that both veterinary professionals and pet owners can do to improve quality of life and increase longevity, and many of these strategies are easy to implement and don’t need to be heroic or expensive. Additionally, not all vet clinics provide all available services, so ask your vet about what treatment options might be available elsewhere, for example at specialist centres or university clinics.

Cee’s story

I first met Cee at a shelter when she was 6 weeks old, and adopted her at the age of 10 weeks. Cee was a domestic shorthair and until the age of 15 she had no significant health issues. 

As a senior cat, she had vet check-ups at least twice a year, with blood and urine testing and blood pressure checks. At the age of 15, she was diagnosed with early renal disease (IRIS Stage 1), based on observations of her drinking and urinating more often, and blood and urine results. We increased her vet monitoring to every 3 months. At 16 years old, in early IRIS Stage 2, she transitioned onto a renal diet and also medication to control her high blood pressure.

Cee maintained a good appetite and fluid intake; fortunately, she loved the new food and there were never any issues with not eating. The progression of her renal disease was very slow once the renal diet commenced and her blood pressure stabilised at the high end of normal until the age of 19. 

Cee on her 18th birthday!
She was healthy enough to undergo a dental procedure at the age of 17, with special precautions taken by her veterinary team to ensure the general anaesthetic carried minimal risks.

At 19 years and 4 months, Cee’s blood pressure medication was increased because her hypertension was becoming worse, however she continued to remain at IRIS Stage 2 and enjoyed a good quality of life: playing with toys, sleeping in favourite spots in the garden and hogging the warmest part of the bed.

Cee passed away very suddenly at 19 years and 5 months, 4 years after her renal disease was first identified. The disease had progressed minimally, mainly due to her eating a renal diet as the sole food, which reduced the workload on her kidneys, and also due to controlling her blood pressure. Her death was not directly related to her renal disease, but likely caused by an underlying heart condition, another common issue in older cats, that we had also been monitoring.

Cee: "It's important for elderly cats
 to be comfortable!"
The take-home message from Cee’s story is that with early recognition, regular monitoring and eating a renal diet, Cee enjoyed another 4 years of good-quality life. 

This time would have been significantly shorter and less happy if the disease had gone undiagnosed or untreated. 

Unfortunately, the aging process affects us all in the end and we can’t keep our pets alive forever, but Cee is an example of a cat who did not progress to the later, more devastating stages of renal disease. 

She was a very dignified little old kitty who seemed to enjoy her life right up to the very last minute. That’s a precious gift.

Maggie’s story

I adopted Maggie from a shelter as an older cat in 2018; her age at that time was estimated to be 8 years (Maggie’s not telling!) Her previous history is unknown, except that she was left at the shelter with skin cancer on her nose. She underwent surgery and recovered in foster care before being put up for adoption.

Maggie attends a cat-only veterinary clinic which is excellent at minimising stress via its design and procedures and in the experience of its staff in cat behaviour and handling. 

Because she gets very stressed and angry about going to the vet, likely due to events in her previous life, Maggie is given sedation before each visit. 

Until 2020, Maggie had vet check-ups twice a year which included blood and urine checks to monitor for age-related diseases, as well as a full physical examination and weight monitoring. In late 2020, she was flagged as possibly having early renal disease, so she had another check with blood/urine and blood pressure testing in early 2021 to compare with the earlier results. 

At this stage, Maggie displayed no obvious signs of renal disease, such as drinking and urinating more, and visually her behaviour and health appeared good.

In January 2021, Maggie was diagnosed with renal disease. Because of ongoing health checks and regular testing, like Cee, she has been diagnosed quite early. 

She now eats a prescription diet formulated for both renal disease and osteoarthritis, which was not available when Cee was alive. 

Most older cats have some degree of osteoarthritis, even if it’s not obvious to their owners. Cats mask pain very well as a defensive strategy so it’s reasonable to assume Maggie has some level of degenerative joint disease at the age of 11 years.

Maggie's vet Carolyn checks her retinas
Maggie’s blood pressure is borderline-high so she now has it checked every 3 months and her retinas are also checked to ensure they are not damaged by hypertension, which can lead to blindness. 

At this stage, Maggie doesn’t need medication for her hypertension and her retinas are healthy.

Maggie absolutely LOVES FOOD and eats her renal diet with much enthusiasm. 

I have a variety of wet and dry foods and so far there’s only one flavour she’s not keen on so I’ve withdrawn it for now and will try it again at a later stage. Maggie has a water fountain and also a bowl at the other end of the house, with fresh water always available. I keep track of her eating, drinking, and deposits in her litter tray and on her behaviour in general.

With a renal diet and regular veterinary checks (every 3 months), we are hopefully slowing the progression of Maggie’s renal disease, and if new problems arise we can identify and address them quickly. Maggie continues to enjoy a good quality of life, mostly while under a blanket now the weather’s turned cold! 

With luck and good monitoring and treatment, the hope is that this will continue for several years. However, whichever challenges senior life deals Maggie, we are in the best position to ensure she continues to remain happy and healthy for as long as possible.

written by Candice Drew, June 2021 for Australian Cat Lover (all rights reserved).

About the Writer

Candice qualified as a veterinary nurse in Australia in 2005, being awarded the Novartis Award for Outstanding Achievement in Veterinary Nursing in her qualifying year. 

She has worked extensively in Australia and the UK, and is a UK Registered Veterinary Nurse. Candice is experienced in general practice, shelter nursing and referral nursing (Surgery and Emergency & Critical Care [ECC]). 

She attained the Diploma of Veterinary Nursing (surgical) in 2009, qualified as a trainer & assessor in 2015, and completed the ISFM Diploma in Feline Nursing in 2018. Candice is interested in most aspects of veterinary nursing but her passions are feline nursing, ECC and working with students. 

Candice is the happy slave of an 11-year-old rescue cat named “Maggie”, whom she adopted in January 2018.


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