FELINE MEDICINE
about therapy when cats are in the early stages of CKD
(International Renal Interest Society [IRIS] stages 1 and
2) will help pave the way to successful management.
These early stages are a good time to talk about
nutritional changes. For example, if the client is
feeding Fancy Feast, which is high in phosphorus,
then talk about switching to a high-quality senior diet.
This is also a good time to plant the seeds about regular
follow-up and explain that it’s important to track
changes over time. These simple conversations will
help guide your client and avoid overwhelming them,
which erodes the human-animal bond. Early CKD is
also a good time to talk about doing some additional
diagnostics to determine if there’s identifiable disease
that can be treated, such as imaging to look for kidney
stones or urine cultures to look for chronic infection,
says Dr. St. Denis. If there are money constraints,
then you can plan to test over time to help soften the
financial impact. Utilize the phrase “If not today, how
about next month?” to direct your client’s actions.
Therapeutic kidney diets—they get the job
done
The most important thing to ponder about nutrition
in feline CKD is whether the cat is eating enough, Dr.
St. Denis says. This is more important than what the
cat is eating. Maintaining adequate caloric intake and
muscle mass is critical to avoid protein malnutrition.
But, as you already know, ensuring adequate intake in
a cat can be very challenging. Working with the client
and providing education in this area is an important
therapeutic strategy. If the cat isn’t eating enough or is
underweight, then Dr. St. Denis recommends feeding
1.2 to 1.4 times the resting energy requirement (RER).
Most geriatric cats need at least 1.1 times RER.
We all know that switching diets on a CKD cat that’s
experiencing decreased appetite can be challenging
(understatement of the century). Dr. St. Denis
recommends changing the diet earlier rather than
later. Cats with CKD should be eating a diet that
contains restricted phosphorus and highly digestible
protein that meets or exceeds minimum standards. A
therapeutic kidney diet that meets protein needs and
contains complete amino acid profiles, plus omega-3
fatty acids, which have renal protective properties, will
help ensure that your clients’ cats will get everything
they need.
for nausea and inappetence. If the cat won’t eat or
is severely malnourished, don’t hesitate to place a
feeding tube to ensure caloric intake and medication
administration.
What about uraemic gastritis and ulcers? Historically,
we prescribed antacids in CKD cats to prevent
gastritis, but a new study has found that cats with CKD
may not have elevated stomach acidity as compared
with healthy cats. 1 Dr. St. Denis hypothesizes that the
inappetence associated with uraemia is more likely
due to chemoreceptors in the brain and less likely to
be associated with elevated gastric acidity, making
antacid treatment in cats with CKD less likely to help
with nausea and inappetence. Avoid polypharmacy!
Don’t reach for the antacid unless you are seeing
melena or bloody vomitus.
If nausea is under control, then appetite stimulants
are helpful. In fact, the FDA recently approved a
transdermal formulation of mirtazapine for cats.
Mirtazapine can be used daily, but if you’re noticing
serotonin syndrome with administration, (“hyperactive
meowing,” as Dr. St. Denis calls it), then dial down the
dose and use cyproheptadine as an antidote.
Pain management
When I graduated from vet school, we didn’t
automatically associate pain with feline CKD, but now
we know that these cats are hiding pain, due not only
to CKD but also to occult degenerative joint disease
(DJD), which is prevalent and underreported in senior
cats and a serious obstacle to a good quality-of-life
goal. Dr. St. Denis recommends talking to your clients
about subtle signs of stress and pain from DJD and
getting these cats on pain management sooner rather
than later.
Here are Dr. St. Denis’ favorite pain medications for
cats:
•
•
•
Old, scrappy and not hungry
If your CKD patient isn’t eating, determine if the
inappetence or nausea is due to a contributing
disease, dehydration or azotaemia and treat that
first, before starting appetite stimulants. Maropitant
is safe to use in cats with CKD, and it’s labeled for
oral, subcutaneous and intravenous administration.
Ondansetron is also effective for nausea, either
orally or intravenously. Mirtazapine also works well
•
•
•
•
Buprenorphine, as a sustained release formulation
or given intravenously for hospitalised patients
Gabapentin (Dr. St. Denis recommends starting
with evening administration because of initial
ataxia and sedation and says to be sure to advise
clients of initial side effects)
Nonsteroidal anti-inflammatory drugs (NSAIDs):
robenacoxib (Onsior—Elanco) and meloxicam
have good studies that show safe long-term
administration, provided that the cat is hydrated
and properly monitored and that the client
understands the risks and benefits.
Ketamine intravenous constant-rate infusion for
hospitalised patients
Polysulfated glycosaminoglycan (Adequan—
Luitpold Animal Health)
Duralactin (PRN Pharmacal)
Prescription Diet k/d + Mobility (Hill’s).
Issue 03 | JULY 2018 | 17