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Part Three of Three:
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Kidney Disease in Cats - Chronic Renal Failure
Signs of Renal failure in cats. Increased thirst is often the first symptom
Kidney disease, in the form of chronic renal failure (CRF), is a common problem in older cats. I have seen kidney failure in cats as young as 4 years, but far more frequently in much older cats. The most noticeable symptom is an increase in water consumption and urination ("drink-a-lot, pee-a-lot syndrome"). A blood test should be done if you notice these symptoms, as there are several conditions that can cause this. The increase in drinking and urinating in CRF is due to loss of the kidney's ability to concentrate the urine. The kidneys have a very large reserve capacity, and symptoms of kidney failure are not seen until approximately 75% of kidney tissue is non-functional. In my experience, kidney failure is the most common cause of death in older cats.
Laboratory tests are needed to definitively diagnose CRF. A blood test alone is usually not sufficient; a urinalysis must be taken at the same time the blood is drawn. Kidney disease is likely present when the cat is “azotemic” AND the urine is not sufficiently concentrated. “Azotemia” means that there is an increase in particular compounds in the blood; specifically blood urea nitrogen– BUN–and/or creatinine. The measurement of urine concentration is called Urine Specific Gravity (USG). If the cat’s USG is less than 1.035 (1.030 in dogs) AND azotemia is present, then kidney function is abnormal. BUN and/or creatinine may be high if the animal is dehydrated (common in cats who eat a lot of dry food, or during hot weather or after a stressful car ride). They may also be increased in animals on a high protein diet. As long as the kidneys are able to concentrate the urine, small elevations in BUN and/or creatinine are usually not a cause for alarm.
Causes of Chronic Renal Failure
Recent research suggests a link between vaccination for feline distemper and immune-mediated inflammation of the kidneys, which is thought to be the cause of CRF.
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Annual boosters for distemper are completely unnecessary. Be sure to discuss all recommended vaccines with your veterinarian. A cat with kidney disease or kidney failure should not be vaccinated at all.
Long-term feeding of an all-dry-food diet is also suspected as a factor in Chronic Renal Failure. Cats' kidneys are highly efficient and adapted to life in the desert, where they would get most or all of their water from eating their prey. Cats eating dry cat food take in only half the water that cats on a canned or homemade diet get; this chronic dehydration can cause stress on the kidneys over time. Dry diets also predispose cats to lower urinary tract disease (FLUTD, LUTD, FUS, crystals, stones, cystitis) because they force such a high degree of urine concentration.
Chronic or recurrent bladder disease may also be a factor in the development of CRF.
Treatment of Chronic Renal Failure
Chronic kidney failure is progressive and incurable. No conventional or alternative medical treatment can reverse its course, since the disease involves the loss of kidney cells and replacement by scar tissue. The rate of progression in any individual cat probably cannot be slowed to any significant degree. When the process is advanced, the kidneys become small and lumpy, and the amount of functional tissue is greatly limited. The most significant problems caused by the loss of function are build-up of blood toxins, and anemia. These can cause weight loss, lethargy, vomiting, loss of appetite, weakness, and other signs of illness.
The Protein Controversy
You may have heard that restricting protein is recommended for cats in kidney failure. Although this has been the “standard” treatment for decades, as far as cats are concerned, it has always been–and remains–very controversial. Restricted protein does not prevent kidney failure in a healthy cat. Some experts also suggest that protein has no effect on the ultimate progression of renal disease. Research also shows that even very high protein diets do not make renal failure worse in cats (although high protein does worsen the disease in dogs and humans). (One pet food maker recently completed a study it claims shows that its restricted-protein diet increases lifespan in CRF cats.
However, because the study has not yet been published, it is impossible to evaluate the data, which is contradicted by other research. The real culprit is actually phosphorus, which meat contains in large amounts. Decreasing phosphorus intake (by restricting protein) can help some cats feel better, so it may be worth a try in a symptomatic cat.
S ome studies have suggested that excessive restriction of protein may actually cause further damage to the kidneys and other organs, because there is not enough protein for normal body maintenance and repair. Experts say that these diets are not appropriate until the BUN (Blood Urea Nitrogen) is at least double what it should be normally (about 60-80 mg/dl).
Furthermore, there is one big problem with using the protein-restricted commercial diets: many cats don't like them, and won't eat them. Obviously, it does little good to provide a special diet if the cat is going to starve to death!
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Experts emphasize that it is much more important to feed the cat what he likes and will eat, and maintain weight and body condition, than to be overly concerned about protein content. (Please note that if you add any other protein source to the diet, it will completely negate any possible beneficial effect from the low-phosphorus renal diet. It is useless to feed both a renal diet and a normal protein food or meat-based treats at the same time.)
Let me say this again, because it is the single most important thing to know about CRF: feed the cat anything she will eat! IF THE CAT WON'T EAT IT, IT WON'T HELP THE CAT! Weight loss is your cat's worst enemy in this disease; so let the cat eat what she wants!
Because water balance is so crucial, it is best to feed a high-moisture diet to help keep the cat hydrated; do not feed only dry food. Feeding mostly or only canned food, even though it is high in phosphorus and protein, provides the moisture and calories that these cats need, in a very palatable form that most cats will happily eat. You can also get low-phosphorus renal diets in canned form. Dry cat food causes dehydration even in healthy cats, and is not appropriate for CRF cats (unless, of course, it's the only food he will eat!).
The best thing you can do is feed a home-prepared diet; but only if the cat will eat it! If the cat has never eaten homemade food, or does not have a hearty appetite, this is not a good time to make this switch! There are several good books on home cooking for animals, such as Dr. Pitcairn's Guide to Natural Health for Dogs and Cats, by Richard Pitcairn, DVM, and Susan Pitcairn. (Rodale Press. ISBN 075962432.) They discuss why a diet made from fresh, raw foods is important, and provide recipes, including a special recipe specifically designed for animals with kidney disease. Another excellent book is Home-Prepared Dog and Cat Diets: the Healthful Alternative by Donald R. Strombeck, DVM. (Iowa State University Press. ISBN 0813821495.) If you choose to use Dr. Strombeck's recipes, I suggest substituting 1 capsule of taurine (250 mg) for the canned clams, since clams do not contain enough taurine for proper maintenance.
Special Nutrition for Chronic Renal Failure
Several nutritional supplements may be helpful for cats with kidney disease. Omega-3 fatty acids have been shown to be beneficial in CRF. Antioxidants are also important. Both of these are contained in the highly digestible algae, Biosuperfood . A nutritional supplement called "Renafood" from Standard Process, is a good renal detoxifier and helps to maximize kidney function in cats. Give one or two a day. Most cats eat them readily if they are crushed into the food. Call Standard Process at 1-800-558-8740 to find a distributor in your area. Remember, though, that the basic diet is the most important factor in your cat's health, and no supplement will make up for poor quality nutrition. For more info on feeding, choosing a good food, and switching to a better diet, see the many nutrition articles in our Library .
Your veterinarian can give your cat subcutaneous fluids in the clinic, or teach you how to give them at home.
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This is the least intrusive and most beneficial treatment you can give your cat. Cats in chronic renal failure drink a lot of water, but they cannot drink enough to compensate for the loss of water through the kidneys. Subcutaneous fluids are an excellent way to help keep the toxins flushed out of the bloodstream and make the cat feel much better. If the cat is sick or not eating, it may be necessary to hospitalize it for a few days for intravenous fluid therapy, followed by subcutaneous fluids at home as needed. A semi-permanent "port" that can be inserted in the cat's skin has taken much of the hassle out of this procedure; talk to your vet about having this installed. It is best to have this procedure done by a veterinarian who has lots of experience with these ports since there can be many complications.
Holistic Veterinary Care
While no treatment can create new kidney cells when scar tissue has already formed, homeopathy, herbs, flower essences or acupuncture may be able to help your cat feel better and live a better quality of life.
Pet Loss Support
Losing a beloved cat to CRF is just as traumatic as losing a human family member, but friends and
family don’t always understand. There are many resources to help you through the difficult times and
tough decisions you will have to make for your cat, and to support you afterward. Many of these are
listed on the Feline CRF pet loss support page.
Fatty Liver Disease Facts
- Non alcholic fatty liver disease is characterized by increased accumulation of fat, especially triglycerides, in the liver cells.
- It is normal for the liver to contain some fat and by itself, this causes no symptoms. In some patients, the excess fat can cause inflammation called steatohepatitis (steato=fat+hepar=liver +itis=inflammation), although there is no relationship between the amount of fat present and the potential for inflammation.
- Steatohepatitis can lead to cirrhosis (fibrosis, scarring and hardening of the liver). There is also an association with liver cancer (hepatocellular carcinoma).
What Causes Fatty Liver Disease?
Fatty liver can be classified as alcohol and nonalcohol related. Alcohol is a direct toxin to the liver and can cause inflammation. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic related steatohepatitis (NASH) are markedly different illnesses and there are many potential causes that are linked to fat accumulation in the liver.
Some of the causes of fatty liver include:
- Diet: Consumption of excess calories in the diet (the excess caloric intake overwhelms the liver's ability to metabolize fat in a normal fashion, which results in fat accumulation in the liver).
- Diseases: Fatty liver is also associated with type II diabetes, obesity, and high triglyceride levels in the blood, celiac disease, and Wilson's disease (abnormality of copper metabolism).
- Medical conditions: Rapid weight loss and malnutrition.
- Medications: Medications such as tamoxifen (Soltamox), amiodarone injection (Nestorone), amiodarone oral (Cordarone, Pacerone), and methotrexate (Rheumatrex Dose Pack, Trexall) are associated with NAFLD.
There is evidence to suggest the presence of an association between insulin resistance and the development of NAFLD.
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In this situation, although the body makes adequate insulin, the ability of cells to adequately use that insulin to metabolize glucose is abnormal. The relative excess of glucose is then stored as fat and can accumulate in the liver.
Fatty Liver Disease Symptoms
For the majority of patients, NAFLD is a benign disease and is not associated with any symptoms. It is only when the liver manifests signs of inflammation, either NASH or alcoholic steatohepatitis, that the patient may experience symptoms. As with other types of hepatitis, the initial symptoms are non-specific and include malaise, fatigue, and upper abdominal fullness and discomfort.
If steatohepatitis progresses to cirrhosis, symptoms of liver failure may develop. Symptoms of liver failure include:
- jaundice (because of the accumulation of bilirubin),
- ascites and edema (swelling of the body) due of decreased protein production by the liver,
- increased bruising, and
- associated mental confusion.
When to Seek Medical Care With this Fatty Liver Disease
Since fatty liver disease is asymptomatic until liver inflammation occurs, the diagnosis is often made incidentally. The health care practitioner may note a slightlyenlarged liver on physical examination, or screening blood tests may show mild abnormalities of liver function.
Patients who have abdominal swelling, jaundice, and easy bruising should seek medical care, though the cause may not necessarily be steatohepatitis or cirrhosis.
Fatty Liver Disease Diagnosis
Physical Exam and Medical History
When concern exists for the presence of fatty liver disease, the health care practitioner will try to find the underlying cause and risk factors. Questions may be asked regarding alcohol consumption, medication use (both prescription and over-the-counter) and past medical history, especially concerning previous history of viral hepatitis (the most common are A, B, and C) and immunizations against infectious hepatitis. Screening for diabetes may be appropriate.
Physical examination may reveal an enlarged liver that can be palpated or felt in the abdomen below the right rib margin. Otherwise, it may require the development of cirrhosis to elicit abnormalities on physical examination. These may initially include jaundice or a yellowish tinge to the skin and eyes, muscle wasting, hair thinning, abnormal skin blood vessels called spider angiomata, and splenomegaly (enlarged spleen).
Blood tests may be helpful as screening tests for liver inflammation, although liver function studies such as serum transaminases (AST, ALT) may be normal or elevated and not necessarily related to the severity of the liver disease. Other liver tests such as alkaline phosphatase and bilirubin are often normal. Serum ferritin (a measure of iron storage) may be abnormal. In patients with NAFLD and NASH, cholesterol levels including triglycerides are often elevated.
Ultrasound of the liver can reveal patterns suggestive of fatty infiltration of the liver. Computerized tomography (CT scan) and magnetic resonance imaging (MRI scan) are also useful in the evaluation of fatty liver.
The definitive diagnosis of fatty liver disease can only be confirmed by liver biopsy, where a needle is inserted into the liver through the abdominal wall to obtain a piece of tissue which is analyzed under the microscope.
How to Treat Fatty Liver Disease
The treatment of fatty liver disease is to decrease the potential risk exposures to the liver.
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For those with alcoholic liver disease, abstaining from alcohol is a must. For those with NALFD or NASH, appropriate diet, weight loss, diabetes control, and cholesterol/triglyceride control are important both for treatment and to prevent progression of the disease from NAFLD to NASH, and from NASH to cirrhosis.
Patients with celiac disease who maintain a strict gluten free diet can reverse fat accumulation in the liver.
Cardiovascular exercise can help promote weight loss and weight training can increase muscle mass. This not only improves metabolism and promotes weight loss, but the increase in muscle mass helps to sensitize the cells to insulin and reduces insulin resistance.
Medical Treatment for Fatty Liver Disease
The patient and health care practitioner should work together to formulate a plan that involves lifestyle changes. A balanced diet, increased in physical activity and exercise, and medication if needed to control cholesterol and blood sugar levels, can minimize the risk factors that lead to fat infiltration of liver cells.
Medications for Fatty Liver Disease
Though there is much research underway, presently there are no medications proven to be effective in fatty liver disease; however, medications to control and lower cholesterol and triglyceride levels can be used in association with diet and exercise.
Surgery for Fatty Liver Disease
In patients who are morbidity obese, bariatric surgery to promote weight loss is very effective in decreasing liver inflammation and NASH.
Patients with fatty liver disease should be seen routinely in follow-up visits to their health care practitioner in order to monitor their liver function and progression to more serious liver abnormalities. Since weight loss, diet, and physical activity are the most important tools in minimizing the risk of fatty liver disease, and are the most effective treatments, consultations with a dietician and a physical trainer may be appropriate.
Fatty Liver Disease Prevention
Fatty liver disease is a preventable illness with the institution of a healthy lifestyle including a well balanced diet, weight control, avoidance of excess alcohol consumption, and a regular physical exercise program. This does not guarantee success in disease prevention as some people may still develop the liver disease.
Fatty Liver Disease Prognosis
Research studies are underway to better understand, prevent, and control fatty liver disease. There is ample evidence to suggest that NAFLD, NASH, and alcoholic steatohepatitis are reversible, and progression to cirrhosis is preventable. Numerous research trials are being carried out to understand the factors responsible for fat accumulation in the liver and to explore medications both new and old, that maybe effective in treatment.