End Stage Feline Kidney Disease: 7 Signs to Watch For

Identifying the signs of kidney failure in cats can help you make the best choices for your pet. Modern treatments slow the deterioration of kidney disease and keep the cat well for longer, but there is a time when the kidneys shut down and quality of life becomes an issue. This is when truly caring for your cat may mean recognizing it is time to say goodbye.

Understanding Renal Failure in Cats

International Cat Care explains "renal" or kidney disease is common in cats and a normal part of aging. The kidney has a limited ability to repair itself, and over the course of the pet's life, active kidney tissue is replaced with nonfunctional scar tissue. The kidneys' job is to filter naturally occurring toxins out of the blood and get rid of them in urine.

In addition, the kidney regulates the body's hydration status and has a role in the production of red blood cells. When the kidneys aren't working properly, a number of things happen.

Feline Kidney Disease Stages

The International Renal Interest Society divides renal disease into four different stages. These range from mild, early disease to end stage. According to these IRIS guidelines, a cat is technically in end-stage failure when they have less than 10 percent of normal renal function. Markers of kidney function, which predict when a cat has entered end-stage, include:

• Extremely high blood creatinine levels
• Excessive amounts of protein in the urine
• Very weak urine
• High blood pressure
• Anemia

However, as Prof. Johnathan Elliott advises, test results are only ever a guide to the cat's health, and it's important to treat the cat rather than the numbers. For example, some cats have shocking blood results but are relatively well, while others have OK results on paper, but are very sick in reality.

What Is End-Stage Kidney Disease?

Treatment is aimed at tackling these complications, resting the kidney, and slowing deterioration. The sooner the problem is diagnosed and treated, the longer the cat's survival time. Inevitably, deterioration happens to a point where kidney function fails and the cat becomes gives in to their final illness. This is known as end-stage feline renal disease.

Symptoms of End-Stage Renal Disease in Cats

A cat in end-stage renal disease is in poor condition, and their welfare should be of uppermost importance in the pet parent's mind. VCA Hospitals note the nature of the illness means the cat is often painfully thin, with little or no muscle mass, and they have a dull, starry coat. In addition, other symptoms of end-stage include:

• Nausea: Rise in toxins levels (most notably creatinine and urea) in the blood, leading to nausea, vomiting, and poor appetite.
• Dilute urine: The cat struggles to concentrate their urine, leading to water loss and dehydration. In an attempt to flush toxins from the blood, the cat is usually very thirsty and produces lots of urine. The end is often near when the cat stops drinking or producing urine.
• Muscle wasting: Protein leaks through the kidney and is lost, leading to muscle wastage and poor body condition.
• Anemia: Poor production of red blood cells, resulting in anemia.
• High blood pressure: Hormones that increase blood pressure are retained, leading to hypertension (high blood pressure).

• Bad breath: High toxin levels in the blood cause them to have bad breath.
• Dehydration. Dehydration produces a lack of elasticity in the skin. The classic sign is skin tenting. To detect dehydration, lift the skin over the cat's shoulder and let go. The skin should instantly ping back into place, but dehydrated skin takes a second or more to fall back into place, or worse still stays at a peak.

How Your Cat Feels in End-Stage Kidney Failure

The cat in end-stage renal disease feels nauseated and weak. They refuse food and may be very thirsty or stop drinking altogether. They will also be thin, and the anemia means they lack energy even to do simple things like groom.

Sadly, a mistake often made by owners is to think a purring cat is happy. A sick cat purrs to comfort themselves, so the hard decision to say goodbye should not be postponed because the cat is still purring and presumed content.

Treating Your Cat's End Stage Renal Failure

With less than 10 percent functional kidney tissue left, therapy aims to ease the unpleasant complications of kidney failure. Research on renal disease explains it's best to maximize quality of life rather than length of life.

Sometimes the best that can be hoped for is to make the cat comfortable and ease suffering. If therapy fails to help, an owner faces the unenviable decision to say goodbye and save the cat from distress.

Correcting Dehydration

Dehydration makes a cat feel weak and nauseated. The problem is the kidneys are so damaged they cannot retain fluid, meaning whatever the cat drinks passes straight through. To correct dehydration, the cat needs to gain more fluid than they lose. It is rarely possible to eliminate dehydration altogether, but boosting the amount of water going into the cat may help them feel better. AAHA guildelines suggest:

• Intravenous Fluids: On the plus side, a drip puts fluid via a vein directly into the circulation. On the minus, the cat stays at a clinic and is not at home in their last few days or weeks. How long the cat benefits from these 'top up' fluids depends on how sick they are, ranging from no response at all to several weeks.
• Subcutaneous Fluids: An owner may be taught how to slowly inject depots of sterile saline solution under the skin. Around 60 - 120 mL is injected subcutaneously per day in three to four sites. Unfortunately, in a very sick cat, their circulation is so bad that the body struggles to absorb the fluid.
• Oral Fluids: This involves slowly syringing water into the cat's mouth, giving them plenty of time to swallow each mouthful. On average, around 100 - 150 mL is given by this route. Most cats only tolerate around 5 mL at a time, which makes it a huge commitment for the owner.

Supporting Appetite

Rising toxin levels mean the cat has no desire to eat, so the cat becomes progressively weaker. Encouraging the cat to eat can give them vital energy. While prescription renal food is ideal, some food is better than none for a cat that's not eating.

• Vitamin B Injections: Vitamin B stimulates the appetite, but sadly this water-soluble vitamin is lost in urine. Weekly vitamin B injections can help maintain levels, which in turn, supports appetite.
• Anabolic Steroid Injections: This remains controversial because there is little proof that it is effective. However, for decades vets have given weekly or monthly injections of anabolic steroids, which owners anecdotally report improves appetite.
• Appetite Stimulant Tablets: Low doses of appetite stimulants such as Periactin or mirtazapine can help some cats to eat.
• Nursing Care: Providing a favorite food, warming the food, and hand feeding may all encourage eating.

Managing Nausea

Toxin accumulation in the bloodstream makes the cat feel sick. ISFM suggests strategies to reduce nausea can make a big difference in quality of life:

• Antacid Medications: Medications which either prevent stomach acid production or neutralize it (for example, Omeprazole or Ranitidine) make the cat more comfortable.
• Phosphate binders: Another complication is rising blood phosphate levels, which are also linked to nausea. Adding a phosphate binder such as Ipakitine to food can contribute to lowering blood phosphate levels.
• 'Bandaging' the Stomach: Liquid medications such as Antepsin ease nausea by forming a bandage layer over an inflamed stomach lining.
• Centrally acting anti-sickness medication: Maropitant, which usually goes by the brand name Cerenia, acts on the brain to switch off feelings of nausea.

Correcting High Blood Pressure

A probable consequence of renal failure is high blood pressure. This can lead to dizziness or a stroke. It is not always appropriate to give an end stage cat medication to reduce blood pressure, but should your vet decide it is safe for that individual cat, they may prescribe amlodipine.

Addressing Anemia

Severe anemia leads to weakness and a poor quality of life. Some veterinary referral centers use injections of erythropoietin to stimulate increased production of red blood cells. However, the American Journal of Veterinary Research suggests this treatment is problematic as many cats become sensitized to the erythropoietin and can develop life-threatening allergic reactions to it.

Correcting Secondary Problems

Renal disease may cause problems such as infection or low blood potassium levels. As cat expert Dr. Sarah Caney writes in In Practice, correcting secondary problems is important.

• Low Blood Potassium Levels: Low potassium causes extreme muscle weakness, sometimes so severe the cat cannot hold their head up. Correcting this with a potassium supplement may be all that's needed to make a difference.
• Urinary Infections: Weak urine allows bacteria to grow, which can make the cat feel unwell. Culturing the urine to determine an appropriate antibiotic can improve quality of life.

Nursing the Cat in End-Stage Kidney Failure

Nursing is an essential part of caring for a seriously ill cat. These tips can help make your cat more comfortable.

• You should keep the cat indoors for their own protection.
• Bed the cat down on a comfortable padded surface, such as Vetbed or a puppy pad on top of blankets.
• Check regularly in case they have soiled and are lying in urine. If they are not moving around, encourage them to change position when awake to reduce the risk of bedsores.
• They may feel the cold easily, so ensure the room is warm or provide a heat mat.
• The cat will not want to walk far so place a litter box, food, and water within easy reach.
• Most sick cats feel better for a gentle brush and having their eyes, nose, and mouth wiped clean with damp cotton wool.
• Let them rest but also provide quiet companionship and fuss when they are awake.

When to Euthanize Cats With End-Stage Kidney Disease

Sadly, leaving a cat to die naturally may cause suffering. Those high toxin levels often lead to seizures, and their last few days are likely to be unpleasant. Instead, before this happens, it is kinder to ease their distress by making the humane decision to say goodbye.

Making the ultimate decision is less difficult if you have planned ahead and written down at what stage you consider it unfair to the cat to continue. To aid decision making, it is helpful to think of your cat in their prime and what you would consider an unacceptable quality of life back then.

For example, if your cat was a greedy eater, then a lack of appetite is a sure sign they are not themselves. Weigh factors such as:

• Dignity: Do they soil themselves?
• Lack of pain or discomfort: Are they vomiting regularly? Do they appear in pain?
• Playfulness: Do they now hide away?

These intangible factors often tell you a lot about how sick the cat has become.

Helping Your Cat With Kidney Disease

You love your cat, and it breaks your heart to see them so sick. By all means, do everything possible to comfort them, but know sometimes it is kinder to say goodbye than battle on. Euthanasia is hard for an owner, but know you are putting the cat's best interests first and preventing suffering.

Ultimately, saying goodbye is a brave decision made from a sense of self-sacrifice. It is not what you want, but what the cat needs, that is of paramount importance in the end.