Appetite: the real battle

Why won't my cat with kidney disease eat?

This is the part that will take up most of your emotional energy, and it's where people feel most like they're losing. So start here: she isn't being stubborn, and she hasn't given up.

Eating makes her feel worse. Uremic waste products dull her appetite, high phosphorus makes her feel unwell, and a stomach producing too much acid turns food into something that hurts. Add the mild dehydration that comes with damaged kidneys and you have a cat who feels queasy most of the time.

Which means the answer usually isn't a better flavor. It's treating the reason food stopped being appealing.

Work through it in this order

Chasing food before you've dealt with the medical reasons is how people burn through forty cans and two weeks. There's an order to this.

Work through it in this order

One at a time. Mark each one off as you and your vet deal with it, and the next step opens.

1. 1 Nausea

   An antiemetic, given thirty to sixty minutes before food. This alone fixes a lot of cats, and most nauseated cats never vomit, so absence of vomiting is not evidence against it.

   Nausea and vomiting

2. 2 Stomach acid

   An acid reducer, if your vet agrees she needs one. Inexpensive, and it makes eating comfortable rather than sore.

   The three shelves of drugs

3. 3 Phosphorus

   High phosphorus is a direct cause of feeling awful. Diet, or a binder, or both.

   Phosphorus binders

4. 4 Hydration

   A dehydrated cat is a flat cat. Fluids under the skin often bring her appetite back within a day.

   Subcutaneous fluids

5. 5 Her mouth

   A painful tooth or an ulcer looks exactly like nausea. Rule it out before you accept it is not that. In a kidney cat I treat the pain rather than reach for a dental.

   Why I would not do a dental

6. 6 Then, and only then, appetite stimulants

   They make a comfortable cat hungry. They do not make a sick cat well. Mirtazapine or capromorelin, and the dosing rules matter.

   Every medication explained

What to actually try at the bowl

None of this is a trick, and none of it costs anything.

Warm it. A few seconds in the microwave, stirred through, until it's about body temperature. Never hot, and check it with a fingertip. Cats eat with their nose first, and food straight out of the refrigerator has almost no smell.

Serve it fresh and take it away. Twenty minutes, then the bowl goes. Food that's been sitting out for four hours has gone stale and sour to a cat, and leaving it down mostly teaches her that food smells wrong.

Use a wide, shallow dish. Flat and open, so her face and whiskers aren't down inside a bowl. It takes ten seconds to try and it helps more cats than you'd expect.

Move the bowl. Away from the litter box, away from the noisy appliance, away from the other cat. Somewhere she doesn't have to keep watch while she eats.

Change the texture, not just the flavor. Pate, chunks in gravy, shredded, minced. A cat who has given up on pate will sometimes eat shredded without hesitating. Texture is a bigger lever than flavor and people almost always reach for flavor first.

Toppers, used sparingly. A spoon of the water from a can of tuna or plain chicken in water, crumbled freeze-dried chicken, a little low-sodium broth. Read the label on anything made for people and check there's no onion or garlic in it, which rules out most baby food and most gravies.

One new thing at a time. This is the discipline that matters and the one everybody breaks. If you open six cans tonight and she refuses all six while she's feeling sick, you haven't learned anything, you've just burned six options.

The appetite stimulants, and how to use them safely

Two drugs do most of this work. Both are prescriptions, both are useful, and both get used in ways that cause trouble.

Mirtazapine. A tablet, usually a small dose every two to three days rather than daily in a cat with kidney disease, because her kidneys clear it more slowly. There's also Mirataz, an ointment you rub into the inside of her ear, which suits cats who fight tablets.

The ointment is where I want to be specific, because this is the mistake I see most:

• Measure the ribbon against the tube. Don't estimate it, and don't add extra because yesterday's dose didn't seem to do much.
• Wear a glove or a finger cot. It goes through your skin too, and you don't want a dose of it.
• Alternate ears each day, and wipe the previous spot clean.
• If she shakes her head and flings some off, that was still the dose. Don't top it up.
• Too much mirtazapine looks like agitation. Constant loud vocalizing, pacing, restlessness, wide pupils, fast breathing, sometimes tremors. If that's what you're seeing, wipe her ear clean with a damp cloth and call your vet.

Capromorelin, sold as Elura. A daily liquid by mouth, and the one drug in this area specifically approved for weight loss in cats with chronic kidney disease. It works. Some cats drool at it or find the taste unpleasant, and a few get mild vomiting in the first few days.

Neither of these treats nausea. Worth repeating, because it's the usual reason they seem not to work.

Mirataz, applied properly

Video coming. I'm filming these myself.

Weigh her, don't judge by the bowl

Appetite is a terrible thing to measure by feel. You'll remember the two good days and forget the four flat ones, or the reverse on a bad week.

Buy a cheap kitchen scale, sit her in a box or a carrier on top of it, and weigh her once a week on the same day. Write it down with the date. A quarter of a pound lost over a month tells you something no impression of her appetite ever will, and weight is the number I'd rather have at a recheck than almost anything else.

There's more on what's worth tracking at home on the monitoring page.

The notebook is the real subject of that picture. A wide shallow dish, a cheap scale, and somewhere to write the number down is the whole kit.

What about a feeding tube?

You'll come across this one, so here's where I stand on it.

A feeding tube, usually an esophagostomy tube running through the side of the neck into the esophagus, does solve the mechanical problem. Food, water and medication go down it in a couple of minutes and the nightly fight in the kitchen ends. That part is true and I'm not going to pretend otherwise.

The part that isn't discussed enough is what it takes to place one. It's general anesthesia. And anesthesia drops blood pressure, lower blood pressure means less blood moving through kidneys that are already short of it, and a cat with damaged kidneys can come out of an anesthetic a step worse and not come back up. So the price of the tube isn't the tube. It's most likely a permanent notch of kidney function, spent on an advanced cat.

Weigh that against what it buys. In a cat far enough along that she's stopped eating for good, my read is that it buys a little time rather than a lot, and it spends some of her good days on the anesthetic and the recovery to get there. I don't push them, and I wouldn't in my own cat.

If your vet has recommended one, that isn't a disagreement you need to referee. Ask two specific questions: what do they expect it to give her, in weeks rather than in principle, and how will they protect her blood pressure while she's under. If the honest answer to the first one is short, that tells you something.

And if she's reached the point where she needs to be fed rather than tempted, the real question underneath it usually isn't about tubes. It's the one on the quality of life page, and it's worth reading before you decide anything.

The part I most want you to hear

You aren't failing at this because your cat won't eat. A cat who won't eat is a medical problem having a conversation with you, and there's nearly always something concrete to be done about it.

Early on, push for the kidney diet, because lowering phosphorus genuinely buys her time. Further along, the brand on the can matters less and her eating at all matters more. If she's happy and eating something, I'm not going to spend her good days arguing with her about food.

There's more on the food itself, including how to transition without triggering a refusal, on the kidney diets page.