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An Urban Experience
the renal diet was 615 days compared with 252 days in dogs consuming the maintenance diet. Furthermore, the risk of death irrespective of cause was reduced by 66% and the risk of death from renal causes was reduced
by 69%. Median survival time for dogs consuming the renal diet was 594 days compared with 198 days for dogs consuming the maintenance diet. In the feline trial, cats in IRIS CKD stage 2 and 3 were evaluated.(6) The risks of uremic crises and renal deaths were significantly reduced. Among the cats fed the renal diet, there were no uremic crises or renal deaths and only three deaths from non-renal causes over the 2 year study period. In contrast, among the cats consuming the maintenance diet, 6 developed uremic crises, 5 died of renal causes, and 5 died of non-renal causes. In another study of cats with CKD, feeding a renal diet was associated with a significantly longer survival with a median survival time of 633 days for cats fed the renal diet versus 264 days for cats fed the maintenance diet.(8)
RECOMMENDATIONS
There are no clear cut recommendations concerning dietary protein with CKD; however, some recommendations can be made. Limiting dietary
protein intake may help ameliorate clinical signs in patients. Although currently available evidence fails to support a recommendation for or against limiting dietary protein intake alone in non-uremic patients, with CKD, there are potential benefits assuming that patients maintain adequate caloric intake, body condition, and muscle condition. Patients may be more likely to accept a new renal diet if offered before uremia develops.(9) Although not discussed, dietary phosphorous restriction has been shown by itself to slow progression of CKD and it is difficult to achieve this degree of phosphorous restriction using typical ingredients without limiting dietary protein.(10) But it is not impossible. In determining
how much protein to recommend for dogs and cats with CKD, patients should be monitored for signs
of protein malnutrition and nutritional management adjusted to maintain optimal body condition and muscle condition minimally. For cats with CKD, the minimum dietary protein requirement was 20% of calories(11), which equates to 24% protein (on a dry matter basis; DMB). Similar studies have not been reported in
dogs. The Association of American Feed Control Officials recommends a minimum of 18% (DMB) for dogs and 26% (DMB) for cats. Recommendations for dogs with CKD is 14-20% (DMB) and for cats with CKD it is 28-35% (DMB). It is emphasized that less total dietary protein can be fed if high biologic value protein are fed.
Uremic gastrointestinal complications may be present in patients with CKD. These may be overt (e.g. vomiting, anorexia), but may be more covert with only hyporexia being present. Patients with CKD may benefit from anti-emetics, ant-acids, and/or gastroprotectant
pharmacologic therapy. Hypokalemia, which occurs more frequently in cats with CKD than in dogs, is not only associated with muscle weakness but hyporexia to anorexia. If necessary, nutritional therapy can be facilitated through use of feeding tubes.
In patients with CKD that experience sacropenia,
a thorough physical examination and biochemical evaluation should be undertaken. Metabolic acidosis does not occur until late in progression of CKD in cats; however, if present it induces protein metabolism and loss of lean body mass. In patients with sacropenia, an attempt should be made to increase dietary protein while monitoring response. If azotemia or acidosis worsens
or if electrolyte and mineral imbalances occur, then the nutritional plan should be re-evaluated and adjusted.
There are several novel treatments for CKD. In pre- dialytic human patients with CKD, feeding a low protein diet supplemented with ketoanalogues of essential amino acids (keto-diet) proved effective in ameliorating metabolic disturbances of advanced CKD and delaying the initiation of dialysis without deleterious effects on nutritional status. Several recent studies report that the keto-diet could also slow down the rate of decline in renal function, with better outcomes after the initiation
of dialysis. Enteric dialysis using an oral sorbent may also permit feeding of higher protein diets. A probiotic formula is currently available for use in dogs and cats with CKD and is marketed as enteric dialysis although no data substantiate this claim. These treatments especially use of keto-acids represent unexplored territory in the treatment of CKD in pet dogs and cats.
REFERENCES
1 Brown RG. Protein in dog foods. Can Vet J. 1989;30:528-31.
2 Parker VJ, Freeman LM. Association between Body Condition and Survival in Dogs with Acquired Chronic Kidney Disease. J Vet Intern Med. 2011;25(6):1306-11.
3 Adams LG, Polzin DJ, Osborne CA, O’Brien TD, Hostetter TH. Influence of dietary protein/calorie intake on renal morphology and function in cats with 5/6 nephrectomy. Lab Invest. 1994;70(3):347-57.
4 Finco DR, Brown SA, Brown CA, Crowell WA, Sunvold G, Cooper TL. Protein and calorie effects on progression of induced chronic renal failure in cats. Am J Vet Res. 1998;59(5):575-82.
5 Jacob F, Polzin DJ, Osborne CA, Allen TA, Kirk CA, Neaton JD, et al. Clinical evaluation of dietary modification for treatment of spontaneous chronic renal failure in dogs. J Am Vet Med Assoc. 2002;220(8):1163-70.
6 Ross SJ, Osborne CA, Kirk CA, Lowry SR, Koehler LA, Polzin DJ. Clinical evaluation of dietary modification for treatment of spontaneous chronic kidney disease in cats. J Am Vet Med Assoc. 2006;229(6):949-57.
7 Harte JG, Markwell PJ, Moraillon RM, Gettinby GG, Smith BH, Wills JM. Dietary management of naturally occurring chronic renal failure in cats. J Nutr. 1994;124(12 Suppl):2660S-2S.
8 Elliott J, Rawlings JM, Markwell PJ, Barber PJ. Survival of cats with naturally occurring chronic renal failure: effect of dietary management. J Small Anim Pract. 2000;41(6):235-42.
9 Polzin DJ. Chronic kidney disease. In: Bartges J, Polzin DJ, editors. Nephrology and Urology of Small Animals. Ames: Wiley-Blackwell; 2011. p. 433-71.
10Burkholder WJ. Dietary considerations for dogs and cats with renal disease. J Am Vet Med Assoc. 2000;216(11):1730-4.
11Kirk CA, Hickman MA. Dietary protein requirements of cats with spontaneous renal disease. J Vet Intern Med. 2000;14:351.
 42ND WORLD SMALL ANIMAL VETERINARY ASSOCIATION CONGRESS AND FECAVA 23RD EUROCONGRESS
  




































































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