Peer Reviewed ACVN NUTRITION NOTES

NUTRITIONAL MANAGEMENT
OF CHRONIC KIDNEY
DISEASE IN CATS & DOGS
RACE-APPROVED Martha G. Cline, DVM, Diplomate ACVN
CE CREDIT Red Bank Veterinary Hospital, Tinton Falls, New Jersey
ARTICLE

The American College of Veterinary Nutrition (acvn.org) and Today’s Veterinary Practice are
delighted to bring you the Nutrition Notes column, which provides the highest quality, cutting
edge information on companion animal nutrition, provided by the ACVN’s foremost nutrition
specialists.
The primary objectives of the ACVN are to:
• Advance the specialty area of veterinary nutrition
• Increase the competence of those practicing in this field
• Establish requirements for certification in veterinary nutrition
• Encourage continuing education for both specialists and general practitioners
• Promote evidence-based research
• Enhance dissemination of the latest veterinary nutrition knowledge.
The ACVN achieves these objectives in many ways, including designating specialists in animal
nutrition, providing continuing education through several media, supporting veterinary nutrition
residency programs, and offering a wide array of resources related to veterinary nutrition, such
as this column.

Nutritional intervention is a cornerstone in

TABLE 1.
the treatment of patients with chronic kidney
Nutritional Assessment Checklist for
Turn to page 66 to disease (CKD). However, a complete nutritional
Patients with Chronic Kidney Disease
read this article’s assessment and staging of the patient’s kidney
learning objectives disease are indicated before any dietary Diet history Appetite
and accompanying recommendations are made (Table 1). Guidelines Current diet
continuing Evaluation of current protein
for complete nutritional assessment are available
intake
education quiz. through the World Small Animal Veterinary Treats/table foods
CE credit and Association.1 Foods for medication
RACE-approval The International Renal Interest Society (IRIS) administration
provided by recommends nutritional intervention in both cats Supplements
vetmedteam.com. and dogs at IRIS stage 2, but in my opinion, a Laboratory Creatinine
diet change at IRIS stage 1 may be required once values Blood urea nitrogen
a complete assessment of the patient has been Phosphorus
performed. IRIS guidelines are available at: Potassium
• Staging of CKD: iris-kidney.com/guidelines/ Albumin
staging.aspx Bicarbonate (HCO3)
• Treatment recommendations for CKD: iris- Urine specific gravity
Urine protein-to-creatinine ratio
kidney.com/guidelines/recommendations.aspx.
Patient Body weight
EFFICACY OF THERAPEUTIC DIETS assessment Body condition score
Therapeutic kidney diets are used to improve a Muscle condition score
Systolic blood pressure
patient’s quality of life by controlling signs of

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 ACVN NUTRITION NOTES Peer Reviewed

uremia and increasing life span by altering disease spontaneous IRIS stage 2 or greater CKD were
progression. fed a therapeutic kidney diet (n = 21) or adult
Double-blinded, randomized, controlled clinical maintenance diet (n = 17) and evaluated for 24
trials have compared the effectiveness of diets months.4 Dogs in the therapeutic kidney diet
formulated for CKD with adult maintenance diets in group had a median time to uremic crisis of 615
dogs and cats. The studies evaluated characteristics of days (1.7 years) and a median time of 594 days
therapeutic kidney diets, such as reduced phosphorus, (1.6 years) before deaths occurred, while those in
protein, and sodium and the addition of omega-3 the maintenance diet group had median times to
fatty acids (eicosapentaenoic acid [EPA] and uremic crisis of 252 days (0.7 years) and 188 days
docosahexaenoic acid [DHA]) (Table 2). (0.5 years) before deaths occurred, respectively.
At the end of the study, only 33% of dogs in the
In the Literature: Cats therapeutic kidney diet group died of a renal-
In a study by Ross and colleagues, cats with related cause compared with 65% of dogs in the
spontaneous IRIS stage 2 and 3 CKD were fed maintenance group.
a therapeutic kidney diet (n = 22) or an adult
maintenance diet (n = 23) and evaluated for 24 KEY NUTRIENTS FOR CKD
months.2 In the therapeutic diet group, no cats Key nutrients that need to be considered when
experienced a uremic crisis and no renal-related feeding patients with CKD include:
deaths occurred, whereas, in the maintenance diet • Protein
group, 26% of cats had uremic crisis and 21.7% of • Phosphorus
cats died of renal-related causes. • Omega-3 fatty acids
In a study by Elliott and colleagues, client- • Sodium
owned cats with spontaneous stable CKD were • Potassium.
fed a therapeutic kidney diet (n = 29) or an Additional nutrient considerations include fat,
adult maintenance diet (n = 21).3 Those fed a acid–base balance, antioxidants, and fiber.
maintenance diet received one because they refused In the November/December 2015 issue of
a therapeutic kidney diet or their owners did not Today’s Veterinary Practice, the article—The
want to change their diet. Feeding a therapeutic Protein Paradigm: Assessing Dietary Protein
kidney diet helped reduce plasma phosphate, in Health & Disease—provided an in-depth
blood urea nitrogen, and parathyroid hormone discussion of the implications of dietary protein
concentrations. The median survival time for cats in both healthy dogs and cats and those affected
receiving a therapeutic kidney diet was 633 days by obesity, urinary tract and kidney disease, food
(1.7 years) compared with 264 days (0.7 years) for allergies, and liver disease.
cats receiving a maintenance diet.
DIETARY PROTEIN
In the Literature: Dogs Protein restricted diets are commonly recommended
In a study by Jacob and colleagues, dogs with for the management of CKD in both cats and dogs.

TABLE 2.
Ranges of Dietary Components in Typical Therapeutic Renal Diets

THERAPEUTIC AAFCO THERAPEUTIC AAFCO

COMPONENT
RENAL DIETS MINIMUM* RENAL DIETS MINIMUM*

DOGS CATS

Protein (g/1000 kcal) 25–55 45 58–82 65

Phosphorus (g/1000 kcal) 0.4–1.2 1 0.8–1.35 1.25

Sodium (g/1000 kcal) 0.4–1.2 0.2 0.5–1 0.5

Potassium (g/1000 kcal) 0.8–2.1 1.5 1.4–2.6 1.5

EPA + DHA (g/1000 kcal) 32–1200 n/a 31–1910 n/a

* 2016 AAFCO adult dog maintenance minimum

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Peer Reviewed ACVN NUTRITION NOTES

TABLE 3.
Protein Requirements & Levels in Adult Cats & Dogs
NRC
NRC MINIMUM AAFCO LOW MODERATE HIGH
RECOMMENDED
REQUIREMENT MINIMUM PROTEIN PROTEIN PROTEIN
ALLOWANCE

Cats 40 50 65 < 80 80–120 > 120

Dogs 20 25 45 < 60 60–90 > 90
Notes
• Values in table are expressed as g/1000 kcal.
• Low, moderate, and high descriptors are a general comparison among commercial pet foods.

The primary reasons a protein restricted diet is quirement of adult cats based on the maintenance
recommended include reduction in nitrogenous of lean body mass.9
wastes and glomerular proteinuria. • Nitrogen balance was achieved with a diet
Nitrogenous wastes can contribute to: containing 56 g protein/1000 kcal. Nitrogen
• Clinical signs associated with azotemia and balance can be achieved on a low protein diet;
uremia however, this may be at the expense of lean body
• Polyuria and polydipsia; reduction in mass through the utilization of endogenous
nitrogenous wastes can improve polyuria and proteins. A diet containing 95 g protein/1000
polydipsia by reducing the solute load to the kcal was needed to maintain lean body mass.
kidney • On the basis of regression analysis, the
• Anemia through gastrointestinal ulceration and researchers suggested that, although 1.5 g
blood loss. Nitrogenous wastes may also shorten protein/kg body weight is required for nitrogen
the life span of red blood cells5 and cause platelet balance in adult cats, 5.2 g/kg is recommended
dysfunction6 as demonstrated in the human to maintain lean body mass.
literature. This study was performed in healthy adult male
However, the necessity of protein restriction cats, and additional studies are needed to evaluate
for both dogs and cats has remained a point of the protein requirement to maintain lean body
controversy and discussion for many years. This mass in dogs and cats with CKD.
includes the timing at which protein restriction
should occur and the provision of sufficient dietary Protein Restriction
protein to avoid protein malnutrition and loss of The amount of protein needed to achieve restriction
lean body mass. The role of protein restriction in the is not clearly defined. Categories for low, moderate,
progression of CKD in both cats and dogs is unclear. and high protein diets are provided10 (Table 3)
but, for some animals, protein restriction may be
Protein Requirements relative to their current intake based on an accurate
Protein requirements for adult dogs and cats have diet history (see Examples of Protein Restriction
been established through use of nitrogen balance Relative to Current Intake). In addition,
studies, wherein nitrogen intake is equivalent to protein restriction does not equate to feeding
nitrogen loss. The National Research Council below the established NRC minimum nutritional
(NRC) Ad Hoc Committee on Dog and Cat requirements.
Nutrition has established minimum requirements At this time, typical therapeutic diets labeled
and recommended allowances in adult cats and for various stages of CKD range from 25 to 55
dogs based on these types of studies (Table 3).7 g/1000 kcal for dogs and 58 to 82 g/1000 kcal for
The Association of American Feed Control cats, with allowance for some tailoring of protein
Officials (AAFCO) also recommends a minimum content to a patient’s needs.
crude protein content for adult dogs and cats,
taking into account not only recommendations Proteinuria in Dogs
from the NRC for healthy adults but also changes In dogs with proteinuria secondary to glomerular
in protein digestibility that occur during the disease, the American College of Veterinary
processing of pet food (Table 3).8 Internal Medicine Consensus Statement
A more recent study evaluated the protein re- recommends reduced protein intake.11

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 ACVN NUTRITION NOTES Peer Reviewed

In dogs with hereditary nephritis, feeding a

protein restricted therapeutic renal diet reduced Examples of Protein Restriction Relative to Current Intake
structural damage to glomeruli by decreasing Two 10-kg spayed female mixed breed dogs with glomerular proteinuria
glomerular basement membrane splitting and and IRIS stage 1 CKD are consuming approximately 550 kcal/day
delaying the progression of renal failure.12 In both (calculation, 1.4 × (70 × kg body weight0.75)). Diet recommendations are
humans and rats, protein causes direct injury to the listed in Table 4.
tubulointerstitium through release of vasoactive
Dog A
and inflammatory substances that trigger renal
Diet history:
scarring and loss of function.13 • Adult maintenance dry food (100 g protein/1000 kcal); consuming
Additional studies have shown that dogs with approximately 500 kcal/day for a total of 50 g protein/day
spontaneous CKD and urine protein-to-creatinine • ¼ cup boiled, chopped, boneless, skinless chicken breast; consuming
ratios (UPCs) of 1 or greater are at increased approximately 53 kcal and 10 g protein/day
risk for uremic crisis and death compared with • No other treats or table foods provided
dogs that have UPCs less than 1.14 In dogs with • Total protein intake approximately 60 g protein/day or 109 g
protein/1000 kcal
inherited glomerulonephropathy, proteinuria was
reduced significantly when they were switched Dog B
from a diet containing 72 g protein/1000 kcal to Diet history:
one containing 33 g protein/1000 kcal, but this • Adult maintenance dry food (60 g protein/1000 kcal); consuming
finding was not evaluated in relation to patient approximately 525 kcal/day for a total of 31.5 g protein/day
morbidity and mortality.15 • One commercial dog treat (20 g protein/1000 kcal); consuming
A reduction in dietary protein intake by 25% to approximately 25 kcal/treat and 0.5 g protein/day
• No other treats or table food provided
50%, based on severity of proteinuria, azotemia,
• Total protein intake approximately 32 g protein/day or 58 g
and clinical signs, has been recommended.16
protein/1000 kcal

Proteinuria in Cats TABLE 4.

Proteinuria is inversely associated with survival in Dietary Recommendations for Protein Restriction
azotemic cats and significantly associated with the
PROTEIN
development of azotemia in nonazotemic cats.17,18 DOG DIETARY NEEDS RECOMMENDED DIET
REDUCTION
Studies investigating the role of reduced protein
Dog A 25%–50% Diet containing • Commercial adult
diets in cats are limited to those with confounding
reduction approximately maintenance dry
dietary variables, such as phosphorus restriction. 54–82 g food (containing 60 g
As a result, the independent influence of protein protein/1000 kcal protein/1000 kcal)
on disease progression in these patients is not well • Discontinuation of
known. chicken breast
Dog B 25%–50% Diet containing • Therapeutic renal
Later Stage CKD reduction approximately diet (containing 39 g
In both dogs and cats with IRIS stages 3 and 4 29–44 g protein/1000 kcal)
CKD, reduced protein intake may help reduce protein/1000 kcal • One current
accumulation of nitrogenous wastes from protein commercial dog
treat/day
metabolism that contribute to azotemia and
uremia. High protein intake may exacerbate
uremia, contributing to the morbidity associated Cachexia
with CKD.
Cachexia—loss of lean body mass—is common
Studies in both dogs and cats with CKD have
in patients with CKD and may alter strength,
demonstrated that modifying protein intake
immune function, wound healing, and overall
reduces blood urea nitrogen.2,3 While urea is not a
major uremic toxin in cats and dogs, it is a marker survival.19 Although the overall prevalence of renal
for nitrogenous wastes that contribute to uremia. cachexia is unknown in dogs and cats, a recent
Additionally, hyporexia, which occurs commonly study found that underweight dogs—those with a
with late stage CKD and/or suboptimal protein body condition score (BCS) of 1 to 3 out of 9—
intake, can increase the production of uremic had reduced survival compared with dogs with a
toxins through endogenous protein catabolism. BCS of 4 or greater.20

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Peer Reviewed ACVN NUTRITION NOTES

Prevention of cachexia and protein malnutrition In the Literature

are the primary reasons clinicians debate protein In a study by Finco and colleagues, 24 dogs with
restriction. Each patient should be assessed induced kidney disease were divided into 2 groups
individually for signs of cachexia, and protein intake and fed one of the following diets21:
should be balanced in light of proteinuria and uremia. • Phosphorus restricted diet (0.44% dry matter
basis (DMB); estimated 1.1 g/1000 kcal based
Further Defining Protein’s Role on a 4000 kcal/kg DMB)
The role of protein restriction in the progression of • High phosphorus diet (1.44% DMB; estimated
CKD in dogs and cats is not clear at this time and 3.6 g/1000 kcal).
requires further investigation. Over a 24-month period, dogs receiving the
• In studies demonstrating improved survival high phosphorus diet had significantly lower
times in dogs and cats receiving a therapeutic glomerular filtration rates and decreased survival
kidney diet compared with those eating a compared with those in the phosphorus restricted
maintenance diet, the benefit of protein group (survival, 33% versus 75%).
restriction cannot be separated from the In a study by Ross and colleagues, cats with
benefits of phosphorus restriction and other induced kidney disease were also divided into 2
characteristics of therapeutic kidney diets. groups and fed either a normal or low phosphorus
• In the veterinary literature, no definitive conclusion diet.22 Those that received a:
• Normal phosphorus diet (1.56% DMB;
has been reached regarding which diet is more
estimated 3.9 g/1000 kcal based on a 4000 kcal/
beneficial for dogs and cats with CKD: a diet with
kg DMB) had evidence of renal mineralization,
unrestricted protein but the remaining features
fibrosis, and mononuclear cell infiltrates
of therapeutic renal diets or a protein restricted
• Low phosphorus diet (0.24% DMB; estimated
therapeutic renal diet. This is likely dependent on
0.6 g/1000 kcal) had mild to no histologic
the IRIS stage and substage of disease.
changes.
DIETARY PHOSPHORUS
IRIS Recommendations
Phosphorus retention and subsequent hyperphos-
IRIS recommends maintaining plasma phosphate
phatemia are common in patients with CKD due
concentrations:
to decreased glomerular filtration. This results in
• Between 2.7 and 4.6 mg/dL (0.9–1.5 mmol/L)
renal secondary hyperparathyroidism and calcitriol
for patients with IRIS stage 2 CKD
deficiency, and can lead to soft tissue mineraliza-
• Less than 5 mg/dL (1.6 mmol/L) and less than
tion and fibrous osteodystrophy. 6 mg/dL (1.9 mmol/L) for patients with IRIS
stages 3 and 4 CKD, respectively.
Phosphorus Restriction If hyperphosphatemia persists despite dietary
Phosphorus restriction, independent of other phosphorus restriction, then an enteric phosphate
nutritional factors, delays progression of CKD; binder, such as aluminum hydroxide, is recom-
thus, it is a vitally important nutrient, if not mended with each meal. Plasma phosphate concen-
the most important, with regard to nutrition trations should be monitored every 2 to 4 weeks
for patients with renal disease. Due to the high until the target concentration is achieved.
phosphorus content of many meat-based proteins,
reducing protein content also helps reduce the total OMEGA-3 FATTY ACIDS
phosphorus content of a diet. Supplementation with polyunsaturated omega-3 fatty
Maintenance diets often contain added acids (EPA and DHA) exerts renoprotective effects.
phosphorus beyond that found in protein because,
in healthy animals, phosphorus deficiency is In the Literature
more concerning than excess phosphorus. While Dogs with experimentally induced renal disease
maintenance diets generally contain greater than fed a diet supplemented with a high dose of
1.5 g/1000 kcal of phosphorus, the phosphorus fish oil had reduced proteinuria, creatinine, and
content of typical therapeutic diets labeled for histopathologic lesions (decreased mesangial
various stages of CKD ranges from 0.4 to 1.2 matrix expansion, glomerulosclerosis, and renal
g/1000 kcal and 0.8 to 1.35 g/1000 kcal for dogs interstitial cellular infiltrates) compared with
and cats, respectively. those fed diets supplemented with safflower

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 ACVN NUTRITION NOTES Peer Reviewed

oil or beef tallow.23 All diets with supplemental further studies are needed.
fat had an overall content of 16.8% fat on a The sodium content of typical therapeutic diets
DMB (approximately 42 g/1000 kcal assuming labeled for various stages of CKD ranges from 0.4
the diet contained 4000 kcal/kg on a DMB in to 1.2 g/1000 kcal for dogs and 0.5 to 1 g/1000
which the base diet contained 1.8% fat DMB, or kcal for cats.
approximately 4.5 g/1000 kcal).
Fewer data are available in cats, although DIETARY POTASSIUM
a retrospective study reported that cats on a Hypokalemia in Cats
therapeutic kidney diet with a higher concentration Hypokalemia is common in cats with CKD,
of EPA had longer survival times compared with and diets formulated for CKD may provide
cats receiving other therapeutic kidney diets.24 supplemental potassium beyond that added to
maintenance diets. The typical potassium content
Feeding Recommendations of therapeutic kidney diets for cats ranges from 1.4
A standard dosage of 40 mg/kg EPA plus 25 mg/ to 2.6 g/1000 kcal.
kg DHA Q 24 H is recommended for both dogs Maintaining the plasma potassium concentration
and cats with CKD, which is approximately 1.16 in the middle or upper half of the laboratory
to 1.18 g of EPA plus DHA/1000 kcal of diet reference range is recommended. Oral
for a cat consuming 1.2× and a dog consuming supplementation with potassium gluconate
1.4× its resting energy requirement (RER) for (2 mEq/kg PO Q 12 H) or potassium citrate
adult maintenance. Recently, a specific dose of 140 (75 mg/kg PO Q 12 H) is recommended if
mg EPA plus DHA/(kg body weight)0.75 or 790 persistent hypokalemia is noted despite feeding an
mg EPA plus DHA/10 kg body weight has been appropriate therapeutic diet.
recommended in dogs with CKD.25
Companies often add omega-3 fatty acids, Hyperkalemia in Dogs
including EPA, DHA, and alpha-linolenic acid, to Although hyperkalemia is typically associated with
therapeutic kidney diets. However, alpha-linolenic acute kidney failure, it may be a complication in some
acid is insufficiently converted to EPA and DHA dogs with CKD. Hyperkalemia has been corrected
in both dogs and cats. Therefore, if additional in dogs with CKD by feeding home-prepared
supplementation is considered and EPA and DHA potassium reduced diets (0.91 ± 0.14 g/1000 kcal).29
levels on a g/1000 kcal basis are not available, Therapeutic kidney diets for dogs contain 0.8
contacting the manufacturer is recommended. to 2.1 g/1000 kcal; therefore, some (although
limited) commercial therapeutic kidney diets
DIETARY SODIUM provide potassium within a range reported to
Reducing sodium intake may be beneficial in correct hyperkalemia in dogs. Consultation with a
patients with CKD due to sodium retention and board-certified veterinary nutritionist for home-
the potential for systemic arterial hypertension. prepared diet formulation should be considered if
At this time, no evidence suggests that hyperkalemia persists in a dog with CKD.
decreasing dietary sodium reduces arterial blood
pressure in cats and dogs. Recent studies in healthy OTHER DIETARY COMPONENTS
aged cats without CKD did not demonstrate Therapeutic kidney diets also feature the following
an effect of a high sodium diet (3.1 g/1000 characteristics:
kcal) compared with a lower sodium diet (1 • Calorie dense and moderate to high levels
g/1000 kcal) on renal function or arterial blood of dietary fat; these characteristics promote
pressure.26,27 However, these studies have not been increased caloric intake in animals that may
performed in cats with CKD. be prone to hyporexia and help maintain
Increased plasma aldosterone concentration palatability when protein is reduced
was noted in dogs with asymptomatic chronic • Supplementation with alkalinizing agents, such
valvular disease that were fed a diet containing as potassium citrate, to help correct metabolic
0.32 g sodium/1000 kcal fed for 4 weeks.28 Diets acidosis, which can worsen hypokalemia
significantly reduced in sodium may activate the (especially in cats)
renin-angiotensin-aldosterone system, which could • Increased levels of antioxidants, such as vitamins
be detrimental to patients with CKD, although C and E, to reduce renal oxidative stress

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 Peer Reviewed ACVN NUTRITION NOTES

Feeding Tubes
Role of Body Condition in Patients with CKD Feeding tubes can be useful, especially with
Underweight dogs (BCS, 1 to 3/9) with IRIS stages 2 to 4 CKD had patients in uremic crisis. Liquid enteral
significantly shorter survival times compared with dogs of moderate body formulations within the recommended nutrient
weight (BCS, 4 to 6/9) and overweight dogs (BCS, 7 to 9/9); survival did criteria are advised for nasoesophageal or
not differ between moderate weight and overweight dogs.16 nasogastric feeding tubes. When esophagostomy
• Underweight dogs and cats should be fed to gain weight or, if or gastrostomy feeding tubes are in place, a slurry
warranted, should receive assisted feeding to facilitate intake of
of a canned therapeutic diet is recommended.
calories.
To improve the caloric density of a slurry
• Dogs and cats with ideal body weight should be fed to maintain their
current body weight. Feeding amounts should be adjusted if body and decrease the volume of slurry administered,
weight decreases or muscle condition score changes. use of a liquid enteral diet rather than water is
• Overweight/obese dogs and cats must be assessed on an individual recommended to create a slurry with the selected
basis. canned diet. Ideally, the liquid diet should be
Overweight or obese dogs and cats may have more muscle mass to phosphorus restricted. Most liquid diets designed
protect against catabolic disease processes, such as CKD, although for over-the-counter use in humans and in
further research is needed to explore this hypothesis. Generally, use of convalescent veterinary patients contain less than
a therapeutic kidney diet takes precedence in dogs and cats with later 1.5 g phosphorus/1000 kcal.
stage CKD. In obese dogs and cats with early stage CKD (IRIS stage 1
Water needs and medications can also be
± 2), a weight loss plan may be considered after a complete nutritional
supplied through the feeding tube.
assessment and only if close monitoring is available.
If progression of CKD is noted, active weight loss should be
suspended and appropriate diet modifications should occur until further Home-Prepared Diets
evaluation. Consultation with a board-certified veterinary nutritionist is A home-prepared diet may be useful in patients
recommended for obese patients with CKD. with poor or selective appetites. Referral to a board-
certified veterinary nutritionist is recommended
for formulation. Evaluation of home-prepared
• Added soluble fiber to promote colonic bacterial
diets from books and websites has revealed
growth and utilization of nitrogen and urea;
many inadequacies; therefore, these diets are not
soluble fiber may also be beneficial in cats with
recommended.30 These inadequacies include:
constipation, a common complication in cats • Lack of specificity for ingredients and
with CKD. supplements
• No specification for type or severity of disease
FEEDING A PATIENT WITH CKD • Inadequate protein, or deficiency in at least one
Therapeutic Diets amino acid for 76.9% of recipes for dogs and
Several therapeutic kidney diets in a variety of 42.9% of recipes for cats
forms, flavors, and textures are available for both • Mineral inadequacies, including calcium
cats and dogs. Introducing a patient to a therapeutic deficiency (56.4% of canine and 25% of feline
kidney diet is recommended before signs of uremia recipes).
occur, although this is not always possible. Before referral, updated IRIS staging, including
Samples of various therapeutic diets should systolic blood pressure and UPC, is recommended.
be sent home with patients to establish their
preferences after diagnosis. Use caution when IN SUMMARY
introducing a therapeutic kidney diet to a Nutritional intervention in a cat or dog with CKD
hospitalized patient because this may lead to can greatly affect morbidity and mortality. Diet
aversion to a diet suggested for long-term feeding. selection should be based on a complete nutritional
assessment of the patient, including staging the
patient’s CKD. Supplementation with the omega-3
MARTHA G. CLINE fatty acids EPA and DHA is recommended if the diet
Martha G. Cline, DVM, Diplomate ACVN, practices small animal does not provide those nutrients. Patients with a poor
veterinary clinical nutrition at Red Bank Veterinary Hospital in Tinton Falls,
or selective appetite may benefit from assisted feeding
New Jersey. She received her DVM from University of Tennessee and
completed a small animal rotating internship at Oradell Animal Hospital
or consultation with a board-certified veterinary
in Paramus, New Jersey, before returning to University of Tennessee to nutritionist for a home-prepared diet formulation. A
complete her small animal clinical nutrition residency. directory of board-certified veterinary nutritionists is
available at acvn.org/directory.

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 ACVN NUTRITION NOTES Peer Reviewed

AAFCO = Association of American Feed Control Officials; 24. Plantinga EA, Everts H, Kastelein AMC, et al.
Retrospective study of the survival of cats with
BCS = body condition score; CKD = chronic kidney
acquired chronic renal insufficiency offered
disease; DHA = docosahexaenoic acid; DMB = dry matter different commercial diets. Vet Rec 2005;
basis; EPA = eicosapentaenoic acid; IRIS = International 157(7):185-187.
Renal Interest Society; NRC = National Research Council; 25. Bauer JE. Therapeutic use of fish oils in
companion animals. JAVMA 2011; 239(11):1441-
RER = resting energy requirement; UPC = urine protein- 1451.
to-creatinine ratio 26. Chetboul V, Reynolds BS, Trehiou-Sechi E, et al.
Cardiovascular effects of dietary salt intake in aged
healthy cats: A 2-year prospective randomized,
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March/April 65
 Peer Reviewed ACVN NUTRITION NOTES

CE Test: Nutritional Management of Chronic

Kidney Disease in Cats & Dogs
This article is RACE-approved for 1 hour of continuing education credit. To receive credit,
take the approved test online at VetMedTeam.com.

Learning Objective
After reading this article, readers should be able to identify the role of key nutritional factors for
chronic kidney disease (CKD) patients as well as prepare an appropriate nutritional plan for cats
and dogs with CKD based on a complete nutritional assessment.

1. Based on International Renal Interest delay the progression of CKD in both dogs
Society (IRIS) guidelines, when is nutritional and cats?
intervention for both dogs and cats a. Protein
recommended? b. Sodium
a. IRIS stage 1 c. Potassium
b. IRIS stage 2 d. Phosphorus
c. IRIS stage 3
d. IRIS stage 4 7. The following uncommon electrolyte distur-
bance in dogs with CKD has been corrected
2. Which omega-3 fatty acid can be supple- by feeding a home-prepared diet formulated
mented to pet food, but is inefficiently by a board-certified veterinary nutritionist.
converted to eicosapentaenoic acid (EPA) a. Hyperkalemia
and docosahexaenoic acid (DHA) in dogs b. Hypokalemia
and cats? c. Hypophosphatemia
a. Linoleic acid d. Hypernatremia
b. Docosapentaenoic acid (DPA)
c. Alpha-linolenic acid 8. The protein requirement of dogs and
d. Arachidonic acid cats is typically evaluated through the
use of nitrogen balance studies. What is
3. What type of studies have been performed another method for evaluating the protein
in both cats and dogs to provide evidence- requirement?
based medicine that therapeutic kidney a. Urine albumin-to-creatinine ratio
diets improve a patient’s quality of life and b. Serial evaluation of serum albumin and
increase life span? creatinine concentration
a. Prospective cohort studies c. Maintenance of lean body mass
b. Double-blinded, randomized, controlled d. Muscle condition score
clinical trials
c. Case-control studies 9. Which of the following is a concern
d. Adaptive clinical trials regarding feeding a protein restricted diet
to a patient with CKD?
4. Improvement of anemia may be associated a. Feeding below the National Research
with restriction of which of the following Council’s minimum nutritional require-
nutrients? ments for protein
a. Protein b. Production of excess urea and creatinine
b. Phosphorus c. Failure to achieve caloric needs
c. Potassium d. Endogenous protein catabolism and loss of
Note: d. Sodium lean body mass

Questions and 5. Urea is a major uremic toxin in the dog and 10. Reducing protein intake by 25% to 50%
answers online may cat. of current intake based on an accurate
differ from those at a. True diet history in a patient with moderate
right; tests are valid b. False glomerular proteinuria and mild azotemia is
for 2 years from date a reasonable recommendation.
of approval. 6. Restriction of which one of the following a. True
nutrients has been independently shown to b. False

66 TODAY’S VETERINARY PRACTICE | March/April 2016 | tvpjournal.com