Nutrition!

The Key to Managing Chronic Renal Disease

Ed Carlson, CVT, VTS (Nutrition)
Ethos Veterinary Health and VetBloom
ecarlson@ethosvet.com

Chronic kidney disease (CKD) causes a progressive loss of renal function resulting in the
reduced ability to concentrate urine. As a result, phosphorus, urea, and other by-products of
protein metabolism are not excreted effectively. CKD is the most common type of kidney
disease in dogs and cats. It can occur at any age, but is more common in senior dogs and cats.
Clinical signs of chronic kidney disease include polyuria, polydipsia, depression, vomiting,
diarrhea, anorexia, weight loss, and dehydration.
An important function of the kidneys is the regulation of acid base balance. As renal function
declines, the kidneys ability to excrete hydrogen and reabsorb bicarbonate is reduced resulting
in metabolic acidosis. Metabolic acidosis may contribute to the progression of renal disease for
a variety of reasons such as increased catabolism of muscle protein and increased likelihood of
hypokalemia. Hypokalemia may cause muscle weakness, cervical ventroflexion, a stiff gait,
weight loss, and may contribute to polyuria. Potassium supplementation is indicated when
serum concentration is less the 4mEq/L. Oral potassium gluconate or potassium citrate are
generally used and muscle weakness often resolves within 5 days of beginning
supplementation.
The International Renal Interest Society (IRIS), an independent non-profit organization,
established an internationally recognized set of guidelines on the diagnosis and assessment of
renal disease in small animals (IRIS Staging of Chronic Kidney Disease (CKD)). The four stages
of the disease are based initially on serum creatinine concentrations and sub-staged based on
proteinuria and blood pressure. Patients in stage 1 have kidney damage without azotemia. In
stages 2-4 patients suffer from worsening stages of azotemia. When making a nutritional
recommendation for patients suffering from chronic renal disease, it is important to consider the
patients IRIS status; additional information may be found on at www.IRIS-kidney.com.
Monitoring the hydration status and addressing dehydration is one of the most important actions
that must be taken when managing patients with chronic kidney disease. Dehydration can result
in electrolyte imbalances as well as an increase in the concentration of urine that causes the
kidneys to work harder. Patients should have access to water at all times. As the disease
advances, patients may benefit from subcutaneous fluid administration, or if an esophageal
feeding tube has been placed, additional water may be administered via the tube.
Nutritional Management of CKD
The goals of nutritional management of chronic kidney disease are to reduce uremia, maintain
nitrogen balance by providing optimal protein nutrition, provide non-protein calories, normalize
serum phosphorus, and maintain electrolyte balance in order to slow or lessen clinical
symposiums of the disease. Therapeutic veterinary diets generally contain less protein,
phosphorus, and sodium with increased fat, omega-3, fatty acids, and buffering capacity. Feline
diets contain increased potassium in an effort to prevent hypokalemia. A therapeutic diet is
indicated when serum creatinine is ≥2 mg/dl. Feeding canned foods is preferred, if accepted by
the patient, because of their high moisture content. If the patient prefers a dry diet, adding water
may help to increase their water intake.
Excessive dietary protein should be avoided for dogs and cats with chronic kidney disease in
order to control clinical signs of uremia. However, overly restricting protein, especially in older
dogs and cats, when not necessary, may cause protein and amino acid deficiency. Increased fat
and carbohydrate content allows for increased energy density of reduced protein diets without
increasing the volume of food the patient must eat.
Restricting dietary phosphorous has been shown to help slow the progression of renal disease.
Several studies have shown feeding therapeutic veterinary diets increases survival rates and
have been associated with significantly reducing plasma phosphorus and PTH levels compared
to patients fed diets higher in phosphorus. As renal disease progresses it may become
impossible to keep phosphorus concentrations within the IRIS guidelines using diet alone. In
these cases, phosphate binders should be used in addition to the lowest phosphorus diet that is
appropriate for the patient.
High levels of sodium in the diets fed to patients with chronic kidney disease may cause sodium
retention with expansion of extracellular fluid volume and can cause hypertension, fluid
overload, and edema. However, excessively limiting dietary sodium may cause a negative
sodium balance resulting in reduced extracellular fluid volume, plasma volume, and glomerular
filtration rate (GFR). Hypertension is common in dogs and cats with chronic kidney disease,
however there is no evidence that reducing sodium intake reduces blood pressure in cats and
dogs with CKD.
Cats with chronic kidney disease are prone to potassium deficiency; however, this is not
common in dogs. Decreased potassium may be caused by anoxia, vomiting, and increased
urinary losses due to polyuria. Serum potassium should be monitored and supplemented when
necessary. For cats with hypokalemia, oral supplementation with potassium gluconate should
be considered if diet alone does not maintain serum potassium concentration above 4.0mEq/l
(Polzin, 2007). Oral administration is safest and is the preferred method unless a critical
emergency exists or if oral administration is impossible or contraindicated. Oral potassium
gluconate appears to be tolerated well by most patients. The dose is adjusted based on the
patient’s clinical signs and serum potassium levels, which initially should be checked every 2 to
4 days until stable and then every 2 to 4 weeks.
Feeding fermentable fiber in the diets of chronic kidney disease patients has been shown to
influence nitrogen excretions by shifting urea excretion away from the kidneys, where normally it
is excreted in the urine, to the large intestine for excretion via feces.
Omega-3 Fatty Acids, EPA and DHA, used in combination with antioxidants has been shown to
reduce renal oxidative damage in dogs, however, there are no documented studies in cats.
Studies in humans and rats have shown benefits when diet is supplemented with antioxidants
and may possibly help to slow the progression of kidney disease. A 2006 study by Yu et al.
found supplementing renal diets with antioxidants significantly reduced serum creatinine levels
in dogs. Yu and Paetau-Robinson also published a study in 2006 that showed similar results in
cats.

Key Nutritional Factors

Chronic Kidney Disease
All values listed are on a dry matter basis.
Dogs Cats
Protein 14 to 20% 28 to 35%
Phosphorous 0.2 to 0.5% 0.3 to 0.6%
Sodium ≤ 0.3% ≤ 0.4%
Chloride 1.5 x sodium level 1.5 x sodium level

Nutri&on! The Key to Managing Chronic Renal Disease

Ed Carlson, CVT, VTS (Nutri&on)
 Potassium* 0.4 to 0.8% 0.7 to 1.2%
Omega-3 fatty acids 0.4 to 2.5% 0.4 to 2.5%
Omega-6 to omega-3 fatty acid ratio 1:1 to 7:1 1:1 to 7:1
Antioxidants
Vitamin E ≥400 IU/kg ≥500 IU/kg
Vitamin C ≥100 mg/kg 100 to 200 mg / kg
* lower in hyperkalemic patients

The daily energy requirement (DER) for dogs with CKD is 1.1 to 1.6 times the patient’s resting
energy requirement (RER) and is 1.1 to 1.4 times for cats. Veterinary therapeutic diets have
been shown to slow the progression of the disease and are strongly recommended for patients
with chronic kidney disease. A gradual transition (dogs over 1 to 2 weeks or more, cats over 3 to
4 weeks or more) is recommended to potentially slow the change in decrease urinary sodium
levels that often accompany renal dysfunction. The author cannot stress enough the importance
of educating owners on the importance of feeding appropriate diets to these patients and the
need to transition gradually! Cats, in particular, can be resistant to diet changes. Some patients
may be less resistant to a diet change when transitioned at a slow rate. Some patients accept
new foods more easily if the new and old diets are offered in separate side-by-side dishes than
if the diets are combined in one dish. Some cats seem to be more accepting of a new diet if it is
offered in a flat dish rather than a bowl, even if they normally eat in a bowl. This may have to do
with their whiskers rubbing on the sides of the dish, something that does not happen when they
eat from a plate. Sometimes adding low sodium tuna juice or chicken broth to a renal diet to
encourage patients to eat the new food works. This may be gradually eliminated once they
become accustomed to the new food. Also, sometimes just adding additional water to the new
food will encourage the canine and feline patient to eat. Warming the food sometimes increases
palatability with some patients.
Veterinary therapeutic diets are strongly recommended for dogs and cats with stage 2 and
above chronic kidney disease and have been shown to slow the progression of the disease.
Some clinicians support transitioning stage 1 patients to a renal diet. There have not been
significate studies to support doing so however there is no evidence to indicate this would be
harmful. Anorexia is common especially in more advanced stages of chronic kidney disease. In
cases of severe anorexia, getting these patients to eat is of the utmost importance. If the patient
refuses to eat a veterinary therapeutic diet, another option might need to be considered. A
canned diet that meets the key nutritional factors listed above might encourage the patient to
begin eating. Carbohydrate and fat provide non-protein sources of energy; fat provides
approximately twice the energy per gram compared to carbohydrate. Therefore, diets high in fat
allow the patient to consume smaller amounts of food to maintain energy requirements.
Another, often better, option is the use of an esophageal feeding tube. E-tubes can extend a
patient’s life and improve not only the quality of life of the patient, but also the quality of life of
the owner. Veterinary therapeutic diets may be made into slurry and clients are able to easily
manage assisted feeding at home. Clients are also easily able to administer the multiple
medications that many chronic kidney disease patients have been prescribed via the feeding,
often more easily than by mouth. Additional water may be administered via the feeding tube that
can eliminate the need for subcutaneous fluids; not only is this easier for most clients, but is
also more easily used by the body.
Hospitalized CKD patients should have water available even when on IV fluids, unless they are
actively vomiting, are NPO prior to surgery, or have another medical reason that requires water

Nutri&on! The Key to Managing Chronic Renal Disease

Ed Carlson, CVT, VTS (Nutri&on)
be withheld. Watch these patients for signs of nausea; drooling and/or looking away from food
when offered, as these are two signs your patient may be nauseous. Bring this to the
veterinarian’s attention and request they prescribe anti-nausea medication such as
Metoclopramide or maropitant citrate. Do not leave food in the cage with a nauseous patient,
rather offer small amounts frequently and remove it after a few minutes if the patient shows no
interest in eating. Discuss the possibility of placing a feeding tube with the veterinarian. Anoxia
is very common in dogs and cats suffering from chronic kidney disease. Food, most
medications, and water can be administered via a feeding tube. Placement of a feeding tube
may help to extend the life of a patient with CKD and provide improved quality of life for the
patient and the owner.

Avoid introducing therapeutic renal diets to patients in the hospital as this can cause food
aversion. Wait until the patient is feeling better and ideally has been home from the hospital and
eating well for a few days before starting to transition to a therapeutic diet. Avoid force feeding,
especially nauseous patients as this may also cause a food aversion! Be a patient advocate,
discuss place a feeding tube with the veterinarian if possible rather than force feeding.

Nursing Care

Providing excellent nursing care and being a patient advocate are perhaps the most important
two roles of the veterinary technician!

Provide client education and support to owners of patients that are suffering from chronic kidney
disease. Avoid sending home a variety of therapeutic diets with clients in the hope that the
patient will “like” one. Diet options are limited for these patients; offering multiple choices can
cause a food aversion. Select the diet best suited for the patient and encourage the owner to be
patient, allowing their pet time to adjust to the new diet. Educate owners on the importance of
allowing their pet to have access to clean, fresh water at all times. Patients with CKD often drink
more; they may require a larger water bowl or multiple bowls to ensure they have water
available. Explain the importance of feeding a veterinary therapeutic renal diet and that it has
been shown to slow the progression of the disease. Most chronic kidney disease patients
become anorexic at some point as the disease progresses. Explain this to clients when their pet
is first diagnosed with CKD. Introduce them to the idea of a feeding tube being placed in the
future, explain the benefits and, if possible, offer to put them in touch with another client that
uses or has used a feeding tube (provided of course you have the clients’ permission to do so).
Share your favorite tricks for encouraging a patient to eat when they are not interested in food.

Uremic breath with or without excessive drooling is often an indication of oral ulcers which are
not uncommon in CKD patients especially in the later stages of the disease. Oral rinses
containing topical pain medications, designed for veterinary patients, are commercial available.
Monitor CKD patients for possible oral ulcers and bring your suspicions to the veterinarians’
attention and suggest they prescribe these products if appropriate.

In conclusion remember, patients don’t eat when they feel better, they feel better when they eat!
Be a nutritional advocate for your patients!

References

Small Animal Clinical Nutrition, 5th Edition, Hand, Tharcher, Remillard, Roudebush, Novomy
Nutritional Management of Renal Disease. ‘What to Feed and When to Start’, C. Heinze, VMD, MS,
DACVN, 2013
Encyclopedia of Feline Clinical Nutrition, Royal Canin Pibot, Biourge, Elliott

Nutri&on! The Key to Managing Chronic Renal Disease

Ed Carlson, CVT, VTS (Nutri&on)
Encyclopedia of Canine Clinical Nutrition, Royal Canin, Pibot et al, 2006
Applied Veterinary Clinical Nutrition. Freeman and Delaney, 2012

Nutri&on! The Key to Managing Chronic Renal Disease

Ed Carlson, CVT, VTS (Nutri&on)