Dietary management in CKD

• What makes a therapeutic diet for CKD?

  The diet should be introduced gradually. Renal prescription diets are especially proven for cats with stage 3 and 4 renal disease.

  • Protein restriction
  • Phosphate restriction
  • High palatability and calorie content.
  • Potassium B and vitamin supplementation.
  • Non-acidifying
  • Omega 3 fatty acids.
• Common complications of CKD

  Azoatemia

  Uraemia

  Metabolic acidosis

  Dehydration

  Electrolyte disturbances

  Hypertension

  Loss of muscle mass and poor BCS

  Accumulation of drugs and toxins

  Renal secondary hyperparathyroidism

  Anaemia
• Palatability and calorie density - inappetent CKD patient

  Calorie density is vital - we want to maintain normal BCS and muscle mass. CKD Pateints often display significant weight loss.

  High fat and calorie content aids palatability.

  Consider supportive nursing techniques to encourage eating - hand feeding, offering slightly warmed food and sitting with the cat, and stroking it while it eats.

  Can use appetite stimulants and anti-emetics
• What’s the significance of cats being an obligatory carnivore?

  Cats require more protein than dogs or other omnivores but protein restriction has been recommended for patients with renal disease for decades.
• Protein restriction in cats

  The benefits of protein restriction on disease progression rate have not yet been demonstrated in cats. However, protein restriction and the feeding of high biological value protein can help manage clinical signs.

  The biological value of protein is determined by how readily the amino acids are broken down and used by the body.
• Why does the reduction of protein manage CKD symptoms?

  Accumulation of protein breakdown products is one of the causes of uraemic clinical signs.

  Protein restricted diet helps to reduce the severity of azotaemia.

  Reduction of associated clinical signs - nausea, vomiting, anorexia, lethargy.
• Hyperphosphataemia and phosphate restriction in CKD patients

  CKD patients are vulnerable to electrolyte disturbances as regulation depends in the effective glomerular filtration and excretion.

  Hyperphosphataemia is a major contributor to the development of renal secondary hyperparathyroidism.

  It is believed to be damaging to the kidneys, contributing to continued and worsening renal injury. Associated with a poor prognosis.
• Further modifications in commercial renal diet preparations - omega 3 - fatty acids

  Increased renal blood flow to minimise hypoxic damage and potentially reduce inflammatory mediators.

  This is useful for all stages of CKD.
• Further modifications in commercial renal diet preparations - water soluble vitamins

  Supplementation of vitamin B to compensate for depleted levels due to CKD related to polyuria.

  This is useful for all stages of CKD.
• Further modifications in commercial renal diet preparations - sodium

  Avoid excess however there is no evidence that restriction is beneficial.

  Avoid all excess in any diet.
• Further modifications in commercial renal diet preparations - fibre

  Nitrogenous waste products, such as urea, are bound in the bowel and eliminated with the faeces rather than being absorbed into the body.

  Take into account patient life style.
• Further modifications in commercial renal diet preparations - non-acidifying

  Helps prevent development of metabolic acidosis, a common CKD complication. Maintaining a normal acid base can also help prevent hypokalaemia.

  Useful for all stages of CKD.
• CKD cats - potassium

  Cats with CKD are vulnerable to losing excessive amounts of potassium in the urine. Hypokalaemia is often associated with clinical signs such as malaise and inappetence. More marked hypokalaemia is associated with severe muscle weakness and ventroflexion.
• Transitioning cats to a renal diet

  Long term aim- introduce slowly, can be counterproductive if cat is in the hospital or clinically unwell, consider use of feeding tube.

  Introduce early - Before progression of CKD.

  Education of owners - welfare implications and benefits on quality of life, increase compliance and understanding.

  Wet food is preferred to dry - water content.

  A standard commercial senior diet can be useful when cost is an issue especially in the early stages of CKD.