Page 1228 - Clinical Small Animal Internal Medicine

1166 Section 10 Renal and Genitourinary Disease

Table 125.1 IRIS chronic kidney disease stages in cats and dogs parison to a maintenance diet, renal diets are typically
VetBooks.ir Serum creatinine values (mg/dL) formulated to contain modified amounts of high‐quality
protein, increased caloric, soluble fiber and B vitamins,
omega‐3 polyunsaturated fatty acid and antioxidant con-
Cat Dog tent, reduced amounts of phosphorus and sodium, and
to have a neutral effect on acid–base balance. In addition,
Stage 1 <1.6 <1.4 feline renal diets are supplemented with potassium.
Stage 2 1.6–2.8 1.4–2.0 Recently, early‐stage renal diets that are phosphorus
Stage 3 2.9–5.0 2.1–5.0 restricted but with less restricted protein content have
Stage 4 >5.0 >5.0 also become available for cats.
The greatest clinical challenge with recommending a
www.iris‐kidney.com renal diet is acceptance by the animal. The failure of the
patient to eat the formulated diet negates the benefit of
Table 125.2 Classification of proteinuria in cats and dogs dietary management, and therefore a key therapeutic
target for these patients is the maintenance of appetite
Urine protein:creatinine ratio and food intake. Poor body condition is associated with
decreased prognosis in several species and it also has a
Cat Dog negative effect on owner perception of quality of life. As
animals with CKD often suffer from poor appetite, this
Nonproteinuric <0.2 <0.2 should be actively addressed in a management plan.
Borderline proteinuric 0.2–0.4 0.2–0.5 Nonacceptance of renal diets can potentially be over-
Proteinuric >0.4 >0.5 come by addressing underlying metabolic complications
of CKD as well as gradually introducing the renal diet
www.iris-kidney.com over several weeks. Many animals will readily accept and
continue eating a renal diet provided the transition
Medical Management of Chronic period is adequately slow. Other tips to encourage
acceptance of renal diet include increasing owner com-
Kidney Disease pliance with education regarding the benefits of the diet,
avoiding transitioning to the renal diet during a uremic
Medical management of CKD consists of treatments crisis event to prevent food aversion, trying different
designed to provide supportive and symptomatic care temperatures, textures and brand formulations of food,
for the animal, with the goal of correcting nutritional, and medically managing nausea and inappetence associ-
fluid, electrolyte, endocrine, and acid–base imbalances. ated with uremic syndrome.
These treatments aim to minimize the clinicopathologic It is particularly important that the patient eat suffi-
and pathophysiologic effects of kidney dysfunction. ciently to satisfy caloric requirements. A nutritional
Unfortunately, medical management is not expected to assessment should be performed at each visit including
halt, reverse or cure kidney dysfunction or any associ- body weight, body condition score, muscle mass score,
ated renal lesions. If any treatable underlying cause of and a thorough nutritional history (www.wsava.org/
disease is identified, such as infection or obstruction, it is nutrition‐toolkit). Insufficient caloric intake could
imperative that it be addressed. The management guide- potentially lead to protein malnutrition as evidenced by
lines presented in this chapter are intended for animals decreased muscle mass, anemia and decreased serum
with stable chronic disease, not those currently undergo- albumin or total protein concentrations.
ing a uremic crisis. If caloric requirements are not being met, yet metabolic
complications are controlled and medical management
Nutrition and Dietary Therapy of inappetence is unsuccessful, supplementation with a
diet palatable to the animal or assisted feeding should be
Several studies have documented the therapeutic value considered. Assisted feeding options include placement
of specially formulated diets in the management of CKD, of an esophagostomy or percutaneous gastrostomy tube
including evidence of decreased incidence of uremic cri- for long‐term nutritional management. Tube feeding has
sis and increased survival and modulation of biomarkers. the additional advantage of allowing the owner to deliver
It is perhaps a common misconception that the sole pur- oral water and medications to the patient and can be a
pose of these diets is protein restriction. Other modifica- valuable tool for long‐term management of CKD.
tions present in these diets are as important, or potentially Disadvantages of tube feeding include the anesthesia
even more important than protein restriction. In com- required for placement and tube site complications.