CANINE KIDNEY DISEASE & NUTRITIONAL TREATMENT

KIDNEY DISEASE & TREATMENT

KIDNEY DISEASE & DIETARY TREATMENT Kidney failure is one of the most serious medical problems encountered by the canine & feline community. It is third largest killer of all dogs In its acute stage, it comes on suddenly, and will cause death unless immediate treatment is obtained. For this reason, all people with companion cats should familiarize themselves with the following: As with humans, felines and canines require good kidney function in order to get rid of toxins and maintain normal balances of sodium, phosphorus, and other elements in their blood stream. When urine and blood tests indicate that the kidneys are not doing their job, the condition is classified as either Acute Renal Failure (ARF), if it comes on suddenly, or Chronic Renal Failure (CRF), if it develops over time.

The distinction between these two diagnoses is very important, because ARF is reversible but not treatable, while CRF is treatable, but not reversible. Especially in younger pets, ARF may be caused by poison, injury, or obstruction of the kidney due to injury or disease. If the pet timely receives antidotes, surgery, or other treatment alleviating the cause, kidneys function may be completely restored, and the pet may live a normal lifespan.

Unfortunately it may be difficult for even a veterinarian to make the call between the two forms of kidney failure. While CRF may be discovered at an early stage, particularly if it is caused by another disease such as cancer, many times a pet will show no symptoms at all until over 75% of the kidney cells have shut down. Once the 75% mark is passed, the pet's body is no longer able to cope with the problem. Suddenly the pet will have all of the symptoms of ARF and will likely be treated as having acute rather than chronic kidney disease.

Diagnosis When your pet is exhibiting unusual symptoms and behaviors, a veterinarian will conduct a physical examination and evaluate

clinical signs. When kidney disease is suspected, a diagnosis will be made through the use of blood tests and urinalysis.

There are many substances that a veterinary doctor can test for in a patient's blood in order to check for the presence of kidney disease. However, there are two main components that are particularly helpful when it comes to diagnosing this condition -- blood urea nitrogen and creatinine.

Both urea and creatinine are products of metabolism and are usually filtered out of the body by healthy kidneys. When kidneys are not functioning properly, these two substances will likely be present in higher concentrations than normal. In some cases, a urinalysis may be conducted in order to confirm a diagnosis of feline kidney disease. This involves obtaining a urine sample from the patient and testing its concentration level. For a pet with kidney disease, the urine sample will typically be much more diluted than would be the case with a healthy cat. In addition, a veterinarian can also check a urine sample for higher than normal concentrations of other substances, such as protein and sugar. The presence of blood in the urine can also be an indicator of kidney disease. Thus, blood tests and urinalysis are the most commonly employed methods when it comes to diagnosing a case of cat kidney disease.

Pathophysiology Finding out that your beloved pet is sick is always distressing, and often confusing. Having a basic knowledge of the disease that is affecting your cat may help you to understand what is happening and why certain treatments are required. Therefore, in the case of kidney disease, it may be helpful to have a basic understanding of kidney function and the physiological occurrences that take place when these organs cease to work properly.

Typically, a pet has two kidneys, each one connected to the bladder by a ureter. The ureters drain urine from the kidneys to the bladder so it can be removed from the body. The kidneys are comprised of millions of tiny units known as nephrons. These nephrons, and the kidneys as a whole, are responsible for carrying out numerous physiological tasks,

including the regulation of blood concentration as well as maintaining the acid-base balance of the blood. The primary physiological function that these organs are charged with, however, is the filtration of waste products and other unneeded substances.

Kidney cells can become damaged or can suffer from the natural wear and tear that comes with age. When this occurs, the remaining healthy kidney cells have to work harder in order to compensate for those that are no longer functioning properly. Since kidney disease tends to be of the chronic form, developing slowly, a dog or cat's kidneys will often compensating in this way for a significant period of time before any outward symptoms or warning signs become apparent. In fact, kidney disease generally does not reveal itself until approximately two-thirds of normal kidney function has been lost. Symptoms begin to show at this point because the remaining healthy kidney cells are no longer able to compensate for all of the damaged or destroyed cells. Thus, the organs' functions are no longer carried out properly; the kidneys fail to sufficiently regulate blood concentration and waste products are no longer removed from the body.

When balances in the blood are not maintained and waste and toxins are allowed to accumulate in the body, many other physiological pathways are disrupted and the cat's system begins to become poisoned. This is a very miserable and uncomfortable situation for your pet to be in, and if not quickly identified and controlled, feline kidney disease can become deadly.

Causes kidney disease can be caused by a number of different factors and influences. The acute form of this condition may be triggered by trauma or significant blood loss, or by toxins such as antifreeze. The chronic form of kidney disease, which is far more common among cats, can also be caused by several different factors. Sometimes, this condition is simply the result of age, developing as natural wear and tear on the body begins to affect the cells of the kidneys. In other cases, feline kidney

disease may develop as a result of an infection or an inherited defect. Often, however, a specific cause of kidney disease in an individual cat cannot be determined and will remain a mystery.

Kidney disease is not limited to any particular age or breed, but is one of the most common problems of older cats and dogs and is a leading cause of death for these animals.

Recent research suggests a link between vaccination for distemper and immune-mediated inflammation of the kidneys, which is thought to be the cause of CRF. Annual boosters for distemper are completely unnecessary. Be sure to discuss all recommended vaccines with your veterinarian. A pet with kidney disease or kidney failure should not be vaccinated at all.

Symptoms If kidney disease destroys the kidney’s ability to perform properly, waste materials accumulate in the blood. Signs associated with kidney failure are: • Loss of appetite • Increased thirst • Frequent urination or increased volume • Poor hair coat • Depression and/or vomiting Long-term feeding of an all-dry-food diet is also suspected as a factor in Chronic Renal Failure. Cats' kidneys are highly efficient and adapted to life in the desert, where they would get most or all of their water from eating their prey. Cats eating dry cat food take in only half the water that cats on a canned or homemade diet get; this chronic dehydration can cause stress on the kidneys over time. Dry diets also predispose pets to lower urinary tract disease (FLUTD, LUTD, FUS, crystals, stones, cystitis) because they force such a high degree of urine concentration. Chronic or recurrent bladder disease may also be a factor in the development of CRF.

Treatment of Chronic Renal Failure Chronic kidney failure is progressive and incurable. No conventional or alternative medical treatment can reverse its course, since the disease involves the loss of kidney cells and replacement by scar tissue. The rate of progression in any individual cat probably cannot be slowed to any significant degree. When the process is advanced, the kidneys become small and lumpy, and the amount of functional tissue is greatly limited. The most significant problems caused by the loss of function are build-up of blood toxins, and anemia. These can cause weight loss, lethargy, vomiting, loss of appetite, weakness, and other signs of illness.

Some pets are able to maintain their body weight and live relatively comfortable lives for months to years, while others succumb to the disease more quickly. In conventional medicine, there are drugs that can minimize anemia, and phosphate binders to prevent phosphorus precipitates from further damaging the kidneys. However, these may not be palatable, and may cause adverse reactions. They are also of little or no value unless the pet is eating a restricted protein/low phosphorus diet exclusively. It may also be important to supplement potassium in the food.

As mentioned previously, there is no cure for kidney disease.

However, it is possible to control this condition with proper treatment. The prognosis will vary from case to case, depending upon the amount of damage already done and the amount of kidney function still remaining. While treatment plans will be specifically tailored for an individual feline patient, dietary adjustments are frequently included as part of the strategy to control this disease.

To begin with, encouraging increased ingestion of water is very important. By drinking plenty of water, a cat will be less likely to become dehydrated and its kidneys will have an easier time functioning. Furthermore, restricting sodium and protein

intake may be necessary. Reducing these substances can help to alleviate some of the stress on the kidneys, but this should only be done under the supervision of a veterinarian, as reducing the intake by too much can weaken your pet and cause further problems.

In addition to the above dietary changes, natural substances and supplements can also be very helpful with regards to treating kidney disease. Multivitamins or other supplements may be recommended in order to boost your pet's immune system, increasing its strength and health. Also, herbs and other natural substances can be used to relieve some of the troubling and uncomfortable symptoms of this condition while improving your cat's overall well-being. For instance, wild hydrangea and stone root act as anti-inflammatories and prevent or reduce the formation of painful kidney stones.

Other natural ingredients such as purple coneflower and Oregon grape have antibiotic and immunostimulating properties. Homeopathic remedies use a combination of such ingredients, providing a number of different benefits for a cat suffering from kidney disease.

Pet Nutrition Systems sample of Kidney Recipe 1.

55% Salmon (other type of fish can be used) Brown Rice Garlic Parsley Purple Coneflower tomato flaxseed oil 2.

55% Ground lamb Boiled Yams steamed broccoli Blueberry extra virgin olive oil

A note: the percentage of meat is not an indication of the over all percentage of protein. most meat has a high moisture content bringing the about or percentage of protein down dramatically.

Kidney problems can cover a wide variety of issues. Most health professionals will tell you to reduce protein when renal values are elevated, but in reality, it is the level of phosphorus that needs to be reduced. This means familiarizing yourself with the phosphorus values of different foods. It can also mean increasing fat to add calories. PNS generally will start you on a special diet when the values of BUN reach 80, and the creatinine is over 2. And it is important to run tests to try to find out the source of the problem. This would include a blood titer for leptospirosis, blood test for tick borne diseases, a sterile urine culture (long term urinary tract infections can cause kidney problems) and ruling out Cushing’s disease or Addison’s disease. Occasionally I see websites offering herbal and other ‘cures’ for renal disease. Disregard these sites and their advise. Always get thorough testing done to find out what mode of treatment will be most successful then allow PNS to adapt a diet plan to complement it. Most regular commercial diets have around 1-2% phosphorus on a dry matter basis.

A dog with early stage kidney disease should be limited to around 0.6% phosphorus on a dry matter (DM) basis. Another way to figure it is that you want to feed no more than 30 mg phosphorus per pound of your dog's body weight daily if your dog has early stage kidney disease. These numbers must be reduced further for dogs with moderate stage kidney disease: aim for around 0.45% phosphorus DM, or 20 mg/lb of body weight. Dogs with advanced, late-stage kidney disease need even lower phosphorus: around 0.3% DM, or 10 mg/lb of body weight daily. It has occurred to me that another possible choice for feeding a commercial diet to dogs with kidney problems is to use a diet developed for cats with kidney problems. Because cats require higher protein, these diets will have more protein

than the diets developed for dogs with kidney problems, while still reducing phosphorus. The biggest concern is that cat foods are quite high in fat, which could predispose your dog to pancreatitis. Also, for the most part these are still not high quality foods, though Royal Canin is probably better than Hill's and Iams (formerly Eukanuba). I strongly suggest that people opt not to feed processed food to reasonably healthy dog and it should be avoided at all cost for ill pets. With that said......

Add water If you feed dry food, it's best to add water to help your dog stay hydrated. Remember that dry food will spoil once water is added, so you shouldn't leave it out all day. Add fresh foods: Note that when feeding a prescription kidney diet to a dog with early stage kidney disease,you can improve the overall quality of the diet and increase the amount of protein without

pushing

the

amount

of

phosphorus

too

high

by adding fresh foods such as fatty meats, egg whites (and a limited number of whole eggs), dairy, and other animalbased foods. Do not add grains or vegetables, since the prescription

kidney

diets

are

already

high

in

carbohydrates. Compare the mg of phosphorus per 100 kcals (far right column) in the prescription kidney diets below with some of the fresh foods listed in the Tables of Nutritional Values and you'll see that many of these foods have similar or less phosphorus per calorie than the kidney diets do. For dogs with early stage kidney disease, look for foods to add with 150 mg of phosphorus or less per 100 kcals. Be sure to add calcium at the rate of 1/2 tsp ground eggshell (1,000 mg calcium) per pound of added food.

Creating Homemade Meals: Elements of Concern Reduce Phosphorus Feeding a low phosphorus diet has been shown to slow progression of kidney disease. VPN guidelines are to feed no more than 22.25 mg/kg phosphorus daily (about 10 mg per pound of body weight) for a dog with advanced kidney failure.

For dogs in early stages, recommended phosphorus amounts can be as high as 60 mg/kg or 30 mg/lb. Anywhere from 1540 mg/kg (7 - 18 mg/lb) is considered a low phosphorus diet.

In general, foods highest in phosphorus include bones, dairy products, fish (with bones), organ meats, and egg yolks. That does not mean not to feed these foods at all, as they are an important component of a healthy diet, but they should be fed in moderation. Be wary also of the amount of phosphorus in grains and vegetables that you feed. The PNS Tables of Nutritional Values lists some approximate values for a variety of different foods. Examples of the amount of phosphorus you should be feeding daily, based on the range of 15-40 mg/kg, and 60 mg/kg for very early stages (the further advanced the kidney disease is, the less phosphorus you should be feeding):

10 pound dog: 68 - 182 mg (up to 272 mg in very early stages) 25 pound dog: 170 - 455 mg (up to 682 mg in very early stages) 50 pound dog: 340 - 900 mg (up to 1364 mg in very early stages) 75 pound dog: 511 - 1364 mg (up to 2045 in very early stages) 100 pound dog: 680 - 1818 mg (up to 2727 in very early stages)

Moderate Protein How much protein to feed is still a matter of some debate, although it is not necessary to feed a low protein diet unless your dog is uremic. Protein may need to be moderately reduced for dogs with glomerulonephritis, to reduce protein loss in the urine which contributes to inflammation.

Recommendations for dogs with mild to moderate CRF (creatinine 1.6-4.5 mg/dL, or 141-398 Âľmol/L) are 2.0 - 2.2 g/kg body weight of high biologic value protein, or around 1 gram of protein per pound of body weight daily. This is higher than the recommendations for normal, healthy dogs.

As long as the amount of phosphorus is kept within desirable limits, and your dog is not uremic and does not have excessive

proteinuria, you really don't have to worry much about feeding too much protein (you may need to be careful not to feed too little). It is important to feed high quality protein. Eggs have the highest quality protein, but egg yolks are very high in phosphorus, so you may want to feed 2 - 3 egg whites for every egg yolk that you feed. Egg whites should be cooked, as raw egg whites bind biotin (a B vitamin) and the protein is less bioavailable. Raw or lightly cooked meat is another high quality source of protein. Green Tripe may be an excellent food for dogs with kidney disease, see below for more info.

Carbohydrates Dogs have no nutritional need for carbohydrates, but in order to reduce phosphorus, you will probably need to feed around 50% carbohydrates. In general, the goal is to add calories without adding much phosphorus. For this reason, grains like Farina, pasta, and vegetables like sweet potatoes and winter squashes are good choices. Phosphorus amounts given below in parentheses are taken from the USDA Nutrient Database and are shown in mg per 100 grams. If a range of numbers is given, the lower number is for cooked, the higher number is for raw. If only one number is given, it is for raw.

Vegetables must be either steamed, cooked or pureed in juicer, food processor or blender in order to be digestible by dogs and to make the vegetables more bio-available.

Cooking leaches out phosphorus (as well as potassium and magnesium), so it may be the better way to feed for dogs in kidney disease, although cooking also leaches out or destroys vitamins. Boiling or steaming removes more phosphorus than baking, as long as you don't also give the water the food was cooked in. Note that celery, parsley and dandelion greens are diuretics, which may not be desirable for dogs with kidney disease. Dogs with arthritis should avoid white potatoes, tomatoes, eggplant and peppers.

Cabbage is good for ulcers, which are common with kidney disease. Other vegetables, with phosphorus amounts in parentheses, include: asparagus (56), beets (40),broccoli (66), carrots (4 4), cauliflower (44), celery (25), collargreens (10), dandelion green

greens (66),endive (28), green

peppers (19), Jerusalem

beans (19-38),

artichoke/sunchoke (78),

kale (56),parsley (58), parsnip (71), peas (77-117), pumpkin (44), red cabbage (42), romaine lettuce (45),acorn squash (27), butternut squash (27), crookneck squash (32), spaghetti squash (14), tomato (24),watercress (60), zucchini (32). Fruits: You can also feed fruits, including apple (7), avocado (41), banana (20), cantaloupe ( 17),cranberries (9), cucumber (20), mango (11), peach (12), pear (11), pineapple (7). Fruit does not have to be cooked or pureed in order to be digestible. Colored fruits, such as papaya and mango, are especially good for dogs with

arthritis. Bananas and pumpkin are

high

in potassium. Too

much fruit may lead to loose stools. Grains: If you do feed grains, stick to those that are lowest in phosphorus. In general, white rice is lower in phosphorus than brown rice. Farina (Cream of Wheat Cereal), Cream of Rice Cereal, Malt-O-Meal, and Tapioca are low phosphorus alternatives that can also be used. Try adding butter, meat juices or meat fat for flavor and calories, and cooking in broth or gravy rather than water for added flavor (use low or no sodium broth).Pasta: Pasta with butter added is a good choice for tasty, low-phosphorus calories. Honey: Raw honey is good for dogs in general and can be fed to dogs with kidney problems as well. Phosphorus amount is negligible.

Moderate to High Fat Fat provides low-phosphorus calories, and so can be used to increase caloric intake without increasing phosphorus. With rare exception, dogs do not suffer from high cholesterol or other human problems associated with high fat intake.

However, too much fat can be problematic for some dogs, and renal disease can predispose dogs to pancreatitis (or it's possible that the combination of low protein and high fat found in prescription diets may be the underlying cause, as this combination is known to predispose a dog to pancreatitis).

If your dog is overweight or relatively inactive, and doesn't need a lot of calories, then feed moderate amounts of fat. If your dog is quite active and needs a lot of calories, then you can increase the amount of fat to provide more calories without increasing phosphorus. Too much fat may lead to diarrhea or mucousy stools, and dogs that are prone to pancreatitis cannot handle too much fat.

It is important to increase the amount of fat you feed gradually, to avoid digestive upset and to try to avoid the possibility of pancreatitis. If you see signs of problems, such as your dog seeming uncomfortable after meals, loose stools, loss of appetite, vomiting or diarrhea, that is a sign to decrease the amount of fat in the diet right away to a level your dog can tolerate.

Dietary sources of fat include: Fatty Meats -- use the highest fat hamburger you can get. Lamb is especially high in fat. Pork is also high fat. Dark meat chicken and turkey has

more

fat

than

white

meat,

although poultry is still a low fat meat, so it's best to include the skin if

you

feed

chicken

or

turkey. Beef has

less

phosphorus than chicken.Lamb and turkey are in between.

Use whole milk yogurt, cottage cheese, ricotta cheese, etc. - since these foods are high in phosphorus, they should be fed in moderation, but use the kind with the most fat when they are fed. Try goat's milk yogurt for flavor if your dog doesn't

like the regular kind.

Egg Yolks are high in fat, but also very high in phosphorus, so should be fed in moderation.

Fat can also be added in the form of bacon fat, (no or low sodium) chicken fat, butter (use unsalted if your dog has high blood pressure). Be very careful about adding pure fat to the diet -- start with very small amounts and stop immediately if you see signs of problems.

In general, vegetable oils are not recommended as a source of fat. They are high in omega-6 essential fatty acids, which are inflammatory, and are not a good source of nutrition for dogs.

Omega-6 fatty acids have been found to be harmful to dogs with kidney disease. Instead of vegetables oils, use Fish Oil, such as Salmon Oil or EPA oil (NOT cod liver oil). While Flax seed oil has more omega-3 fatty acids than most plant oils, it is also high in omega-6 and so is not recommended. Olive oil is probably OK to use in small amounts, as it is mostly omega-9, which as far as I know does not affect kidney function..

Again, be cautious when adding fat to the diet. Increase amounts gradually, and back off if you see any signs of your dog having problems with the higher amounts.

Sodium Dogs with kidney disease often also have hypertension (high blood pressure), and the standard recommendation is to feed a reduced-sodium diet. However, it is questionable whether this is necessary, and a low-sodium diet may even be harmful: "Chronic Renal Disease: The Importance of Nutrition" (Elliott, LeFebvre) says, "It has long been recommended to reduce the sodium content in the diets of patients with CRD. However, recent work (see chapter seven) would appear to show that too low of a sodium content (0.4- 0.5 mg/1000 kcal) could have a deleterious effect on renal function. Low sodium intake could contribute to glomerular hypertension by increasing the secretion of aldosterone and activating the renin-angiotensin system. These results are yet to be confirmed but they caution against too severe sodium restriction in the diet of patients with CRD." They conclude with "Current recommendations are normal to mildly restricted sodium diets."

The Encyclopedia of Canine Clinical Nutrition says, "Several studies have shown that moderately increased dietary salt intakes (up to 3.2 g Na/1000 Kcal ME) do not alter blood pressure in healthy dogs, or in dogs with induced renal disease."

There is no evidence that lowering dietary Na will reduce blood pressure. If dietary Na reduction is attempted, it should be accomplished gradually and be used in combination with pharmacological therapy.

If you do reduce sodium, it's important to do so gradually, as reducing sodium too quickly in dogs with kidney disease can cause dehydration and bring on a renal crisis.

Green Tripe Green tripe may be an excellent food for dogs with kidney disease, as it is fairly low in phosphorus and is highly palatable to dogs. You need to find green tripe, as the bleached tripe that is sold for human consumption does not have the same nutritional value. Most dogs love green tripe, so it might tempt a dog to eat that was anorexic. I've never heard of a dog having digestive upset from green tripe (though sometimes the owners do, it has a fairly strong smell, and some prefer to feed it outside). Unbleached green tripe is hard to find, see the following (note many will ship, although the cost can be high to ship frozen products):

Water Dogs with kidney disease should always have access to water, even if it causes accidents in the house. Distilled water may be

best to use, or maybe purified water, such as with a faucet filter. Well water may be very high in minerals and is best avoided, use bottled water instead, or find a filter that will remove excess minerals. If you use a water softener at your house, your water will be high in sodium, which is not a good idea if your dog has high blood pressure. Again, switch to bottled water (filters do not remove sodium from water). It is important that your dog stay hydrated, as dehydration is very harmful to the kidneys. Adding water to the food, particularly if you feed dry food, may help with this. If your dog is drinking a LOT of water, I would definitely consider giving sub-q fluids to help him stay hydrated.

Supplements: (When you order your pet's meals from Pet Nutrition Systems there is no need to add supplements to

the meals, they are in your meals saving you time, money and a lot of guess work) If you are preparing your pet's meal PNS strongly suggest that you ADD 1/2 TEASPOON GROUND EGGSHELL (or 1,000 mg plain calcium) PER POUND OF FOOD FED TO EACH MEAL.This is so the calcium will act as a phosphorus binder, not just to balance out the calcium:phosphorus ratio. Do not add calcium if it is elevated in your dog's blood work (ask your vet about using other calcium binders instead). If you do not want to use ground eggshell, you can use other forms of calcium instead. Never use bone meal as a source of calcium, as it contains high amounts of phosphorus. 
Fish Oil is another important supplement. You should give 1,000 mg fish oil (body oil, not liver oil) per 10 lbs of your dog's body weight daily. The omega-3 fatty acids in fish oil help protect the kidneys and are one of the best things you can do for a dog with kidney problems.

Other supplements that may be helpful are Vitamin BComplex, and small amounts of Vitamins C and E. Don't add Vitamin D (or cod liver oil) beyond minimum amounts to dogs with kidney problems unless directed to by your vet. It is also best to avoid supplementing with Vitamin A as well, or use only in small amounts, preferably in the form of beta carotene. 
You can also add small amounts of kelp and alfalfa, or something like Berte's Green Blend. These supplements

should be used sparingly, as kelp contains sodium and alfalfa can act as a natural diuretic. Using them once or twice a week may be preferable to daily, especially if your dog has moderate to severe kidney disease, or has high blood pressure. Note that a home made diet is naturally low in sodium, unless you add salt or use high sodium prepared foods (including cottage cheese).

Adjust the amount of food fed as needed for the size of your dog, remembering that smaller dogs generally need more food per pound, while larger dogs on average need less (for example, a 20 lb dog would probably eat a little more than half the amounts shown, while an 80 lb dog would eat a little less than twice the amounts given). 8 ounces is about 1 cup of food. Keep an eye on your dog's weight, and increase or decrease the amounts if you see unwanted weight loss or gain.

This diet can be fed cooked or raw (except for the cereal, rice and sweet potatoes, which should be cooked). If you do cook it, light cooking is better than overcooking. You can break the diet down into two or three meals a day (you can also feed just one meal a day, but it is supposed to be easier on the kidneys to feed multiple smaller meals). You can mix the foods together, or feed them separately, depending on what your dog prefers and what is easiest for you.

NUTRITIONAL ANALYSIS: The diet shown here, for a 40 lb dog, would be 1.2 grams of protein and 13.5 mg of

phosphorus per pound of body weight. For comparison purposes to prescription kidney diets, it is about 0.37% phosphorus on a dry matter basis. As fed, this diet contains 9.0% protein, 10.5% fat, 6.7% carbohydrates, 0.5% fiber, 0.7% ash, and 72.6% moisture (based on the USDA Nutrient Database). 
You should feed a minimum of 1 gram of protein per pound of body weight daily (more is fine). Phosphorus restriction varies according to the degree of kidney disease.

For early stage, 20 mg phosphorus per pound daily is a good goal. For dogs with elevated phosphorus, or late stage kidney disease (creatinine over about 4.0 mg/dL, or 354 Âľmol/L), this should be reduced to 11 mg per pound.

Ingredient Details MEAT For lowest phosphorus, use high fat meats, such as lamb, pork, and high fat hamburger, but it is also good to include some heart in the diet. Dark meat chicken and turkey are higher fat than light meat, and the skin is where most of the fat resides, so include it if possible when you feed chicken and turkey. Tripe can be used in this category, it is lower in phosphorus than most meats. It is OK to use more eggs and egg whites (use a ratio of one or more egg whites to each whole egg) in place of some of the meat. Small amounts of high fat cottage cheese and canned fish (Jack Mackerel, Pink Salmon or Sardines packed in water -- drain and rinse the fish if sodium is a concern) are also OK, but do not use cottage cheese if your dog has high blood pressure. Feeding a variety of foods is better than feeding just the same thing all the time,

both for nutritional purposes, and because your dog will be less likely to tire of the diet, but if there are foods your dog won't eat, it's OK to avoid them.

GRAINS and VEGETABLES Use only low phosphorus grains and vegetables. You may add the extras (butter, heavy whipping cream and yogurt -- see below) to the grains and veggies for added flavor -- you can also try low or no sodium gravy or broth. Winter squashes are the hard bodied ones, such as Acorn Squash, Spaghetti Squash, and Butternut Squash. You may want to alternate between the suggestions below so that your dog doesn't get

tired of always eating the same thing, but it is OK to use only the ones your dog likes.

GRAIN & VEGETABLES

EGGS Use at least one egg white per each whole egg you feed, for lower phosphorus (most of the phosphorus is in the yolks, but

eggs are such nutritious foods that it's good to feed at least some whole eggs).

ORGAN MEATS (LIVER and KIDNEY) Although these foods are high in phosphorus, they also have a lot of vitamins and nutrients and are good to feed in small amounts. It is not necessary to feed them every day, but don't feed large amounts at one time, as too much can lead to loose stools. Although liver is easier to find, try to include some kidney in the diet if possible.

ORGAN MEAT

EXTRAS Add low phosphorus, high fat foods for extra flavor and

calories without adding much phosphorus. Butter (use real butter, not margarine -- use unsalted if your dog's blood pressure is high) and heavy whipping cream are great for adding flavor to rice, cereal and vegetables, but they're high in fat, so use sparingly. Whole milk yogurt is higher in phosphorus, but is still good for variety in small amounts. Beef fat and bacon grease could also be used, again in very small amounts, to add flavor without too much fat. Be careful when increasing fat in your dog's diet, as too much fat can lead to loose stools and sometimes even pancreatitis, in dogs that are prone to it. Increase amounts gradually, and back off right away if you see signs of problems, such as discomfort after eating, or any vomiting or loose or mucousy stools.

To reduce phosphorus even further, feed more egg whites and fewer whole eggs, feed less organ meat (liver and kidney), and feed a little more cereal/rice/sweet potatoes and a little less meat. Compare the calories to the amount of phosphorus to look for the lowest phosphorus amounts per calorie -those marked in green are the best foods for low phosphorus, while those marked in red have the highest amount of phosphorus per calorie. However, they are still important foods to feed for nutritional purposes, unless your dog is in end stage renal failure.

Below you will find a link to PNS website in which you may download our Veterinary Nutrition Service form for you and/ or

your vet to fill out them email back to me and a link to our VPN service program guideline that you should share with you veterinarian. Please feel free to call me or write anytime, I look forward to helping you help your companion pet to better health and a higher quality of life.