Hello, I'm Anthony Chadwick from the webinar Vet, welcoming you to the 3rd in our series of webinars for been kindly sponsored by Hills, and today we're going to be talking about managing chronic kidney disease patients with comorbidities. Really fascinating area. I'm really looking forward to the webinar.
We're very fortunate today to have Lisa Restein and Becky Mullis on the line. Doctor Lisa earned her Bachelor of Science in Animal Science from Rutgers University, and she received a DVM degree from Western University of Health Sciences in Southern Southern California. She began practising feline medicine right after graduation at a cat only practise.
And in 2020 she achieved board certification in feline practise by the American Board of Veterinary Practitioners. She's lectured veterinarians nationally and internationally and served as a co-editor of the sixth edition of a veterinary feline textbook. She joined Hill's in 2023 as the feline Professional Veterinary Affairs Manager, and she works with veterinary healthcare team members and pet parents on a global scale to educate and improve health and well-being of cats.
Doctor Becky is a board certified veterinary nutritionist in the American College of Veterinary Internal Medicine. She received her bachelor's in Animal Science from the University of Maryland and her DVM from the University of Tennessee. After graduation, she completed a one year rotating internship and worked as an emergency veterinarian for a few years before returning to the University of Tennessee, where she completed her residency in clinical nutrition.
She's now the veterinary corporate affairs senior manager with Hill's Pet Nutrition. So really looking forward to the webinar, looking forward to hearing what you've got to say, Lisa and Becky. I'm gonna mute myself, turn the video off, sit back in my chair and enjoy the next hour, over to you.
Thank you very much for that introduction. So, I'm really excited, to talk about this. I know, it's very rare for us in practise to see a cat with just one condition.
They like to collect them. So, hopefully, this will help us, work through. We can use the, what we learn here, with our senior kitties and CKD and use this method in our other senior patients as well.
So we're gonna learn how to recognise some of the common comorbidities in senior cats. And then how do we create a strategy for managing them when they have multiple conditions. So we're gonna figure out what needs to be treated and how we choose a proper nutrition, especially if those conditions and diseases have different nutritional requirements.
And we're going to do this, through use of an example case to kind of help tie everything together. So, just to kind of give a little bit of a disclaimer, we aren't gonna go too deeply into a lot of specific medical management strategies for these conditions. But we wanna try to have a plan and, and learn a way of thinking, so we can apply this very broadly as well.
So this is our example case. And I wanna know if this patient sounds familiar to you. So this is Maggie.
She's a 15 year old female spayed, domestic medium hair. And she transferred to you, after moving to a new location. So previously, Maggie was diagnosed with a chronic inflammatory neuropathy, and she was being managed with ZD, a hydrolyzed diet for this condition, and intermittently prednisolone, based on the records that you have.
When you talk to her caregiver, the history reveals some signs of DJD. It sounds like Maggie's slowing down a bit at home with her mobility. And then when after you did your exam and got your results back, you found CKD and hypertension.
So Maggie has now a whole list of things that is going on with her. And each of these conditions requires its own management technique. Now, before we go into the diseases specifically, I just want to cover a little bit of nuance with the words that we're using, and what we're not using geriatric for these senior cats.
Just because they're old does not mean that they're geriatric. So, this is a shift in terminology. It's really coming from the human side.
Senior, we're saying these cats are usually 10 years of age or older. And then some breeds, especially on the dog side, they, they will say they're gonna age faster, and that can happen as early as 8 years. But we're even in the cat world, Maine Coons and things, but some of those larger cat breeds, we can call them seniors a bit earlier.
Geriatric is a health status. So it really has nothing to do with how old these cats are, but it has to do with frailty. And frailty is a syndrome.
It is more common with advancing age, but This is when a patient has a decreased functional reserve that leads to a decline in both physiologic and cognitive performance. So they're more likely to have poor medical outcomes. So this is what we're talking about with geriatrics.
So just to kind of separate the two, I like to throw that in here because it is a shift in the publication terminology as well. And there's a lot of text on the slide, and you're not meant to read all of it. But these are just some of the articles that have been published about documented comorbidities in our cats.
And you can see that there are quite a few. This is, you know, this is even older now. It's a few from a few years ago.
But if you look at what goes along with CKD we can see we have hyperthyroidism. DJD, heart failure, dental issues, diabetes, like you can add CKD to almost anything, because it's one of the most common diseases that our senior cats do get. And if we look at this chart and Maggie, she, there are publications for all of the things that she has, except that chronic inflammatory neuropathy, but we know that that can be a comorbidity with many things as well.
So these are our senior cat comorbid conditions. And I think when we look at this list, we, we can even maybe think of some of our patients that might have all of these things going on, although I would say it's probably not common they have everything. But, you know, like our patient Maggie, CKD and hypertension really go together very frequently.
And hyperthyroidism also can go along very frequently with CKD. And then things like cognitive dysfunction and DJD is something that will happen in a lot of our senior cats. So, this is, when we think about those conditions, we really want to think about how they're playing with each other and how they're affecting these body systems a little bit differently.
And when you look at this list, many of these conditions will have different medical and dietary requirements for proper management. Like the dietary management of kidney disease and diabetes is not going to be the same. And the same with our medications, they might not play well together.
So how do we kind of manage all of these things? So, this, we know this is can be really hard. But just like anything, if we have a consistent approach to handling these cases, and we think about them similarly, it will get easier, and we can recognise our patterns, and we'll know what's going to work best in most of our cases.
And we also know that cats don't like to read the textbooks, and they like to do what they want to do. So, keep in mind that there will always be exceptions to anything that, you know, we're talking about here because it's really important to recognise that each cat is an individual, when we're managing them. So, even though these treatments may appear to conflict, there are going to be common issues.
And that is like the first step to determining that treatment plan is figuring out what these diseases and conditions have in common and how we can use that to our advantage. So we go back to Maggie as our example, and let's consider what her therapeutic goals are. And in order to do that, we have to kind of go back to our training and make our problem list.
So this is Maggie's problem, problem list. So, we know now she has chronic kidney disease. And what are the management goals that we have for each condition?
So what do, what do I wanna do if Maggie only had just one of these things? So for CKD we really wanna think about optimising our hydration. We wanna manage our phosphorus, that's really important with our diet.
We wanna support overall renal health. And then if there is any hypertension and proteinuria, we wanna make sure that that is controlled as well. And during this whole process, we obviously want Maggie to feel good.
With hypertension, our goal is to get that down to a normal blood pressure. But we really wanna decrease our risk of that target organ damage. So eyes, and kidneys, brain, you know, obviously, there's many other organs that we worry about.
And we want to make sure that we're decreasing that risk there. With our neuropathy, we wanna ideally utilise nutrition as much as possible to manage this condition. And if that's not enough, we can treat with anti-inflammatories as needed.
We know in Maggie's case, that she does not, that hers is an inflammation, and can be controlled with a combination of diet and, and anti-inflammatories based on her medical history. And then with our degenerative joint disease, we want Maggie to feel better. So, we want to improve her comfort through analgesia, and that can be through environment, medical, methods, as well as nutritional methods.
We want Maggie to be able to move around and, and optimise her mobility. And make sure that she has access to all of the resources that she needs for a good quality of life. So, they, you can see that in looking at this list, there are some things that do overlap here.
And, you know, that's a, a really good place to start when we have all of this written out. So now, we can say, OK, what are our common needs that are for all of our conditions? Like, and there are really 4 important considerations for every patient, Maggie included.
The first one is hydration. So this is especially important in our CKD patients, but this is important in any disease management as well. And then we want to think about optimising our nutritional support.
And while we may not, in practise, always recognise how important nutrition can be, there is always a, a nutritional aspect to any condition we are managing. Some have a lot larger aspects than others, but we want to make sure we're thinking about that. We wanna make sure that we have analgesia, if, if necessary.
And son, again, in our senior cast, sometimes that can be very simple, and we'll talk about that. And then we wanna talk about, Their environmental and behavioural needs. And we don't want to say, I don't like to say we're going to have environmental enrichment, because this isn't things that this is making life better for them.
This is things that they act that are essential to them to be happy. So we look at these 4 categories, and I'm gonna turn it over to Becky now to go over, starting with optimising the hydration and what we're gonna look for in Maggie's case. So thank you, Lisa.
And since I'm a nutritionist, we're gonna gonna start with hydration cause that's always vital for all nutritional plans. We can't forget water intake, but we're gonna deep dive into managing nutrition as well. So we look at hydration, especially when we're talking about cats, we're often thinking about how we can increase water consumption.
Things like kidney disease especially, but also urinary tract disease, helping them take in more water can be beneficial. Now, it probably seems very simple, offering canned food, that's one thing we can do, and we're gonna talk about that in a minute. But we can also work on improving water bowl desirability.
So, yes, we wanna make sure it's clean, fresh water at all times. We wanna make sure we have enough water bowls. We want to make sure that's optimised.
Maybe moving it a little farther away from the food. We don't necessarily want them right next to each other. And in a conversation I had with Lisa earlier this week, she actually mentioned something that I didn't know.
But it's moving that water bottle or water bowl in different areas in the house. So changing the location can actually stimulate water intake for those cats. I knew water fountains can help in some cats, but the moving water bowls was something that was unique for me.
So, thank you for that tidbit. We can also consider nutrient enriched water. Now, that can help increase water intake.
It also does increase the cost of managing that condition. So it also, often we need to look at the overall caretaker burden, what they can handle and which strategies we want to use. Sometimes we might start with one strategy and then start adding others if we need to.
When we look at wet food, we all know, I think there were some older papers years ago looking at wet food increasing the amount of water that cats will take in. But there was a study published just this year that looked at a wellness food in healthy cats. And what I think was interesting is they had another group.
They had dry food, a mixed feeding, so half wet food, half dry food, and then only wet food. And they did this in not only colony cats, but they did it in a real home setting too. So, you have that real-life environment.
Now, these were all healthy cats eating a maintenance food. So, it's not necessarily applicable to all the disease categories, but I think the principle probably still applies, but it would be great to have additional studies on the different conditions and seeing how that will affect them as well. But what I think is really interesting is you see dry food, you have most of the Most of the water intake coming from free water, so that water bowl water.
But when you get that mixed feeding, you start having a lot more water coming from the food, but overall, the water intake those cats take in is gonna be higher than just feeding dry, and you get the most effect when you see wet food only. And this applied not only to the colony cats, but those privately owned cats as well. So I think this is a really nice Good discussion point when you're having a conversation about, with owners about feeding wet food, it looks like from the study, we might have a benefit if we're doing wet and dry as well, but we might get the most impact from wet if that owner can incorporate a small amount of wet food that still may provide some additional benefit to the pet.
And then, well, you know, I'm a nutritionist, mostly focusing on oral intake, I think subcutaneous fluids are something that we need to think about. It may not work for all pets, and it may not work for all owners. This is something that some owners are not gonna feel very comfortable with.
Not every cat's gonna sit calmly and handle this in a stress-free manner. So, definitely keep it in your toolbox. It's something that can really help cats, but always use your judgement.
On what cat is the right one for this treatment, and iCAT Care has some really great patient or client handouts to help with those clients who may be interested in this option. So definitely go there if you need some handouts, some resources for pet owners. So, when we're looking at making sure these pets are hydrated, what are we gonna see in these cats when they're well hydrated?
Well, things like good quality, better stool character can be a sign of good hydration. Obviously, there's firm, hard stools may be a sign we're not taking enough water intake. Granted, there can be other factors there as well.
But you may see these cats, behaviour changing with, I mean, grooming grooming habits, interaction, interactivity in the house with many other pets, people, posture. So, really looking at the overall. Well-being of that cat, that quality of life.
When we look at nutrition. We're gonna have to, when we have these multiple disease processes, look at what Lisa was saying before. All of these different diseases, what do we need to do?
How are we gonna balance it? Because those strategies that might apply for a kidney disease cat may not work for Maggie because she has chronic inflammatory neuropathy. So, the food I choose normally for early kidney disease is not what I'm gonna choose now.
And then we also have to layer on top of this, what foods are currently available on the market. There's lots of changes all the time with new foods being developed, but you have to know what's out there, and there are limitations on what's being made because obviously, we can't make foods for every single disease possibility out there. So, there's a paper, there's two nutritionists who authored this paper and it was published in 2025.
And I think this is a great resource. You can pull it up if you're interested in kind of deep diving into this topic. But they created this nice flow chart to help us think about how we make nutritional decisions for these cats with comorbidities.
Now, this is similar to what was created in the paper. I redesigned it a bit to make it simpler for this purpose, but I think it's a great resource if you want a copy, pull the paper out, it's in there. So, what I'm thinking about when I have these complex cases, these cats with more than one condition that's nutritional sensitive.
So what I'm gonna do is take each of those disease processes and think about what I want to change for the nutritional plan. Then when I'm looking at these list of nutrients, we say, hey, are they compatible? If I have one disease process where I say, oh, I want a high protein food, and the other I'm saying I'm restricting protein, we're gonna have a problem.
We're gonna have to compromise a little bit on what we're doing. But we'll start first with, what if they're compatible? The first thing I'm gonna do is say, hey, if they're compatible, is the food available on the market?
If they are, that's great. If not, then I'm gonna have to look at, hey, is there a nutritionist in my area? Can I consult for a homemade diet?
Or do I need to look at if one of those foods that's available is close enough to meet my needs? And the same with if they're not compatible, then I'm gonna start saying, how do I prioritise what I do? And some of it has to do with the disease condition.
How it impacts that cat's quality of life, their survival, their lifespan, patient and caregiver preferences. Not all cats will eat wet food. I could say feed the wet food and if the cat won't eat it, it's no good.
That nutritional plan won't work. Maybe the owner won't buy wet food, they won't dry. So you have to work around that family situation as well.
Maybe there's other treatment options. Maybe I would love to do a certain nutritional strategy, but Because it's not available, but I know there's medication that will help address that. So looking at that and then the strength of the evidence behind certain nutritional adaptations.
So that's kind of the thought process. It's complex and that's why we're using Maggie as a case here to help walk us through that. But we, before we get that, I wanna break down the nutritional plan to a more of a four-step process because we, we skipped over some of the initial part.
So the first thing you're gonna do is develop a or have a nutritional assessment. We really need to see where that cat is today. We want to develop our wish list.
What I was, what I was saying that kind of the nutritional needs for each disease process, so we have a wish list of what we'd like, then we start looking at, are they compatible? And the fourth step is choosing that food and the feeding amount. We always want to make a thorough nutritional recommendation.
We can't just say the food, we need to give the owner more instructions, and we'll break this down a little bit more. So the nutritional assessment, I think Lisa already covered this a bit when she was talking about Maggie. We didn't go into detail cause we only have an hour here, but we need that more depth nutritional assessment.
So, we know already Maggie is on ZD or ZD if you're in the US. So, we know the food, but really we'd be looking at how much she's eating, how they're feeding, what the body condition score, the muscle condition score. We get that whole picture as part of that nutritional assessment.
And if you're not doing this, you're not doing a thorough nutritional assessment in your practise today, the World Small Animal Veterinary Association website has some great tools to get you started. They have diet history forms, nutritional assessment checklists. So, if you wanna kind of make sure you're looking at this, from this perspective, those are some great tools to get you started.
So once you can assess what we have going on with this cat, where those nutritional needs are falling, we're gonna create that wish list of nutritional features. Now, we're writing this out today. I typically am doing this in my head, so, it's just a mental exercise of what does this pet need.
For example, if we have kidney disease, we know we're gonna have to look at the protein level, especially if they're proteinuric. We're gonna look at phosphorus level. And then we're gonna think about things like fish oil, but we're gonna have that priority list of what we'd like to see for each disease process.
And sometimes it's not just that nutrient level, it could be ingredients because if we have a food allergy, we're gonna be looking at that dietary history, that nutritional assessment, and going, hey, what hasn't this pet been exposed to? Or maybe it's been exposed to a lot, and that's gonna change my nutritional strategy. So, it's all aspects of That food you may be looking at.
And then what we're gonna do is look at if they're compatible. So, We're gonna see, you know, do these needs meet up real nice. For example, in Maggie's case, we have chronic kidney disease and joint disease.
Fish oil, higher levels is great for both. The levels may be different, but that's an easy combination. So, once you kind of know What you're looking at, you also have to look at commercial foods versus homemade foods, and what is gonna be best for that patient.
So, if you're looking at a commercial food, these are real nice, they're easy to use pet owners. Can access them very easy. There's multiple forms, sometimes textures, flavours, so you can meet that cat's preference.
And often there's clinical studies to perform, to really prove the efficacy of that product. Homemade foods are great, but they have challenging, challenges. The owner has to follow detailed instructions.
There's a lot of measuring. And over time, owners tend to deviate from that initial recipe. They may stop giving supplements, so there's a technical challenge on the owner, and some cats really don't like the homemade food.
So it's really nice to think about what fits that pet best and what fits that owner. And just because the owner said the cat loves eating bites of tuna. Does not mean the cat wants a full homemade diet made with that.
It likes the little treats but maybe not a full bowl of that food every day. So it's something to keep in mind, cause owners sometimes are very enthusiastic about this cooking and creating foods, but it's really not what that cat is used to feeding. And then, if we're selecting a commercial food, we want to look first at comorbidities with compatible nutritional strategies.
So sometimes you can already find foods on the market. That are labelled and designed for pets with comorbidity. So, it's real clear, it's kidney disease and joint disease.
It is weight loss and joint disease. It's really clearly defined on that product. That makes it easy.
And then, you also have to think about for some of these cats with other issues, sometimes there's other benefits for that food. Maybe it's controlled minerals for urinary health. Maybe it's a controlled sodium level for heart health.
So, sometimes you have to dig a little deeper into the nutrient profile to really know. All of those other features, and that's where, helplines for the pet food companies can come into play. They can really help guide you when you have a lot of these cases to the right food with the right nutrient profile for your patient.
But it's also important sometimes, even though the nutrient profile is completely compatible, Doesn't mean it's available on the market today. So that's why it's always nice to, when product guides are available or There's changes to the portfolio is take a quick glance at that, see what the new offering is. So when you have patients come in, you at least have a quick understanding of what's currently available for that patient.
And then if they're incompatible, You have to make decisions. As I was saying on that flow chart, and on that bottom blue box, we have to start looking at quality of life, patient preferences, you know, where do we prioritise if this cat has chronic enteropathy and has horrible diarrhoea every time it switches foods, well, I'm gonna have to prioritise that because that's unacceptable for the quality of life of the cat, the pet owner, so we have to look at that individual patient. And where kind of that quality of life falls.
Maybe I want to do something, but I'm gonna have to manage it a different way because I have to prioritise quality of life. So You have to prioritise diseases sometimes, but I want to call out here is When you're making these decisions, we cannot mix necessarily two different foods. So, if we have a patient with kidney disease and GI disease, we're not gonna take a 50/50 mix of both foods and mix them because then we're going to lose that ideal nutritional profile for both.
And if it was a limited ingredient, we're adding a lot more ingredients to that food. So, sometimes, I can't say it would never be done. There may be a situation where a nutritionist is making decisions like that.
But we are looking at every single nutrient to make sure it falls where we want. But in general, that is not an encouraged practise for managing their nutrition. Usually, I would pick one food, and then if it's kidney disease, add phosphate binders or other things to make sure it meets that cats or dogs needs.
And then, we can't forget, while this is not part of the nutritional decision making, we can never forget that we have to transition these cats to this food. And this can be a make or break situation when it gets, when it comes to getting them on the new food. Usually, for many patients, we say a seven-day transition is fine.
But when you start getting, for example, cats with chronic kidney disease, GI disease, and other chronic issues, We want that transition period to be up to 1 month, 6 weeks in some cases, because we want them to stay on that long term. So if it takes a week for that cat to try the food. And then move on in that transition, that's fine, because we're making progress and we're gonna get there at some point, but we don't want to stress the cat out over this food transition.
So take your time on these food transitions, it's OK. We also wanna keep in mind that some of these pets may be at risk for a food aversion. So if you have a patient with chronic kidney disease, never transition them while they're in the hospital, wait till they get home, so that you can do that food transition in a stress-free environment.
And then when you're offering the new foods, sometimes offering a separate bowl rather than mixing all the food together can be more acceptable for that cat. Some cats may take mixing just fine, but others may prefer not having them touch. So just keep that in mind, and then always check up when you make a food recommendation.
So, usually about a one week, either they're coming in, someone's calling them, to say, hey, How did that transition go? Is your pet trying that new food? Because then you can coach them, get them to come in if you need.
You don't wanna wait till 8 weeks and you have a recheck, finding out there was no food transition, they didn't follow through on your recommendation. So, that 1 week can catch a lot of Problems early on and then obviously making sure the owner is monitoring intake, calling the clinic if there's problems. So now I'll pass it back to Lisa to talk about analgesia.
Thanks. I, I always love listening to nutritionists talk about nutrition. It makes me so happy.
I always learn something. And then we're gonna focus on the different analgesia options, for our cats that need help with pain management. And if you have practised for any amount of time, and like when I started, our options were incredibly limited in what we could use to manage pain.
And now, we have many more options to choose from. And there are multiple medications that we can safely use long-term. There have been guidelines published about using NSAIDs in our senior cats with kidney disease and non-senior cats.
So, we can be a little bit more comfortable using some of these drugs. There's actually been some, a couple of studies looking at, ENCor and potentially seeing a decrease in some of our, our renal values on blood work over time, whether that's just those cats being more active and moving, you know, we don't know the cause, but there was no negative effects from giving, at least that NSAID long term. So, don't be afraid of that as a good first line.
In Maggie's case, she's already on prednisolone, and we still don't wanna mix our steroids and our non-steroidals. So for her, unfortunately, NSAIDs are not going to be a really good option. We have gabapentin and we have pregabalin now as well available for cats.
I don't like this as a first line if, if possible. I don't think it's as effective for long-term chronic pain. And we also find that a lot of these guys with RCKD, this is a 100%.
Excuse me, really excreted drug, so I think I swallowed some spit. I apologise. OK.
So, we want to make sure we're cautious with our dosing in these senior cats and that we're not overdoing it, or decreasing our dosing if they have CKD. Calencia has been a huge game changer for cats since it's come out. It's incredibly effective.
It's lovely because it's a once a month injection, and so you're not giving it oral daily medication. It's not 100%, 0 my goodness, we can use this safely in every cat. I still think there needs to be some more long-term studies done just to make sure.
That there's not, no, significant negative effects. So just be cautious and monitor your kiddies on it. But this is something that we can feel pretty safe and confident using in these guys.
Opioids, while they exist, and I think they're a wonderful option for short-term pain management. This isn't something that I choose for my long-term patients. We worry about buildup of tolerance, we worry about a risk of constipation, which is already something.
Thing we're concerned about in our CKD or DJ out, you know, sometimes risk of, of that caregiver potentially abusing us. So, this is more my short, short-term hospice or after surgery, but this isn't something that I'm gonna put these kitties on for life. And there's been a limited amount of research in dogs and humans.
Nothing in cats about microdosing of ketamine. There's been no study showing that it's efficacious. Anecdotally, some people say it does seem to work.
So, it's something I think we should have on our radar for the future. But it's not something that I would recommend at this point because we don't have the scientific, backup there with any of the studies. And there are other pain modalities that should be considered other than just giving medications.
So supplements, specifically our fatty acids, and in cats, DHA is, is the one that we really like to focus on. And this is something that we can give as an, as an oral supplement, or if we're choosing a diet that has a therapeutic amount of this in there, it's one less thing that we have to give that cat as a medication or supplement daily. So that's something that we can look at with our kitties, and trying to decrease that polypharmacy and caregiver burden.
Things like acupuncture have been shown to be effective, especially in these chronic pain kitties. So, I know, you know, if we can find someone or if you are able to do acupuncture in some of these cats, definitely something that can be effective as part of our multimodal management. And then, cold laser therapy can also be really beneficial in these guys as well.
We have found that glucosamine chondroitin, I think you'll notice this is lacking on this, slide here, has been really nothing more than a placebo effect in people, and similar in animals. So we're not really utilising that, strongly for our joint support. It's absolutely not gonna Hurt these guys.
And, you know, it's, it's, but it's just one more thing that these caregivers have to worry about. So, if they really want to give it, it's totally fine. But there really doesn't seem to be as much benefit as we initially believed.
So, that's unfortunate, but something to keep in mind as well. And then lastly, but it's not the least important is we have environmental changes. And we utilise these along with everything else we're doing.
So, a lot of these are going to make a lot of sense to you, but sometimes it's something that the caregiver doesn't think about. So, I was just talking with a colleague yesterday, actually, and she mentioned she had a cat who was 17, a patient, and he was presented to her for inappropriate elimination, and she was a, she's a house call veterinarian, and when she went to the house and looked at the litter box, it was one of those big plastic tubs, and they didn't have any cutouts, and the cat had to jump in over the sides. And so, of course, this cat did not want to jump, the 17 year old cat over these, you know, tall sides.
Because it was painful. So, making sure we educate about what good environment is. So that low entry litter box.
And we don't want to pile in tonnes of litter. Walking on sand for us is a little rough on our joints, and deep litter can be a little bit difficult for these guys as well. I want to make sure they have lots of places to rest.
I love those like heated mats that will, when they, they're pressure sensitive, so when the cat or dog lays on them, they will like warm up. My cat uses hers constantly, even in the heat of the summer, it's her favourite. She's 18.
And we want to make sure that they have accessible resources. So, you know, they're not keeping that food and water up on the counter to keep it away from the toddler or the puppy, or they're not living in a tall, you know, 2 or 3 story apartment or house, and have that cat spend most of the time on the 3rd or 2nd floor, and then the very bottom floor is where all of their resources are. We want to make sure that everything is kind of kept localised to where this cat spends most of their time.
And we want to make sure that things are kept close together, but not directly on top of each other. Cats don't like to eat where they defecate, and just similar to us, they don't, you're not gonna have your, your dinner in the bathroom. So, even though they're close together, there's still enough separation that there are separate places.
And then as these cats get older, they're not going to want to groom as much. So making sure we're helping with that, so they don't get matted, which is gonna increase their discomfort. Sometimes that's as simple as brushing, sometimes we have to shave them.
It just kind of depends on the cat. And low impact play is great for them. You know, cats have different preferences on toys.
The only thing we we typically recommend avoiding is laser pointers cause they can kind of obsess over that. There's no satisfaction of catching that little red dot, but feather toys, sometimes throwing treats around, we want to Make sure that we're maintaining that muscle mass. And then providing other stimuli.
And that could be as simple as an open window that they can look out of, or a back porch they can go out onto, or if they are safe going outside. YouTube has great kind of TV channels. Sometimes that stimuli is just interaction with the caregiver.
It just depends on what that individual cat's like. And then we wanna make sure that we're keeping their nails trimmed so they don't become ingrown, as that's a common issue with our older kitties. And then we can think about things like sta steps, ramps, and then raising the food and water bowls up, oh, maybe 6 to 8 inches.
I'm sorry, centimetres is not, I'm not great with centimetres off the ground. So they don't have to bend over and squat as much when they're eating their food. So we've covered our four kind of big categories, and so we can take this back to Maggie and see how we can kind of put this all together and figure out what, you know, what she needs for each condition, and then we're gonna develop a plan for her.
So, we'll start with her CKD. So, our overall management goals, we wanna make sure that we're managing the proteinuria. If she is dehydrated on presentation, which 40 to 75% of cats with CKD present with dehydration, we wanna make sure that she, we, we, we rehydrate and maintain hydration.
We wanna make sure that we're maintaining her appetite to hopefully help prevent some muscle loss, and then we want to control or monitor any anaemia that's occurring for her. So when it comes to dietary recommendations, we wanna make sure we're supporting hydration. So ideally, you have some kind of wet food if the owner and the cat are both interested there, and ideally we're gonna offer a renal food.
So these are specially designed foods with controlled protein and phosphorus, increased potassium, they're typically alkalalizing, sodium is kept in moderation. They have a high calorie density. Cats with CKD tend to lose weight.
They are actually losing weight prior to their diagnosis in many cases, so we really want that high calorie density to maintain that body weight. And then because of the gut kidney access that we know about now, we want to provide fibres to help support, the microbiome in this disease process now too. And then with our medications, if that controlled phosphorus level isn't enough, we might need to add phosphate binders, and these are all as needed.
We're never just gonna throw all of these at the cat. This is only on an as-needed basis. If they're proteinuric, our ARBs or ACE inhibitor.
Can be very beneficial. We have our modulostat, which is good for anaemia, and then controlling clinical signs. So antiemetics, appetite stimulants.
We talked about fluids and just anything else kind of to help, Maggie feel better as needed. And then we're gonna reassess her weight, but we're also gonna look at her body condition score and muscle condition scores, checking to see if there's any muscle loss, checking our blood values, and getting a good overview of her quality of life at home. So, that can happen depending, a minimum every 6 months, but as she progresses with her CKD we'll find that we may need to do this more frequently.
So with our hypertension, our management goals, we want to detect this as early as possible, so we're not causing permanent damage to those target organs mentioned before, eyes, brain, and kidneys, obviously cardiovascular system, and there are other ones. And up to 65% of cats that are hyper or that have CKD are also hypertensive, so they definitely go together commonly. And we also can see some proteinuric, proteinuria with these hypertensive cats.
Our long term goal is to get her to 140 millimetres of mercury as management, but we're OK if it's 160 or less in the beginning. OK. So, sorry, typically, I mean, there's, there's a limited amount we can do nutritionally for just sys systemic hypertension alone.
Typically, we're recommending sodium moderation, but the literature, there's not a lot to support a specific level of sodium. Sodium. So we tend, tend to avoid very high sodium foods, keep it in more moderate level, and then obviously if there's proteinuria, then we have to look at the protein level of the food as well, but that's more of the secondary consequences to the actual hypertension.
And with our medications, there are a few options available. Calcium channel blockers are kind of what I like as my first line, but I also like to use it either with telomemisartan or an ACE inhibitor, which I'm probably worried about our renal, issues as when I'm thinking about that. Propranolol is on the list, but that's really only for our severe refractory cases.
You almost will never need to reach for that in a cat. So, there are multiple options, and we can dose it till we get where we wanna be. And we wanna be cautious that if we are managing something like anaemia, that we're watching that hypertension because we can cause an increase in blood pressure when we are in, treating our anaemia.
And with our reassessment, you'll see it's gonna look extremely similar to our CKD reassessment, but we're adding blood pressure in there as well. So it's not like we have to do a tonne of extra things, we're just monitoring the condition, when she comes in. I would say in the beginning, you want to check their, their blood pressure a little bit more frequently, but once they're stabilised, you know, and if they've been stable for a while, every 6 months is OK.
But usually in the beginning, you wanna be a little bit more frequent with your checks to make sure that you don't have any significant damage. So with our chronic inflammatory neuropathy, luckily for us, Maggie came in already managed. But we want to control her clinical signs.
We want her to feel better. So no vomiting, no diarrhoea, no weight loss, and maintaining that muscle mass as well. And similar to chronic kidney disease where they lose a lot of weight.
Chronic inflammatory neuropathy cats tend to lose weight as well. So, really wanna make sure we have that maintenance of muscle mass and body weight. Now, for dietary recommendations, especially when a cat is already well managed on a novel or hydrolyzed protein food, probably wanna stay on that food, but there are other strategies available to see what works best on the individual patient.
This is one of the conditions where What that cat responds to best is gonna be unique based on the cat. I, it's, sometimes I can tell based on clinical signs or kind of what they responded to in the past, but sometimes it is trial and error with GI disease. But fibre enhanced foods, highly digestible foods can also be used, but we generally are recommending.
A dietary change for a newly diagnosed chronic inflammatory neuropathy. And then, because we know there can be dysbiosis and changes to the microbiome, we really wanna make sure we have adequate support for the gut bacteria as well. And if that's not enough, which ideally we can manage with diet alone, we can use prednisolone, which Maggie did need periodically, intermittently for her case.
And it's always a good idea to consider cobalamin supplementation, even if you're not testing. It's, you know, B12 is not gonna hurt anybody. And then probiotics can be beneficial, but if we're not feeding the good bacteria, then, you know, I, for me, I've, I'm always more interested in trying to feed the, the that animal's individual microbiome and supplementing externally, but we can see definitely some benefits from probiotics as well.
And then same thing with our reassessment, we're just looking at our clinical signs. We're not gonna like re-biopsy, we're probably not gonna re-ultrasound every single time, but how is Maggie feeling? And that's our big thing with that.
And then lastly, her DJD. We want her to feel better, we want her to move better, and if we can slow the progression of the disease, which it's really hard to say if that's effective cause we're, we can't compare what would have been if we didn't intervene, but that's, we're hoping that she stays mobile for longer, and so we can do that with our diet. And so typically, we're recommending high levels of omega-3 fatty acids, so the EPA and DHA in cats, it seems like DHA is the more influential.
So, that's when you're looking at the foods on the market that are already supplemented, we know you have enough DHA if you're adding supplements on top, which sometimes you may need to. That, ratio of EPA to DHA may vary depending on the product, so it's something just to to watch out for and then antioxidants as well can be beneficial, but usually DHA, but fish oil in general is my general nutritional recommendation. I already mentioned, the analgesia, and what we would choose for Maggie.
We wouldn't use an NSAID because she's on prednisolone, but if she was not, that would probably be my first choice. And just to keep in mind when we're doing pain management, we're never stopping one and adding another one. We're always going to add one more to what we're already doing.
We never wanna take anything away. And again, looking at a reassessment, it's gonna be exactly the same, except we're gonna be a little bit more focused maybe on her, her clinical signs of pain here. And this, we can check in, you know, if she is on an NSAID again every 6 months to monitor, but we're, it, it doesn't have to be very frequent for DJD.
OK, so, when we're looking at all of the nutritional needs, I have laid it out so we can all be on the same page in the next part of the discussion. So you can see here we have our nutritional needs for CKD, DJD, hypertension, and chronic inflammatory neuropathy. And luckily, we don't have any severe like conflicting nutritional needs.
We have some very unique ones if we're using a hydrolyzed protein that kind of narrows down options, but we have a lot that match controlled sodium in CKD and hypertension, DHA and EPA and CKD and DJD. So, I think we have enough here that overlap. So, what we, I would do now.
And look at what commercial options are available to me. And so, here I've listed, this is what I would do in practise, is kind of get out the product guide and say, hey, what options do I have? And so you can see here in the red box, we have prescription diet ZD because that is where we're starting today.
So, you can see the protein, phosphorus, sodium, EPA, DHA. These are the things I would look at, but this is not inclusive of everything. As a nutritionist, I would, but this is some general guidelines.
So, we, we start with kidney disease. I put KD and KD plus mobility here because they may be options and also GI biome because that's a different type of strategy for chronic enteropathy. So, let's just see how this Compares.
So we look at kidney disease, we're generally going a little bit on the lower side with protein. We have to be careful in cats. We're not restricting the same level we do in dogs, but we do want that controlled level.
And you can see here in the kidney diets, we lower that phosphorus, which is nice for managing kidney disease. GI biome doesn't provide any benefits on lowering the phosphorus content, so we're not getting any kidney benefits there. If we look at the sodium level, they're all very moderate.
Usually I'm looking at around that 100 milligramme mark, but that's, again, a little arbitrary but that's generally what I'm pulling from other literature saying, hey, that seems like a good level, no concern here. If we look at EPA and DHA and I'm gonna think about the joint disease cause that's usually where I'm wanting the highest levels. You can see here that KD plus mobility has the highest levels, but even moving to KD would increase that level a bit.
We look at dietary fibre, because she's on a kind of a lower, highly, lower level fibre, highly digestible, I don't necessarily wanna move that fibre level anywhere because it's well-controlled disease right now. You can see GI bio, different strategy, much higher fibre level. So, I'm happy where she is there.
I'm happy with the protein source that hydrolyzed chicken, liver, and rice seems to be controlling signs pretty well right now. And then all of them, we have a web available. So here you have options.
You, you could stay on ZD, add phosphate binders, you could go to KD plus mobility, cross your fingers, have a slow transition C. If the GI signs are well controlled, neither one is an ideal situation. This is why it's nice when new products come on the market, because when you have that combination diet already made, You have a lot more of a tailored, very specific nutrient profile to work with.
And you can see here, prescription diet KD plus hydrolyzed protein is a food that's been available in the US for, at least a few months now. And is coming to Europe next year. But this option allows us to really get the protein level we want, that restricted phosphorus were decreasing, even from the ZD product she was starting on, so that's already an improvement.
Sodium stays consistent. While the EPA and DHA is not as high as KD plus mobility, it's still better than the previous ZG she was on. So, we're already getting some, and if needed, we could always add a supplement to hit the levels in JD or the KD plus mobility if we wanted to later on.
But we keep that same controlled fibre level, we keep the same protein source that she was already responding to. So, it makes it a nice, easy choice to say, hey, we responded well to this food. Let's just pick the option with the lower phosphorus protein to address the kidney disease without disrupting what's already working.
So, it's always nice when foods like this are available. It makes that clinical decision making a little easier. And hopefully less medications, a little less caregiver burden, and also burden on the cat.
Save that extra medications and steps for as the disease progresses and you need to add things on that are critical for pet health. So just to summarise for Ms. Maggie, what her treatment plan looked like, for her hydration, we did add, subcutaneous fluids.
That's the official dose, but it ends up being around 100 millilitres per cat, as needed. I always start low with Maggie, I started at about 1000 mLs a week, and then we increased either to twice a week and then every other day as her kidney disease progressed. And then we did our water management, and luckily for us, Maggie did eat her canned food.
This is what we were looking for again to summarise with her nutrition. So, this is what Maggie ended up on. She is a US patient, so it's already available.
So I, we do have that option for her. Maggie was started on Calencia, and then we used gabapentin or pregabalin, as needed, when she was having bad days. And then we did all of the environmental things with the caregivers that we talked about and just giving her a little extra TLC.
So that, that was kind of following our steps of what she looked like. For her hypertension, we managed it with amlodipine and telmisartan, and we continued her prednisolone as needed if she had any flare-ups, for, with her chronic inflammatory enteropathies. So, our key takeaways is, these are hopefully guidelines.
We looked at Maggie's specific case, but each patient is our individual. So, we really want to look at a comprehensive care plan for that cat. We are not treating a disease, we are treating a patient and with a caregiver.
And so that is going to be unique in every case. And we just need to make sure that we are, keeping all of those needs in mind. And then what we start with doesn't have to be what we continue with.
So we can change things. It's not, that's definitely not wrong to change medications, to add new ones, to change diets, as long as we do it properly, and explain with that caregiver why we're making these changes. And then we're focusing on Maggie, in Maggie's case, we wanted her to feel better.
So we want to control GI signs, help with her mobility, help with her feeling. Feeling like a normal cat for as long as possible. And then we do that by managing things like hypertension and, and renal function and things like that.
But what we see is how she feels, and that's really what our primary focus is here. So hopefully, this was helpful to kind of get a perspective of how to do something like this in practise. And I think we have a few minutes now to go over any questions.
Thank you very much Lisa, thanks Becky, that was really, really good, I think we've got some questions coming up. Let me see, what if the owner has already a homemade food they give for dinner, they say yes, I will give you that commercial diet, but you know at home they do it only in the morning but keep the dinner ritual. It's got to be better to do half than nothing, hasn't it?
Well, while it's better to have at least part of the nutrition complete and balanced or tailored to that, I think we need to start talking to the owner about, depends on what they're doing as well. You might get more information about what they're actually feeding. Is it something that may be actually helpful to the pet?
Certain Nutrients, like if we're giving liver, we're, we're gonna start getting high levels of, for example, maybe vitamin A. So, looking at what they're feeding, because maybe there's some concerns that you can address with them, and maybe there's a small percentage they could still do, but maybe we substitute it out for a little bit more of the right nutrition and work with the owner on how that plan would progress. So, I wouldn't completely let it go, but I might start digging in and getting them to tell me more.
Brilliant, thanks Becky, coming through fairly quickly now let's see if I can make these a bit bigger. To spot them Do you manufacture a diet for cats with CKD, DM, hypertension, and OA? Oh, that's a lot of diseases in one.
I, in the US I believe the multi-organ, has a little bit of a compromise in the nutritional profile for CKD and diabetes mellitus. It's not perfect for each one, but if you have Early chronic kidney disease. This is a nice food with higher protein, a little bit lower carbohydrate.
I mean, it's going to be controlled in sodium, but it doesn't necessarily have the exact level of EPA and DHA for joint disease, if I'm remembering correctly, but I believe there is still a good amount in there. So if you're in the US there was an option. In Europe, there's not a good choice right now, but maybe in The future will have that here as well.
We have somebody asking anonymously, I seem to have missed something at some stage, but is it safe to give meloxicam to cats with CKD that's a fairly new thing cos I think we always used to say no it wasn't, but I've seen and and heard more people saying, you know, and, and I think it's really important to keep a cat comfortable, isn't it, so. If somewhere down the track there is a problem, but it it's giving good quality of life in the here and now is important as well, isn't it? And we can never say, oh, it's 100% safe in all cats with CKD to give meloxicam, but there are published guidelines for using it in our CKD cats safely.
So, it's in the feline Journal, it's open access. I think it was a few years ago now, but it, they, you can, use it with correct dosing and monitoring, in most cases. Obviously, there's exceptions.
We have, are we allowed a a dog question or are we gonna stay just on cats? I can't answer a dog question, but if it's nutrition, I'm sure Becky can. I probably can.
Actually we've got Sarah who is saying she has an interesting, case. How important is it to restrict fat in the diet of a dog when pancreatitis has been an issue, but we also have CKD DJD, and hypertension going on. And I, I think that may depend on the dietary history too.
Was it on an extreme high fat level when it had pancreatitis? And was it an acute episode and then completely resolved versus chronic pancreatitis? I think when you have diseases like chronic kidney disease, that fat level is pretty high.
So you do want to use caution. If you're going that route, there are some depending on where you, you live, I think there may be some options that maybe are a little lower in fat. So that's when I'm calling the consultation services for the pet food companies are really helpful because you can tell them, hey, I'm concerned about this fat level.
What other options do I have with a little bit lower phosphorus to start? Or also really, really slow transitions, to monitor their tolerance to that fat level. So it's, it's a balance, but there's no perfect low fat kidney disease.
Combination where you can get the same ultra low fat nutrition. Thanks very much Becky, Claire is asking, do we need to be careful with fat content of fish oils and chronic enteropathies? I think fish oil, sometimes you can see GI upset when you're starting fish oil, so it's something that we want to be, use caution, when you're starting high fish oil food, but especially if you're adding it on top of the nutrition, because then you are adding a lot of extra fat to the diet, and if it's already a moderate to high fat diet, we're adding a lot of extra fat.
It also adds calories too, so you may be predisposing that pet to gain weight. So it's, it's something where if it can be included in the food, I think you're usually good with that level, but just slow transition to get them adjusted to that. And just from a cat perspective, they usually don't like fish oil.
It's not palatable, which is interesting, and we think it might be, but they typically don't enjoy it, so we have that aspect as well, just to keep in mind. Yeah, really interesting, you started off with something perhaps we, we forget and class, don't class as nutrition, but you know that hydration level. Somebody was asking the question about the water supplements, that you were recommending for azomic patients or for, you know, obviously any cap that you want to just, increase palatability of the water, are you aware of any brands that you would recommend that the Hills do any of those products?
I don't, I think, I mean, I think Purina has the hydrocare, but my biggest issue again was cost. Like, it was, it ended up being at the time, which is a few years back, like $60 US dollars a month. And when you added that on to everything else that these caregivers were doing, my compliance with them was fairly low.
Just because of that aspect, not even covering whether the cats would eat it or anything like that. It was purely just like one more thing for that caregiver to worry about. So I think they're, they can be really beneficial, but it was like one of those, it was like, OK, well, if we have to cut back on something, that was probably where I was going to make the cut to start.
Brilliant, let me see if there are any others that we haven't covered, . I think we've covered most questions there, if obviously anybody has any extra questions and you email those, well Anna's actually just maybe to finish, which phosphor binders are do you recommend? This is like my, one of my favourite things.
So, I typically steer clear of any calcium-based phosphate binders because of metabolic bone disease and the risk of hypercalcemia, so I don't really use those at all. Historically, aluminium hydroxide was kind of my go to, but you can see an increased risk of constipation. Now, there's like a new, kind of group of them.
So Catney1 being in that group, and that's been really effective, and pretty palatable, and, and so very well accepted. So that's kind of been the go to for where we are now, just based on, on acceptance in the research, so. Thank you so much, thank you again for the great webinar, people have really enjoyed it.
Thank you obviously for Hills for sponsoring it as well. This will be going up on the site within the next 24, 48 hours, you'll have a chance to get your, personalised certificates. If you've got colleagues in practise who want to have a look, then it will be on the site, as I say, within the next 24, 48 hours.
Just thank you everyone for listening, hope you have a great rest of the day wherever you're listening from. We've had people, listening from, from all over the world, Lisa and Becky, so thank you again for, for sponsoring and, and giving such a, a great talk. Thank you.
Thank you for having us. Yes, thank you very much. Cheers, take care.
Bye bye everyone.
