Good afternoon everybody, and thank you very much for joining us today, be that live or watching this as a recording. If anybody does have any questions for our speaker, Lisa, please put them into the dedicated Q&A box. Or if you have any comments or any other queries, please use the chat box.
So I will now introduce you to our wonderful speaker for what I know is gonna be a really wonderful presentation. So, welcome Doctor Lisa Estein. Lisa grew up in New Jersey and earned her Bachelor of Science in Animal Science from Rutgers University.
She received a DVM degree from Western University of Health Sciences in Southern California in 2014. And Lisa began practising feline medicine right after graduation at a cat-only practise in San Antonio, Texas. In 2020, Lisa achieved her board certification in feline practise by the American Board of Veterinary Practitioners.
During her career, Lisa has lectured veterinarians both nationally and internationally, and served as co-editor of the sixth edition of Veterinary Feline Textbook. She joined the Hill's team in October 2023 as a feline Professional Veterinary Affairs Affairs Manager, and in this role, Lisa works with veterinary healthcare team members and pet parents on a global scale to educate and improve the health and well-being of cats. So welcome, Lisa.
Thank you very much. I'm really excited to be here today. And we're gonna talk about, our senior kitties, specifically our renal senior kitties, and how we can get them to eat.
And we know that cats are notoriously picky and can be a little bit finicky, and there are a lot of ways that we can work around that and kind of get in their heads and help them to help themselves. So, in order to help our cats when they are ill, we really need to understand how they taste and what they like, their eating preferences, and we'll do a basic overview of appetite because I think that's really important to understand. And then what we're looking for specifically with our senior kitties, and this will apply to most of our renal cats as well.
I mean, there are a few that will not be seniors, but the majority of our, our renal cats are seniors. And then, I'm just gonna touch on a brief overview of some of the chronic kidney disease, just so we have, have it in our heads. And then, you know, what do we do with this decreasing appetite?
How do we manage it? What are some tips and tricks that we can use? So jumping right in, we, we, we think about taste and really, you know, we, we like different things.
Everyone has preferences. But this was really developed in order to help animals decide what is worth eating. So, is, is what is going in my mouth toxic or harmful to me?
Is this going to be beneficial? They've actually, done studies, and cats and dogs can kind of assess how much fat and protein and carbohydrates are in certain, food, foods, not the processed foods, but materials and meats and things. And, you know, it's not gonna be perfect, but they kind of know what they're eating and how to balance their own diets.
And for cats, they're a little bit different than dogs and people. They do not have nearly as many taste buds. So, for them, odour is really, really important.
The taste that they actually do prefer is umami, which is the flavour of tuna. And their sense of smell is 14 times stronger than ours. So they really taste through their nose.
And when you kind of come back from the clinic, and I don't know what you touched that day or whose anal glands are on you, and they kind of do that cute little open mouth breathing. That's called the phlegm and response, and they're essentially cataloguing everything that you touched and you did that day through scent. So they can really get a lot of information just through their nose.
And so, if they do not like the odour of the food, then they are not going to eat it. And if they do like the odour of the food, they're gonna continue to eat that food, and it's really unlikely that they're going to swap to a different food, because they already know that they like what's in front of them. They're very change averse, as, as we know.
When we talk about our palatability with cats, unfortunately for us as veterinarians, these develop as kittens, and they're usually pretty young. We don't have an exact time frame, for when they stop developing these preferences, but it's through kittenhood and weaning, and some, some sources say up to 6 months, some say up to 9 weeks. So, sometimes it can be even before that first visit, if you, depending on what you read.
And that can make it really difficult. So, sometimes, it can be harder when they're older if we don't, you know, kind of get them to develop really good preferences when they're younger. So, this feeding our finicky renal cats actually kind of starts with our kittens and having this conversation with our new cat parents and saying, hey, it's a really good idea to offer your kitten different flavours, different textures, different types of food.
And, making sure, . That everything is, like, available for them to try. And cats are really interesting where they will actually choose what their mother prefers over other food that they may, we may think they prefer.
And my favourite study to kind of demonstrate this is a study where they fed the mother cat bananas. And there are certain medications. That are flavoured like bananas, and cats do not like bananas typically.
But this particular mother did like bananas, and all of her kittens then went on to like bananas because they saw that mom ate it and had good preferences. So, it's, it's really, really important that this conversation actually starts as young as possible with our, our, patients that are coming in before we need to worry about their appetite and what they're eating. And unfortunately, we also know that hunger has nothing to do with whether or not cats will eat.
So, the, Cats will starve themselves. Like, you can't just change their food and say, well, you know, eventually, they're gonna start eating it. We know that that's not how cats work.
They will just leave it alone, and then they make themselves very sick. So, we are really cautious with our transitions. When we talk about our food transitions, we do not want to do it suddenly.
You know, as, as far as GI goes, like, you know, we say, OK, over a week to make sure that their gut doesn't get upset. But some of these cats, especially these senior cats, and especially these renal cats that already have appetite issues, the transition can take months to fully do. And the best way to kind of tackle that is to have that conversation upfront and set expectations.
Hey, it's OK if your cat does not like this food right away, you know, that is normal. And That is the best way to have a good transition, because as they age and they're older, they can't smell it, so it doesn't smell as appetising, even if it's delicious, it's new, and if they've never had this type of food before, they're probably not gonna want it as a senior. So, it's, we need to try to help with kind of mitigating some of those things.
And when we talk about our appetite in these cats, you know, it's not just like, well, I'm hungry and I'm going to eat. Appetite is affected by a lot of things, you know, what kind of food they're used to eating. So, canned, dry, is it available all of the time?
You know, if you're used to waking up every morning at 7:00 a.m. And eating a huge breakfast, you are going to feel hungry every morning at 7.
A.m. But if you fast through the morning and you really don't eat breakfast, your body is going to learn to not really feel hunger during that time.
And cats are very similar. So, their routines play a big role into how they feel hunger and, and when they want to eat. And then on top of that, what they're eating, and if they like what they're eating, and the environment that they're eating it in, all factor into, am I hungry.
So, You know, that's something to consider. And when we have a cat that comes in and, you know, the, the client might say, hey, you know, Fluffy's not eating very well, these are some of the things we need to ask about and ask if there have been any other changes, because that can also factor into how we get them to eat more in the future. And we'll touch more on, on tips that we can use to do this practically, but this is really an important part of your history.
I'm not gonna go into details because this is like very, very high level for appetite. But there are a lot of things going on in the body to make you feel hungry and to make you feel full. And they all work together and, you know, there are disease processes that can kind of make these not work as well.
I mean, we know things like ghrelin, we actually use our ghrelin analogue to influence appetite. But there's a lot of things going on that we just kind of need to keep in the back of our head that, hey, this is, appetite isn't just a feeling. There are hormones and things that control this, and we need to be aware that that is, could potentially be affected by, you know, in this case, kidney disease.
And then there are other factors that influence appetite. And I, I hate looking at this picture, this lecture, and every time I look at it, I can smell it. But, you know, these cats that are, you know, have chronic kidney disease may also have other things, you know, they may have dental disease, as you can see here.
This cat was not eating, very well. Once we took care of what was going on in her mouth, she was a lot more comfortable and much, much better at eating. You know, we have things like diabetes, thyroid disease that are gonna increase their appetite.
They could have concurrent GI disease, which may cause an increase or decrease in appetite depending on how they feel. We use medications to affect appetite, but there are medications Obviously, that will decrease it. You know, antibiotics can cause nausea and things like that.
You know, some of the medications may not have a good taste to them that we're using, and so that can change how they want to eat. And then we have our environmental and social factors. So, the example I like to use here is, my, my old lady, she's 17, and for 17 years, she has sat by like the edge of my doorway or down the stairs, wherever I'm living, and waited for me to come and watch her eat breakfast.
She has food out free choice, and she just likes me to stand there and stare at her. She, she is a social eater with humans. And then there are those other cats that, you know, you'll ask them, are they eating?
And the client will say, well, the food disappears overnight, so someone's eating it, but they never see them at the food bowl. So those again are just really important questions to ask, to try to figure out what type of eater this cat is. Most cats prefer to eat alone, but you will have those social eaters, and And, you know, are there resource, you know, availability issues?
Are there 5 cats and 3 food bowls? Are all the food bowls right next to each other where they're not, you know, able to really eat in a comfortable way? Is this, is this like a really, you know, big house with 3 stories, and the cat spends most of its time upstairs, and the, you know, the food is, you know, 2 levels down.
And yes, this cat might have some arthritis and, and other issues where it just doesn't want to move around the house, so. There's a lot of factors that may discourage that cat from eating as well. So, you know, again, like new puppy or baby in the house, we keep the cat bowls on the counter.
This older kitty is probably not gonna want to jump on the counter as frequently to get to the bowl. So that could also be a reason why that we have a decrease in our appetite. And again, I'm not gonna go into a lot of detail, but we just need to remember that cats are different.
And, you know, when we're talking about their appetite and what they need, it's gonna be different than dogs or, and people because they are carnivores. And I think the big ones that I like to kind of stress here too is their GI tract is shorter, so transit time is less. So that, that's something to keep in mind too when we're talking about how often they should have bowel movements, you know, ideally, it's at least once a day.
And then we know, kind of, you know, they, they need Tori and they need the, you know, these things that are, you know, that are unique to cats, and, you know, I'm not going to stress about that because that's going to be in all of our complete and balanced foods. What we really do need to focus on is our senior nutrition. Like I said, most of these renal cats are senior.
And in the world of the cat, the, their resting energy requirements, or their RAR, which is just the energy it takes for them to exist, on a day to day, at the age of 12 starts to increase. So, it just is going to require more energy for them to be alive. And unfortunately, as they age, their ability to break down fat and protein is going to decrease.
So 33% of cats are gonna have a decreased ability to break down fat, and 20% of these cats over 12 are gonna have a decreased ability to break down protein. So we don't want to restrict these things in the food. They're also huge in palatability.
Cats prefer fat and protein tastes versus other things. And, you know, we worry that, you know, we don't want to overfeed protein because we get nervous with, with hearing protein and kidney disease, espe especially in cats. But if we don't have a renal cat, and it's just a regular senior cat, we don't need to restrict protein.
We can feed, you know, a normal amount. But we do know that our renal cats cannot deal with protein in the same way. And so what we're looking for is a food that has controlled levels of high-quality protein.
And, and the way I kind of break it down and, and think about it is, protein is the big picture, and we're looking at the amino acids, which are our building blocks. And we don't, they don't need all of the amino acids, they need their essential amino acids. So we want to have those in a really high amount.
The amino Amino acids are actually gonna be useful and decrease that, those excess or waste amino acids that are in there. And so they don't have to philtre those out. So, they'll get all the essential amino acids they need.
They're not deficient in protein, but those kidneys don't have to work as hard to philtre things. And that's kind of what we're looking for when we're talking about our, our senior nutrition, specifically with our amino kidneys. We also really want to include omega 3 fatty acids.
This can be kind of difficult because you would think that cats would enjoy the taste of fish oil, but most of the time they do not. But fish oil is very helpful for a whole host of issues, inflammatory conditions, cognitive conditions, joint, issues. So, we like to have food with omega-threes in there.
We like L-carnitine, which is really good for muscle function and keeping lean muscle mass. And then antioxidants are really good for our renal kidneys as well. With our CKD cats, we obviously wanna have an increased moisture in the food.
So, either doing a canned diet, if that cat will tolerate that and that client will tolerate that, or, or adding some extra water to the canned diet. Again, that's gonna change the texture, so they may not want to eat it. So we have to be cautious with what we do.
And then we do not want a diet that's high in sodium. The cats do like the taste of salt. It's easy to make a cat eat a, a diet that's really high in salt, but now those kidneys are gonna have to work harder to philtre things out.
And if they have underlying heart disease, it's gonna put more strain on the heart as well. So, we don't need a low sodium diet, but we really want to avoid anything that's super high in sodium. So, when we look at all of this, now we're saying, OK, well, we kind of do want to restrict a little bit maybe of how much excess protein is going in there.
So that's gonna change the taste, and we're not giving as much sodium, so that's gonna change the taste, and cats don't like fish oil, so that's gonna change the taste. So, we, we work really hard to make sure that, you know, the diets are palatable, but it's going to taste different. And that makes it new, and they might not want to change to it as easily.
So, when we do, again, when we do the swap to our senior foods, I usually will tell people minimum 2 weeks. And I know a lot of the, the bags will say 1 week, but I say like, just give them 2 weeks. Like, let's just take our time.
We don't wanna mix the foods together. And like, you don't wanna eat your tuna and your, your, like, ground beef in the same bowl. Like, but it's just not, it does not taste good, and it's gonna mix smells.
So, we have the two bowls side by side, old bowl, new bowl. I recommend usually rotating every day, which, which food is in which bowl after cleaning them. And then slowly over time, decreasing the amount of that old food that's available, and, and switching them over to the new food.
And like, like I said before, I, I always give the warning, hey, this can take a couple months, and that's OK. It, we expect cats to be a little bit difficult when it comes to this kind of thing, and, you know, it just makes your cat special, and, and people really kind of, I think, appreciate the fact that their cat, you know, that their, their cat is similar to other cats, but also unique in their own way, and I think it's really helpful to set those expectations up front. So now we'll jump into the, our brief overview of, of kidney disease, which we just want to review so we can remember.
I, I'm not gonna spend a tonne of time and this is not gonna be super detailed, before we get into our final part, and go into the actual feeding guide and, and tips. So we know this is super common. You know, this happens in, in a lot of older kitties, kind of, you know, I used to tell my clients, like, if nothing else happens, like inevitably, it'll be your kidneys, for your cat.
It's very, very different than canine renal disease. We see, it, it, it, the kidneys, tend to do a little bit better for a lot longer. The dogs are, are on a much more accelerated path with their chronic kidney disease.
We see a lot of interstitial inflammation, and some of glomerular hypertrophy, but not nearly as much as we see in dogs. And then it's like those small lumpy kidneys that we can palpate in these older kid, in these older cats. And as of right now, we don't know why this is so common.
But there are some theories to that. And These are, we know that it goes through the this initiation phase, and these are some of the things that kind of go along with that. And some of these make sense, you know, they put, you know, polycystic kidney disease and, and amyloidosis.
And so those are big on there. And yeah, that makes sense. If there's a disease affecting the kidneys, they're going to have problems later in life.
But then they throw like ageing on the list, and I'm like, well, that's kind of a cop-out. I mean, yeah, sure, you can't say old age is a disease, but it is considered part of that initiation phase. The big one that we should think about, I think is like the ischemia and acute insults.
And so when you have these cats that come in, you're blocked toms, that have, you know, they're in full blown, kidney failure when they, when they come in, we can get them, their kidneys back to normal on paper, but there will always be scar tissue, and residual issues from that event. And we think that that's gonna predispose them to chronic kidney disease later in life. You know, we don't, again, we don't know, but we can suspect an ischemic insult, so low blood pressure during surgeries, you know, a lot of that blood flow will go straight to the kidneys.
And if we lose some of that blood pressure, Then we're gonna see, you know, we're gonna see those kidneys potentially develop an ischemic insult, and that can happen during a spay or neuter. So, we just wanna make sure that we're careful with, you know, our spays and neuters when they're young. So, a lot of this is gonna start even before those renal cats walk through the door, to help because ideally, we can help prevent, you know, causing this.
And, you know, all we know is that we see some of these changes in our kidneys, and that's gonna cause our chronic renal disease later in life. Our, our clinical presentation is pretty straightforward. When they're in early stages, a lot of times, we won't see any clinical signs.
We may see some very, very mild weight loss or muscle wasting. And, you know, as they get worse, we'll see an increase in PUPD, more weight loss. We'll see those GI signs, maybe some drooling and bad breath, and then on physical exam, we'll be able to palpate those small kidneys.
But most of the time, you're gonna make the diagnosis before the CAT's showing these signs, if you're doing kind of routines in your blood work. And we're looking at our, our labs, again, this should all kind of be a review. We're looking at our increased creatinine, increased BUM.
We see our phosphorus go up, and that's a big deal when it comes to diet as well, and potassium go down. And the reason why phosphorus is so big in diet is because, the, we see a lot of the, the regular foods, are not restricted in phosphorus, and can have pretty high levels, and those kidneys are not able to function. And when we see those that phosphorus go up, that's It's gonna kind of affect calcium.
And so, they end up with what's called mineral bone disorder or mineral bone disease, and that leads to renal secondary hyperparathyroidism. So, we really wanna pay a lot of attention to phosphorus because that does not make them feel good. And then, they're gonna not wanna eat further.
And then, you know, we're gonna see our dilute urine and things like that. So, the other big thing I wanna bring up is that calc the total calcium versus the ionised calcium. Our ionise is gonna be much more specific.
And, so I always recommend checking an ionised calcium. I know it's not always available, but, I had a cat who came in and her total calcium was 10.2 in US units, which 10.3 was up to the normal.
And her ionised calcium was 4 times what it should have been. And so, I almost, you know, it was high normal and it was a change, so we pursued it, but it is very, very possible for them to have a completely normal total calcium and actually have hypercalcemia. And we talk about our iris staging.
This, this is probably not a big, big as a problem, in Europe as it is in the US where our labs are not in, they don't agree with our iris staging. So, you know, we'll say our creatinine, basically, our labs can say like our creatinine would be up to like 150, 160, and that would be considered normal, which is very much not. So, you know, this is just kind of a reminder.
Make sure you're using your iris ageing and not just what, you know, laboratory normals are going by when you're making your decisions. So, I don't have to spend too much time here. We also need to think about the things that kind of go along with it.
So, our hypertension, if these cats are hypertensive or even mildly hypertensive, like, you know, they're going to get headaches and not feel good, and just, we don't, we don't know exactly how cats feel, cause they can't tell us, but we know how humans feel, and we can extrapolate to that. So, we want to make sure we're screening for this, because that's gonna make them not want to eat. And if you're going through your diagnostics and you're not sure if this is truly chronic kidney disease versus acute kidney disease or something else, then you can go do, you know, you know, X-rays, ultrasound, renal biopsies, all of the things.
But if this is an older kiddy with kidney issues, like you really don't have to go through a lot of those diagnostics. And then you wanna monitor your, at least your renal values and your electrolytes because that's going to help you understand where they are in the disease. Is their potassium getting lower because that's going to make them feel weak and inappotent.
Is that phosphorus higher where we're gonna see a lot more nausea, you know, that ionised calcium, is that high? So, are they hypercalcemic? Because then, you know, we know that they're definitely inappotent if they're hypercalcemic.
And then we warn about UTIs. They can have low-grade UTIs or specific gravity is really low. In humans, that can actually cause dementia signs, but it also can cause nausea.
So we wanna make sure that we are like talking about what those look like and screening for these things as well. And then when we talk about our management. Our first thing is our increased water intake, and I mentioned this before.
So, with cats, it's not just about, you know, like I said, we can't just add water to the food. And hope that that'll be enough, or if this cat has only eaten dry food its entire life, and you wanna put it on strictly canned, while that may be medically best, that cat's probably not gonna eat it, or they might not eat enough of it to get their calorie intake, and that's a really important part of this to remember is they need to, you need to make sure that they're getting enough calories into them as well. Remember that resting energy requirement is higher in these cats.
So, what we typically do. Is we, you know, we said, well, let's get a fountain, because cats love moving water, and they do. But what it, what makes them drink more is not necessarily that there's moving water, it's that it's a novel water source.
So, what has been shown to be more helpful to get them to at least drink more, is having multiple water sources and moving them into different areas around the house. And I cannot say that scientifically, that I've done this with more than my own cats, but I have tried it with my own, and it does seem to work, where I will move the bowls around, and they all will fight over wherever the new bowl is. So, they really do prefer the new sources, and that does help them drink more water and making sure it stays fresh and clean.
I don't keep it by the food cause we don't want it to get contaminated because they, they will inevitably drop food into it. And we'd obviously don't want to keep it near the litter either for clean, cleanliness reasons. There are also supplements that you can add to the water to help them drink more.
If they'll take it, then, you know, that can be really helpful, but again, it's gonna change the taste and texture, so they might not want to drink that water. Or as much either, so keep that in mind too. Then we have our medications.
You know, whether we use these in all of our renal cats or just when we see proteinuria, I think we're leaning much more towards the one we see proteinuria or they're hypertensive. But our, our benazepril, at least, one of the side effects of benazepril is increased appetite. So, that's something to consider, where it, it has been shown to help them, at least eat more food when they're on it.
So, we wanna keep that in mind when we're making our treatment decisions. And then we look at our, our renal diet. So, I'm, I'm using KD as an example, but the renal diet is gonna have all of those things that I mentioned for our senior cats.
And then specifically for the KD it has, the E-technology, which makes it taste really good. And You know, when I first started practising, KD was not nearly as good until it went through its upgrade, at least palatability. I would, it was still my go to renal, diet and practise.
And now my parents have an older kitty, and of course, I recommended that she go on KD and they have two younger, males, and they are fighting for her KD. They really, really like it. And I just think that It's a really good example of the fact that, you know, it does actually taste good for them.
So, you know, we, we want to make sure that we're, we're looking for a food that has all of those things. And then specifically, we're that, that controlled protein being a big one there. And then I really also, like the fact that it's not going to be high in sodium too.
And then our other things. I mentioned how important phosphorus was. And so, managing hyperphosphatemia is, is a really, really important part because that is going to, if they have really high phosphorus levels, they don't want to eat.
And, we like, we like to use phosphate binders, but we only want to reach for those after we have them on a renal diet, because the renal diets are gonna be lower in phosphorus, and that's gonna be the best way to control it, especially in the beginning. If that's not enough, that's when we're going to that phosphate binder level. And if we use these phosphate binders, remember, they need to be given with food.
This is the only thing that I can say 100% of the time, it has to be given at mealtime for it to be effective, because it binds to the phosphorus in the gut. So if it's not phosphorus isn't there, these aren't gonna work. And so it will change taste and texture, and odour of the food.
So it may discourage them from eating depending on the formulation that you use. You can give, there's different options, you know, I think my go to in practise, because it was readily available and inexpensive, was aluminium hydroxide. I avoid most calcium-based, the phosphate binders, because I, I'm, I'm concerned about hypercalcemia and Not everyone wants to run an ionised calcium.
So for me, it was just easier to avoid. But there are other options out there now that are not aluminium hydroxide or calcium-based. I think CapE1 is a, is one of the new ones.
And so those have been readily, been doing very well also. So, you know, just make, make your choice based on your individual patient. And look at your iris guidelines for your phosphorus levels and what your ideal phosphorus level should be, because that will help them eat more too, like I said.
Our calcium is also, or, sorry, potassium is also really important. They feel very weak and, you know, inappotent. So we wanna make sure that we are keeping their potassium where it should be.
Again, that's really helpful. But potassium is, a medicine, a medicine, a metal. So it does not taste good.
So, putting it in food can be difficult. Putting in subcu fluids can burn. So, again, we just have to find the best way to, to make sure that their potassium stays up.
And I, and I would not recommend putting this directly into their meal that you want them to continue to eat. And then if they do have, you know, a renal secondary hyperparathyroidism, that needs to be kind of monitored and managed in its own way, which I'm not gonna get into all of the details there. Diet is huge, you know, looking for an appropriate diet.
Which those renal diets often fall into that category. We also want to manage our anaemia. You know, anaemia makes you feel very fatigued, not wanna eat.
So if you're kind of, kind of seeing a lot of this, there's a lot of secondary issues that go along with our CKD cats that are going to Potentially makes them feel badly. So we can't just say, well, let me give an appetite stimulant and get them on a good food. That's why I'm going through all of these things, because all of these things can decrease appetite.
And if we ignore it or miss it, then, you know, we might not be able to get this cat to eat, and they're going to decline further. So, it's, it does all tie together when we, we think about our whole patient. So, anaemia, we have, you know, older options with the Darbypoitin.
I really don't reach for erythropoietin very often. Arbenzin is now available, and these are really helpful. I'm not, again, this is not gonna go into all the details.
So it's whatever works best for your patient, and then managing hypertension. Most of the time, getting a calcium channel blocker with an ACE inhibitor or an ARB will be really helpful. In very, very refractory cases, you may need to reach for something more.
But, you know, we don't want to reach for everything up front either. That's, and that's another problem with this is kidney disease likes to come with extra fun things to manage as I've just covered. And most of those things require additional medications or therapeutics.
And now we're trying to get all of these things into this cat. So, this cat's now potentially on, you know, let's say, benazepril, and maybe it, it's in so it's hypertensive, so we're having it on amlodipine, and we changed its diet, and we're, you know, we're now trying to get its potassium up, so it's on potassium supplement. And, you know, a lot, a lot of people just want to put that all in the food, and the cat's not gonna want to eat that food.
So, we have to be really cautious with how much we're doing. And if we're not putting it in the food, and we're using it as treats and things, then, you know, it's becomes, every time when you're approaching that cat, are they running away because they know that you're coming at them with a pill gun or with something they don't want. So, that's a really, really big part of this, is making sure that, you know, we're not overmedicating these guys.
Because that, that's not going to help them in the end, you know, polypharmacy is a huge problem in every species, and we have to be really careful. So, kind of diving into that, how do we help specifically with appetite? And sure, there are, there are a whole list of drugs.
And, and on here, I know, you know, ondansetron is not like a true, anti-emetic, but I, you know, for simplicity purposes, I just kind of have them split up. In this way. But we have all of these options, and sure, you can give all of these things to cats, but everything is gonna come with a drawback, and you don't wanna use all of them, and you don't wanna use them every day if you don't have to, you know, famotidine over time, they start to kind of build up a tolerance to it, so it's just not gonna work as well.
It's better if it's pulse dosing. Omeprazole is not really readily absorbed in cats very well orally. You know, mirtazapine, the transdermal formulation is fabulous.
But, you know, orally, it can be a little bit difficult to give, and it can make them, it is an antidepressant, so it can make them a little restless in some cases. And then our aura, so the, so, yeah, so the aora, like, I love it, but it tastes terrible. Like, it makes them drool and foam, and to get it into their mouth, it can be really, really difficult.
So as much as I feel like it does work, sometimes the administration isn't necessarily worth the results. So these are all things to really consider, when we're talking about this. So it's not just about You know, managing, making them not feel nauseous, and making them want to eat, it's about taking all of those other factors and trying to control all of those things that are going on in the body, that are making them feel poorly and not just masking that nausea.
For that inhabitants. Like, can we actually stop that at its source? And that's gonna be the most helpful.
And then focusing on our, our environmental factors, you know, is this cat not eating because of something externally, you know, or is this truly their kidney disease? And the other big thing that we wanna consider is managing pain. And I don't wanna go into too many details of, of all of the options, but pain is a wonderful appetite suppressant.
Like if, when you are in pain, you're usually not very hungry. So these cats are like chronic arthritis, or other issues that may be causing them discomfort, we have to really focus on managing that as well. And unfortunately, that means adding more supplements or medications potentially to their day to day, which can be a problem.
So, we wanna make sure that we're not overmedicating. I think that is just as big of a problem as undermedicating, and not and ignoring things. So, it's a really, really delicate balance, and it's something that will vary greatly between cats, and I don't think that there's one perfect way to do this.
I think every cat is different, and every client is different. Giving subcutaneous fluids can be really beneficial, but there are some people now saying, hey, actually giving fluids to a kidney cats making those kidneys work harder, so maybe it's not as helpful, and you may hear that more, and for me, and it does seem to make them feel better, but until, so until like we're directly told not to, it's something I still make that recommendation. But potentially getting a needle under the skin, you know, we eat weekly, daily, that cat's gonna start to really hate that, and, and it's gonna change its day to day life, and maybe hiding under the bed more, and not going to the food bowl as much.
So, these are all things we need to keep into account, and, and we're making those recommendations, you know, not just because the book says we should, but is this really the best for this patient and this and this owner. When we talk about our diet, we, we need something palatable with that, that, for that cat. But it has to be nutritionally appropriate.
A lot of the, over the counter foods are going to have, really high phosphorus levels, which is fine for a normal cat, but it's not ideal for our renal patients. And then we wanna really think about our uremic toxins. These are associated with nausea.
And they, as kidney disease increases, so, so do these toxins. And so, I like, again, the KD, with that active biome plus kidney defence does have a, a special blend, and I'm sure Fiona will talk a little bit about this, but it helps to decrease the uremic toxins. And to me, that what I like about that the most is that means I can decrease or avoid using supplements in the food that will, that are meant to do the same thing.
So something like porous one, which I think works really well, but again, it's one more thing that now I'm putting into that cat's food or into a part of their dietary routine that can be difficult. We talked about our water intake, and doing moist food, adding water, the multiple water sources. Other things to consider are, you know, how big are these bowls.
Cats do get whisker fatigue, so we don't want really small bowls with high sides, like wider bowls can be better. I also find having them elevated, both food and water bowls, like, a, a little bit off the ground. I apologise for my American units, but like 6 inches to 8 inches off the ground.
It's helpful where they don't have to squat as much. So if they do have some arthritis in their elbows, or, you know, the hips or their knees, it's a little A little bit more of a comfortable position. And so I think that can be really beneficial too.
And then just making sure that there's not like a puppy or a toddler chasing them around when they're trying to eat or drink, because that can be really stressful, especially for an older kitty. And I don't know if we're getting the theme here about overmedicating, but we don't want to overmedicate these cats. That is a that that is kind of the underlying theme here that I really, really want to stress, .
And then The, the, the, almost, almost the last part is now our environment. So, I, I, I mentioned earlier about our senior friendly bowls and locations, but we also want to consider adding or, or warming up the food. You can warm the dry food a little bit, if you maybe put, like, I will put it over like a boiling pot of water just to kind of steam it a little, but it makes it soft, and now we're changing texture, and it's very, it's developed specifically and as for a texture that they like to chew.
So I don't usually recommend doing that. But warming it, I think they prefer it. It's like 86 °F.
I don't know what that goes to in Celsius, unfortunately. But it will make that odour a lot stronger. So just popping it in the microwave for a few seconds, can be really helpful.
It's just to make it smell good, and, and, and help with that, their inability to smell the food as well. It may make that odour more familiar, especially if that's the food they've been on. But, you know, like I mentioned, with their sense of smell decreasing, that smell changes, and that food that they've been eating for however long now becomes new, because it doesn't smell the same, even though it is the same, they don't recognise it as the same smell, because their sense of smell is changing.
It makes sense. We wanna offer frequent and fresh meals. They're not gonna wanna eat crusty food that's been out all day, if it's canned and dry, a lot of them will eat the kibble and then leave those crumbs, and they don't really like to eat those crumbs, so they'll just sit at the bottom of the bowl.
So, it's hard, but we do wanna kind of clear things out and refresh it frequently. Again, that will keep it smelling better as well. And then, with the medications, the only thing that needs to be 100% given with food or at mealtimes is the phosphate binder.
Everything else, for the most part, can be given at different times or maybe around mealtime. And I never, never, never recommend putting anything into the diet that you want that cat to eat long term. Because you're going to potentially, they're gonna, you know, eat, they'll be loving their kidney diet and they're chowing down.
And they're gonna take a bite and be like, this tastes terrible, and they get to that, you know, that Cerenia tablet. So, we really want to avoid that aversion. And the best way to do that is to have a separate food or treat that you can use for medication administration.
At least for the KD, as long as you're feeding 90% of their total daily intake with that, all of the claims and, and how well it's gonna work is going to, to still be accurate. You know, if you're feeding half kidney diet and half something else, we're not gonna see those same benefits, cause they're not getting all of the same proportions of what, what, you know, is, is in just the kidney diet. But at that 90% level, we're still OK.
So it gives us a 10% buffer to be able to, you know, use things like churros and treats to get these medications on board, and those can rotate and change. So, we don't have to be consistent. We can, we can jump around with those and still be OK.
We, we wanna be careful to, to avoid things that are really high in phosphorus, but for the most part, at that 10% level, we'll be OK. And then it's a really good way to help bond it, but bond with that cat owner as well, so they're not just shoving medications down, but trying to, you know, at least make it less stressful. There are all sorts of pill maskers and, and treats, and, and people use butter, lunch meats, all sorts of things, and as long as it's in in in moderation for these cats, like, I, I, it may not be what a nutritionist says, but I'm on board because I really do not want to stress these guys out by constantly shoving medications down their throat.
And don't overmedicate them. So that's, I think that's the last time I say it, but I think that's, I think we get the point. And then our last bit of this, it does not matter how good of a doctor you are, how wonderful your treatment plan is, if we cannot communicate this successfully to our cat owners, we're not going to see success with our patients.
So we have to have that communication. We need to set our expectations, let them know, hey, this is what we're talking about. Yes, this food's gonna take 2 months to transition to, and that's normal.
These are the side effects of this medication. You know, when we say, hey, your cat has, you know, early stage kidney disease, we know that most cats will live years of good quality of life with that. But, you know, not everyone knows that, and they hear kidney disease, they think kidney failure, they get on Google and they freak themselves out.
So just understanding where they're coming from, knowing that the treatment plan that might be the best for that patient, might not be the best for that owner, and that's OK, you know, I really don't like using things like feeding tubes and these end-stage renal cats. I think they're really good means to getting them back to eating on their own, but for me, If it's gonna be a lifelong thing, I, I just think it can be very stressful for everyone. So that's, that's a personal preference, and there are some people that are all about it, and I don't think that's wrong.
I just think we need to find what's best for everybody. . Like, most of these cats are very old, they've been with their owners for a really long time.
So they're really attached, and they really, really want to do what's best by them. So, it's our job to keep things, you know, stress-free, but encouraging them to come back, and then thoroughly explaining any changes we make and why we're making them, so that they're on board, and they can feel as part of the team, and everything. So, the last little bit I'm gonna leave you with before I let Fiona give, her a bit of the talk is don't overmedicate these guys.
So, that's all, that I have for you on these renal kitties and tips and tricks to feed them. So we will swap over now to Fiona and let her go over some, details on the kidney diet portion. Thank you.
OK, so I'm just gonna reiterate a few things that in fact Lisa's already mentioned to you, but I think a bit like don't overmedicate, there are things that bear repeating. I would absolutely encourage all of you vets listening today to involve your, your veterinary nurse to help support you and to support your clients. We know how time constrained you are in the average consultation.
And actually these conversations can can sometimes take a while. So if you have an enthusiastic and knowledgeable in the field of nutrition veterinary nurse at your side, I would really encourage you to make the initial recommendation of a diet change, but then actually refer that client across to your veterinary nurse to help identify the, the, the the right food for that patient, which we'll look at in just a moment. I know there are lots of great things that we can tell owners about the wonderful things that our diets do, but when it comes to kidney diets, there's probably the the the very best statement you could ever make about, about foods applied to kidney diets, and they are the things that we really need to tell our owners.
So rather than getting weighed weighed down in the nitty gritty of the, of the changes that we might be making with the diet, the really important things to tell our clients are the. The fact that we know that this, these diets are clinically proven to improve both quality of life and longevity of life, and we know that is what every owner wants for their pet, is for them to live as long as possible and to feel as well as possible. So they are the important things to tell your client when you're making the recommendation.
So the veterinary nurse can then have a conversation with your client to identify what the patient preferences might be. Do we have a cat that normally only eats dry food, or is a cat that only eats wet food or has a combination of the two? Are there a cat that really likes things that have a fish flavour?
Are there a cat that likes things to be, chunks in grain? So we can identify what might be the the best food to send that particular animal home with, and it is important that this diet change does happen at home rather than us trying to do it at the practise because we're trying to avoid food aversions that we know can unfortunately happen, particularly in patients who aren't feeling at their best. Lisa's touched upon this many times, but it's really important that we manage our owners' expectations by explaining to them what are normal feeding behaviours for their, for their cat, and particularly a cat that isn't feeling very well.
You know, many owners really don't understand that we have to introduce a food slowly to their animal, because we might be quite happy for a new food to be put in front of us. They don't always appreciate that that is not the case for these animals. So not only have we got a cat that's perhaps not feeling as well.
Well as we might like them to be feeling, which is why they've been brought in in the first place. But we know that even healthy cats do not adapt very well to sudden changes in their food. So make sure the owner understands that it's quite normal for their cat to reject the food when it is first presented to them, and that the introduction must be done very, very slowly.
I actually always used to send, kidney cats home with, 4 weeks' worth of food. And I would explain to the owner that this was completely normal and and it might actually take even longer than 4 weeks, but I just kept reiterating the length of life and the quality of life to get that, that owner on board, and, and doing that nice gradual change, like I wanted them to. So make sure you send the owner home with enough food, I know it's very tempting to send the client home with a couple of sachets of this or a couple of sachets of that.
But actually we're really setting ourselves up to fail when we do that. So it's really important that we, we pick a particular type of dry or wet or both, and we send the animal home with, with just that variant would be my advice to you, because then if they, they don't like that food or they do develop an aversion to it because they're not feeling great, we have another variant, another flavour or another texture that we can then try at a later time. Make sure your client knows this is a change for life.
I've had clients where I haven't explained this to them properly and they literally thought they just had to buy a bag of food, feed that bag, and then that was it. So that, that was on me, not explaining to them that this was a change that they needed to make for the rest of their cat's life. And if you're able to, I'd really encourage you to arrange some kind of follow up, and once again this is where the veterinary nurse comes into their own.
You know, if they're recommending that, that food and they're sending the, the cat home on Tuesday with their new diet, perhaps we can make a note in the diary to perhaps give them a call on Thursday or Friday, or arrange for an over the phone consultation with the veterinary nurse to follow up and see how they're getting on. Check are they doing that nice gradual introduction or not, are they waiting for their old bag of food to run out, which we know can really commonly happen even though we might have explained to them not to do that. Just popping a QR code up here cos this takes takes you to a document covering all the things we've talked about today in terms of tips for introducing a kidney diet in all the ways that we would recommend to, to hopefully get the the the most successful transition onto the new food that you might have.
Just gonna mention a few things about our, our, our kidney diet to you, our, our KD portfolio. You can see here that we have a really extensive portfolio for our feline kidney patients, and that includes our, our, our KD and JD, our combination diet, which is for cats that have kidney disease alongside mobility problems, because as Lisa mentioned, it can be really tricky to manage these two diseases concurrently. But you'll see here that we have lots of different flavour variants, we have different dry flavour variants, we have a number of different wet variants, including different textures.
So our chunks in gravy pouches, for example, versus our our, our, our stew variants in a can or our loaf variants in a can. So there are lots. The difference that are available to help you find the best product for your, your specific patient.
Our dry foods have our enhanced appetite trigger technology. I'm sure the marketing teams took a long time to, to come up with that fantastic acronym, but it really does summarise really nicely the technology that we have in our dry food, where we look at a whole combination of a number of things, for example, how one ingredient works alongside another, how the aroma of the food, the shape of the food, how the food feels in the animal. Mouth, all these things in combination, but most importantly designed very specifically for the desires of a cat that has kidney disease, because as Lisa said, we know that the disease process messes with that, with that cat's perception of, of taste and flavour, and what a cat might normally want to eat can be very different when they have kidney disease.
All the foods that we make have a 100% money back guarantee, so there's no risk attached to an owner taking this food away if that might be a concern to them, which understandably it might be, so you can really reassure them that they don't need to worry about that. And the last thing I just wanted to mention about our kidney diets is our active biome kidney defence technology, which Lisa touched upon. So we've known for a long time that, gut derived uremic toxins can be an issue for animals with kidney disease, but I think historically we've always thought it being an issue, in animals once they have clinical signs of the disease.
So, you know, perhaps, you know, stage 3 or stage 4 of the disease. But actually we now know that we see an increase in uremic toxins in the animal's gut, at stage 1 and stage 2 kidney disease in both dogs and cats. And we also now know that these uremic toxins do actually contribute to the progression of kidney disease.
So it's really important, that we include this in our nutritional strategy when we're moving an animal onto a diet once we know that they have kidney disease. So animals that have kidney disease commonly have a dysbiosis, so, a disruption to their normal gut bacteria, and that's because of this gut kidney axis, this, this connection between the gut and the kidney. And that means that we see very commonly, many more protolytic bacteria in the animal's gut, and that means the production of many more of these uremic toxins.
So our active biome plus kidney defence technology is clinically proven to help correct that disposis, resulting in a reduction in the production of those uremic toxins. So it's a combination of fructo oligosaccharides, oat beater, glucan, and betae, which has really great osmolytic properties. So some really great properties, that we have in the whole of our, our KD portfolio for both dogs and cats.
Before we finish today and we move over to Lisa for any questions you might have, I just wanted to give you a bit of information about International Cat Care. I'm sure many of you are very familiar with I Cat Care and the wonderful work that they do, but for those of you who aren't, International Cat Care is a global feline welfare charity that focuses on advancing cat friendly care. It works very closely with veterinary professionals, caregivers and organisations to promote practical, evidence-based approaches to feline medicine, behaviour and welfare.
And a key focus of IA care is advancing cat friendly care, helping to raise standards across a wide range of settings, including veterinary clinics, homes and community environments. And through its technical resources, research initiatives and international programmes, ICA care. Supports veterinary teams in delivering high quality cat centred care.
Ultimately its mission is to ensure that cats experience cat friendly care in every interaction that they have with people and environments where, care is provided. And I know they're an incredibly knowledgeable and passionate, group of people. If you'd like to learn more about international cat care, you can visit their website, just simply scan the cat QR code that you can see here, you can become a member, you can find clinical resources and guidelines and access feline specific CPD courses and materials and find out about all the excellent cat friendly clinic accreditation scheme that ICA Care run.
And I know that's something that that is a really desirable thing for any veterinary practise to have. Their annual World Feline Congress event, tickets are now on sale, and this is actually happening in, in Wales, I think in May, this year, but you can also follow them on their social pages, so Facebook, Instagram and LinkedIn. And we at Hill's Pet Nutrition are very proud to be supporters of International Cat Care, and we share their commitment to improving the lives of cats worldwide.
So thank you. And we'll go over and have a look if we have any questions from you guys for our speaker. So yes, we do have some questions for you Lisa.
So the first question is why is there a higher risk of urinary tract infections in chronic kidney disease patients? So their urine specific gravity is lower. There's less concentration, so they're just less protection against some of that bacteria, and they are able to kind of take hold a little bit easier.
So, it's just, it's a slightly higher risk, but it is there. Thank you. Another question is, does adding some yoghurt to water make them drink it?
I would say that that might be cat dependent, but I'd be a little nervous like to leave that out, like if it's gonna spoil or go rancid, but if you, you know, periodically if you add a little bit and like for an hour and then get like, you know, change the water out, if it works it works, but remember, most cats don't tolerate dairy very well, so there is that too. OK, you'll forgive me please for the next question, cos one of these drug names is something I'm not familiar with, so I'm hoping you know what it is. So it's does is it telmarzitan also have an impact on CKD cats' appetites like benazepril?
That I don't know. I, I can say it's on like, at least in the Canadian version of benazepril, it was on label as a, as a side effect, the appetite, the increase in appetite, but I can't say if for the telmisartan if we see the same effects. OK, thank you.
The next question is, when should I start kidney food? If I had one blood sample result with mildly mildly elevated creatinine and or SDMA, should I start kidney food immediately or wait for, birth control, i.e., 3 months?
Usually these cats don't come back. Is the lower protein bigger risk if the cat is an early stage, for example, they lose muscle, faster compared to normal senior food. So, it's hard if they don't come back, but I usually, if they're borderline and just it's like like their first elevation, I'll usually recheck it, and then maybe in like like 3 to 4 months if I can.
But a lot of those senior diets, even though they're not formulated for renal, like, I know at least the Hill senior diets, they're still going to be that, that like, not as high a protein amount. It's still gonna be that high quality controlled protein level, not at the same level as a, as a prescription renal diet, but You know, a senior food can still be helpful, but I, I usually wait till I have consistent, like two in a row, or if I've seen this patient for a long time, and I'm tracking a trend, and it has been trending upwards, and now it's finally reached that across the threshold, then I'm OK starting with just one level. Oh, thank you.
So I would like to ask, er, what can I recommend with a good heart to the owners when they insist on at least some homemade or cooked food? And I think that's, that's difficult. Like, if you're within that 10% rule, and you want to give like a little bit of homemade like chicken or something like that, but if they're really interested, like, I would refer to a veterinary nutritionist because, you know, getting a homemade diet that's balanced for our renal cats is not something I could do well without help, and it's so, you know, I'm sure there are recipes available, but I think like getting a nutritionist on board, if they're really interested, would be the way to go.
Yeah, I, I, I think, I think you're right there. I think the last thing you want to do is the client to waste their money buying a prescription diet and then they're adding things to it that completely negate the efficacy of it. So, yeah.
We don't have any other questions, thank you. So, I guess all that remains for me is to say thank you so much, to Lisa, for a really wonderful presentation today. Thank you to Hills, which I feel a bit strange saying because I work for them, but thank you to Hills for sponsoring today's talk.
And, you will be available, to you within 24 hours will be your CPD certificates, along with a recording of the webinar. So I think that's everything. Thank you so much.
Thank you for having me. It was wonderful. Thank you.
