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A healthy weight starts with healthy habits

The fat-sensitive renal patient

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01 March 2015, at 12:00am

LEE DANKS in this third in a series of monthly columns from Royal Canin exploring a wide range of clinical conundrums, looks at how to manage a renal case with a previous history of pancreatitis

“SEB” is an 11-year-old MN English Bull Terrier who can do no wrong by his owner. He’s a lively chap regardless of growing long in the tooth and has always been a “lover of food”.

You and I would dub him a scavenger … or at least prone to episodes of dietary indiscretion.

A colleague has described Seb as a “grumbling pancreatitis” case in his clinical history but you’re not so sure on this point. On at least two occasions he has presented as an “acute abdomen” with profuse diarrhoea and a period of anorexia after grabbing a sausage from the dinner table or eating two steak pasties while playing with the kids.

On the most recent episode, Seb was recommended and is now being fed a low-fat formula (with the extras the owner insists upon of course!) and you’re mindful that walks for Seb are a minefield as (contrary to your strong advice) you often see him out without a lead, rummaging through whatever he can find, introducing himself to strangers all the way. For this reason you mentioned a Baskerville muzzle in last year’s health check. Today he’s in for a lump removal and has dutifully allowed pre-op bloods to be taken as per your practice protocol for any dog over seven years old. Bloods come back insignificant except for: (1) mildly elevated PCV and (2) a creatinine above the reference range at 150umol/L. Given this is a starved sample and you feel Seb is pretty well hydrated, your “renal” alarm bells start ringing.

To step back for a moment, I’d like to highlight Seb as a typical case often presented to our nutritional helpline. Many a “fat-sensitive” patient is managed well on a low-fat formula recommended years ago after a bout of intolerance.

On responding so well to a diet which is usually a highly digestible gastrointestinal formula, it’s understandable that some are reluctant to move to another food or challenge the loose “pancreatitis” suspicion further.

Your renal workup has disclosed a consistently low USG and a UP/C which suggests that Seb has IRIS stage 2 renal disease. Given that a high proportion of his nephrons are currently not functioning at this stage, kidney workload should be minimised as soon as possible.

So regardless of how you might proceed with managing Seb’s lump removal, there will be the question of “Now what do I feed him?” hanging over you before you discharge him from the surgery.

Slowing the progression

Much literature attests that we can slow the progression of nephron damage by transitioning to a renal diet, so you reach for that as a knee-jerk reaction. But will this risk a GI intolerance? Indeed, the product book highlights that this diet isn’t suitable for dogs with pancreatitis!

There are a couple of questions to consider in Seb’s case before we make a dietary recommendation. Let’s first assess the issue of pancreatitis. While it’s a common condition, without a definitive work-up we can’t be absolutely sure if we’re dealing with a chronic pancreatitis case, a series of acute flares or just simply a fat intolerance brought on by dietary indiscretion. All we know is that a fatty meal has coincided with an upset and is resolved on the gastrointestinal low-fat diet.

Without knowledge of what Seb was originally fed (which very well could have had a significantly greater fat content or included many high-fat table scraps for example), there’s no saying whether a simple move to consistent feeding of a decent quality, high digestibility, lower fat food of any description might have achieved the same result.

A work-up should always be considered (PLI, ultrasound, cytology/histopathology) and hypertriglycerideamia noted as the major indication that we should restrict dietary fat (to <15% fat on a dry matter basis is the general consensus).

Low-fat diets are one of the mainstays of managing dogs with chronic pancreatitis; however, the necessity to do so in nonhypertriglyceridaemic acute pancreatitis cases is yet to be proven necessary.

In Seb’s case we might consider either taking those further steps in bloodwork or, given the likelihood that simply scavenging high-fat foods has led to his gut sensitivity, we might consider challenging him with a slightly higherfat maintenance diet (while eliminating all other sources of food).

Given we now have a second clinical condition to consider and that the evidence supporting the dietary management of dogs (and cats) with chronic kidney disease is so remarkable, the question of what food to recommend can be stretching.

A slower decline in renal function, reduced uraemic signs and lower mortality has been noted in dogs fed a renal diet. Given that there is now a plethora of renal products of varying fat levels available on the veterinary market, selecting the lowest fat option for Seb makes sense.

This is a recommendation not taken lightly and we should put a system in place for both practice staff and his owner to monitor Seb’s (gastrointestinal) response over the next month.

We are all presented with patients who on the surface have conflicting interests, or two or three priorities, all needing simultaneous attention. We know that a systematic, evidence-based approach should be taken and what’s most important is that we realise each patient deserves a tailored approach, regular review and a bit of research in between.

Let’s remember that rarely does a one-size-fits-all approach to nutrition work and we should take advantage of all of the options available, seeking owner feedback and monitoring progress along the way.

References and further reading

Hernandez, J., Pastor, J., Simpson, K. and Watson, P. (2010) Main Pitfalls in the Management of Pancreatitis. Focus Special Edition: Royal Canin, Aimargues. IRIS staging of CKD: available at www.iris-kidney.com/guidelines/staging.shtml. Accessed 10th Feb., 2015.

Jacob, F. et al (2002) Clinical evaluation of dietary modification for treatment of spontaneous chronic renal failure in dogs. Journal of the American Veterinary Association 220 (8): 1,163- 1,170.

Jensen, K. and Chan, D. (2014) Nutritional management of acute pancreatitis in dogs and cats. Journal of Veterinary Emergency and Critical Care 24 (3): 240-50.

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