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nausea should always be considered as a possible cause even if the cat is not vomiting. Maropitant (1 mg/kg,
PO, every 24 hours) has been shown to reduce vomiting7 and mirtazapine (1.88 mg/cat, PO, every 48 hours) has been shown to reduce vomiting, increase appetite
and promote weight gain.8 Other effective anti-emetic drugs include ondansetron (0.5-1 mg/kg, IV, SC or PO, every 8 hours)9 and dolasetron (0.6-1 mg/kg, IV, SC or PO, every 24 hours). While hyperacidity may occur in some cats with CKD, gastric ulceration is typically not found. Instead, gastric mineralization and fibrosis are the most significant lesions.10 If therapy for hyperacidity is considered, omeprazole (1 mg/kg, PO, every 12
hours) is superior to famotidine.11,12 Cats that are not achieving adequate food intake with drug therapy may benefit from placement of an esophagostomy feeding tube to maintain hydration, dminister drugs and provide nutrition.
Nutritional plan
A complete nutritional evaluation (http://www.wsava. org/guidelines/global-nutrition-guidelines) should be carried out before making recommendations. These recommendations should include:
1. When to start dietary management: The recommendation is to change to a CKD diet in stages
II to IV. Patients with stage I only require diet change if they present proteinuria, where they will benefit from a moderate protein diet. Earlier change will result in better acceptance.
2. What to feed
There are several commercial feline CKD diets, choice will depend on stage of disease, price, availability, palatability, and nutrient characteristics.
3. How much to feed
The amount of food should be enough to maintain a stable body weight and ideal body condition score (BCS). Label instructions are a good start but they will need twice a month adjustments. Patients with low BCS should be fed 20% more than label instructions/formulas.
4. How to feed
Multiple small feedings or ad libitum feeding is indicated in thin patients. Overweight cats should be fed portion- controlled amounts to at least prevent further weight gain. Feeding tubes can be used in patients that are
not eating enough to provide an adequate diet (plus medications and water).
Summary
For each CKD patient, the IRIS stage should be established and an individual treatment plan should be developed, considering what is most appropriate for each patient and owner. The options should be
prioritized based on the cat’s medical needs and the owner’s preferences and abilities. The plan should
be reviewed with the owners and their commitment confirmed. A reassessment and monitoring schedule should be established to assess the patient’s response, make any necessary changes to the treatment plan, ensure the owner understands the treatments and uncover compliance issues.
References
1. Ross SJ, Osborne CA, Kirk CA, Lowry SR, Koehler LA, Polzin DJ. Clinical evaluation of dietary modification for treatment of spontaneous chronic kidney disease in cats. J Am Vet Med Assoc. 2006 Sep 15;229(6):949-57
2. Elliott DA. Nutritional management of chronic renal disease in dogs and cats. Vet Clin North Am Small Anim Pract 2006; 36:1377-84.
3. Buranakarl C, Mathur S, Brown SA. Effects of dietary sodium chloride intake on renal function and blood pressure in cats with normal and reduced renal function. Am J Vet Res. 2004 May;65(5):620-7.
4. National Research Council. Nutrient requirements of dogs and cats. 2006. National Academies Press, Washington DC.
5. Plantinga EA, Everts H, Kastelein AM, Beynen AC. Retrospective study of the survival of cats with acquired chronic renal insufficiency offered different commercial diets. Vet Rec. 2005 Aug 13;157(7):185-7.
6. Sparkes AH, Caney SMA, Chalhoub S, et al. ISFM Consensus Guidelines on the Diagnosis and Management of Feline Chronic Kidney Disease. J Feline Med Surg. 2016, 18(3), 219–239.
7. Quimby JM, Brock WT, Moses K, et al. Chronic use of maropitant for the management of vomiting and inappetence in cats with chronic kidney disease: a blinded placebo-controlled clinical trial. J Feline Med Surg. 2015; 17(8), 692–697.
8. Quimby JM, Lunn KF. Mirtazapine as an appetite stimulant and anti-emetic in cats with chronic kidney disease: A masked placebo-controlled crossover clinical trial. Vet J. 2013; 197(3), 651–655.
9. Quimby JM, Lake RC, Hansen RJ, et al. Oral, subcutaneous, and intravenous pharmacokinetics of ondansetron in healthy cats. J Vet Pharmacol Ther. 2014; 37(4), 348–353.
10. McLeland SM, Lunn KF, Duncan CG, et al. Relationship among serum creatinine, serum gastrin, calcium-phosphorus product, and uremic gastropathy in cats with chronic kidney disease. J Vet Intern Med. 2014; 28(3), 827–37.
11. Parkinson S, Tolbert K, Messenger K, et al. Evaluation of the Effect of Orally Administered Acid Suppressants On Intragastric pH in Cats. J Vet Intern Med. 2015; 29(1), 104–112.
12. Šutalo S, Ruetten M, Hartnack S, et al. The Effect of Orally Administered Ranitidine and Once-Daily or Twice-Daily Orally Administered Omeprazole on Intragastric pH in Cats. J Vet Intern Med, 2015; 29(3), 840–846.
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