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Nattie's Story of Kidney Disease

Photo of Nattie at age 15

Pictured is my dog, Nattie, at age 15. She was diagnosed with chronic kidney disease at age 14. She lived for two more years without any further progression of the kidney disease following a change to a homemade low-phosphorus diet. Below is the story of how I managed her condition through diet, supplements and medications.

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Disclaimer: I am not a veterinarian, nor do I have any formal training in any medical field. The information presented here is not meant to replace your vet's advice or prescribed medications, but only to suggest additional options to explore, based on your dog's condition.


Introduction

In February, 2003, my 14 1/2 year old dog Nattie was diagnosed with early renal insufficiency. Her (fasting) blood work showed Creatinine 2.3, BUN 51, and urine specific gravity 1.020 (higher is better), all of which indicate kidney disease. These numbers had all worsened in the three months since she was last tested.

Here are my notes on diet changes (the amounts of protein and phosphorus shown are for the amounts of food shown). Note that Nattie weighs 44 pounds (20 kg).

My primary goal in dietary modification is to reduce phosphorus. I am not concerned about protein, other than making sure I am feeding the highest quality protein (eggs and raw meat). Protein levels do come down naturally when phosphorus is reduced. I would also like to increase fat, to add calories without phosphorus.

Up until now, Nattie has been getting 8 ounces of raw meaty bones for dinner (around 30 grams of protein and 1,000 mg phosphorus). For breakfast, she got 3 ounces muscle meat, 1 ounce liver, an egg every other day, plus veggies.

The first thing I discovered is that bones have far more phosphorus than any other food, so my biggest change has been to reduce the amount of bones I feed. In an older dog, I'm not too concerned with what she may be missing nutritionally from the bones, although I am adding calcium (1/2 teaspoon ground eggshell, which provides 1,000 mg calcium, per pound of food), which acts as a phosphorus binder. I am replacing raw meaty bones with muscle meat, tripe and whole milk yogurt. I am also adding Farina (an ultra-low phosphorus grain) and boiled/steamed sweet potatoes and winter squash (boiling/steaming helps remove some of the phosphorus as long as you don't give the water they were cooked in, and I'm using sweet potatoes and winter squashes for the added calories).

Dietary Action Plan 1

Breakfast (total approx 6.5-7 oz): Note: she also gets a B-50 complex, 500mg vitamin C with bioflavonoids, and 200 IU vitamin E, no changes there. Salmon oil is being increased to 1,000 mg per 10 pounds of body weight, split into two doses. She also gets a small amount of a sea mixture (Berte's Green Blend), a little apple cider vinegar, and some raw crushed garlic.

Dinner (total 8 oz):

Look into adding Standard Process Renafood, Renatrophin or Canine Renal Support (see supplements), plus add Pepcid.

Based on the above, Nattie is now getting an average of 690 mg phosphorus daily, or 34.5 mg/kg. Low phosphorus is defined as 15-40 mg/kg. High phosphorus is 60-80 mg/kg. I may have to reduce this further if her kidney values continue to worsen.

She is also getting an average of 48 grams of protein daily, or 2.4 g/kg. Low protein is defined as 2.0 - 2.2 g/kg. I do not believe that protein needs to be that low and am happy with the amount she is getting.

Here are the questions I went over with my vet:

Note Nattie is asymptomatic, other than drinking more water than usual (make sure your dog always has access to as much fresh water as she wants). As a result, she was incontinent a couple of times, but a late night potty trip has solved that problem. She still feels fine, appetite is normal, etc.

We also did a sterile urine culture to rule out kidney infection. Neither my vet nor I suspected kidney infection, but we both felt it made sense to rule it out (the culture did come back negative).

UPDATE 1: Two weeks after starting her new kidney diet, Nattie seemed to be doing very well. Her water intake had lessened, and I had hopes that her kidney values were improving. Then she came down with an episode of Shar-Pei Fever/Swollen Hock Syndrome (something that only Shar-Pei get, characterized by fever and swollen hocks). She was sick for two days, but continued to eat well during that time. However, after she recovered, she stopped eating (see Help with Inappetence below for some of the foods that were recommended when she wouldn't eat). Her kidney values were actually improved (Creatinine 2.1, down from 2.3; BUN 42, down from 51), so that wasn't the cause. We ran every test imaginable (x-rays, ultrasound, Addison's Disease, Leptospirosis, tick panel, endoscopy), ruled out lots of things, but were never able to pinpoint what was wrong. We finally put her on a low dose of prednisone to help her appetite, even though we know it is hard on her kidneys. She is now eating well, but is picky about certain things (will not eat yogurt, sweet potatoes or any other veggies, or liver), so I had to revise her diet. She lost a couple of pounds during this time, so I fed more for the first few weeks until she gained the weight back. She is also getting sub-q fluids now, 800 ml twice a week.

Dietary Action Plan 2 -- Nattie's New Diet

Here is her new diet after gaining back the weight that she lost (Nattie weighs 45 pounds now) -- note that Nattie eats better at night than in the morning, which is why she gets more food then. Nattie will no longer eat veggies of any kind, yogurt, or fresh liver or kidney, and is particular about the way her food is prepared, which is reflected below. Numbers shown are for phosphorus amounts.

Breakfast (total 3 1/2 oz):

Lunch (total 6.5 oz):
Cook up 2 tablespoons of Farina/Cream of Wheat cereal (20) or Cream of Rice cereal (29) or Malt-O-Meal (17) in 2/3 cup water (makes about 6 ounces) . Cream of Rice is cooked with broth or has gravy added for more flavor. Add half an ounce of butter (3.3) (or heavy whipping cream, beef fat, chicken skin, or bacon grease) for fat/flavor. Total 20.3 - 32.3 mg phosphorus. Note that over time, she came to dislike the Farina and Cream of Rice cereal, so I began alternating Malt-o-Meal with 4-6 ounces of white rice. She loves it when I add satay sauce to the rice.
Dinner (total 6 oz): Supplements (all given with soft cream cheese or braunschweiger sausage): If you have trouble getting your dog to take pills, see Giving Pills for some helpful hints.

Based on the above, Nattie is now getting an average of 630 mg phosphorus daily, or 31.5 mg/kg. Low phosphorus is defined as 15-40 mg/kg. High phosphorus is 60-80 mg/kg.

She is also getting an average of 44.4 grams of protein daily, or 2.2 g/kg. Low protein is defined as 2.0 - 2.2 g/kg. Even though this is not my goal, it has naturally reduced by reducing phosphorus and increasing fat.

Nattie is sometimes incontinent at night now, particularly when she gets fluids, but I have a number of Changing Table Pads that I put under her bedding so the urine does not soak thru, and I just wash those and the bedding in the morning as needed. See Incontinence Aids for more help dealing with this problem. I've also found that making sure she goes out last thing before bed, and letting her out once in the middle of the night on the days that she gets sub-q fluids, has greatly reduced the incidence of incontinence.

Updates

UPDATE 2: Five months after Nattie's initial diagnosis and the diet changes outlined above, Nattie's kidney values have all improved. Her Creatinine is down to 2.0, her BUN is 44, her Phosphorus, while it has always stayed in the normal range, has dropped from a high of 5.0 down to 3.7. Although she gets fluids twice a week, I was careful to do the blood test as far away from the fluids as possible (on day 4), so that they would not influence the results. She feels good, is eating well (though I still have to prepare her food the way she likes it), and is no longer incontinent. She has gained back the weight she lost and then some, and her energy level is very good. She will be 15 in two more months. Since her kidney values had all been worsening for some months prior to these changes, I firmly believe that the diet modifications I made, lowering phosphorus but continuing to feed a lot of very high quality protein, have been beneficial.

UPDATE 3: It has now been 8 months since Nattie's initial diagnosis, and her kidney values continue to improve. Her Creatinine is down to 1.7, her BUN is 56 (slightly higher, possibly because she ate breakfast an hour before the blood was drawn), all other numbers remain in the normal range. She was off sub-q fluids for awhile, but I have had to put her on prednisone for a separate problem (chronic bronchitis), so we have resumed giving fluids -- because the higher amount seemed to make her cough more, she is now getting 500 ml three times a week (rather than 800 ml twice a week). She feels good, is eating well (though I still have to prepare her food the way she likes it), and is no longer incontinent. Her weight is normal, and her energy level is very good. She turned 15 last month. I continue with her supplements and am just starting to give CoQ10 (see Coenzyme Q10 for more info).

UPDATE 4: It has now been 11 months since Nattie's initial diagnosis, and her kidney values are still improving. Her Creatinine is down to 1.4 (which is actually in the normal range), her BUN is 44, all other numbers remain in the normal range. She continues to get 500 ml sub-q fluids three times a week because she is on prednisone (for her bronchitis). She feels good, and is eating well (though we had a problem last month due to either gastritis from something she got into, or a drug reaction to an antihistamine I was trying for her bronchitis, but she returned to normal fairly quickly, and I just fed her what she would eat in the interim -- I also discovered that she likes goat's milk yogurt, while she won't touch the regular kind any more). She is occasionally incontinent, only if I don't remind her to go out one last time before bedtime (I also usually take her out once in the middle of the night when she gets fluids). Her weight is normal, and her energy level remains good, we continue to walk an hour every day. She is now 15 years 4 months. I continue with the same supplements and medications (prednisone and pepcid).

UPDATE 5: It has now been 15 months since Nattie's initial diagnosis, and her kidney values are still improving. Her Creatinine is down to 1.1 (which is well within the normal range), her BUN is 48 (still elevated, but not markedly so, and she was not fasted before the test). I'm not sure why her creatinine is so low, but at least I know that what I'm doing isn't hurting her! Her most recent blood work did show elevated liver enzymes, and she has developed a heart arrhythmia, so we have now stopped giving her sub-q fluids and Pepcid. She had gotten worse for a couple of weeks (poor appetite, not feeling well) but has been doing great since I stopped the fluids and Pepcid (it's possible the Pepcid contributed to her arrhythmia, it's been reported as an uncommon side effect and she had been on this medication for over a year). She feels good, and is eating well. She has not been incontinent since I stopped giving her fluids, and although her drinking has increased, it's not nearly as much as when she was first diagnosed. Her weight is normal, and we continue to walk an hour every day, though she's pretty slow now. She is now 15 years 8 months. I continue with the same supplements and medications (prednisone for her bronchitis) except for the Pepcid.

UPDATE 6: Nattie turned 16 last month! It has now been 20 months since Nattie's initial diagnosis with renal insufficiency. I have not rechecked blood work since the last time (five months ago), since there isn't a lot I can do no matter what is found. My vet thought we were going to lose her to the heart arrhythmia, and she also developed a problem with mineral deposits in one eye that came dangerously close to a perforation, but both seem to be under control now (she gets an eye ointment four times a day, we're on a first name basis with the ophthalmologist). We did do x-rays three months ago, and her heart is not enlarged, but her bronchitis was worse and my vet thinks she may have pulmonary hypertension. Because of the elevated liver enzymes last time, I now have her on SAM-e (200 mg daily, given away from meals, with a B-complex vitamin). I also started her on Animal Apawthecary's Senior Blend, which may help her kidneys and heart. Other supplements remain the same, with no Pepcid and no sub-q fluids. She continues to feel good, and is eating well, no incontinence though she is weak in the rear and sometimes has trouble holding her stool long enough to get outside (fortunately, it tends to be dry and firm). Our walks have decreased to about 40 minutes a day, and we're very slow now. I'm sure the prednisone is contributing to her weakness, but it's the only thing that keeps her bronchitis under control -- every time I try to reduce it, her coughing gets much worse, and other medications we've tried have all made her stop eating (she had a very bad reaction to one of them and took almost a week to recover following a single dose). All in all, for a 16 year old dog with chronic bronchitis, chronic kidney disease, a serious heart arrhythmia, elevated liver enzymes, rear end weakness (that may also be related to spinal problems), and corneal deposits, her quality of life remains decent and she's doing better than I or my vet ever expected.

FINAL UPDATE: Nattie was doing pretty well thru Christmas, though she had become progressively weaker and could no longer manage to go on walks. She would also fall periodically and sometimes be unable to get up without help. She had become almost completely blind from the mineral deposits in one eye, and nuclear sclerosis in the other, and she would pace constantly thru the house searching for me when I had to be gone for any reason. After Christmas, her coughing became much worse. She was waking up about every half hour through the night and struggling to get up to cough. We increased her prednisone to maximum levels, but it wasn't enough. I finally made the difficult decision to let her go on January 31, 2005. She was 16 years, 4 months and 11 days old. As far as I know, her kidneys were still doing fine, two years after her initial diagnosis; it was the chronic bronchitis, blindness and back end weakness (probably caused by spinal degeneration) that destroyed her quality of life. With the help of my vet, she passed away peacefully, without pain or fear.

Help with Inappetence

See my article on Inappetence for updated information.

Here are some of the foods we tried and that were suggested when Nattie wouldn't eat. Note that many of these foods are NOT renal friendly and are not recommended long term, but if you have a dog that won't eat, it's better that they eat something, even if it's not the best food for them, than that they starve themselves (which is also very hard on the kidneys).

One thing I've found that might be helpful in getting a picky dog to eat is to make a flavorful "soup." I discovered this somewhat by accident. I steam veggies for my dog every other morning, and pour the water into her food so that she'll get the benefit of minerals that get leached out during the cooking process. I've learned to save any leftover gravy, sauces, juices, drippings, and seasoned foods, which I add to the steaming water in small amounts. It's surprising how little is needed. I've also used chicken bones (removing the bones before feeding the broth). The net result is a very savory "soup" that makes the whole meal taste delicious. Note this might be an easy way to cook up some meat or even eggs (I've used meat but haven't tried eggs) to add to the meals as well. You don't have to use veggies, which many dogs dislike.

Here's a recipe for a nutritious broth you can make:

1. Use all the bones from a roast chicken plus giblets if possible or 2-3 lbs. of bony chicken parts (necks, backs,breastbones, etc.). Chop the bones (and feet) into several pieces with a cleaver if possible to expose the marrow. They can also be broken with a hammer. Other bones can be substituted for chicken.

2. Put chicken parts in a stainless steel pot and add 2-5 carrots and 1/2 bunch celery, chopped,
or any veggies of your choice (not onions).

3. Cover with 4 qts. cold filtered or spring water.

4. Bring to a boil, then reduce heat, cover and simmer for 12 to 24 hrs. [I've cooked for as little as 10 minutes and still created a tasty, gelatinous broth.]

5. Refrigerate. When cold, the fat will rise to the top. Skim fat off.

Adding garlic powder to various things can make them more appealing, as can sprinkling with parmesan or feta cheese. I originally got her to eat cooked cereal by leaving it out to get cold and congealed (she wouldn't eat it warm and soupy). Then I tried adding a large pat of butter and mixing it in, and she ate that right away. She also likes Berte's Ultra Probiotic Powder sprinkled on her food.

When you have a dog that won't eat, try experimenting with different temperatures, different textures, different seasonings. Offer small amounts of several types of food, separated (not mixed together). Try switching around rather than feeding the same thing each time. Offer multiple meals a day, not just one or two. My Nattie eats well now, but she still prefers to get smaller amounts of two or three foods per meal, rather than a larger amount of just one kind, unless it's one of her favorites, and she never gets the same food two days or two meals in a row.

Note that at one point, we put Nattie on Cyproheptadine to help her appetite. In her case, we were unable to determine the cause of her inappetence (it was not due to her kidney problems). Cyproheptadine is an antihistamine that has the side effect of stimulating the appetite, though it's used more with cats than with dogs. It's considered safe and did seem to help some with Nattie. Other drugs that can help with inappetence include:

For more information, see this article on Inappetence.

There are also some herbal blends that can be used for nausea, such as Ginger-Mint from Animals' Apawthecary, Tasha's Ginger Tummy and Minty Ginger from Herbs for Kids (available at Whole Foods and other health food stores). You can also give ginger capsules or ginger tea. Some studies have found ginger to be as effective as metoclopramide for nausea and vomiting.

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You can contact me if you have any comments, but I regret to say that I can no longer respond to questions about individual dogs. See my Contact page for more information. My name is Mary Straus and you can email me at either or

   


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