• Introduction
• Tests Used to Diagnose Kidney Disease
• Is Feeding a Low Protein Diet Necessary or Desirable?
• Creating a Diet for Dogs with Kidney Disease
• Green Tripe Sources
• Table of Nutrional Values of Selected Foods
• Prescription Renal Diets
• Non-Prescription Commercial Diets
• Supplements
• Medications
• Sub-Q Fluidsand Incontinence Aids
• Putting It All Together
• Sample Daily Diet for Early to Moderate Stage Kidney Failure
• Nattie's Diet
• Help with Inappetence
• Links to More Information

The first section is about the tests used to diagnose kidney disease. This section will help you to understand your dog's diagnosis, and help you decide whether additional tests might be advisable. It is important to know the severity of your dog's problem to best understand how to treat it, and it can also be meaningful to find the cause of the problem, especially in younger dogs, who may be suffering from Acute Renal Failure (ARF) rather than Chronic Renal Failure (CRF). See Tests Used to Diagnose Kidney Disease below.

Next, you will find links to and excerpts from a number of different articles and studies that show that feeding a low protein diet will not prolong your dog's life or slow the progression of the disease, and in fact can lead to malnutrition, which causes the body to cannibalize itself, producing more waste products than if an adequate amount of protein were fed. See Is Feeding a Low Protein Diet Necessary or Desirable? below.

Next will be a section on Creating a Diet for Dogs in Kidney Failure. This section will not provide specific diets, but will give you the information you need to create your own diet that is right for your dog. It includes a section on where to buy Green Tripe, and a table that lists nutritional values for a number of different foods you may want to feed. I have also included information on Commercial Renal Diets.

In addition to diet information, I have also provided info on Supplements, Medications, and the use of Sub-Q Fluids.

Near the bottom is a section called Putting It All Together, which includes specific diets and treatment that I have used with my own dog.

At the bottom of the page you will find Links to More Information.

Blood Tests

Note about measurements: I refer to the standard US measurement of Creatinine and BUN in mg/dL, but have also supplied the converted numbers in mmol/L (BUN, or Urea) and µmol/L (Creatinine) for those outside the US. To convert BUN (Urea) from mmol/L to mg/dL, divide by 0.357 (or multiply by 2.8). To convert Creatinine from µmol/L to mg/dL, divide by 88.4. See the Clinical Chemistry SI Conversion Factors in the Merck Manual Reference Guides for more info.

• Creatinine is the most specific test for kidney disease. When creatinine is elevated above the normal range (usually around 1.6 mg/dL, or 141 µmol/L), this generally means that there is a problem with the kidneys. It does not tell you whether the problem is acute or chronic, or what the cause is, or whether it can be cured, but it is a sign that your dog is having kidney problems and action needs to be taken.
• Early Renal Insufficiency: In general, creatinine values up to around 2.0 (177 µmol/L) are  indicative of mild, or early stage, kidney disease (or early renal insufficiency, as my vet terms it). In cases like these, it may still hhe to make dietary modifications to reduce phosphorus, but these reductions do not need to be as drastic as when the values are higher, and it is probably not necessary to do other treatments at this stage, such as sub-q fluids (unless your dog is drinking so much that she is having trouble staying hydrated, such as getting up during the night to drink). Adding calcium to each meal if you are feeding a home made diet (to act as a phosphorus binder) would be advisable, and possibly antacids, particularly if your dog is showing any signs of inappetence or gastric problems. I would also give fish oil supplements (body oil, NOT liver oil), at the rate of 1,000 mg (300 mg combined DHA and EPA) per 10 lbs of body weight, along withVitamin E (100, 200 or 400 IU for small, medium and large dogs), and discontinue any Vitamin A and D supplements (including cod liver oil) added to commercial foods. Additional recommended supplements include a B-complex vitamin and Co-Q10, which may be beneficial for dogs with kidney disease. See the Supplements section below for more info.
• Moderate Kidney Disease: Values from around 2.1 up to about 5.0 (180-439 µmol/L) are more significant, but it is still likely that your dog may not be showing any symptoms (other than increased drinking and urination) with these values. At this stage, a greater level of phosphorus reduction would be indicated, along with antacids, calcium (which acts as a phosphorus binder) if you are feeding a home made diet, and probably sub-q fluids, particularly if your dog is polydypsic (drinking a lot of water). The same supplement advice mentioned above, regarding giving fish oil, Vitamin E, Vitamin B-complex and Co-Q10, and avoiding added Vitamins A and D supplements (beyond minimum daily requirements), would continue to apply.
• Severe Kidney Failure: Values above 5.0 (440 µmol/L) indicate more severe kidney failure, and are often accompanied by clinical signs such as vomiting and lack of appetite. At this stage, fluids can be very important, especially when your dog is vomiting, and your dog may even need to be hospitalized for IV fluids (I personally feel it is best to bring them home at night, even if they need to stay at the vet's during the day, if at all possible). Antacids (Pepcid, Zantac or Tagamet) and Carafate (anti-ulcer medication) should be given, along with Reglan (metaclopramide) for vomiting if needed, with your vet's approval. Protein in the diet may need to be reduced at this time to control symptoms, though if your dog does not want to eat, it's most important that you get some food into them, even if it isn't the best. Use the same supplements as recommended above (give fish oil, vitamin E, vitamin B-complex and Co-Q10, do not give extra vitamins A or D). Note that when kidney function is seriously reduced, the amount of some medications, such as Pepcid, may also need to be reduced, due to the increased time it takes for the kidneys to clear them from the body. Be sure to discuss the dosage of any medications you are giving with your vet.
• BUN (Blood Urea Nitrogen, also sometimes just called Urea) is also commonly used to diagnose kidney problems, although it is not kidney specific, and values may be elevated for other reasons, particularly if you did not fast your dog for 12 hours before the test was done. If BUN is slightly above normal but creatinine is in the normal range, the odds are that the kidneys are fine, especially if the urinalysis is also OK (normal urine specific gravity and no significant amount of protein in the urine).
• Values in the high 20's, up to even the mid 30's (around 12.5 mmol/L) if the dog was not fasted, are not a concern if other values (creatinine, urine specific gravity, protein in the urine) are normal. Dehydration and stress can also contribute to elevated BUN.
• If BUN is above 80 mg/dL (28.6 mmol/L), this is a sign of uremia and is usually accompanied by clinical signs such as vomiting and inappetence. In this case, as when creatinine is above 4.5 mg/dL (398 µmol/L), it may be necessary to reduce protein in the diet to help control these symptoms. BUN is more reflective of diet, and less reflective of the stage of kidney disease, than creatinine, but it is still not necessary to feed a low protein diet when BUN is below 80 mg/dL (28.6 mmol/L), although you should definitely be feeding a lower phosphorus diet at that point.
• Phosphorus: Elevated phosphorus is dangerous and needs to be controlled. It is questionable how important dietary phosphorus is when blood levels remain below 4.5 mg/dl (1.45 mmol/l), but my feeling is that it may still help to reduce phosphorus in the diet. You should also be sure to use adequate calcium (which binds phosphorus), even when phosphorus levels are normal. When phosphorus levels are above 4.5, then it is important to both reduce phosphorus in the diet and use phosphorus binders, plus you may need to do other treatments as well. If you are home feeding, and your dog's phosphorus levels are <4.5, you can add calcium to help bind phosphorus. Add about 1/2 to 3/4 teaspoon of ground eggshell per pound of food (1/2 teaspoon ground eggshell yields about 2750 mg of calcium carbonate, which has 1100 mg of elemental calcium). If you prefer, you can use Tums instead (be sure to use the product that contains only calcium), or another form of calcium (see phosphate binders below for more information). If the phosphorus levels are over 4.5, you may need to use more calcium, or talk to your vet about using an aluminum based phosphorus binder instead. See the section on Phosphate Binders below for more information. Elevated phosphorus levels (hyperphosphatemia) can be related to abnormal parathyroid hormone (PTH), which can be caused by kidney disease, so if it persists, you should do a PTH test so it can be treated if needed.
• Calcium: Elevated calcium is often a sign of abnormal parathyroid hormone (PTH). When your dog's calcium levels are elevated, it is important that you NOT give additional calcium as a phosphorus binder, but use one of the aluminum based binders instead (although if you are feeding a home made diet, you would still add some calcium to ensure that nutritional requirements are met). Calcitriol can be used to help control hyperparathyroidism, but only if phosphorus levels are normal. See the section on Calcitriol below for more info. Another possible cause of elevated calcium is Addison's Disease. According to the Merck Veterinary Manual, "Mild hypercalcemia (less than or equal to 15 mg/dL) has been reported in up to 30% of dogs with hypoadrenocorticism (Addison's disease)." Keep in mind that your dog could have atypical Addison's Disease, where only cortisol is low, even if the sodium/potassium ratio is normal. Since elevated calcium levels are an unusual side effect of kidney disease in dogs, I would have your dog tested for Addison's if the calcium levels are high.
• Sodium/Potassium Ratio: If your dog's sodium:potassium ratio (sodium level divided by potassium level) is below normal (27 or below), this is an indication of Addison's Disease (hypoadrenocorticism), which can cause kidney failure. Adidson's Disease can be fatal if not treated, but it is treatable. Addison's Disease is often misdiagnosed as kidney disease, so it may be worth testing for this disease, even if the sodium:potassium ratio is normal, especially in younger female dogs. See this article on Addison's Disease for more info.
• Total Protein and Albumin levels may be decreased if you are not feeding your dog enough protein, or if your dog has a protein losing disease. Albumin is needed to help absorb fluids, so it is important that it stays in the normal range. Increase protein in the diet if needed to keep the albumin level at adequate levels. Low albumin combined with high globulin can be a sign of tick disease, such as Ehrlichia. In a case like this, I would probably try treating the dog presumptively with high doses of Doxycycline, particularly if any other symptoms of tick disease, such as anemia or thrombocytopenia (low platelets) are present.
• Hematocrit (HCT), Platelets, RBC, WBC. Anemia can be caused by kidney disease, and is measured by Hematocrit (also called Packed Cell Volume, or PCV) and RBC (red blood cells). If your dog is anemic, you may need to treat with hormone (Erythropoetin/Epogen) injections, or even a blood transfusion. Elevated WBC (white blood cells) may indicate infection, such as with Leptospirosis. Low platelets may be a sign of Tick Disease. See the section on Additional Tests below for more information on testing for these diseases.

Urine Tests

Azotemia (elevated BUN and Creatinine) combined with normal urine specific gravity (1.030 and above) may indicate prerenal problems, such as Addison's Disease, or postrenal problems, such as kidney or bladder stones. see Localization of azotemia: Test your skill for more information.

It is also important to do a urine culture and sensitivity when you have indication of kidney disease. A urine culture is the only way to rule out a urinary tract infection, this cannot be done by simple urinalysis and observation of whether there is bacteria in the urine or not. A culture and sensitivity will also help you determine the best antibiotic to use for treatment, if an infection is present. Bacterial infections can cause kidney disease (pyelonephritis), so it is important to rule this out when dealing with kidney problems. Dogs with kidney problems are also at greater risk of devloping urinary tract infections. Although vets prefer to do a urine culture using a sterile urine sample (cystocentesis), I hve had good luck doing cultures on free caught samples.

Proteinuria: If more than a trace amount of protein is found in the urine, you should do a urine protein:creatinine (UPC) ratio to determine how significant it is. Significance to some extent is related to the stage of kidney disease: for dogs with normal kidney function (creatinine < 1.5), a UPC of 2.0 or less should be investigated for an underlying cause and closely monitored, while those with UPC > 2.0 should be treated. For dogs with creatinine levels above 1.4, UPC over 0.5 should be treated.

Certain types of kidney disease, particularly glomerlonephritis (GN), are associated with high amounts of protein in the urine (UPC > 3.0), and this may be the first sign of kidney problems  in dogs affected with these diseases. See the Links section below for more information on GN. Note that Antech offers a Urine Profile (see SA570 under Diagnostic Profiles) that includes a urinalysis, UPC ratio and numerous other values that can be helpful for only about $30 more than a UPC alone, so this might be something to ask your vet about if you are dealing with a dog that has or is suspected to have kidney problems. This article on Proteinuria is technical, but has a great deal of information about the meaning of protein in the urine, and what these additional tests may mean. There can be many causes of protein loss in the kidneys -- according to the article Protein Losing Nephropathy: An Overview, "Some of the more common infectious agents to keep in mind when diagnosing protein losing kidney diseases include: Brucellosis, Ehrlichiosis [Tick Disease], Leptospirosis, Boreliosis [Lyme Disease], Leishmaniasis [uncommon in the U.S.], chronic bacterial infections, and heartworm disease. Noninfectious causes include inflammatory bowel disease [IBD], systemic lupus erythematosis [SLE] and hyperadrenocorticism [Cushing's Disease], among others." See below for more information on testing for Leptospirosis and Tick Disease.

There is a new test that can find trace amounts of protein in the urine and serve as an early warning of kidney disease. This test is called the Heska ERD (Early Renal Disease Detection). See The E.R.D.-Screen™ Urine Test for information on this test specifically related to the Chinese Shar-Pei. There is additional information about the meaning of this test in the E.R.D. Healthscreen Urine Test Clinic Lab Book.

There is also a urine test called Electrophoresis that can provide diagnostic clues to the source of protein in the urine. See the following sites for a little more info:
Urinary and Serum Protein Alterations in Dogs with Natural Ehrlichia Canis Infection using Electrophoresis
Total Protein Electrophoresis
Glomerulonephritis

Additional Tests

• Leptospirosis is a bacterial infection that can cause kidney failure, especially in young dogs, and more often in male dogs, though females can also be affected. Most standard vaccinations include Lepto, but that does not mean your dog will not get this disease. The vaccinations do not last very long (vaccinations against bacterial diseases are not as long-term as vaccinations against viruses), the estimated duration is generally 3 to 9 months, and vaccinations will only cover 2 to 4 of at least 8 types of lepto that are known to affect dogs. While lepto has been considered rare, I am hearing more and more cases of it, and am beginning to think it may be much more common than is commonly believed, especially since dogs can have lepto without showing any symptoms. The treatment for Lepto is penicillin, so if you have a dog who suddenly shows symptoms of kidney disease (excess drinking and peeing) and has elevated creatinine and BUN, it makes sense to go ahead and start treatment while waiting for the results of the test to come back, which can take several days, especially if your dog is young. The test for lepto is a blood test for titers, and may not show positive results until the dog has been symptomatic for at least a week, so even a negative test, if done early, does not rule out this disease. Treatment with penicillin for two weeks is followed by treatment with doxycycline for four weeks, to eliminate the carrier state. In animals with only mild clinical signs, doxycycline can be used for both initial and elimination therapy. See the Links section below for more information on this disease.
• Tick Disease: there are several kinds of tick disease that can cause kidney problems, including Lyme Disease, Ehrlichia, and Babesiosis. The treatment for most of these is high doses of Doxycycline, so again, it may make sense to try treatment while waiting for tests to come back if tick disease is suspected, especially if other symptoms are present, including thrombocytopenia (low blood platelets) or nonregenerative anemia. As with Lepto, the test is a blood test for titers, which may not show up immediately. See Tick Disease and Tick Disease FAQ for more information.
• Addison's Disease: as mentioned above, Addison's Disease (hypoadrenocorticism) is often mistaken for kidney disease, as it can affect the kidneys. Although a sodium:potassium ratio of 27 or below is indicative of Addison's Disease, a normal ratio does not rule it out. The test for Addison's is a blood test called an ACTH Stimulation Test, which involves taking some blood, then injecting the dog with a substance, waiting one hour, and taking blood again. The test is not dangerous or terribly expensive and may be worth doing, especially in younger, female dogs, who are the ones most likely to be affected by Addison's. Hypothyroidism is also often linked to adrenal dysfunction, especially Addison's Disease, so it may be especially important to test for Addison's if your hypothyroid dog seems to be showing signs of kidney failure. See this article on Addison's Disease for more information.
• Cushing's Disease (hyperadrenocorticism) is the opposite of Addison's Disease, and is more common in older dogs. Cushing's will generally show other symptoms as well as kidney disease, such as hair loss, pot belly and increased appetite, so it is probably not worth testing for unless you see these types of symptoms. See this article on Cushing's Disease for more information.
• Blood Pressure may be elevated in dogs with kidney disease, although this is less common than with people. Unfortunately, it is difficult to test blood pressure in dogs, so it may be difficult to determine whether your dog has this problem or not (and difficult to monitor treatment, if it is thought to be needed). Ace inhibitors can be helpful with high blood pressure, see the section on Medications below for more info. Note that there is no evidence that lowering dietary sodium will help to lower blood pressure. See this article on High Blood Pressure and IRIS 2006 Treatment Recommendations for more info on this condition.
• Biopsy: vets often want to do a kidney biopsy to determine the cause of kidney failure, but I am opposed to this test. A biopsy will damage the kidney, and usually will not provide information that changes the prognosis or treatment (my guideline for when an invasive or expensive test might be warranted). I would question your vet strongly about how such a test might help your dog (and how likely they are to survive it) before proceeding with such an invasive and dangerous test.
• Iohexol Clearance Test: this is another test I do not recommend, as Iohexol can actually damage kidneys. This test estimates GFR (Glomerular Filtration Rate), but the UPC (urine protein:creatinine ratio) test can also do this (see above under Urine Test for more info). Personally, I would never think of using something that is potentially toxic to the kidneys to measure GFR, which is not very important -- it is simply a measure of kidney function, and if you have elevated creatinine and BUN, you already know that the kidneys are not functioning as well as they should and any action you take can be based on that, without knowing GFR, which would not change either treatment or prognosis.
• Renal Scintigraphy: this advanced (and probably expensive) test is one of the only ways of determining how much each kidney is affected. Since kidney disease will not show up until 75% of kidney function is lost, both kidneys would be affected and I don't know how useful this type of test might be. The one person I know who had it done had a very young dog that had a chronic kidney infection that took several months to diagnose, and she wanted to know how badly the kidneys had been affected.

Dogs with kidney problems by Dr. Lucy Pinkston, D.V.M.
"Because by-products of protein digestion are the main toxins that need to be excreted by the kidneys, an obvious assumption might be that all one needs to do is to cut out the protein and the kidneys wouldn't have any more hard work to do. . . . There is significant evidence, however, that the daily protein requirements actually increase slightly for dogs in chronic renal failure. Therefore, severely restricting the protein for such a dog is likely to result in protein malnutrition, in spite of the fact that the levels of blood urea nitrogen, or BUN (the primary by-product of protein metabolism) would be correspondingly lower." This article contains a great deal more useful information in easy to read format.

Are High Protein Diets Harmful to a Dog's Kidneys? from the Veterinary Services Department, Drs. Foster & Smith, Inc.
"The myth that high-protein diets are harmful to kidneys probably started because, in the past, patients with kidney disease were commonly placed on low-protein (and thus low-nitrogen) diets. Now we often put them on a diet that is not necessarily very low in protein but contains protein that is more digestible so there are fewer nitrogen by-products."

The Mythology of Protein Restriction for Dogs with Reduced Renal Function by Kenneth C. Bovee, DVM, MMedSc
"Morris subsequently developed, produced, and sold a low-protein diet, KD, for dogs with renal failure. He and others were influenced by the erroneous work hypertrophy concept for urea excretion advanced by Addis. While experimental or clinical data were never published to support the value of this or other diets, the concept was broadly accepted without challenge in the veterinary literature." This article talks about the history of protein restriction, and about 10 recent experimental studies that have failed to provide evidence of the benefit of reduced dietary protein to influence the course of renal failure. This report is no longer available online, but I have a copy that I can send to anyone who is interested in reading more, just email me (contact info at bottom of page) and ask for Bovee.pdf.
Also see Influence of Dietary Protein on Renal Function in Dogs by the same author, which concludes, "These results do not support the hypothesis that feeding a high protein diet had a significant adverse effect on renal function or morphology."

Nutrition and Renal Function from the Purina Research Report
"Dietary Protein and Renal Function: Results of multiple studies indicated that there were no adverse effects of the high protein diets." This report also includes information on metabolic acidosis and on the beneficial effects of omega-3 essential fatty acids in patients with chronic renal failure. The complete reports on each of the three studies mentioned in this report are no longer available online, but I have copies of them that I could send to anyone who is interested in reading more, as follows: "Effects of Dietary Lipids on Renal Function in Dogs and Cats" (ask for Brown.pdf); "Effects of Dietary Protein Intake on Renal Functions" (ask for Finco.pdf); and "Acid-Base, Electrolytes, and Renal Failure" (ask for Polzin.pdf).

Feeding the Older Dog from the SpeedyVet Clinical Nutrition Library
"The assumption was that low-protein diets retarded the progression of renal degeneration. This assumption was disproved, using partially nephrectomised dogs, which showed no uraemic signs and had reduced but stable renal function for 48 months. These dogs did better on moderate-protein diets than on low-protein diets. There is no direct evidence that high protein intake damages canine kidneys or that reducing protein intake in dogs with renal dysfunction results in preservation of either renal structure or function."

Dietary Management of Chronic Polyuric Renal Failure from the SpeedyVet Clinical Nutrition Library
"Dietary protein restriction improves the clinical signs and quality of life of uraemic animals with both naturally occurring and experimentally induced renal failure. . . . However it is highly questionable whether protein restriction is appropriate in the azotaemic, but non-uraemic patient. The main risk of protein restriction is protein deficiency. The protein and amino acid requirements of dogs and cats with chronic renal failure have not been established, but may well be increased. . . . The main justification for protein restriction early in the course of renal failure would be if it was proven to slow progression of disease. The data that are available do not support this case in dogs. Dietary protein has been shown to affect renal haemodynamics in the dog, however, moderate protein restriction does not alleviate glomerular hypertension, hyperfiltration and hypertrophy. . . . Thus there is no evidence that moderate protein restriction slows the progression of renal failure in dogs, and it is not recommended in dogs which are not uraemic."

Demystifying Myths About Protein from Today's Breeder Magazine
"In contrast, research over the past 10 years or so has shown that protein does not harm the kidney of dogs. In studies conducted at the University of Georgia in the early 1990s, both in dogs with chronic kidney failure and in older dogs with only one kidney, protein levels as high as 34 percent caused no ill effects. . . . In other studies, David S. Kronfeld, Ph.D., indicated that compared with high- or low-protein diets, moderate-protein diets, those with up to 34 percent protein, had no ill effects in dogs with chronic renal failure and were associated with general improvement."

Fortify The Food Bowl For The Aging Canine by Susan Thorpe-Vargas, Ph.D. and John C. Cargill, M.A., M.B.A., M.S.
"Because of certain biochemical requirements, the healthy geriatric dog requires about 50 percent more protein than the young adult, and depending on the quality of the protein, it should make up 20 percent to 30 percent of the total calories ingested. . . . Until recently, protein restriction was recommended in an effort to protect renal function. Limiting protein fails to prevent urinary filtration problems . . . Indeed, newer research shows dietary protein is not detrimental to kidney function. On the contrary, protein restriction can result in impaired wound healing, diminished immune function and lowered enzyme activities and cellular turnover. Those dogs with impaired renal function do better with dietary phosphorus restriction; however, limiting this mineral is unlikely to delay the onset of renal disease or to benefit healthy geriatric dogs."

Dietary Management for Clinical Disorders in Dogs from the Journal of Indian Veterinary Association, Kerala
"Recent research on dietary protein and the kidney has shown that
o dietary protein does not cause renal failure
o dietary protein does not appear to be involved in the progression of chronic renal failure
o inappropriate restriction of dietary protein may actually have an adverse effect on the normal or compromised kidney"

Kidney Failure from the Iams nutrition symposium
“'For years, physicians and veterinarians have treated renal failure by reducing protein levels in diets,' said Gregory Reinhart PhD, an Iams researcher. 'After working with leading universities, we have now found that restricting protein in a dog's diet may do more harm than good by potentially putting the companion animal at risk of protein malnutrition.'”

Managing a Renal Crisis by Martha S. Gearhart, DVM
". . . at least one study has taken several groups of dogs in kidney failure and fed them diets that varied in protein level and phosphorus level. The groups with severely restricted phosphorus lived longer than the groups with normal or high levels of phosphorus. The protein intake made no difference at all in longevity. . . .
"It is important to remember that phosphorus is more important than protein -- feeding vegetables or salt-free crackers to a dog in kidney failure will not add protein but it will add phosphorus."

Dietary Protein and the Kidney by Patricia Schenck, DVM, PhD, Veterinary Nutritionist
"High protein diets cause an increase in blood flow through the kidney (glomerular filtration rate). The myth has been that if the dietary protein is restricted, this will make the kidney work less, and will ‘spare' the kidney from damage. Thus in the past, many have recommended low protein diets to ‘protect' a dog from developing kidney disease. This has been the focus of considerable research over the last 10 years. There has been no scientific evidence to support this theory. The feeding of low levels of dietary protein are NOT protective against the development of kidney disease.
"Reducing dietary protein in the older pet will not protect them from the development of renal disease. In fact, reducing the protein in the older dog's diet may have adverse effects. As pets age, their ability to utilize nutrients decreases. The older pet actually requires a higher level of protein to maintain its body stores of protein than does the younger adult dog. . . .
"Dietary protein restriction is appropriate in renal failure when the disease has become severe. Restriction of protein is based on the appearance of clinical signs. It has been recommended to start protein restriction when the dog's BUN (blood urea nitrogen) is greater than 80 mg/dL [28.6 mmol/L], and the serum creatinine is greater than 2.5 mg/dL [221 µmol/L]. Both BUN and serum creatinine are good indicators of kidney function. Protein is restricted in an attempt to keep the BUN below 60 mg/dL [21.4 mmol/L]. Dietary protein may need to be gradually decreased over time as renal failure progresses."

Effects of low phosphorus, medium protein diets in dogs with chronic renal failure
"In this study, 60 dogs with early CRF were fed either Medium Protein Diet, (CMP group) or a home-made diet (HMD group) which respectively contained 0.36% phosphorus, 27% protein, and 0.38% phosphorus, 21.5% protein on a dry matter basis, over a 28 week period. . . .
"From the results of this study, it can be concluded that many dogs with mild to moderate CRF can benefit from early diagnosis of the condition and dietary management using a diet with a low phosphorus and moderate protein content."

Dietary Protein by Dr. Jeff Vidt, specialist in Chinese Shar-Pei and Renal Amyloidosis

"Increased levels of dietary protein do not seem to change rate of progression of kidney failure. Protein levels in the diet do not seem to affect mortality, rate of progression of uremia or the development of kidney lesions.

Decreased protein levels in the diet may impair immune responses, decrease hemo-globin levels, cause anemia, decrease total protein levels and result in muscle wasting. . . .

Dietary protein levels do not appear to be involved in the progression of renal disease or play a role in the prevention of kidney failure. . . .

When the BUN is greater than 75mg/dl [26.8 mmol/L] and/or signs of uremia develop, moderate protein restriction is indicated to decrease the BUN and the clinical signs. Phosphorus restriction is also indicated at this time."

Kidney Failure in the Dog and Cat
"Contrary to popular myth, diets rich in protein ("high protein levels") do not cause kidney damage.  Research done decades ago indicated that rodent kidneysHigh protein diets do not cause kidney damage. were adversely affected by diets high in protein... and misguided researchers extrapolated that data to apply to the canine. There is no evidence that feeding dogs and cats diets rich in or "high" in protein actually causes kidney damage or disease.  Some day this myth will be finally be put to rest.  In fact, there is ample research and well documented studies that prove that dogs and cats thrive on diets with levels of protein consistent with a meat-eater's (carnivore) natural prey selection.  Read more about protein in dog and cat diets here.

"Additionally,documented research on dogs indicates that reducing dietary protein levels in older dogs may be unwise; however, if kidney damage is already present to the extent that the BUN levels are 75mg/dl or above, some restriction of dietary protein may be beneficial for metabolic reasons... not renal reasons.  "...restriction of protein intake does not alter the development of renal lesions nor does it preserve renal function." (See KIRKS VETERINARY THERAPY XIII, Small Animal Practice, W. B. Saunders, page 861).  Restricting dietary protein may be helpful to those patients whose BUN levels are rather high and that are already in advanced kidney failure."

Note that the above sites are from very traditional sources, including Purina and Iams. I think Hills is the only company still toeing the "low protein" line. The thinking now is that low protein can actually be harmful, and that a  moderate amount of high quality protein is desirable for dogs with kidney disease. In addition, feeding reduced protein to dogs with normal kidneys does not help prevent kidney failure.

See http://lpi.orst.edu/infocenter/minerals/phosphorus/ for (human oriented) information on phosphorus and what excess levels in the blood do.

Also see this letter that I wrote to Hill's in response to their complaints about an article I helped write for the Whole Dog Journal on the myth of low protein diets for dogs with kidney disease.

If your dog is not uremic, then the consensus seems to be to feed a moderate amount of very high quality protein. Eggs have the highest quality protein (although egg yolks are high in phosphorus), followed by raw meat, then lightly cooked meat, then well cooked meat. The lowest quality protein comes from processed meat, as is found in commercial dog foods, and from grains.

The site at http://www.vetinfo4dogs.com/dogdiet.html says "High quality proteins are ones that closely match the proper mix of amino acids the body needs. Ideally, there would be exactly the right number of every amino acid and no excess of protein material, making both the liver and the kidneys happy. In general, animal source proteins, such as meat, milk and eggs are higher quality than plant source proteins. This is because the animal that produced these items already made the proper proteins and so they are already in the proper mix. That is why cottage cheese is  considered to be a higher quality protein source then soy, for instance." Note that some amino acids, such as taurine, are sensitive to heat, which is one of the reasons why raw meat is considered higher quality than cooked meat.

When developing a diet for your dog with kidney failure, the goal is to feed moderate to high fat, moderate amounts of high quality protein, low phosphorus, and low phosphorus carbohydrates to fill in. Here are some guidelines:

Moderate to High Fat: Fat provides low-phosphorus calories, and so can be used to increase caloric intake without increasing phosphorus. With rare exception, dogs do not suffer from high cholesterol or other human problems associated with high fat intake. However, too much fat can be problematic for some dogs, and renal disease can predispose dogs to pancreatitis (or it's possible that the combination of low protein and high fat found in prescription diets may be the underlying cause, as this combination is known to predispose a dog to pancreatitis). If your dog is overweight or relatively inactive, and doesn't need a lot of calories, then feed moderate amounts of fat. If your dog is quite active and needs a lot of calories, then you can increase the amount of fat to provide more calories without increasing phosphorus. Too much fat may lead to diarrhea or mucousy stools, and dogs that are prone to pancreatitis cannot handle too much fat. It is important to increase the amount of fat you feed gradually, to avoid digestive upset and to try to avoid the possibility of pancreatitis -- if you see signs of problems, such as your dog seeming uncomfortable after meals, or any vomiting or diarrhea, that is a sign to decrease the amount of fat in the diet to a level your dog can tolerate. Dietary sources of fat include:

• Fatty Meats -- use the highest fat hamburger you can get. Lamb is especially high in fat. Pork is also high fat. Dark meat chicken and turkey has more fat than white meat, although poultry is still a low fat meat, so it's best to include the skin if you feed chicken or turkey. Beef has less phosphorus than chicken. Lamb and turkey are in between.
• Use whole milk yogurt, cottage cheese, ricotta cheese, etc. -- since these foods are high in phosphorus, they should be fed in moderation, but use the kind with the most fat when they are fed. Try goat's milk yogurt for flavor if your dog doesn't like the regular kind.
• Egg Yolks are high in fat, but also very high in phosphorus, so should be fed in moderation.
• Fat can also be added in the form of bacon fat, (no or low sodium) chicken fat, butter (use unsalted if your dog has high blood pressure).
• In general, vegetable oils are not recommended as a source of fat. They are high in omega-6 essential fatty acids, which are inflammatory, and are not a good source of nutrition for dogs. Omega-6 fatty acids have been found to be harmful to dogs with kidney disease. Instead of vegetables ols, use Fish Oil, such as Salmon Oil or EPA oil (NOT cod liver oil). While Flax seed oil has more omega-3 fatty acids than most plant oils, it is also high in omega-6 and so is not recommended. Olive oil is probably OK to use in small amounts, as it is mostly omega-9, which as far as I know does not affect kidney function..

Moderate Protein: How much protein to feed is still a matter of some debate, although it is not necessary to feed a low protein diet unless your dog is uremic (see above). Protein may need to be moderately reduced for dogs with glomerulonephritis, to reduce protein loss in the urine which contributes to inflammation.

Recommendations for dogs with mild to moderate CRF (creatinine 1.6-4.5 mg/dL, or 141-398 µmol/L) are 2.0 - 2.2 g/kg body weight of high biologic value protein, or around 1 gram of protein per pound of body weight (see the section on How Much Protein? from the Journal of Nutrition). This is higher than the recommendations for normal, healthy dogs.

As long as the amount of phosphorus is kept within desirable limits, and your dog is not uremic and does not have excessive proteinuria, you really don't have to worry much about feeding too much protein (you may need to be careful not to feed too little). It is important to feed high quality protein. Eggs have the highest quality protein, but egg yolks are very high in phosphorus, so you may want to feed 2 - 3 egg whites for every egg yolk that you feed. Note that cooking egg whites will increase their bioavailability. Raw or lightly cooked meat is another high quality source of protein. Green Tripe may be an excellent food for dogs with kidney failure, see below for more info.

Low Phosphorus: Feeding a low phosphorus diet has definitely been shown to be beneficial for dogs with kidney disease. NRC guidelines are to feed no more than 22.25 mg/kg phosphorus daily (about 10 mg per pound of body weight)for a dog with advanced kidney failure. For dogs in early stages, recommended phosphorus amounts can be as high as 60 mg/kg (or 30 mg/lb). Anywhere from 15-40 mg/kg (7 - 18 mg/lb) is considered a low phosphorus diet. In general, foods highest in phosphorus include bones, dairy products, fish (with bones), organ meats, and egg yolks. That does not mean not to feed these foods at all, as they are an important component of a healthy diet, but they should be fed in moderation. Be wary also of the amount of phosphorus in grains and vegetables that you feed. The table below lists some approximate values for a variety of different foods. Examples of the amount of phosphorus you should be feeding daily, based on the range of 15-40 mg/kg, and 60 mg/kg for very early stages (the further advanced the kidney disease is, the less phosphorus you should be feeding):

• 10 pound dog: 68 - 182 mg (up to 272 mg in very early stages)
• 25 pound dog: 170 - 455 mg (up to 682 mg in very early stages)
• 50 pound dog: 340 - 900 mg (up to 1364 mg in very early stages)
• 75 pound dog: 511 - 1364 mg (up to 2045 in very early stages)
• 100 pound dog: 680 - 1818 mg (up to 2727 in very early stages)

• Vegetables must be either cooked or pureed in a juicer, food processor or blender in order to be digestible by dogs. Cooking leaches out phosphorus (as well as potassium and magnesium), so it may be the better way to feed for dogs in kidney failure, although cooking also leaches out or destroys vitamins. Boiling or steaming removes more phosphorus than baking, as long as you don't also give the water the food was cooked in. Note that celery, parsley and dandelion greens are diuretics, which may not be desirable for dogs with kidney failure. Dogs with arthritis should avoid white potatoes, tomatoes, eggplant and peppers. Cabbage is good for ulcers, which are common with kidney disease. Information on the phosphorus content of potatoes,sweet potatoes and yams may be found in the table below. Other vegetables, with phosphorus amounts in parentheses, include: asparagus (56), beets (40), broccoli (66), carrots (44), cauliflower (44), celery (25), collard greens (10), dandelion greens (66), endive (28), green beans (19-38), green peppers (19), jerusalem artichoke/sunchoke (78), kale (56), parsley (58), parsnip (71), peas (77-117), pumpkin (44), red cabbage (42), romaine lettuce (45), acorn squash (27), butternut squash (27), crookneck squash (32), spaghetti squash (14), tomato (24), watercress (60), zucchini (32).
• Fruits: You can also feed fruits, includingapple (7), avocado (41), banana (20), cantaloupe (17), cranberries (9), cucumber (20), mango (11), peach (12), pear (11), pineapple (7). Fruit does not have to be cooked or pureed in order to be digestible. Colored fruits, such as papaya and mango, are especially good for dogs with arthritis. Bananas and pumpkin are high in potassium. Avoid grapes and raisins, which have been linked to kidney failure when fed in large amounts to a few dogs. Too much fruit may lead to loose stools.
• Grains: If you do feed grains, stick to those that are lowest in phosphorus (see table below). In general, white rice is lower in phosphorus than brown rice. Farina (Cream of Wheat Cereal), Cream of Rice Cereal, Malt-O-Meal, and Tapioca are low phosphorus alternatives that can also be used. Try adding butter, meat juices or meat fat for flavor and calories, and cooking in broth or gravy rather than water for added flavor (use low or no sodium broth).
• Pasta: Pasta with butter added is a good choice for tasty, low-phosphorus calories.
• Honey: Raw honey is good for dogs in general and can be fed to dogs with kidney problems as well. Phosphorus amount is negligible.

• A recent paper on chronic renal disease says, "It has long been recommended to reduce the sodium content in the diets of patients with CRD. However, recent work (see chapter seven) would appear to show that too low of a sodium content (0.4- 0.5 mg/1000 kcal) could have a deleterious effect on renal function. Low sodium intake could contribute to glomerular hypertension by increasing the secretion of aldosterone and activating the renin-angiotensin system. These results are yet to be confirmed but they caution against too severe sodium restriction in the diet of patients with CRD." They conclude with "Current recommendations are normal to mildly restricted sodium diets."
• The Encyclopedia of Canine Clinical Nutrition says, "Several studies have shown that moderately increased dietary salt intakes (up to 3.2 g Na/1000 Kcal ME) do not alter blood pressure in healthy dogs, or in dogs with induced renal disease."
• The IRIS 2007 Treatment Recommendations Summary says, "there is no evidence that lowering dietary Na will reduce blood pressure. If dietary Na reduction is attempted, it should be accomplished gradually and be used in combination with pharmacological therapy."

Other Restrictions: Most other dietary restrictions depend on your individual dog. If your dog has high potassium, you will need to limit the amount of potassium you feed, for example (bananas, pumpkin, potatoes, sweet potatoes, pears, sardines, kiwi, beets, yogurt, winter squash, banana, carrots, celery, broccoli. are high in potassium) -- keep in mind that high potassium is unusual in dogs with kidney disease and may indicate Addison's Disease instead. Conversely, if your dog's potassium levels are too low, you will need to give potassium salts (both can occur with kidney disease, but it is my understanding that low potassium is more common, and high potassium is only likely to occur when kidney disease is very advanced).

Green Tripe may be an excellent food for dogs with kidney failure, as it is fairly low in phosphorus and is highly palatable to dogs. You need to find green tripe, as the bleached tripe that is sold for human consumption does not have the same nutritional value. Most dogs love green tripe, so it might tempt a dog to eat that was anorexic. I've never heard of a dog having digestive upset from green tripe (though sometimes the owners do, it has a fairly strong smell, and some prefer to feed it outside). Unbleached green tripe is hard to find, see the following (note many will ship, although the cost can be high to ship frozen products):

• GreenTripe.com (California)
• Healthy Pet Products (Georgia)
• A Place for Paws (Ohio)
• Taylor Pond Farms (Michigan)
• Healthy Paws (New Jersey)
• Wholistic Paws (New Jersey)
• Raise a Paw 4 Raw (New York)
• Hare Today Gone Tomorrow (Pennsylvania)
• True Carnivores (British Columbia)
• Paws & Claws Pet Pantry (Ontario)
• Tollden Farms (Ontario)
• Awesome Paws (Toronto, Ontario)
• Totally Raw Natural Dog Food (Brookfield, Nova Scotia)
• Pinnacle Pet Supply (Canada, carries Abady canned/cooked)
• Raw4Dogs (multiple distributors)
• Bravo! (multiple distributors)
• BARFWorld (multiple distributors)
• Oma's Pride (multiple distributors, not from USDA approved sources)
• Tripett (canned/cooked; offers both lamb and beef varieties). Available from Amazon.
• Canine Caviar Venison Tripe (canned/cooked), available from Pet Food Direct and Only Natural Pet Store
• Merrick Before Grain Tripe (canned/cooked)
• ZiwiPeak Daily Dog Cuisine Tripe Lamb/Venison (canned/cooked; also includes other ingredients)
• Waggin Tails carries Canine Caviar and Abady Natural Electives (canned/cooked tripe), and Dr. Harvey's Power Patties and PetKind Tripe Treats (freeze-dried tripe)
• SitStay carries Tripett (canned/cooked), Dr. Harvey's Power Patties and PetKind Tripe Treats (freeze dried raw green tripe)
• Solid Gold Green Cow Tripe Canned Dog Food (cooked)
• Merrick Before Grain Tripe (canned/cooked)
• See my Frozen Raw Food listings for other places that may offer green tripe.

Raw Meaty Bones: For those who feed a diet based on raw meaty bones, you may be able to continue to feed that diet, but you will need to reduce the amount of bone fed as the disease progresses (BUN and Creatinine increase), or if your dog has problems with elevated mineral values, such as magnesium, in their blood work. Bones are high in phosphorus and other minerals that can be hard on kidney patients. The table below lists some approximate values for a variety of raw meaty bones. If you substantially reduce or eliminate the amount of bone in the diet, you should add 1/2 to 3/4 teaspoon ground eggshell per pound of meat fed to balance out the calcium/phosphorus ratio. If your dog's calcium values are too high, you may need to use aluminum based phosphorus binders instead (see below).

Treats: I don't worry much about treats, since they're such a small part of the diet. There are no foods that you have to avoid for dogs with kidney failure -- the goal is to reduce phosphorus levels, but again, if treats are a small part of the diet, the amount of phosphorus in them would not be significant. You might want to avoid things like dried liver for that reason, though very small amounts would be fine. I would also avoid chicken jerkey treats imported from China, due to fears of potential contamination -- see my Pet Food Recall web page for more information on this topic. Biscuits by Lambchop offers low-phosphorus, gluten-free treats, but again, they're not really necessary.

Water: Dogs with kidney disease should always have access to water, even if it causes accidents in the house. Distilled water may be best to use, or maybe purified water, such as with a faucet filter. Well water may be very high in minerals and is best avoided, use bottled water instead, or find a filter that will remove excess minerals. If you use a water softener at your house, your water will be high in sodium, which is not a good idea if your dog has high blood pressure. Again, switch to bottled water (filters do not remove sodium from water). It is important that your dog stay hydrated, as dehydration is very harmful to the kidneys. Adding water to the food, particularly if you feed dry food, may help with this. If your dog is drinking a LOT of water, I would definitely consider giving sub-q fluids to help him stay hydrated.

See Prescription Kidney Diets below for information on ways to combine fresh foods with commercial foods to create a diet appropriate for dogs with kidney disease.

See Recipes for Home-Made Meals for Dogs with Renal Disease and CRF Homemade Diets (created for cats, but the recipes can be used for dogs as well) for a selection of recipes that have been suggested for dogs with kidney disease. As you learn more, you should be able to make substitutions to reduce the phosphorus in these recipes, and increase the protein, making them even more beneficial for your dog. Keep in mind, too, that most food is more nutritious and easier to digest when fed raw. Exceptions include egg whites (more bioavailable when cooked), starchy vegetables, such as potatoes, sweet potatoes and winter squashes, and grains, although grains can also be soaked overnight and fed raw.

Table of Nutritional Info on Selected Foods from the USDA Nutrient Database (the same information is available in different format at Nutrition Data)

Notes on using this table:

• The most important value is on the far right, mg of phosphorus per 100 kcals. This allows you to compare different foods to each other, and to prescription kidney diets in the section below. For dogs with early stage kidney disease, try to find a combination of foods that average out to 150 mg of phosphorus or less per 100 kcals. The prescription diets for late stage kidney disease have anywhere from 45 to 95 mg phosphorus per 100 kcals.
• Remember that dogs with significant amounts of protein in the urine will need moderate protein reduction in their diet, and dogs that are uremic (BUN over 80) will need protein restricted to control symptoms, but otherwise protein is fine to feed in any amount, it's only phosphorus that you need to be concerned with.
• Data on Raw Meaty Bones is from various sources, including Raw Meaty Bones Analysis and Nutritional Analysis of Chicken & Turkey Necks (whole chicken data taken from Nutrient Composition of Whole Vertebrate Prey). Percentages of meat, bone, skin and separable fat are taken from the USDA Nutrient Database. Calorie amounts shown in parentheses are for 100 grams of meat only.
• Values for Protein, Fat and Carbs are grams per 100 grams (approximately 3.5 ounces, or a little less than 1/2 cup). Values for Calcium and Phosphorus are milligrams per 100 grams. Egg yolks are grams per 2 large eggs (34 grams). Egg whites are grams per 2 large eggs (66 grams). All values are as fed, not dry matter.
• Note that values for ground meat can vary based on the amount of fat, whether skin is included, what type of meat (eg, dark meat vs. light meat chicken), and other factors. In general, higher fat, meat with fat, and dark meat (which is fattier) has less protein and less phosphorus.
• Calories for raw meaty bones are unknown. I have used the values from the meat alone, just as a guideline. Numbers are in parentheses to indicate that they are estimates.
• Mg Phos/100 kcals is a quick way of judging the ratio of phosphorus per calorie (lower numbers are better). Lowest values have been flagged in green, while higher values are flagged in red.
• To convert  to ounces, multiply by .2835 (roughly, divide by 4). To convert to pounds, multiply by 4.54 (roughly, by 5).
• Color coding: phosphorus values are colored red as a reminder that this is the number you need to be most concerned about. In the Phosphorus per 100 kcals column, the best values are colored green, the acceptable values are colored blue, and the higher values are colored red, with very high values both bold and red. In the raw meaty bones section, the calorie numbers that are in parentheses are from meat only (not including bone), so are for comparison only, they're not considered accurate. That also means that the Phos/100 kcals are not accurate as well, and are also shown in parentheses.

* Greentripe.com has done two different analyses of their product, with quite different results, which is why I show a range of values. Their web site shows the latest analysis; you can see the prior analysis here. Note that there is an error in the values for calcium and phosphorus on the web site, which are shown for the cooked (dehydrated) product, rather than the raw. I corrected those figures back to "as fed" (raw) above. I have confirmed all of this with the site owner.

**All cereal and grain values are for cooked grains. See the following for info on a variety of grains by dry weight:
http://waltonfeed.com/self/ntr1.html
http://waltonfeed.com/self/ntr2.html
http://waltonfeed.com/self/ntr3.html
http://waltonfeed.com/self/grains.html
Glutinous (sticky) rice can be hard to find. It can be ordered online at quickspice.com.

*** In March 2008, I learned that the phosphorus amounts in Malt-o-Meal had more than doubled from their previous values. Use Farina or Cream of Wheat instead. Check the box for any sign of added phosphorus -- Regular, Instant and Mix'n Eat all have low phosphorus according to the Nutrition Database, but Quick has much more. If "% of Daily Value" is shown, you can calculate the amount of phosphorus, which is based on adult recommendations of 1,000 mg. For example, if the box shows 2% of DV, that would be approximately 20 mg phosphorus. Divide that number by the number of calories per serving and multiply by 100 to determine mg of phosphorus per 100 kcals. For example, if a serving has 20 mg phosphorus and 80 kcals, that would be 25 mg phosphorus per 100 kcals (20/80 * 100).

Prescription Kidney Diets

In the table below, use the "dry matter" percentages for comparing brands, and canned vs. dry. Use the "as fed" values for computing how much you are feeding. In particular, do not use the amount per can or per cup for comparison purposes, as the size of the can/cup varies quite a bit between brands. Remember that low protein is unnecessary and even harmful unless your dog is uremic, but low phosphorus is advisable. Moderate protein reduction may be required if your dog has proteinuria (significant protein in the urine). In general, I think canned food may be preferable to dry, as the extra moisture can help your dog stay hydrated, though you can add water to dry food to accomplish the same purpose.

For comparison purposes, most regular commercial diets have around 1-2% phosphorus on a dry matter basis. A dog with early stage kidney disease should be limited to around 0.6% phosphorus on a dry matter (DM) basis. Another way to figure it is that you want to feed no more than 30 mg phosphorus per pound of your dog's body weight daily if your dog has early stage kidney disease. These numbers must be reduced further for dogs with moderate stage kidney disease: aim for around 0.45% phosphorus DM, or 20 mg/lb of body weight. Dogs with advanced, late-stage kidney disease need even lower phosphorus: around 0.3% DM, or 10 mg/lb of body weight daily.

It has occurred to me that another possible choice for feeding a commercial diet to dogs with kidney problems is to use a diet developed for cats with kidney problems. Because cats require higher protein, these diets will have more protein than the diets developed for dogs with kidney problems, while still reducing phosphorus. Unfortunately, for the most part these are still not high quality foods, though Royal Canin is probably better than Hill's and Iams (formerly Eukanuba). See Dry Cat Food and Canned Cat Food for tables listing the amount of protein, phosphorus and other values in various prescription cat diets.

Add water If you feed dry food, it's best to add water to help your dog stay hydrated. Remember that dry food will spoil once water is added, so you shouldn't leave it out all day.

Add fresh foods: Note that when feeding a prescription kidney diet to a dog with early stage kidney disease, you can improve the overall quality of the diet and increase the amount of protein without pushing the amount of phosphorus too high by adding fresh foods such as fatty meats, egg whites (and a limited number of whole eggs), dairy, and other animal-based foods. Do not add grains or vegetables, since the presciption kidney diets are already high in carbohydrates. Compare the mg of phosphorus per 100 kcals (far right column) in the prescription kidney diets below with some of the fresh foods listed in the Table of Nutritional Values above and you'll see that many of these foods have similar or less phosphorus per calorie than the kidney diets do. For dogs with early stage kidney disease, look for foods to add with 150 mg of phosphorus or less per 100 kcals. Be sure to add calcium at the rate of 3/4 tsp ground eggshell (1,500 mg calcium) per pound of added food.

Do not feed prescription kidney diets to puppies. Prescription kidney diets are too low in calcium and phosporus to meet the needs of a growing puppy, even one with renal disease. A recent case study found that such a diet caused rickets when fed to a Shetland Sheepdog puppy. Lethargy, decreased long bone growth, angular limb deformity, and osteopenia (decrease in bone density) occurred, but these signs resolved within 3 months with nutritional management. See Nutrition-related Skeletal Deformation in a Puppy for more info. If you have a puppy with juvenile renal disease, I would either feed a homemade diet (see below) or add fresh, high-protein foods (see above) if you do feed a prescription kidney diet.

To use the table below, pay most attention to the column in red on the far right, Phosphorus mg per 100 kcals. For dogs with early stage kidney disease, try to find a food (or combination of foods) with 150 mg of phosphorus or less per 100 kcals. The same is true of fresh foods you add to the diet, from the table above.
Also pay attention to the next column to the left, Phosphorus (dry matter). For dogs with early stage kidney disease, you would want to feed a diet that is 0.60% or less phosphorus (dry matter). Again, you may be able to combine two different foods, one with higher phosphorus and one with lower, to get them to average out to the numbers you're looking for. You can also add fresh foods to help reduce the overall percentage of phosphorus in the diet (see above).
The prescription diets for late stage kidney disease have anywhere from 45 to 95 mg phosphorus per 100 kcals. Again, check the table above for fresh, animal-protein foods with similar amounts of phosphorus (color-coded green and blue) that you can add to the diet without increasing the amount of phosphorus that you are feeding.
Note that dogs with significant proteinuria may need a diet moderately reduced in protein in order to control the amount of protein in the urine, most accurately measured by urine protein:creatinine (UPC) ratio. I have not been able to determine exactly what level requires a dietary adjustment. UPC of 0.5 -0.9 is considered questionable and 1.0 is considered definitely abnormal, but glomerulonephritis is not usually diagnosed unless the UPC is 3.0 or above.
If your dog is uremic, with BUN over 80, creatinine over 4.0, and symptoms such as vomiting, nausea, inappetence and lethargy, you will have to reduce the amount of protein, but not otherwise (as long as there is not significant proteinuria), as protein only affects symptoms, it doesn't harm the kidneys (other than increasing inflammation when protein is being lost in the urine).

A number of prescription diets, including Iams (formerly Eukanuba), Royal Canin, Hill's, Purina and Waltham are available online at NationalPetPharmacy and RxPetFood.com (prescription from your vet is required, but prices may be lower).\
 

* Hills Prescription d/d diets are designed for dogs with food allergies, but they are low in both protein and phosphorus, so they can be used for dogs with kidney disease as well.
There are four dry varieties: Rice & Egg, Potato & Venison, Potato & Salmon, and Potato & Duck. Of these, Rice & Egg  is the lowest in phosphorus, with 118 mg phosphorus per 100 kcals, compared to 142 mg phosphorus per 100 kcals for the other three varieties.
There are also four canned varieites: Lamb Formula, Duck Formula, Salmon Formula and Venison Formula. The Lamb Formula is much lower in protein and phosphorus than the other three varieties, and so is shown separately. The average values above are for the Duck, Salmon and Venison Formulas only. Of those, the Venison Formula is the lowest in phosphorus, with 119 mg phosphorus per 100 kcals, compared to 175 mg phosphorus per 100 kcals for the other two varieties.
Dry
Rice & Egg 3885 kcal/kg (383 kcal/cup):
    Protein 13.0% min, 17.0% as fed, 18.5% DM, 4.4 g/100 kcal
    Phosphorus 0.20% min, 0.46% as fed, 0.50% DM, 118 mg/100 kcal
Potato & Venison 3711 kcal/kg (366 kcal/per cup):
    Protein 14.0% min, 16.6% as fed, 18.0% DM, 4.5 g/100 kcal
    Phosphorus 0.35% min, 0.52% as fed, 0.57% DM, 140 mg/100 kcal
Potato & Salmon 3710 kcal/kg (366 kcal/per cup)
    Protein 14.0% min, 16.6% as fed, 18.0% DM, 4.5 g/100 kcal
    Phosphorus 0.35% min, 0.53% as fed, 0.58% DM, 143 mg/100 kcal
Potato & Duck, 3719 kcal/kg (366 kcal/per cup)
    Protein 14.0% min, 16.6% as fed, 18.0% DM, 4.5 g/100 kcal
    Phosphorus 0.35% min, 0.53% as fed, 0.58% DM, 143 mg/100 kcal
Average Dry: 3756 kcal/kg (370 kcal/cup):
    Protein: 13.75% min, 16.7% as fed, 18.125% DM, 4.475 g/100 kcal
    Phosphorus: 8.26% min, 0.5125% as fed, 0.5575% DM, 136 mg/100 kcal
Canned
Lamb Forumla 1330 kcal/kg (492 kcal/ 370 g can ):
    Protein 3.5% min, 4.6% as fed, 15.8% DM, 3.5 g/100 kcal
    Phosphorus 0.08% min, 0.09% as fed, 0.31% DM, 68 mg/100 kcal
Duck Formula 961 kcal/kg (356 kcal/ 370 g can ):
    Protein 3.0% min, 4.3% as fed, 17.4% DM, 4.5 g/100kcal
    Phosphorus 0.10% min, 0.17% as fed, 0.69% DM, 177 mg/100 kcal
Salmon Formula 979 kcal/kg (362 kcal/ 370 g can ):
    Protein 3.5% min, 4.6% as fed, 18.9% DM, 4.7 g/100kcal
    Phosphorus 0.10% min, 0.17% as fed, 0.70% DM, 174 mg/100 kcal
Venison Formula 1091 kcal/kg (404 kcal/ 370 g can ):
    Protein 3.5% min, 4.6% as fed, 18.9% DM, 4.2 g/100 kcal
    Phosphorus 0.10% min, 0.13% as fed, 0.53% DM, 119 mg/100kcal
Average canned: 1010 kcal/kg (374 kcal/360 g can):
    Protein: 3.3% min, 4.5% as fed, 18.4% DM, 4.5 g/100 kcal
    Phosphorus: 0.1% min, 0.16% as fed, 0.64% DM, 157 mg/100 kcal

Non-Prescription Commercial Diets

Not all of the foods listed below are appropriate for dogs with kidney disease, but I've tried to find some with lower than average amounts of phosphorus, which you might be able to use as a base with added low-phosphorus foods, as described below, or combined with a prescription kidney diet to improve the overall quality of the diet..

In the table below, use the "dry matter" percentages for comparing brands, and canned vs. dry. Use the "as fed" values for computing how much you are feeding. In particular, do not use the amount per can or per cup for comparison purposes, as the size of the can/cup varies quite a bit between brands. Remember that low protein is unnecessary and even harmful unless your dog is uremic, but low phosphorus is advisable. Moderate protein reduction may be required if your dog has proteinuria (significant protein in the urine). Canned food may be preferable to dry, as the extra moisture can help your dog stay hydrated, though you can add water to dry food to accomplish the same purpose.

For comparison purposes, most regular commercial diets have around 1-2% phosphorus on a dry matter basis. A dog with early stage kidney disease should be limited to around 0.6% phosphorus on a dry matter basis. Another way to figure it is that you want to feed no more than 30 mg phosphorus per pound of your dog's body weight daily if your dog has early stage kidney disease. These numbers must be reduced further for dogs with moderate stage kidney disease.

In addition to the high-quality foods listed in the table below, the following foods have less than 0.6% phosphorus minimum on a dry matter basis, according to a chart I saw in a book. They're not high-quality foods but may be better choices than lower-protein diets for dogs with early-stage disease:

• Hill's Science Diet Canine Light and Canine Senior (all)
• Hill's Science Diet Canine Maintenance Beef, Beef & Rice, and Beef & Vegetable formulas
• Nutro Natural Choice Large Breed Weight Management (0.5-1.0% phosphorus, 152-305 mg/100 kcal)
• Natural Choice Large Breed Adult Lamb & Rice, Chicken & Rice, Beef & Rice, and Senior Chicken & Rice Formulas (canned)

• Hill's Science Diet Canine Maintenance Beef & Chicken, Chicken, and Turkey formulas (canned)
• Hill's Science Diet Canine Maintenance Dry formula
• Nutro Natural Choice Lite and Natural Choice Herring Meal, Rice & Potato Formula
• Royal Canin LA23, Maxi, Medium and Mini Adult 2 (dry)
• Superior Brands Dr. Ballard Oven Bake Senior (dry).

Add fresh foods: One option to consider, particularly if your dog does not like any of the prescription kidney diets, is to feed a  lower-phosphorus regular (non-prescription) commercial food and add some low-phosphorus fresh foods to reduce the overall percentage of phosphorus in the diet. If you're feeding a high-protein commercial diet, you can add some low-phosphorus carbohydrates such as white rice, pasta, potatoes and sweet potatoes. If you are feeding a low or average protein commercial diet, you could add fatty meats that are low in phosphorus. You can add a combination of both low-phosphorus fatty meats and carbs to any kind of diet. For dogs with early stage kidney disease, look for foods to add in the table above with 100 mg of phosphorus or less per 100 kcals. Dogs with moderate or late-stage kidney disease will need foods with even less phosphorus.

Dog Food Mixes
There are a few dog food mixes on the market that can be used to create a diet for dogs with early stage kidney disease. These mixes are designed to be combined with fresh foods to create a complete diet. Use higher-fat meats, tripe, whole milk ricotta cheese and combinations of whole eggs and egg whites to keep phosphorus levels reasonable. Be sure to use a variety of fresh foods, not just one kind, and it's OK to feed very small amounts of foods that are higher in phosphorus, such as liver, for variety and better nutrition. Use the table above to see the amount of phosphorus per 100 kcals in various foods (far right column).

• Sojo's European Style and Europa -- Sojo's is 0.44% (European Style) and 0.33% (Europa) phosphorus on a dry matter basis, with 117 and 96 mg phosphorus respectively per 100 kcals. These foods are designed to be fed with added meat, eggs and dairy at about a 1:1 ratio of meat and other foods to dry Sojo's mix (measure before rehydrating the mix with water). The amount of phosphorus in Sojo's mixes is in line with prescription kidney diets, but you must average in the amount of phosphorus in the foods you add as well to determine the overall amount of phosphorus in the diet. For example, if you fed half Sojo's Europa (96 mg phosphorus per 100 kcals) with 20% fat ground beef (62 mg phosphorus per 100 kcals), you would average 79 mg phosphorus per 100 kcals (96 + 62 / 2). Of course, this example is simplified; you would need to feed a variety of different foods, not just ground beef.
• Essex Cottage Farms -- ECF has approximately 0.5% phosphorus on a dry matter basis when fed as directed, according to the analysis on their web site. Note that they have a Kidney Diet recipe with only half the usual amount of meat, but this diet is too low in protein to be healthy, in my opinion; I would feed the normal diet unless your dog is uremic (BUN over 80) or has significant amounts of protein in the urine, in which case I would switch to lower phosphorus cereals such as Cream of Wheat, Malt-o-Meal and White Rice mixed with high fat meat and eggs.
• The Honest Kitchen Preference -- Preference is 0.72% phosphorus on a dry matter basis (188 mg phosphorus per 100 kcals). It is designed to be fed with added meat, eggs and dairy at a 1:1 to 2:1 ratio of meat and other foods to Preference (dry measure, before being rehydrated with water). Use the higher ratio (2 parts meat and other foods to 1 part dry Preference), and add fresh foods that are lower than 100 mg phosphorus per 100 kcals, to reduce the overall amount of phosphorus in the diet. For example, 20% fat ground beef has only 62 mg phosphorus per 100 kcals, so it would be a good choice (but be sure to use a variety of fresh foods, not just one kind).
• Wendy Volhard's NDF marketed by Handcraft Collars -- I have heard one direct report of a dog with kidney failure that gained weight, lost foul breath and water consumption went back to normal on this diet (dog was fed less meat than normally called for). See K9KidneyDiet message #2103. They could not provide me with the amount of phosphorus in NDF, only figures that included added protein (80/20 raw beef, lamb or cooked chicken with skin on), which are (dry matter basis): Protein 34.7%, Phosphorus 1.3%, Calories per pound 2,172. That translates to 272 mg phosphorus per 100 kcals, which is too high for dogs with kidney disease.

* Wysong makes high quality foods, but their Nephreon prescription kidney diet is higher in phosphorus than other prescription kidney diets, so it would only be appropriate for dogs with very early stage kidney disease whose phosphorus levels are normal (and it's questionable even then). According to the manufacturer, Nephreon is essentially Archetype with added nutraceuticals to support the kidneys. Most of Wysong's other foods are actually lower in phosphorus than either Nephreon or Archetype. See their table with dry matter percentages of all their regular foods (does not include prescription diets). Note that the canned "Au Jus" foods are just meat and organs, they are not complete diets. Of the three canned Gourmet foods, Liver is the best (lowest) and Seafood is the worst (highest) in terms of phosphorus per 100 kcals.

** You can't compare the figures for the various mixes directly to each other, as ECF figures are as fed (with water and meat added), while the rest are dry (before adding water, meat and other foods):

• Essex Cottage Farm figures are as fed (mixed with meat, fish, eggs and veggies per instructions). Amounts are approximations, as they will vary depending on the fresh foods mixed in. The Kidney Diet numbers shown are for the mix combined with 1 lb of meat, 1/4 lb fish and 2 eggs to 5 cups ECF. This diet is too low in protein. I would use 2 lbs meat unless your dog is uremic (BUN over 80). The Hypoallergenic Diet numbers shown are for the mix combined with 1.5 lbs of meat, plus other foods. Again, I would use 2 lbs of meat instead. Also, do not add sunflower oil, which is high in omega-6 fatty acids that are not advisable for dogs with kidney disease. If you include fatty meats, there should be no need to add oils to the mix.
• Sojos and Honest Kitchen figures are for the mix only, and do not count the meat and other foods that must be added to make this a complete diet.

• Fish Oil (body oil, such as salmon oil or EPA oil, not cod liver oil) has been shown to help with kidney disease. Use an amount that provides 300 mg combined EPA and DHA per 10 pounds of body weight daily, preferably split into two doses. Pay attention to the amount that the analysis applies to -- some supplements will show a combined 600 mg EPA and DHA for two gelcaps, rather than just one, for example.
• Vitamin E -- excellent for renal dogs and recommended whenever you supplement oils (such as salmon oil). Give approximately 50 IUs daily to a small dog (5-25 lbs), 100 IUs daily to a medium dog (25-50 lbs), 200 IUs daily to a large dog (50-75 lbs), and 400 IUs daily to a giant breed. You can give twice this much every other day, if that is easier.
• Coenzyme Q10 -- A recent human study indicates that CoQ10 may be helpful for renal disease. It is an anti-oxidant and should be quite safe. The Q-Gel form appears to be best absorbed. Give around 1 mg per pound of body weight daily, preferably split into two doses. Give with food that contains fat for best absorption. More info on the Feline CRF site. Also see their information on Astro's Oil, which combines fish oil, vitamin E and CoQ10 (ubiquitone).
• Vitamin C -- normally, the Ascorbic Acid form is recommended, so you are not adding additional calcium, sodium or magnesium that you will find in the Ascorbate forms. Give approximately 100 mg twice a day to a small dog (5-25 lb.), 250 mg twice a day to a medium dog (25-50 lb.), 500 mg twice a day to a large dog (50-75 lb.), and 1,000 mg twice a day to larger dogs. Vitamin C can sometimes cause stomach upset of diarrhea, so you may need to discontinue it if this occurs. Vitamin C does not help the kidneys specifically, but it is a water soluble vitamin that is flushed from the body more quickly by dogs with kidney disease, due to their drinking and urinating more than normal.
• Vitamin B-complex -- Most dogs can take a B-50 supplement. Vitamin B does not help the kidneys specifically, but it is a water soluble vitamin that is flushed from the body more quickly by dogs with kidney disease, due to their drinking and urinating more than normal.
• You may need to supplement iron (or feed iron rich foods) for anemia. Pet-tinic has been suggested as supplement, if needed.
• Some people have had success using the Chinese herbal combination Rehmannia 6 or 8. This supplement as well as another Chinese herbal supplementt called Marrow Plus may be particularly helpful for dogs with anemia related to kidney disease. Rehmannia is included in the Vetri-Science Renal Essentials for Dogs (this is a company I like). Talk to your holistic vet or join the K9KidneyDiet list for more information on using these herbs.

Vitamin D can be problematic for dogs with kidney disease, and they may require a special form of vitamin D, see Calcitriol below. Caution should be used in supplementing with vitamin A, which can build up in cases of chronic renal failure. The beta carotene form of vitamin A is safest, as it will not be converted unless the body needs it. If you're feeding a homemade diet, it's OK to provide minimum daily requirements of vitamins A and D, but don't add them to a commercial diet. Since cod liver oil is high in both vitamins A and D, it should not be given to dogs with kidney problems except in small amounts when feeding a homemade diet. I would give no more than 400 IUs vitamin D and 4,000 IUs vitamin A to a large dog, half that much to a medium-sized dog, and 1/4 that amount to a small dog (even less for tiny dogs).

See Vitamin and Mineral Concerns in Dialysis for a little more information, although it is human oriented and geared to patients on dialysis.

Be very careful about using multi-vitamins, as they may contain phosphorus. Very small amounts are OK, but you don't want to be adding phosphorus if you can help it. Thorne Canine Geriatric Nutrients might be a good choice, as it contain appropriate amounts of vitamins B-complex and E, plus about half the amount of CoQ10 you should add for a dog with kidney problems, and only 12.5 mg phosphorus per capsule (0.5 mg per lb when given at the suggested dosage of one capsule  per 25 lbs -- note that the analysis shown for this supplement is per 2 capsules).

There are also glandular supplements that can support the kidneys as well, including Renatrophin PMG, Renafood and Canine Renal Support from Standard Process, available at Spinelife, Alternative Veterinary Hospital, and HealthDesigns.

The herb Hawthorn may be useful for dogs with kidney failure, according to Gregory Tilford, author of Herbs for Pets. He says "When combined with ginkgo biloba (for small capillary circulation) and herbs that improve urinary function, hawthorn may be useful for getting more blood and oxygen into renal arteries and smaller vessels of the kidneys. This, in theory, is thought to slow degeneration of whatever healthy tissue remains in the diseased organs." When supplementing with herbs, I prefer to use tinctures that are made specifically for dogs, so that the dosage will be correct. Brands that I trust include Animal Apawthecary (see Hawthorn Plus and Senior Blend), Azmira Holistic Animal Care, and Tasha's Herbs for Dogs and Cats.

In general, diuretics are not recommended for dogs with renal failure. However, if your dog is having problems urinating, they could be helpful (check with your vet first). Marshmallow (the herb) would fall into this category. One person reported using diuretics during crisis times (blood in the urine, straining to urinate, lethargy, odor in his body or urine, not eating and other symptoms that he was heading into problems) by boiling parsley and using the water (cooled) and pulping parsnips and rolling this in raw honey. She also gave marshmallow fairly frequently, three or four days a week. Watermelon is also a natural diuretic, a good source of potassium, and low in sodium. Parsley, celery and dandelion greens are also natural diuretics. Watermelon tea can also be used.

Phosphate Binders

Phosphate binders are either calcium (carbonate, citrate, or acetate) or straight aluminum hydroxide. The most common aluminum phosphate binders used for renal dogs are Alternagel, Amphojel, Basaljel or AluCaps (last one is available in the UK). Aluminum-based phosphorus binders are more effective than calcium and should be used if either phosphorus or calcium levels are elevated above normal levels. They should be given only under advice from a veterinarian. You can buy generic Aluminum Hydroxide Dry Gel Powder from compounding pharmacies or at thrivingpets.com (offers both powder and capsules). You can read a little more about aluminum hydroxide here.

Calcium can be used as a phosphorus binder, but only if calcium levels in the blood are normal and not elevated (hypercalcemia). Calcium is not as effective as aluminum-based binders, so they are best used when phosphorus levels are still normal. The most common calcium binder is Phoslo (calcium acetate, available by prescription only), or plain calcium carbonate, such as from ground eggshells, or other forms of calcium. Calcium acetate has the strongest phosphorus-binding ability, requiring about 40% less calcium to bind the same amount of phosphorus, and is less likely to lead to high calcium levels in the blood.

• One large eggshell makes about one teaspoon of ground eggshell, and contains about 5,500 mg calcium carbonate, which yields 2,200 mg elemental calcium per teaspoon. You can dry eggshells after washing them out, then grind them in a coffee grinder.
• You can also buy plain calcium carbonate in powder form, such as NOW Calcium Carbonate Powder, or in tablet form. Regular Strength Tums contains 200 mg elemental calcium  per tablet, while Extra Strength has 300 mg and Ultra strength has 400 mg calcium per tablet (they also contain sucrose and other ingredients, so it's better to use plain calcium carbonate instead). Other forms of calcium are also fine to use, such as calcium lactate and calcium citrate.
• Vegetable calcium such as Animal Essentials Natural Calcium contains 24 mg of phosphorus per 1,000 mg of calcium, which is equal to the amount of phosphorus in about half an ounce of 80% lean ground beef and so should be OK to use as long as phosphorus blood levels are not high and kidney disease is not advanced. Never use bone meal, dicalcium phosphate, or other calcium supplements that also include high amounts of phosphorus.
• Do NOT use antacids that also include magnesium, such as Mylanta.
• When feeding a homemade diet to a dog with normal calcium and phosphorus blood levels, add about 1,000 to 1,500 mg (1 - 1.5 grams) elemental calcium (1/2 - 3/4 teaspoon ground eggshell) per pound of food fed.
• If you know how to calculate the amount of calcium and phosphorus in the diet that you're feeding, then use a ratio of about 3:1 calcium to phosphorus.
• These amounts may increase to as much as 100 mg calcium per kg of body weight if using calcium carbonate (60 mg/kg calcium if using calcium acetate) daily, divided into two or three doses and given with meals, if your dog's phosphorus levels are elevated. This is equivalent to about 45 mg/lb of body weight for calcium carbonate (27 mg/lb if using calcium acetate). This amount is in addition to the 1,000 to 1,500 mg of calcium per pound of food that is added to the diet for balance. Ask your vet for more information.

Renagel (sevelamer hydrochloride), which does not contain either calcium or aluminum, is now being used for people. It has not yet been approved for dogs, though some have used it.

All phosphate binders need to be given WITH food (or immediately after) in order to block the excess phosphorus in the food from entering the bloodstream. Give away from other medications (by at least 1 hour, if possible) since antacids may effect absorption. Dosage depends on how bad the phosphorus values are.

See Phosphate Binders: What Are They and How Do They Work? for more information (human oriented). About Phosphorus Binders also has good information on this subject (feline oriented). Although I have no idea if it applies to dogs, apparently people become itchy when their phosphorus levels are too high.

Epakitin and Azodyl

Epakitin (also marketed as Ipakitine in Europe) is a chitosan-based phosphate binder and uremic reducer. It contains lactose, calcium carbonate (the same form of calcium found in ground eggshells), chitosan, and hydrolyzed soy protein. The amount of calcium is pretty small, only 37 mg per gram of powder according to this analysis. Epakitin is administered at the rate of 1 gram per 5 kg (11 lbs) of body weight twice daily. It is the Chitosan that is the primary active ingredient, according to their literature. Chitosan is derived from shellfish and is the major source of the nutritional supplement glucosamine. PDRHealth says, "In animal models of chronic renal failure, chitosan produced decreases in serum urea nitrogen, serum creatine and serum phosphate." There is some more information about Epakitin on the Phosphorus Binders web page of the CRF site for cats.

Epakitin comes in 50, 150 and 300 gram sizes, dosage is two  scoops per 10 lbs of body weight divided evenly between meals. There is apparently 1 gram per scoop, so you will use around 60 grams per 10 lbs of body weight per month. The best prices I saw were at Vet Depot and Amazon). See SupplementWatch for additional information on Chitosan. Chitosan is also marketed as a weight loss product (Vitacost, Now Foods), so you might be able to find it cheaper, but I'm not sure what the dosage would be, nor whether it would be as effective.

Ian Hudgings of ThrivingPets.com, who has done some research on this product, says, "My research on Epakitin revealed that the product is more than 80% lactose. Epakitin is less than 10% calcium carbonate, so it is hard to even refer to this product as a calcium-based phosphorus binder -- in fact Vetoquinol doesn't, they  call it a 'nutritional supplement.' Perhaps chitosan may be of some value to CRF pets, but here again the quantities are very small, as this fiber makes up less than 5% of the product."

If dosage of Epakitin is 2 grams (2,000 mg) per 10 lbs of body weight daily, 5% would be 100 mg chitosan per 10lbs of body weight daily (split evenly between meals). If Epakitin is prohibitively expensive for your size dog, you could try giving plain chitosan at this dosage instead.

Azodyl is a proprietary probiotic product that claims to help break down the by-products of digestion that contribute to uremia (elevated creatinine and BUN). Note that uremia contributes to symptoms of kidney disease, but is not harmful to the kidneys themselves; elevated creatinine and BUN are the result of kidney disease, not the cause. The bacteria are called "Kibow probiotics", from Kibow Biotech in Pennsylvania, who sells the same product under their own brand name, and says it contains three strands of probiotics: streptococcus thermophilus, lactobacillus acidophilus, and bifidobacterium longum, plus psyllium (prebiotic, used to feed the probiotics). See this info in their brochure. This company apparently patented the term "enteric dialysis" that is used to market Azodyl. Once again, you may be able to find these ingredients more cheaply in other probiotics products, such as Source Naturals Life Flora, Udo's Choice (available thru Amazon), and Stonyfield Farm Yogurt. See this ConsumerLab report for other good probiotic brands. Also see PDRHealth for more general info on these and other probiotic strains.

Best price I found is at Amazon.

The Vetoquinol web site shows two small, unpublished and undated studies, one on pigs and one on cats (the one on cats was uncontrolled, neither was double-blind), showing some benefit from the use of Azodyl. I know of no other information that would suggest this product is beneficial to dogs with kidney disease, though there would be no harm in using it and probiotics offer other benefits as well. Ian Hudgings of ThrivingPets.com, who agrees that the claims for Azodyl are overblown, still says, "I don't think Azodyl is a bad product. I think it can help with inappetance issues and improve digestion and absorption of nutrients. I don't think it will improve BUN and Creatinine but it may make your pet eat better and feel better which may lead to a better quality of life and may extend the pet's life as well."

I've heard one direct report from someone whose dog improved on Azodyl, with both BUN and creatinine reduced after one month on the supplement. Others have also reported satisfaction with this product, usually combined with Epakitin (see above).

I heard but was unable to verify that the probiotics in Azodyl are a subset of those found in kefir, a cultured milk product similar to yogurt but with a wider variety of beneficial organisms, and that the manufacturers of Azodyl, when pressed, admitted that the product was derived from kefir. This suggests that feeding kefir might be beneficial for dogs with kidney disease, though Azodyl is probably a more concentrated source. Kefir is easy to make once you get the starter "grains," which look like little cauliflowers (this is not the same as a starter culture that is sometimes sold, but which is not self-propogating. The nutritional profile is very similar to yogurt. See Kefir Resources for more information on kefir.

Calcitriol

A recent study indicates that calcitriol may be beneficial in dogs with chronic kidney disease:
"A salutary effect of calcitriol treatment of CRF was recently shown in a placebocontrolled study of 37 dogs. The dose of calcitriol was adjusted according to serial ionized calcium and PTH determinations, and ranged from 0.75 to 5.0 ng/kg/day. Over the course of 1 year, there was a significant reduction in mortality rate in the group of dogs receiving calcitriol (28%) as compared to the placebo group (63% mortality)." (Prolonging Life and Kidney Function). This article also has information on dosage levels, and suggests that intermittent rather than daily dosing may be preferable when using calcitriol.

Veterinary Partner has this description of Calcitriol in their article on Calcium Phosphorus Balance:

One might think that calcitriol would not be helpful in this situation since it leads the kidney to retain phosphorus. The good news is that when small enough doses are given, calcitriol can still act as the off switch for parathyroid hormone without causing the kidney to retain phosphorus. The amounts needed for this beneficial effect are so small (they are measured in nanograms) that a compounding pharmacy is needed to custom make the product at the proper dose.
    * Calcitriol cannot be used in patients with elevated blood calcium levels.
    * Calcitriol cannot be used in patients with phosphorus levels that are already abnormal. This is a preventive measure more than a treatment.

ACE Inhibitors and Hypertension

The use of ACE inhibitors is still somewhat controversial, and may only be beneficial if high blood pressure is involved, which is less common in dogs than it is in humans, or for glomerulonephritis, where there is a lot of protein loss in the urine. For more information on both sides of the issue, see ACE Inhibitors and CRF Cats and Early Detection and Prevention of Progression of Renal Disease......A Role for ACE Inhibitors (which also talks about the role of phosphorus in renal disease). Also see High Blood Pressure for more info on this condition.

High blood pressure may also be treated with drugs such as amlodipine besylate (Norvasc) and sometimes aldosterone inhibitors, such as spironolactone. Low-dose aspirin (0.5-5 mg/kg twice a day) is also used for dogs with glomerulonephritis for its anti-inflammatory action and its effect on platelets (use aspirin only under guidance from your vet).

Acidosis and Ulcers

Baking soda (sodium bicarbonate) can be used to help neutralize the system, if your vet agrees. Sodium bicarbonatealso can be used to treat hyperkalemia (high potassium). Note that sodium bicarbonate does not contribute to high blood pressure, so there's no need to worry about using it even if your dog is hypertensive. See Fanconi Disease Management for Veterinarians (item 7 under Management Dosing Guidelines and further down under Sodium Bicarbonate Dosing Calculator) for some additional info on treating with sodium bicarbonate tablets.

Potassium Citrate can be used to treat hypokalemia (low potassium) and also to reduce metabolic acidosis (though the article on Fanconi Syndrom above says that it is not effective for that condition).

The amino acid l-glutaminemay help control metabolic acidosis.

Potassium levels are important and can affect the heart, so neither of these should be supplemented without your veterinarian's knowledge and consent.

Carafate (sucralfate) can be used to treat ulcers, if they do occur. It is protective and can help heal any existing ulcers (Tagamet and Pepcid do not help with healing). H2 blockers used to treat uremic gastritis include Tagamet (cimetadine), Pepcid (famotidine) and Zantac (ranitidine). These can be combined with sucralfate. See Current Concepts for the Management of Chronic Renal Failure in the Dog and Cat for dosage amounts for famotidine and ranitidine. Give Carafateaway from meals (at least one hour before or two hours after), and Tagamet, Pepcid or Zantac at a different time, such as half an hour before meals (half an hour after the Carafate) if used together. If you are not using Carafate, give the Tagamet or Pepcid two hours after eating. Slippery Elm can also be beneficial, and raw honey may also help. Signs of ulcers can include vomiting (particularly if you see blood or what looks like coffee grounds in it), diarrhea, and black stools. Note that cabbage juice is good for ulcers -- just boil up some cabbage and then give the water it was boiled in.

It may be helpful to treat a dog with kidney disease prophylactically with something like Pepcid. Ulcers can develop even without metabolic acidosis. Starting the dog on Pepcid when kidney disease is first diagnosed, even without symptoms, may be beneficial in stopping ulceration from developing. WARNING: I had my dog on Pepcid for over a year when I discovered it was contributing to her inappetence. Once I stopped giving it, her appetite improved immediately. I have since heard a similar story from another person. If your dog has problems with inappetence and you are using this drug or something similar (Tagamet, Zantac, etc.), you may want to try stopping the drug to see if it helps.

Anemia

Aranesp (darbepoetin alfa) is a supplement related to Epogen that is used to treat anemia related to kidney disease that has also been used for dogs. A human study found that Aranesp given every two weeks was as effective as Epogen given weekly.

You need to test erythropoietin levels to see if they're the cause of the low red blood cells, otherwise, the medication can be harmful. Anemia can also be caused by malnutrition if you are feeding too little protein. See the following for more info:

Erythropoietin
Erythropoietin (Epogen®, Procrit®)
Epogen

Iron supplements may also be helpful for anemia caused by kidney disease.

Alternative Treatments

Giving Pills

If your dog doesn't like to take pills, there are many things you can use to wrap the pills in and make them go down easily. The best I've found are Pill Pockets -- the smell is very enticing, and you can pinch off just enough to cover the pill, making each one last a long time (I used to think they were too expensive because I thought you had to use a whole pill pocket each time you gave pills).

Before I knew about Pill Pockets, I started with soft cream cheese, then braunschweiger sausage (similar to liverwurst), then peanut butter. When those stopped working (when she went through a period of inappetence, she often didn't want the same foods again), I found that a number of leftovers work great -- Nattie was particularly fond of crab cakes, shrimp or crab dumplings (dim sum), and potstickers. I've also used mashed potatoes and gravy, peanut sauce (Thai satay), string cheese, and fast food (potato wedges from KFC went over very well). Meat doesn't work as well, since she tries to bite it and sometimes bites the pill, I find softer food works better. I've also found that first offering a bite with no pill, followed by the bites with pills, and ending with a no-pill bite, works well for us. Note I use as little of the extras as possible, I'm not talking about giving one pill with a whole pot sticker, for example, but making that pot sticker last for several days and a large number of pills.

You can also get medications compounded into easy to give, palatable liquids or chewable pills, or even ones that can be absorbed thru the skin, if needed. See these sites for more information:
Pilling Cats: There IS Another Way
Compounding Pharmacies
Compounding Pharmacies -- United States (see bottom of page for Australia and Canada)
Animal Pharmacy

In addition to Pill Pockets described above, another treat designed to hide pills is Medi-Crunch, but these have a hard exterior so you couldn't pinch off pieces to get multiple uses per treat as you can with Pill Pockets.

You can find other helpful tools such as the Pill Crusher/Splitter atAmazon, VetAmerica, PetRx and DiscountPetMeds.

It is very important for the dog to always have access to plenty of fresh water, whether or not you are giving fluids. Wet food (raw, cooked, canned, or water added to dry food) also helps them stay hydrated.

Fluids: Lactate Ringers Solution is an electrolyte mix, and is the most common solution used, but if your dog has high potassium levels, then you may want to use just saline, and if your dog has high calcium level, you may need something else. Your vet will be able to advise you which fluids to use.

Amount and frequency: Standard maintenance dosage is around 5 to 15 ml per pound of body weight at one time, but the amount will vary depending on degree of dehydration and how much water your dog is drinking and getting in their food. My vet originally prescribed 800-1,000 ml two or three times a week for my 45 lb dog, but we eventually reduced that to 500 ml (just over 10 ml/lb), as she did better with this amount and didn't appear to need more. Frequency of administering fluids will increase as the dog's condition worsens.

Needles: Terumo 19 gauge thin wall needles have been recommended as the sharpest, most pain-free needles, and the thin wall allows a larger hole, which will reduce the amount of time it takes in infuse the fluids into the dog. However, when I switched to a standard 18 gauge needle, the fluids went in much more quickly, which made it easier on both the dog and me, and the needle caused no more problems than the smaller gauge had.

Warming the fluids is important in order to make the process more comfortable for the dog. This can be done with a large heating pad or in a bowl of hot water or in the microwave. Be certain that the fluids are not too hot, especially if you use a microwave. You want them to be close to body temperature.

Fluids are not recommended if your dog has heart problems or edema, and should never be given if prior fluids are not yet absorbed.

When we first gave fluids to my dog, I believe she did not need fluid thereapy. However, when her water intake increased about threefold, I began giving fluids again. I think that you may be able to judge how much sub-q fluids are needed by how much water your dog is drinking. If your dog is drinking a great deal but has trouble absorbing fluids, this is a sign of low albumin (which can be the result of feeding too little protein), and should be discussed with your vet.

Implantable Catheter Set: There is a new option available for giving sub-q fluids, called the Endo-Sof Subcutaneous Catheter Set or GIF Tube. A catheter is placed in the dog using anesthetic. You then no longer have to stick the dog with a needle, you can just use the catheter port to give the fluids. It lasts up to one year before needing to be replaced. See Subcutaneous Fluids (scroll down to the bottom of the page) for more info. Note that several people have reported problems with the use of this catheter, including infections and clogging up. Before making a decision, I would advise joining the K9KidneyDiet group (they have information in their Files section and people who have used them can tell you about their experiences) and/or the GIF-Tube group for more information.

See the following for information on fluids and where to find them at a reasonable price (some of these sites are oriented towards cats, but the information is the same):
Giving Subcutaneous Fluids to a Dog
Administering Subcutaneous Fluids at Home
Sophia gets her Subcutaneous (sub-Q) Fluids
How to Give Sub-Cutaneous Fluids using a Giving Set
Mail Order Supplies for Cats with Chronic Renal Failure (CRF)
Fluids for CRF Felines -  Buying Locally - Some Sources of Supply
HydroVet Fluid Administration Supplies
Content of Common I.V. Solutions
Valley Vet

Here's a method that was described by one person for giving fluids more quickly:
Shannon Watts (pixxi78 @ yahoo.com), says, "I got it down to under 5 minutes using the following method (it uses more equipment so it is more expensive). In addition to the bag of fluids, tubing, and Terumo 20G x 1" needles, I also bought an additional piece of tubing, a 3-way stopcock, and a large 60cc syringe. Using your current setup, you attach the stopcock (instead of the needle) to the IV tubing coming from the fluid bag. Next, the syringe attaches to one spoke of the stopcock, and the extra tubing to the third spoke of the stopcock, and finally the needle at the end of the extra tubing. This way, I'd use the syringe to pull in 60cc of fluid, flip the stopcock and push the fluids in. It's very fast. To make it affordable, I only switched the tubing/stopcock/syringe about once a week." Note that it's important to maintain sterility, so ask your vet for help before trying to do this yourself.

Incontinence: Dogs on sub-q fluids, or who are simply drinking a lot of water due to kidney disease, are frequently incontinent. These products may help:

• Drs. Foster & Smith offer waterproof liners and pads in lots of different sizes and shapes that can be used to protect dog beds or furniture.
• Waterproof mattress pads sold for kids' beds may be a more affordable option.
• Discount Pet Pads offers both new and used washable underpads in different sizes.
• Petpads are "gently used." Composed of water-resistant material on one side and absorbent on the other.
• Orvis offers waterproof beds and liners, as do many other sites that sell dog beds.
• I have used Changing Table Pads that I put under the bedding so the urine does not soak thru, and then just wash those and the bedding in the morning as needed.
• Sam's Club sells disposable pads such as Member's Mark® Comfort Shape® Underpads. and Disposable Underpads (also available in smaller size).
• Also see Stay At Home Protection Pads and Pooch Pads at KV Vet.
• Little Stinker Housebreaking Pads (available at SitStay) or similar items may also work.
• Poochie Pants cute diaper garments for male and female dogs of all sizes
• Pet Peepers Disposable Pet Diapers this site offers a variety of different diaper garments, including some that are washable.
• Ultimate Vet Fleece extremely soft and thick, this fleece lets liquids run thru so dog stays dry (waterproof liner of some kind needed underneath). The "super deluxe" is so thick that a 4x5 sheet will not fit in a regular-size washing machine.

See the section on Nursing Aids/Other for links to more info on commercial and homemade products for incontinence. 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.

More helpful hints on dealing with incontinence on these sites (they're talking about paralyzed dogs, but many of the recommendations are also applicable to incontinence for other reasons):
Wonderpuppy.net -- see the sections on Bellybands, Diapers, Cleaning the dog and diaper rash, Floors, and Protecting your bed and furniture.
Paralyzed Dogs: How to Care for Them
Dog Diaper Comparison
Diapers and male wraps includes tips on skin care and how to make your own belly bands.

As a general guideline, you want to feed about half meat and half low phosphorus grains, pasta and veggies, with additional eggs and egg whites, small amounts of liver and kidney, and some high fat, low phosphorus extras like butter, whole milk yogurt, and heavy whipping cream, as long as your dog has no problems tolerating fat.

Here is a sample diet for a 40 lb dog. Amounts shown are for about one pound (two cups) of food, plus a couple of extras, which should be about right for a 40  lb dog, though individual dogs will vary. Note that 8 ounces is approximately 1 cup. Compare the mg of phosphorus per 100 kcals (65) to the amount in Hill's k/d (57) and notice that there is very little more phosphorus in this diet while providing much more (and higher quality) protein, which is beneficial for dogs with kidney disease as long as phosphorus is limited.
 

Supplements: YOU MUST ADD 1/2  to 3/4 TEASPOON GROUND EGGSHELL (or an equivalent amount of calcium) PER POUND OF FOOD FED TO EACH MEAL. This is so the calcium will act as a phosphorus binder, not just to balance out the calcium:phosphorus ratio. Do not add calcium if it is elevated in your dog's blood work (ask your vet about using other calcium binders instead). If you do not want to use ground eggshell, you can use other forms of calcium instead (see Phosphate Binders above for more information). Never use bone meal as a source of calcium, as it contains high amounts of phosphorus.
Fish Oil is another important supplement. You should  give 1,000 mg fish oil (body oil, not liver oil) per 10 lbs of your dog's body weight daily. The omega-3 fatty acids in fish oil help protect the kidneys and are one of the best things you can do for a dog with kidney problems.
Other supplements that may be helpful are Vitamin B-Complex, and small amounts of Vitamins C and E. Don't add Vitamin D (or cod liver oil) beyond minimum amounts to dogs with kidney problems unless directed to by your vet. It is also best to avoid supplementing with Vitamin A as well, or use only in small amounts, preferably in the form of beta carotene.
You can also add small amounts of kelp and alfalfa, or something like Berte's Green Blend. These supplements should be used sparingly, as kelp contains sodium and alfalfa can act as a natural diuretic. Using them once or twice a week may be preferable to daily, especially if your dog has moderate to severe kidney failure, or has high blood pressure. Note that a home made diet is naturally low in sodium, unless you add salt or use high sodium prepared foods (including cottage cheese).

Adjust the amount of food fed as needed for the size of your dog, remembering that smaller dogs generally need more food per pound, while larger dogs on average need less (for example, a 20 lb dog would probably eat a little more than half the amounts shown, while an 80 lb dog would eat a little less than twice the amounts given). 8 ounces is about 1 cup of food. Keep an eye on your dog's weight, and increase or decrease the amounts if you see unwanted weight loss or gain.

This diet can be fed cooked or raw (except for the cereal, rice and sweet potatoes, which should be cooked). If you do cook it, light cooking is better than overcooking. You can break the diet down into two or three meals a day (you can also feed just one meal a day, but it is supposed to be easier on the kidneys to feed multiple smaller meals). You can mix the foods together, or feed them separately, depending on what your dog prefers and what is easiest for you.

NUTRITIONAL ANALYSIS: The diet shown here, for a 40 lb dog, would be 1.2 grams of protein and 13.5 mg of phosphorus per pound of body weight. For comparison purposes to prescription kidney diets, it is about 0.37% phosphorus on a dry matter basis. As fed, this diet contains 9.0% protein, 10.5% fat, 6.7% carbohydrates, 0.5% fiber, 0.7% ash, and 72.6% moisture (based on the USDA Nutrient Database).
You should feed a minimum of 1 gram of protein per pound of body weight (more is fine). Phosphorus restriction varies according to the degree of kidney failure. For early stage, 20 mg phosphorus per pound is a good goal. For dogs with elevated phosphorus, or late stage kidney disease (creatinine over about 4.0 mg/dL, or 354 µmol/L), this should be reduced to 11 mg per pound.

Here is more detail on the individual ingredients, and what was used to compute the numbers above:

MEAT: For lowest phosphorus, use high fat meats, such as lamb, pork, and high fat hamburger, but it is also good to include some heart in the diet. Dark meat chicken and turkey are higher fat than light meat, and the skin is where most of the fat resides, so include it if possible when you feed chicken and turkey. Tripe can be used in this category, it is lower in phosphorus than most meats. It is OK to use more eggs and egg whites (use a ratio of one or more egg whites to each whole egg) in place of some of the meat. Small amounts of high fat cottage cheese and canned fish (Jack Mackerel, Pink Salmon or Sardines packed in water -- drain and rinse the fish if sodium is a concern) are also OK, but do not use cottage cheese if your dog has high blood pressure. Feeding a variety of foods is better than feeding just the same thing all the time, both for nutritional purposes, and because your dog will be less likely to tire of the diet, but if there are foods your dog won't eat, it's OK to avoid them.
 

GRAINS AND VEGGIES:Use only low phosphorus grains and vegetables. You may add the extras (butter, heavy whipping cream and yogurt -- see below) to the grains and veggies for added flavor -- you can also try low or no sodium gravy or broth. Winter squashes are the hard bodied ones, such as Acorn Squash, Spaghetti Squash, and Butternut Squash. You may want to alternate between the suggestions below so that your dog doesn't get tired of always eating the same thing, but it is OK to use only the ones your dog likes.
 

EGGS: Use at least one egg white per each whole egg you feed, for lower phosphorus (most of the phosphorus is in the yolks, but eggs are such nutritious foods that it's good to feed at least some whole eggs).
 

LIVER/KIDNEY: Although these foods are high in phosphorus, they also have a lot of vitamins and nutrients and are good to feed in small amounts. It is not necessary to feed them every day, but don't feed large amounts at one time, as too much can lead to loose stools. Although liver is easier to find, try to include some kidney in the diet if possible.
 

EXTRAS: Add low phosphorus, high fat foods for extra flavor and calories without adding much phosphorus. Butter (use real butter, not margarine -- use unsalted if your dog's blood pressure is high) and heavy whipping cream are great for adding flavor to rice, cereal and vegetables. Whole milk yogurt is higher in phosphorus, but is still good for variety in small amounts. Beef fat and bacon grease could also be used. Be careful when increasing fat in your dog's diet, as too much fat can lead to loose stools and sometimes even pancreatitis, in dogs that are prone to it. Increase amounts gradually, and back off right away if you see signs of problems, such as discomfort after eating, or any vomiting or loose or mucousy stools.
 

To reduce phosphorus even further, feed more egg whites and fewer whole eggs, feed less organ meat (liver and kidney), and feed a little more cereal/rice/sweet potatoes and a little less meat. Compare the calories to the amount of phosphorus to look for the lowest phosphorus amounts per calorie -- those marked in green are the best foods for low phosphorus, while those marked in red have the highest amount of phosphorus per calorie. However, they are still important foods to feed for nutritional purposes, unless your dog is in end stage renal failure.

For more recipe suggestions, see Diet for Kidney Needs

Nattie's Diet

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 per pound of boneless meat fed), 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:

• Feed 1/2 oz liver or kidney daily, reduced from 1 oz -- feed kidney more often instead, the vitamin A in liver is not considered good for kidney disease (liver = 2.8 g protein, 45 mg phos; kidney= 2.4 g protein, 30 mg phos)
• Feed 2 oz ground meat daily, reduced from 3 oz (9.4-9.9g protein, 74-89mg phos)
• Add the following daily (rotate between them):
• Every third day, give 1 whole egg plus 1 egg white (9.7 g protein, 93.3 mg phos)
• Every third day, give 4 oz Farina (or Malt-o-Meal) with 1 oz Whole Milk Yogurt (1.6+1 g protein, 13.6+27 mg phos)
• Every third day, give 4 oz Sweet Potato/Squash/Turnips (separately or together), with 1 oz Whole Milk Yogurt (.8-1.9+1 g protein, 18.1-30.6+27 mg phos)
• Increase salmon oil to 2000 mg
• Add calcium (1/2 to 3/4 teaspoon ground eggshell per pound of meat fed)

Dinner (total 8 oz):

• Leave all fat on everything
• Feed 2 oz RMBs (raw meaty bones) daily, reduced from 8 oz (7.2-8.7 g protein, 238-292 mg phos)
• Add the following daily (rotate between them):
• Every other day, add 4 oz Green Tripe (8.8 g protein, 77 mg phos)
• Every other day, add 4 oz Ground Meat (9.4-9.9 g protein, 74-89 mg phos)
• Add 2 oz Whole Milk Yogurt daily (2 g protein, 54 mg phos)
• Once a week, instead of the above, feed 4 oz fish (22.4-26.3 g protein, 341-373 mg phos) w/2 oz tripe and 2 oz yogurt
• I drain the liquid, but no need to rinse fish to remove salt because her blood pressure is normal
• Add calcium (1/2 to 3/4 teaspoon ground eggshell per pound of boneless meat fed)
• Increase Salmon oil to 2000 mg, add 500 mg Ester-C and B-50 Complex

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:

• Estimated life expectancy?
• Cannot say. Some dogs with this diagnosis at a younger age never die of kidney failure.
• Any other blood values out of range? Check Calcium, Phosphorus, CO2, Sodium, Potassium, Anemia
• Everything else in normal range (note treatment will vary if other levels are outside normal ranges)
• Blood Pressure? (Sodium)
• We tested her blood pressure, and it was normal. My vet feels there is no need to worry about reducing sodium unless BP is high. Note that a raw diet is naturally low in sodium anyway (other than a few foods, like cottage cheese). Only mild sodium restriction, if any, is considered necessary for dogs with high blood pressure.
• Ace Inhibitors?
• Only for high blood pressure or glomerulonephritis, where protein is spilling in urine. Note ace inhibitors can hurt kidney function as well as help it, so they're not something you want to use unless necessary. See above for more info.
• Sub-Q Fluids?
• Will not hurt unless dog doesn't like them. Would give 800cc 2-3 times a week to a dog her size.
• We are holding off starting this for now. Will retest in a month. If numbers are still worsening, I may start then.
• Symptoms of ulcers? Only with acidosis?
• Give Pepcid AC prophylactically. 1/2 mg/kg = 10mg daily. Ulceration can occur even without acidosis.
• Have not yet started Pepcid. Will probably start soon, and give 2 hours or more after eating (vet says it doesn't matter when it is given, but I think Pepcid can interfere with digestion, so I don't want to give it with meals)
• What should I give if she gets FSF (Familial Shar-Pei Fever)?
• Note that dogs (and people) with kidney problems should not take aspirin or any other NSAID (though low doses are used for dogs with glomerulonephritis). In the case of high fever (which Shar-Pei get), Ascriptin is OK
• When to recheck?
• 2-3 months unless we see other symptoms
• We are going to probably recheck in a month, just to help determine if my diet modifications are helping, and whether or not to start sub-q fluids.

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:

Breakfast (total 3 1/2 oz):

• Alternate between the following:
• Every other day, give 1 egg (89 mg phos) plus 1 egg white (4.3 mg) scrambled with 1/2 oz mozzarella cheese (50 mg -- try this instead of parmesan, much lower in phosphorus, or try ricotta cheese, which is even lower) or sometimes ground meat (lower phosphorus, but she doesn't like it as well). Total 143 mg phosphorus.
• Every other day, give 2 oz Abady canned kidney (88.5 mg) (she wouldn't eat fresh kidney originally, but now gets half fresh and half canned, alternating the fresh between liver and kidney), plus 1.5 oz muscle meat (w/garlic powder for flavor as needed) (67 mg) or tripe (57.8 mg). Total 146.3 - 155.5 mg phosphorus
• Add Berte's Green Blend and Probiotics (because she was on antibiotics), plus a little eggshell calcium, to food.

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.

• 6 days a week, give 2 oz RMBs or Farmore (approx 250 mg), plus 4 oz tripe (154.2 mg) alternating with 4 oz muscle meat (cook burgers, try garlic powder seasoning, etc.) (avg 179.4 mg). Total approx 404.2-429.4 mg phosphorus.Note for those of you who do not feed raw meaty bones: I include these only because they're her favorite food. It would actually be better for her not to get any bones, as they are higher in phosphorus than anything else you can feed. Instead, use the same amount of muscle meat, dairy or tripe.
• If feeding lamb breast, can give whole meal if it contains little bone, lamb rib w/o bone is only 137 mg/100 grams, or 233 mg phosphorus in 6 oz.
• If feeding chicken necks/backs, give extra skin and fat.
• Once a week, instead of the above, give 4 oz fish (canned jack mackerel or pink salmon or sardines, approx 350 mg) plus 2 oz tripe or muscle meat (approx 77.1-89.7 mg). Total approx 427-440 mg phosphorus.
• Remember to add eggshell calcium (1/2 to 3/4 teaspoon per pound of meat)!

• Methylprednisilone: Given for chronic bronchitis.
• Pepcid: 10mg once a day, given mid-day or bedtime. Helps prevent gastritis from acidity commonly caused by kidney disease.

WARNING: after using Pepcid with Nattie for over a year, I discovered it was contributing to her inappetence. Once I stopped giving it, her appetite improved immediately. If your dog is inappetant and is on Pepcid or similar medication (Zantac, Tagamet, etc.), you may want to try stopping the medication to see if it helps with the appetite.
• Sucralfate (Carafate): 1/2 tablet twice a day, given a couple of hours after breakfast, and at bedtime. Given to help prevent gastric ulcers caused by kidney disease. (Stopped giving this after a couple of months, just didn't feel it was necesary since we had confirmed with an endoscopy she did not have ulcers).
• Salmon Oil (fish body oil): 2 grams twice a day (total 4 grams, which is 1 gram per 10 lbs of body weight), given with meals. Provides omega-3 fatty acids that have been shown to help with kidney disease.
• B-50 Complex: 1 capsule once a day, with breakfast (should probably give twice a day, as B vitamins are water soluble and get peed out).
• Vitamin E: 200 IU once a day, with breakfast.
• Berte's Green Blend: 1/4 tsp once a day, with breakfast (for trace minerals)
• Probiotic Powder: 1/2 tsp sprinkled on breakfast, she likes it (this is because she was on antibiotics). I later started giving her probiotic capsules that include FOS and Bifidum at bedtime, there is a possibility that these beneficial bacteria help absorb nitrogen  from the digestive tract and can help lower BUN. You can get these at any health food store.
• L-Glutamine: 500mg once a day away from meals. May help with intestinal inflammation, muscle wasting (from pred). Only given when also giving prednisone (for bronchitis).
• Calcium -- need to supplement with ground eggshell to help bind the phosphorus both breakfast and dinner (1/2 to 3/4 tsp per pound of meat). Note that Nattie's blood calcium levels are normal; if they were high, I would need to use an aluminum-based phosphorus binder instead, though I would still want to add some calcium to her diet to ensure her needs were met.
• Started giving 500 mg Vitamin C, since she is doing so much better about taking pills.
• Not giving but might want to add: Garlic, ACV.
• CoQ10: started giving 15 mg three times a day (or 30 mg twice a day), see above for more info.

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 above 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.

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 above 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 bloodwork 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 ophthalmalogist). 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 degneration) 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).

• Nutri-Cal (Evsco/Tomlyn) or NutriStat (Tomlyn) food supplement for dogs and cats. Other liquid diets include Rebound and DogSure.
• Braunschweiger sausage (a favorite, you can also try liverwurst)
• Canned Abady Kidney and Green Tripe, or fresh green tripe (see above for sources)
• Scrambled eggs in butter with lots of cheese (I've used shredded parmesan and mozzarella, you can also try cream cheese)
• Baby food (plain meat or Juniors, adding garlic may help)
• White bread
• Canned fish (sardines, salmon, jack mackerel) or smoked salmon
• Treats: Healthy Essentials, Liver Biscotti, Dried beef lung, Freeze dried liver, IVD Select Care
• Natural Balance Dog Food Rolls (they smell wonderful)
• Wysong All Meats Diets (canned) and Archetype (freeze dried)
• Kibble (my dog liked Go Natural and Wellness better than California Natural)
• Canned dog food (especially A/D from Science Diet) or even cat food
• Ground raw meaty bones (various kinds), or chicken necks cut into bite-sized pieces
• Commercial raw food diets (I tried Farmore and Country Pet, she ate both)
• Chicken livers sauteed in butter
• Canned chicken or ham
• Other human food, including seasoned, grilled hamburger, beef stew with gravy, sauteed boneless pork loin, marinated turkey tenderloin, homecooked chicken and broth, shredded chicken in barbecue sauce (also works well when mixed with scrambled eggs), chicken or chicken carcasses boiled with carrots, celery, cabbage and rice for a couple of hours, then remove the bones and mash it all up, etc. Soft boiled eggs, chicken stock, cooked bacon, cooked duck and pizza crust were also suggested. Cioppino (fish stew) was a big hit with my dogs.
• Chinese food: pot stickers, crab and shrimp dumplings (dim sum), crab cakes (I buy these frozen and use them now for giving pills, as they're definitely favorites)
• Cream Cheese, Cottage Cheese, Gorgonzola, or other kinds of cheese
• Deli meats (can roll with other food inside)
• Liver Shakes
• Milk shakes or ice cream
• Macaroni and Cheese
• Add for flavor: Butter, Heavy whipping cream, Sour Cream
• Sprinkle any food with soy sauce, parmesan cheese, feta cheese, satay (Thai peanut) sauce, or garlic powder
• Some dogs like spices, so you can try spaghetti sauce, curry or chili sauce
• Seacure has a strong fishy smell that dogs like, plus it is an easily assimilable protein. It comes in a powder that can be sprinkled on food. It is used to treat malnutrition. Solid Gold Life Exxtension is a similar product that also contains hydrolyzed whitefish.

Here's a recipe for a nutritious broth you can make: http://onibasu.com/archives/kn/167660.html(don't add the vinegar for dogs with kidney disease, as it helps break down the bones in the broth which will increase the phosphorus levels).

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:

• Meclizine (Bonine, Antivert; more info here) can help with nausea. One dog with moderate to severe kidney disease started eating well after being picky for ages and gained over ten pounds after being put on this drug.
• Mirtazapine (Remeron) is an antidepressant that has strong anti-nausea properties and acts as a strong appetite stimulant.
• Ondansetron (Zofran) is a human chemotherapy drug that can be used to stop severe vomiting.

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).

Diet Information

Web Sites with Current Information on Kidney Disease

Very Technical:
Chronic Renal Disease and Failure (CRD, CRF) Very technical but lots of good information.
Class Notes from WSU College of Veterinary Medicine Highly technical but very good information
Class Notes and Links from UW-Madison School of Veterinary Medicine Excellent resource, plus lots of links
The Canine Kidney from the Waltham Course on Clinical Nutrition
Chronic Renal Failure Class notes, highly technical but informative
Chronic Renal Failure Very complete overview of different tests and treatments for various problems relating to kidney disease

Feline oriented:
Tanya's UK Feline Chronic Renal Failure Information Centre Feline oriented, but lots of good information
Feline CRF Information Center Feline oriented, very informative.
Chronic Renal Failurefrom Holisticat

More Links:
Kidney Disease in Dogs Lots of links to information of all kinds. Also includes some homemade diets near the bottom of the page. There is a mirror site at http://www.geocities.com/HotSprings/Falls/9065/ if you can't reach this page.
Canine and Feline Nephrology and Urology Page Links to more info

Glomerulonephritis

These sites are technical, but provide very good information:
Glomerulonephritis remains an important cause of renal disease in dogs (be sure to see both pages)
Glomerulonephritis in Dogs and Cats
Diagnosis and Management of Canine Glomerular Disease
Proteinuria and Renal Disease: A Roundtable Discussion
Strategies for Protein Losing Nephropathy
Treatment of renal proteinuria -how to treat animals with proteinuric nephropathies
Glomerulopathy (glomerulonephritis) (GN)
Protein Losing Nephropathy: An Overview

Leptospirosis (Acute Renal Failure)

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