Kidney Disease and Protein Controversy

coneja

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This last Monday, my newly adopted 11 year old Max was diagnosed with Stage 1 kidney disease. My vet said (in a brief conversation over the phone) that she recommends Hill's k/d or other renal diets as well as another exam and blood test in six months. I was in shock, and now I'm struggling with this advice, as I strongly believe in the value of high meat protein raw food, (Max is on Stella and Chewy's freeze dried raw right now, and he's still a very skinny cat), and very much dislike Hill's but also want to trust my vet. 

The "prominent" vets that I am familiar with and respect (Dr. Pierson of CatInfo.org, Dr. Hofve of LittleBigCat and Dr. Hodgkins of Your Cat) recommend focusing on phosphorus levels and continuing to feed a high protein diet so that the cat doesn't catabolize muscle tissue for energy on a restricted protein diet. But they all say things like "many vets/some experts/research say(s) that a low protein diet is not helpful/can be detrimental." But in my own research so far, and after reading LDG's helpful compilation of research papers in the "High protein, seniors, kidney disease and CRF" thread, I'm still not finding an abundance of backing to support this, even though I am seeing problems with the studies that supposedly show a renal diet is better than a "maintenance" or high protein diet. 

I plan to meet with my vet in the coming week to discus my concerns and talk further about diet. I know this is a grey area and forum members can only give advice but I'm getting really distraught in trying to decide the way forward. I'm reading all that I can (I've gone through FelineCRF.com and and working on Tanya's FelineCRF.org) but still feel no where near confident in understanding all the factors in this disease so that I can make an informed decision. Right now I'm leaning towards finding a high protein but low phosphorus food in conjunction with phosphate binders while we are in Stage 1 and 2, with reassessment when we hit Stage 3. (I unfortunately don't have the blood test numbers in front of me right now, but will get them). But with most research seemingly inconclusive and the low protein advice that's been instilled in the vet practice for kidney disease, I'm not sure how to broach this with my vet, and I feel like I need to be on the same page with her to have the best chance of managing this. I guess I'm looking for any advice or experiences with people in similar situations, or if anyone is aware of new/"hidden" studies (other than Finco et al's from 1998) that weigh in on high protein side (Google Scholar isn't giving me as much as I'd hoped). I'm just feeling very overwhelmed and unsure right now...
 

pushylady

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I'm sorry you're having to deal with all this, particularly so soon after adopting Max. It looks like you're doing all the research you can and will be well informed.
Let us know what your vet has to say on the subject. I'm curious to find out about this as I've read too that there's doubt about the conventional wisdom of reduced protein diets for kidney failure. It's hard to know what's what sometimes when there's so much information out there, and some of it is ill-informed.
 

momto3cats

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I also found all the conflicting studies confusing. I had two different vets insisting that my cat needed the low-protein renal diets, so I ended up trying that (several different brands) for a few months. This was after my cat reached stage 3. What I found was that she deteriorated faster on those diets, and when I finally tried a higher protein diet (out of desperation to get her to eat) she started improving. I have been feeding her moderate-to-high protein, low phosphorus foods for the past 8 months, and my cat is doing much better than I ever would have expected. Her kidney disease is still progressing of course, but slowly, and if I had continued to follow the vet's advice I believe my cat would be dead by now. That's just my experience with one cat.
 
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2bcat

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It's a really tough situation to be in, that is for sure. How is Max feeling at this point? Is he having trouble with eating or anything? When the cat is having appetite trouble sometimes this ends up making your decisions for you. You just feed him whatever you can get him to eat, because that becomes more important than exactly what is in the food.

But since you're asking with such detail I'll assume that is not part of your daily routine. All I can really add is what I concluded when last feeding a kidney patient, about 2 years ago. My reading of various sources led me to believe that if anything, phosphorus was the issue, and that the low protein renal foods are that way because it's the easiest way to get the phosphorus lower. But I even read that restricting phosphorus may do nothing, as in there seemed to be no real indication that feeding a low phosphorus food would keep s CKD cat feeling better longer. The thinking about phosphorus is based somehow on what the kidney function does, but the connection to feeding low in phosphorus may be tenuous.

That said, I vaguely pay attention to phosphorus level when feeding my current healthy cats. Because maybe, just maybe, over that long period of time it'll have some effect on their eventual issues at older age. I don't know though. I don't think I've read anything to support it, just what my mind does. I don't put huge emphasis on it because I'm not picking from too many foods that are especially high anyway.

I figure in either situation lower phosphorus wouldn't hurt. When I last had a CKD cat it was always appetite crisis mode though, so a lot went out the window. Sure I tracked down and bought foods that were lower in phosphorus and also high in calories (the better to get more caloric intake from a smaller amount), but it didn't much get eaten. Were I to be in this scenario again, and my cat was eating Stella & Chewys already, I wouldn't be much inclined to switch. As long as he's getting enough food to maintain weight, that would be good, and I think most S&C varieties are reasonably low in phosphorus although not nearly as low as a renal diet.

None of this will really help in a discussion with a vet I'm afraid. Just one person's processing of the various info. I don't know how I would handle it if my vet was insistent about the food. My vet has rarely been one to insist on specific foods. There are some things I just wouldn't do now, like ever put a cat on dry food, even dry renal food, vs anything wet. And I'd probably be inclined to stay with high quality foods rather than the veterinary diets from Hills and others. You could always fudge it and say you can't get him to eat the renal food or something like that. But awould we be doing this on any kind of evidence or just belief? Im not really sure at this point. I just don't really feel entirely comfortable with the vet diets.
 
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coneja

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Thanks for the info, everybody. Yeah, I've liked my vet so far, as she seems pretty good with my cats, whethers my worrying, and was in favor of me doing a freeze dried and commercial raw mixture (which I've heard some vets oppose) and we've talked briefly about cats as obligate carnivores. So I was surprised when she suggested the k/d food. No matter what, I'll definitely NOT be feeding the dry diet because the last thing he needs is high carbs and low water....

Max plays like a young cat, jumping on everything and seems spry and happy, despite moving like an older cat (which my vet noticed when I took him in.) Right now we just finished a second course of ear drops/cream for a yeast infection, and a further complication is that he may be allergic to chicken. Right now he's eating his food when I sprinkle bonito flakes on it or change it up a little; he seems to get bored of one flavor repeatedly. But he seems kind of bony to me. I can feel some hips and backbone. So he doesn't have a lot of wiggle room in the weight department, and my fear would be that even with a low protein food that's chicken free and palatable, he might not be getting enough of what he needs. I suppose nothing's set in stone: I can see what my vet says, see if he likes any of the wet renal diets, then watch his weight. If it drops too much or he's not eating, etc., I can always put him back on the Stella and Chewy's or something else in conjunction with a phosphorus binder. OR, since I favor the higher protein food, maybe just trying to restrict phosphorus initially while he's in Stage 1 and 2 and seeing how fast the disease advances. Problem is, I've read that as they get sicker, the renal diets become even less palatable.

Too bad there's not more definitive research. :( 2bcat, I'm with you on the vet diets. I hate the "Prescription Diet" schtick and I don't trust the companies. But even reading Tanya's Guide, which many refer to as the "CKD bible," I notice she does use and recommend renal diets under the right circumstances (like, if your cat will eat them) even though she provides a lot of resources for other commercial, low phosphorus foods and acknowledges the controversy. So does FelineCRF.com, which I think I found through Dr. Hofve's site (and she doesn't recommend the renal diets until the BUN is double its normal levels, which I believe falls into the later stages?)

Momto3cats, I'm glad your girl is doing better on the higher protein food. I've heard other people with similar stories in the forums, and every bit of info, whether anecdotal or in a peer-reviewed paper, is appreciated. :)

I'll see if I can schedule a "consultation" or something with my vet for this week, and I'll let y'all know her thoughts.

Edit: This is Max. I fostered him for a month to make sure he got along with my resident cat, Luna, until finalizing the adoption. I was actually on my way to fill out the final paperwork when the vet called with the news. Not that it would have made any difference if I'd know earlier, but I just found it kind of timely.
 ​
 
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mrsgreenjeens

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I was feeding raw when Callie was diagnosed with kidney disease (HAD been feeding kibble though for 12 years prior), and our Vet said  continuing feeding raw was AOK as long as we starting substituting egg shell powder for the calcium source due to the high phosphorus level in bone.  We tried this,but Callie decided she didn't like raw anymore, so it became a moot point. 

My whole point here is, however, that OUR Vet entirely agreed that good quality HIGH protein, low phos is the way to go to maintain muscle mass in a kidney cat.  She said she recently attended a conference on this topic and it was generally agreed that this is the way to go....an entire new way of thinking for the mainstream Vet.   So....Radcat is a premade raw that uses egg shell powder, I believe, but it's not freeze dried.  Or you could make our own, as I did, IF you know what you're doing.  Otherwise, I don't know of any freeze dried raw that uses egg-shell powder vs bone, and I DO still think keeping the phosphorus low is important in lowering creatonine. 
 
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coneja

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Thanks, Ms.Greenjeens. That's sort of what I'm hoping my vet will agree to... It's nice to know other people's everyday vets are saying this, rather than just things I'm hearing online (no matter how much sense it makes from a logical perspective). 

He doesn't need to stay on freeze dried; my other cat gets a mix of Stella and Chewy's (FD) and Raw Advantage, a relatively local raw pet food company. But they have rotational dinners and recipes for complete nutrition, and use ground bone. I will check out RadCat; that's really helpful to know.

I just got percentages of phosphorus and calcium for Stella and Chewy's. They don't have the info on a dry matter basis, but the values are the same for rehydrated freeze dried as their corresponding raw for each dinner. Since the raw is 70% moisture max, and I'm assuming the formulas between FD and frozen are the same, I used the 70% value to calculate phosphorus on a dry matter basis, and as expected, it's up there: 1.7% for the chicken dinner, which has the lowest percentage of phosphorus as fed, which Max can't eat anyway because of suspected issues with chicken. Using the same assumptions, the goose/duck formula he's on now probably has a dry matter phos content of 2.97%. Eeek! Guess we will be finding something lower, either canned or frozen, if we go the commercial route.
 

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When Mr. Grimsby was diagnosed with CKD, I told my vet that I wanted to switch him to a high-protein diet. She was enthusiastic about my decision. She agreed that it doesn't make sense to reduce muscle-building protein intake if he's losing muscle mass. And I've read white papers since then advocating a high-protein, low-phosphorous diet for CKD cats.

If you feel strongly about your cat's diet, then perhaps you should follow your heart, rather than the vet's head.

Let us know how things go.

Best regards.
 

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I'm a member of the Feline Chronic Kidney Disease group on Facebook. I've seen too many cats with Stage 1 CKD have numbers improve (a few to normal) when they were switched to raw (with eggshell) or home cooked with eggshell to think feeding homemade is not healthy for a CKD cat that doesn't have advanced disease. I am convinced the issue is in the quality of the protein. There's less waste / toxins to eliminate on the high quality food, IMO. If feeding a low phos, high protein, truly human grade, minimally processed food, it's less work for the kidneys.

Of course, if considering homemade, please see TCS' thoughts on that: http://www.thecatsite.com/t/282314/recommending-a-homemade-diet-hold-your-horses
 
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coneja

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Thanks, it's reassuring to hear that. Right now I've got him on Lotus canned because it was lower phosphorus than the Stella and Chewy's freeze-dried: 0.92-1.09% DM compared to 2.97%. I haven't been able to talk to my vet yet; last week our schedules didn't mesh. I'm hoping I can talk to her tomorrow... Thus far, I've only used commercially prepared raw and/or freeze dried, because it scares me to have the cat's complete nutrition depend on something I make. Plus, I wouldn't be able to know the nutritional analysis for certain. But if that seems like the best option, I would do it. I guess I'll start looking into info on homemade diets... 

Msgreenjeans, I looked up Radcat's phosphorus levels and it looks like their lamb is the lowest at 0.79 phosphorus, so that's an option if I go that route. Right now I've got Raw Advantage (I've met the lady who runs it, and it's fairly local) but don't have all the nutritional info so I'll be looking to get that too.

PHarber-Murphy, thank you for the warm wishes. I was hoping my vet would be as enthusiastic about a high protein diet as well... I wish I could be confident that I was doing the right thing by insisting on high protein... I guess I'm almost sort of hoping for her to say, "yeah, that could work" or whatever so that things would be more clear cut but that may not be the case...
 

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daryl the cat

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I'm going through the same thing right now.  My newly adopted cat is in stage 3 and won't eat any of the kidney foods I've tried in the last week.  I'm finally getting her to eat some of Daryl's Fancy Feast, which one vet condemned me for, but at least she's eating.  Also chicken breast and Temptation treats and the A/D food in a syringe, but it's a constant struggle to get that in her.  In my experience so far, no vet has been on board with the high protein food.  They all want to push their prescription foods.   

Can any of the low phos foods mentioned here be bought at Petsmart?  I need to find something today.  I left a message with my vet and when she calls back I will ask her thoughts on the high-low protein issue.  There is a holistic vet in her office so I'm hoping she'll be more amenable to it.

Good luck Coneja.  Sending good vibes to you and your kitty.
 
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coneja

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LDG: Awesome, I will check out those links. I had heard of the vitamin premixes before; that makes it much easier. Thank you: I really believe raw and freeze dried are the way to go.

Daryl: I'm not sure... I actually work at a local mom and pop pet food and aquarium store, so hard to say. They may carry the frozen Radcat, but I'm not sure, and some cats might not take to raw immediately (I've heard). They might carry Lotus which is what I'm feeding Max now: the Lotus Just Juicy Turkey and their Chicken has 0.92% DM phosphorus. You could also try Weruva: their lowest would be the Steak Frites at 0.57! But, some cats don't like beef which is the main protein in that one. Their Cats in the Kitchen line has a food called Chick Magnet which is 0.67% DM phosphorus. I've got all these values from CatInfo.org, by the way; here's her list of canned foods and phosphorus. Weruva starts on page 25: http://www.catinfo.org/docs/FoodChartPublic9-22-12.pdf. I posted it to your thread last night as well just as an added resource. :)

I think that's really unfair of the vet to condemn you for getting your cat to eat, even if it's not a kidney food. :( At least she's eating and everywhere I've read really emphasizes that over everything else. Hopefully the holistic vet will give you some more input.
 

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daryl the cat daryl the cat ooops, posting from my phone and hit the wrong thing. Are you familiar with Dr Pierson's food list? I know there's another site with info on phos in commercial foods. Hopefully someone more familiar will chime in. To identify the low phos foods, use the middle columns, where the food is presented on a dry matter basis.

http://www.catinfo.org/?link=cannedfoods#Commercial_Foods

Click on the Cat Food Composition chart. I can't provide a direct link from my phone, it just downloads the PDF file.
 
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coneja

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In my experience so far, no vet has been on board with the high protein food.  They all want to push their prescription foods.   
I feel like we're sort of undergoing a revolution in even the feeding of healthy cats as raw and freeze-dried becomes more mainstream. (At least, that's what it seems like where I work.) And what I've heard -though this might not be true and I'm not trying to start anything or accuse anyone- is that a lot of vet schooling materials (like info on nutrition) are supplied by companies that make the prescription foods. But I'm not a vet, so can't say for sure, obviously. :) I remember reading somewhere (probably from Dr. Pierson's CatInfo.org) that having a bunch of different foods labeled for each single ailment makes it easy to just grab the "appropriate" one off the shelf. And I understand if that's what you know, you probably rely on it to do what the tin says. But I have issues with a lot of those foods and those companies, so I'm definitley biased and skeptical when I'm "prescribed" a food.
 
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coneja

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Yeah, I like her a lot. Her site was the one I read that convinced me to switch my cat from kibble to freeze dried and raw (which I was linked to through this forum, of course).

It's a huge, extensive list but if you can access it on one of those newfangled smart phones, you can probably walk into Petsmart, look at their selection, and check the DM phosphorus on her list by hitting Ctrl F (or Find, or whatever smart phones use)  to find that specific food on her list. Easier than trying to memorize 30+ pages! 


Good luck!
 

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I'm going through the same thing right now.  My newly adopted cat is in stage 3 and won't eat any of the kidney foods I've tried in the last week.  I'm finally getting her to eat some of Daryl's Fancy Feast, which one vet condemned me for, but at least she's eating.  Also chicken breast and Temptation treats and the A/D food in a syringe, but it's a constant struggle to get that in her.  In my experience so far, no vet has been on board with the high protein food.  They all want to push their prescription foods.   

Can any of the low phos foods mentioned here be bought at Petsmart?  I need to find something today.  I left a message with my vet and when she calls back I will ask her thoughts on the high-low protein issue.  There is a holistic vet in her office so I'm hoping she'll be more amenable to it.

Good luck Coneja.  Sending good vibes to you and your kitty.
Dave's Pet Food makes low phosphorus cat food. But, your cat just needs to eat groceries, no matter the protein or phosphorus. You can adjust meds to help bind excess dietary protein and phosphorus better than you can tempt a late stage renal cat to eat unpalatable kidney diets.

Investigate a variety of diets, irregardless of phosphorus content. Quality protein and hydration are key. Inquire with your vet about starting Aluminum Hydroxide gel or powder to administer as a phosphorus binder. It is very inexpensive and effective. Calcium based binders should be avoided, as renal cats are prone to elevated systemic calcium already. They can't filter the calcium and phosphorus from their blood as they once did, making balance within their cells and blood very difficult to achieve without dietary and/or medical management.

Good luck with your girl, and feed as much Fancy Feast as she wants, if this is all she eats! Some vets, as some people in general, just have a hard time acknowledging nothing is one size fits all, that sometimes change and thinking outside the box is warranted, and it's just easier for them to throw a patient on a renal diet rather than balance medications and closely monitor labwork with these changes.
 

the3rdname

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Investigate a variety of diets, irregardless of phosphorus content. Quality protein and hydration are key. Inquire with your vet about starting Aluminum Hydroxide gel or powder to administer as a phosphorus binder. It is very inexpensive and effective. Calcium based binders should be avoided, as renal cats are prone to elevated systemic calcium already. They can't filter the calcium and phosphorus from their blood as they once did, making balance within their cells and blood very difficult to achieve without dietary and/or medical management.
Rory's internal med vet gave Epakitin the thumbs up when her calcium fell back into the normal range (she's been on Epakitin since beginning treatment, even when cal was high- an oversight on regular vet's part!), so I think it could be worth considering if a cat has normal calcium levels.  It's highly palatable and doesn't have the same toxicity risks that come with AH use.  Binders are a PITA...seems like they've all got pros and cons.

A newer one that looks interesting is Lanthanum Carbonate.  Here's a page all about binders for the OP: http://www.felinecrf.org/phosphorus_binders.htm
 

puck

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OMG, he's flame point AND polydactyl! What a stud muffin!

He looks my dad's old cat Leo, crotchety old flame point siamese, abandoned at one of my clinics at 14 for pooping outside the box after the baby started walking :[ Man, was that old man happy livin' with an old man ;] And old cocker, of which only the cranky sweet ole cocker is still living.

Max is very fortunate for his second lease on life as well! At the beginning of disease, we don't decrease their dietary phosphorus unless their blood chemistry yields a high phosphorus. With renal cats, we want to decrease inflammation, increase hydration and diuresis, and maintain protein and groceries, so we don't throw them off their appetite. VetriScience Renal Essentials is a great supplement, available in chew treats and chewable tablets.

Max would benefit from omega 3 fatty acid supplementation also, and the concentrated DHA/EPA in Welactin is great, with proven ingredient potency and absorption of this fish oil. Cats only need 1.5tsp every other day of Welactin; I keep the largest bottle, 480mL, but I also use over 20mL daily amongst many pets/patients. You may want to start with the 240mL bottle, and toss the ridiculous scoop they send. It holds 6mL and gets grimey as it is a porous plastic. A pediatric dropper syringe works great, and you can take it apart and soak it a few times a week to keep the oil from congealing in the bulb of the dropper.

Down the line, when his BUN is high, add prebiotic, aka fiber - psyllium husk, to his regime, as this will bind excess dietary protein before it's absorbed and broken down into nitrogen by the body.  When his phosphorus does spike, aluminum hydroxide is a great phos binder, is inexpensive, and doesn't increase their blood calcium the way other phos binders will. Your vet can help you dose both of these after they report higher labwork results to you, indicating the renal disease is progressing.

The deal with animal nutrition is a DVM must self-teach nutrition. They can sign up for pet food company seminars, a necessary evil as the majority of pet owners feed these diets, both OTC and Rx, and before "balanced" diets is when vets truly profited from high hospital bills, as owners ran their pet to the vet for neurological, cardiac, and developmental deficits/disorders directly linked to poor diet before the age of "pet food" diets. Animal feed industry has benefited, and teaches what their foods contain, and what they were made to do, catering back to the veterinary community after that period of creating pet foods in the 60s and 70s. Vets helped formulate all those diets years ago, and now, to limit EPA/DHA deficiency, taurine deficiency, protein deficiency, copper deficiency, as well as multiple nutrient toxicities and mycotoxicity.

I signed up for all the nutrition possible in undergrad, which was 3 types of animal nutrition courses, as well as human nutrition, and ethics of feed animals and ethics within human nutrition. These were much more informative than the single NCSU CVM nutrition seminar I took while an undergrad, as some of our life sci departments were taught by CVM staff. They must take that kind of initiative to learn and think outside the box. A good vet does this in diagnostics, nutrition, geratric and palliative medicine, pain management, surgical technique, and many other avenues of their continuing eduction and practicing of medicine.

I've toured many facilities, I've had many pet food companies be transparent, and show me the processing, extraction, baking, cold-pressing, spraying of their food. Some people need these diets for their pets. Boarding facilities and shelters without dry and canned options would by hard-pressed to provide for their visiting or resident dogs and cats. DVMs in training can also seek more nutrition information, and certified veterinary nutritionists have large book-loads of recipes for feeding cats and dogs by the condition we are trying to treat. They prefer no bones, just because we clinically pull a lot of obstructing bones from esophagus, stomach, and intestines of critters. I had tried raw whole food with own and fosters over 13 years ago for 3 years, and occasionally, we had a problem with a cervical bone or leg bone getting lodged in the esophagus or stomach. No complete obstructions, thank God, but complete GIFB happened to patients of mine, and only surgery removed that stubborn bone. We sought this kind of diet as we didn't have any skin/GI allergy diets back then, and resolving our pets' issues ourselves was necessary, with good western meds and some of the early VetriScience supplements I've come to trust and employ.

I can understand why your vet may recommend Rx renal diets, as they help control phosphorus/calcium and add potassium, very important factors to progressing renal insufficiency. Starting the diet is easier than recommending regular bloodwork to monitor phosphorus, BUN, CREA, and electrolytes while you adjust some meds and supplements. Many owners, most owners, aren't like some of us here on TCS, and need that easy management option, rather than monitor their cat closely, or add AlHO or fiber to their meds and take their cat in for weekly bloodwork to make sure these meds are effective and the phosphorus is climbing, or potassium dropping. The Royal Canin Renal cat diets are the best Rx option for owners, as they have a higher protein, restricted phos/Ca, and added K compared to Hill's k/d or Purina NF. But, rotating diets is necessary in renal cats, as they become inappetant. This inappetance must also be supported with Cerenia and sometimes, GI protectants, to keep their GI tract calm and happy. But, Max isn't their yet, and TMI already!

Good luck with your lucky boy!
 
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