Nutrition- Final- 3

wilsbach's version from 2016-04-17 22:12

Binky, renal failure

Question Answer
remember elevated TP means...dehydration. If hct is normal in the face of dehydration....anemic too.
If renal patient has high BUN- which KNF do you want to change, why?Want to LOWER PROTEIN. because protein is made of CHON and the N=nitrogen. And if kidney is sick it can't handle that much, which is why the BUN is high in the first place
how much protein do you want to give a kidney pt?want to give them as much as they can tolerate without making them uremic.
how might you be able to keep the protein lower but have them meet their daily requirements?make sure food is DIGESTIBLE. Need the AAs from the protein in the diet-- so if protein can be more efficiently used, you don't need as much
so protein brings in amino acids-- but what are the diff kinds of these? What do they metabolize to? what does this do overall to the body?There are sulfur containing AA and phosphorus containing AAs.... the sulfur ones turn to sulfuric acid. or The P ones to phosphoric acid (what they metabolize to) so add a lot of sulfur containing amino acids (more predom) and it'll acidify body. cats need more sulfur containing acids. Cats have higher requirements of cysteines (sulfur containing one) bc need more glutathione and methionine. They also need taurine. whats taurine? another sulfur containing amino acid.
does animal tissue have more sulfur or phosphorus containing amino acids?Sulfur-- which is why cats are carnivores, and require all these sulfur containing amino acids (ex: taurine)
So if you have a kidney failure cat where you need to avoid excess protein from overloading the kidney with nitrogen, how can you choose your proteins wisely?Cats need sulfur containing amino acids the most, but amino acids are acidic so you only want to give ideal types and amounts bc kidney failure means they are already acidemic. so can suppliment with DL methionine (a sulfur AA) in diet
what other thing is DL methionine good for, aside from getting a sensitive kidney patient just the right type of AAs?also can add DL methonine if cat is having lower UT signs (like male plugging with struvie) wanna acidify urine- and this dissolves the struvites.
what are K+ levels like with kidney dz?usually low-- kidney dz= excrete/lose more K+. And the more they lose, the worse the kidney function--> lose more.
what electrolytes do you want to manipulate in kidney dz diet- and in what direction?INC K+ and DEC P.
what does low TCO2 mean?This is VENOUS CO2. not related to arterial blood gasses. so if there is low TCO2, there is low bicarb, which means they are acidotic. TCO2=BICARB.
why are kidney patients often acidemic?lungs are short term pH buffer-ers, kidneys are long term. If kidneys can't buffer because they are sick, they are sick so can't get rid of excess H+, which means the animal is acidemic. This means you need to make the diet more alkaline to help buffer.
what can you do with the diet to help with the acidemia due to kidneys being too sick to filter H+?Can add sodium bicarb (pinch at first, can inc as needed). Can also use potassium bicarb or citrate. Recheck TCO2 (poor mans bicarb levels) to see acid-base status and if you are giving enough to help.
why is phosphorus bad in kidney pts?kidneys not working well enough to remove P actively from blood, and then it becomes a problem
if phosphorus restriction in diet isnt enough, what else can you do to help the P levels?add phosphorus binders to diet
what are Na and Cl levels like in kidney dz, why?Hypernatremia+hyperchloridemia. Gotta dec salt content (most kidney patients have hypertension bc RAAS system messed up- kidneys not getting enough blood flow, so RAAS inc.. which means its making Na go up too. and kidneys not excreting it. and save Na means save water--> Hypertension). Also Na high bc cat dehydrated.
What are P and Ca and vitamin D levels like in kidney failure?wanna maintain normal Ca:P ratio. Kidney cat already has acidemia so Ca is being resorbed from bones because of the acid. And then they have high P bc kidney isn't filtering it so the P can bind up the Ca. Also kidney's make Vitamin D, if theyre failing vitD levels go down-- cant absorb as much Ca then. so make sure to maintain normal levels of Ca:P ratio, although giving excess Ca isnt good either.
Kidney failure can lead to PU/PD so USG often isosthenuric. What vitamins are you worried about losing in urine which you might wanna suppliment?B-vitamins (water soluble so can lose in lots of urine)
explain the mechanism of how GFR is controlled in the kidney-- and how you can manipulate diet to help with thisRAAS helps maintain filtration. GFR is maintained by constricting or relaxing the efferent (outgoing) arteriole in the glom. This is controlled by prostaglandins. So at first if you need to inc the filtration rate, prostaglandins tell the efferent arteriole to constrict and this inc the pressure in the glom and helps more filtrate go through. This is good in short term, but in long term, this can lead to damage of the arteriole and is undesired (esp since it can be a vicious cycle bc as more gloms damaged-- GFR still dec-- so then they try even harder to constrict). So how can you use diet to help this? Try to dec prostaglandins. Remember that prostaglandins come from arachidonic acid in the cell membrane which is a N6PUFA. So A-acid goes through COX to become a PGF2a. However, you can use diet to change the composition of the fats in the cell membrane, and replace the N6's with N3PUFAs aka EPA (esosapentonoic acid) (aka omega fatty acids like in fish oil). N3's compete with N6's so add more N3's to the diet will dec the N6's which mean there is less "food" for COX to turn into PGF2a--> less constriction of efferent arteriole. Also N3s/EPA encourages vasodilation. Don't go overboard though because you still do need some N6's because prostaglandins play a lot of roles in body upkeep. SO, ADD FISH OIL TO DIET TO HELP DEC VICIOUS CYCLE OF VASOCONSTRICTION IN KIDNEY. (also, fish oil, on top of having EPA also has DHA, which is a precursor for anti-inflammatory compounds-- whereas EPA is competitive for N6.)
do you want wet or dry food for kidney pt?WET FOOD- WANT THEM TO STAY AS HYDRATED AS POSSIBLE
explain "ion trap theory" and how to use it for kidney ptsUse GI as a 3rd kidney-- Add soluble fibers to diet. These reach the large intestine and then are broken down by microbes to make VFAs-- which acidifies the large intestine. And usually nitrogen is broken into ammonia in the large intestine, where it is absorbed to be a huge burden on the sick kidney. but if the environment is acidic, then the ammonia is ionized into the ammonium ion, which CAN'T be resorbed, so it is defecated out instead of going into bloodstream to burden the sick kidney. Less ammonia= less urea= less burdened kidney.
what is the problem with the palatability of these diets for kidney failure, and what do they do about this?Not very palatable-- low protein and low salt. So they inc the fat to make it tastier, and then dec the food dose as to not overfeed.
what are patient factors which make their appetite dec when there is kidney dz? cat is dehydrated. Which is a patient factor which affects palatability. With hct, once fluid expand cat, PCV will go down--- cat will be anemic. which affects appetite. (fix anemia, appetite better) cat prolly feels crappy. bc not excreting urea. So builds up in blood- comes back across mm in oral cavity. And then bact in oral cavity break it down to Ammonia. (urease producing organisms) so then GI ulcers from mouth to rectum. and can be nausea. also might have ulcers bc stomach is acidic bc gastrin is not being filtered out. (can give famotidine to help).
What cation is involved in sense of smell and taste, which can affect appetite?its zinc. ppl with zinc deficiencies just dont eat much bc food doesn't taste good. so maybe look at Zn++. And then know what normals are. but nobody has really looked at this.
simple solution to inappetant kidney patient?put in E or G tube-- permanent way to make sure they eat.
SO, OVERALL KNFs for Kidney diet, as well as additional things to help?LOW PROTEIN (nec nitrogen/ammonia) + suppliment DL methionine (most bang for your buck amino acids for cats), LOW SALT (BP already all messed up and they aren't excreting it, RAAS is making them save too much), INC K(cant save K from urine, and bc of deranged BP, Na is being reserved so K is being dumped), DEC P (can't filter P), suppliment bicarb to help with acidemia (can't filter H+), inc vitD (kidney cant synth bc sick-caution of toxic doses), suppliement B-vitamins (water soluable= PUPD--> losing too many in urine), ADD FISH OIL (replace N6 which turns to prostaglandins with N3 which helps dec glom hypertension), WET FOOD to say hydrated, inc SOLUABLE FIBER (ion trap- prevent ammonia from being absorbed in Lrg int.), inc fat for inc palatability. If not eating, tube it.

Rusty, GI dz cat

Question Answer
know small bowel vs large bowel diarrheayep.
if you wanna look for giardia on fecal, what should you know?should snap neg 3 times before you can say neg (not a great test) Centrifugation concentration technique is most sensitive for giardia.
what is a sudan stain?Special stain-- if you see big yellow/orange globules, its partially broken down fat. if primary GI, you have malassimilation. maldigestion, malabsorption, or both. if partially digested--> not absorbing (not definitive). (so orange globs= not absorbing, as opposed to not digesting)
what do you usually use to tx coccidia?sulfa drugs
cat with IBD most likely has which form?lymphoplasmacytic (lymphocytes!)
why might you give the drug chromalin to a IBD cat?cats with IBD usually have lymphoplasmacytic. And lymphocytes can dump out histamine granules. And chromalin keeps those granules from degranulating (help with CSs)
what are the 5 GI diets for various GI diseases?(1) novel protein (2) hydrolyzed protein (3) highly digestible diet (4) fiber enhanced diets (5) super low fat diets (CANINE ONLY)
what does a highly digestible GI diet usually be composed of?its a highly digestible diet, with low fiber. also added electrolytes. Usually use these with after dx, diarrhea or vomiting (so could have electrolyte abnormalities). moderate protein, moderate fat.
what are "very low fat" diets used for- and why only in dogs?This is bc only dogs get lymphangiectasia, which high fat exacerbates- bc not absorbing fat and fat in lacteals is super inflammatory
when is moderate to high fiber useful for GI stuff?(1) Fiber responsive diarrhea (...duh?) (2) fiber enhanced diet will help with lg intestine things too. (acts as food for bugs, supports good bacteria)
Things you should know when recommending probioticswant greater than a billion colony forming units per dose or higher. If in a pill- no guarantee in what they are, and are they viable? and can they survce GI transit? there is with iams, prostora. purina's fortiflora. or with human stuff its VSL#3. or culturelle <--he likes this if you dont like prostora. Expensive but good. has >10billion CFU per tx. also no good data to say how much probiotics actually help. ALSO if GI isnt fully intact or immunocompromised, you can be setting them up for infection. Go for pre but not pro in this case.
probiotic vs prebiotic?probiotic is bugs. Prebiotics is what bugs eat (fermentable fiber).
why does fiber help fiber responsive diarrhea?the fiber is for the bugs, not the cat
what is "animal fiber"?Collagen
cats eat dry food which has carbs in it-- but cats don't really have enzymes to break down carbs. How does this work then?carbs finely ground and cooked. even tho dont have many enzymes. and can ferment fiber. Cats have totally diff bugs than dogs.
how should you transition a cat onto a GI diet?slowly-- over 10-14d, like most diets.
how long before you could say the diet is the wrong diet/ its a non-diet responsive problem?like 3-6 weeks
So often times diet and immunosuppression can help IBD. But a study found that even without clinical signs, the lymphocytes were still there. So what's going on with this?TLRs (toll-like receptors, which play a role in the immune response) might respond to microflora. And if you change the diet or immunosuppress with steroids, you are changing the microflora. So CSs might have sthing to do with TLRs and microflora instead of inflammatory cells.
IBD cats have a high risk of developing what dz?lymphosarcoma-- the lymphoplasmacytic IBD did not start out as neoplasia, but the chronic inflammation can make it turn into lymphosarcoma.