Exam 3 - Final exam Material Flashcards
(243 cards)
1
Q
How can you prevent struvites in?
A
Infection specific strategies
- Address uti’s
- Continue monitoring
- Address predisposition
- Cranberry extract does not work
- Urine dilution
- precursor intake
2
Q
What is important about sodium in patients with CKD?
A
- Hypertension contributes to CKD progression
- Avoid high salt diets
- May want sodium reduction with hypertension
- May want lower end if active hypertension
- Over-reduction activates RAAS… not good either don’t go <0.3 g/1000 kcal…
3
Q
How can you prevent refeeding syndrome?
A
Prevention:
◦ Identify patients at risk
◦ Supplement with a B complex (thiamin)
◦ Introduce food gradually
◦ Start with 25% RER while monitoring electrolytes ◦ Increase by 25% each day
4
Q
What are the possible consequences of chronic enteritis?
A
Protein-energy malnutrition (poor body condition scores, hypoabuminemia, ascites)
Hypomagnasemia
Anemia/ iron deficiency
Cobalamin and folate deficiency
Vitamin K deficiency ( can cause bleeding, inhibition of formation of some clotting factors)
Antioxidant deficiencies (zinc, vitamin E, riboflavin)
(they will sometimes present like a hypocalecemic patient)
Vitamin D and calcium deficiency
Dysbiosis
5
Q
How long can you feed SD?
A
Deficient in protein, no longer than 3 months.
6
Q
What do you do if patient refuses appropriate CKD diet?
A
• Address underlying issues
• Diet rotation may be appropriate
• Ensure all diets offered are ok for patient
• Olfactory changes may affect
appetite day to day
• Assisted feeding (feeding tubes)
• provide appropriate diet, can still accept treats, etc
• provided additional water &
medications! (improve QOL
7
Q
What is hepacutaneous syndrome?
A
Hepatocutaneus syndrome is a rare syndrome that can occur as a result of a glucagonoma, liver disease (vacuolar hepatopathy), and rarely diabetes mellitus or
chronic phenobarbital treatment
Skin lesions: bilaterally symmetric crusting and ulcerative lesions on mucocutaneous junctions and cutaneous regions where repeated pressure is applied
footpads, ears, periorbital regions, and limb pressure points
Often the patients will show hypoaminoacidemia (low plasma amino acid concentrations)
Glucagon and liver dysfunction lead to a catabolic state which results in amino acid depletion
Protein is vital for epithelial turn-over, especially in pressure points
8
Q
When would we intervene in regards to nutrition?
A
Depends on several factors:
◦ Length of dysrexia:
◦ 1-2 days: monitor food intake ◦ 3-4 days: support is likely required if recovery is not imminent ◦ 5 days: intervention required
◦ Evidence of malnourishment ◦ Puppies/kittens
9
Q
What is the treatment of Failure of passive transfer?
A
- Surrogate colostrum
- Plasma may be used for infusion of antibodies
- Prevention of pathogen exposure
10
Q
What does adiponectin and leptin do? What occurs with obesity?
A
Work synergistically to decrease food
intake and increase energy expenditure
• With obesity, there is an eventual
decrease in response to these hormones
(leptin) or a decrease in production
(adiponectin)
11
Q
Which is most safe and effective in unclogging a feeding tube?
A
Water
12
Q
What are the adipokines?
A
- Steroid hormones
- Growth factors
- Cytokines
- Eicosanoids
- Complement proteins
- Binding proteins
- Vasoactive factors
- Regulators of lipid and glucose metabolism
13
Q
What is the appearence of a liver of a patient with hepacutaneous syndrome on ultrasound? What is the treatment? What is the prognosis for this syndrome?
A
Typical appearance of the liver on ultrasound:
honeycomb liver
Treatment:
IV infusion of amino acids (Aminosyn 10% crystalline amino acid solution (100 mL contains 10 g of amino acids) can be given IV, 500 mL/dog, over 8–12 hr
May need to be repeated as needed until lesions resolve
High protein, high omega-6 fatty acid diet
B vitamins and antioxidants is empirically recommended
Some recommend to add egg yolk as a source of B vitamins, choline
Prognosis- guarded to poor
14
Q
What state are patients in when they have critical disease and what is the cause? In this state what is used for energy and what is at a negative energy balance?
A
- Critical disease -> cytokines (TNFα etc) catabolic state
- Preferential use of amino acid oxidation for energy
- Negative nitrogen and energy balance
15
Q
What is colostrum banking? What is the issues with that? How is it stored?
A
- Donor colostrum is collected 24 hours after whelping
- The IgG concentration decreases from 3830 mg/dl to 1730 mg/dl after 24 hrs
- The colostrum is frozen until use
- Freezing/thawing has minimal effect on antibody activity
16
Q
What are supplements that are used for patients with liver disease?
A
- Zinc
May have antioxidant and hepatoprotective effect independent of dose for reduction of copper absorption - Carnitine
Involved in fat metabolism
Generally not deficient but supplementation may be useful in cases of hepatic lipidosis…
- SAMe
- Milk thistle (sylimarin)
17
Q
What are signs of Klotho deficiency?
A
Animals with Klotho deficiency show signs of FGF‐23 deficiency with high serum phosphate and calcitriol
concentration.
18
Q
What is preferred when feeding through different feeding tubes?
A
CRI preferred for J tube
CRI preferred where GI motility may be abnormal
Bolus or CRI both ok for NE, NG, e-tube, G-tube
No difference in residual and regurgitation rate
19
Q
What are neonates susceptible to at birth? Why?
A
- At birth, the neonate presents an increased susceptibility to infectious agents due to functional immaturity of the immune system
- For example:
- Neutrophils have a small storage pool at birth, and this cell lineage is less responsive to chemoattractants
- Monocytes/macrophages are functionally adequate but have limitations in chemotactic responsiveness
- produce less IFN-α, IFN-γ, and IL-12
20
Q
What are calcium oxalate predispositions?
A
Hypercalcemia (Cancer, hyperparathyroidism, ect)
Increased absorption of calcium and oxalate
Increased excretion of calcium and oxalate excretion is ideal.
21
Q
What conditions may increase energy/ protein requirements?
A
Seizures
Burns
Sepsis
22
Q
Besides total amount of protein in HE what else should you be mindful of? Why? What protien should be avoided? Which is ideal?
A
Not only total amount of protein in HE but also type & quality
–some better tolerated…
–may also reduce incidence of urate
Avoid:
Meat based protein, especially liver
Preferred:
Vegetable, egg, dairy based proteins
23
Q
Who is not likely to have stones?
A
Young animals
24
Q
How can you prevent urolithiasis?
A
- urine dilution
- precursor excretion
- urine composition/ environment modification (add inhibitors/ change ph)
25
What is important about hydration in terms of kidney disease? How can you maintain hydration?
Address/prevent dehydration
• Maintain renal perfusion
• How?
• Increase water consumption -\> water fountains, canned food, etc
• Subcutaneous fluids -\> also contains Na/K (may not be desired) patient tolerance…
• Feeding tube
• More physiologic than
subcutaneous fluids…
26
What are veterinary weight loss diets? What are the aspects they utilize to assist with weight loss?
• There are multiple veterinary weight
loss diets
• Not the same as ‘lite’ OTC diets • Unique aspects that help with weight
loss:
• Increased fiber
• Increased protein
• Increased sodium
• Kibble ‘shape’ ( usually more for owner so they dont feel bad like they are under feeding their pet)
• Nutrient density vs. energy density
27
How are B vitamins utilized / indicated in patients with kidney disease?
• Water-soluble
• Important in energy metabolism!
• Loss may be increased with
polyuria
• Most don’t have large body
stores -\> depletion?
• Most renal diets empirically
supplemented
• Safe!
• oral over-supplementation
difficult
28
How is maternal immunity transferred via colostrum?
• Immunoglobulins represent the most important class of proteins in the colostrum
• In many species, IgG1 are the most important immunoglobulins present in colostrum
• The higher levels of IgG1 in colostrum than in serum corresponds to a selective transfer which becomes active in the weeks before parturition
• A class of Ig G1 receptors in the mammary epithelium having high affinity are present during the last 15 days of gestation
• The presence of these receptors decrease
immediately after the first suckling
• 2 days later, the concentration of IgG
decreases considerably
• Later, the milk proportion of IgA:igG increases
29
What other options are available for dogs with liver dysfunction?
Transition to a liver diet is indicated if there is evidence of copper storage, hepatic encephalopathy or urate urolithiasis
Not every dog with elevated liver enzymes or even liver dysfunction requires diet change!!
When protein and/or copper reduction not indicated…
Highly digestible commercial diet +/- supplementation
Customized complete/balanced home cooked diet
30
Based on all the studies in this lecture what is the overall consensus?
Concentrations of P and Ca in many commercially available
cat foods are highly variable
• Very low and very high both exist as well as inverted Ca:P ratio (under 1)
- Future limits on P, its forms used and Ca:P should be considered.
31
How long should a diet trial last? If cause reintroduced, how long would it take for allergic signs to show up?
The diet should be fed eight to l0 weeks in dogs and four to six weeks in cats, with no other foods, treats, flavored supplements, bones, etc
Called Challenge: When the offending food or ingredient is reintroduced to a food-allergic patient, the pet’s signs will flare-up anywhere from immediately to within three days
Clients often administer medications in cheese, yogurt, or peanut butter and feel the amount given is too small to cause a problem
Limited-ingredient over-the-counter (OTC) diets are not suitable as elimination diets, as they may contain undeclared proteins
Cross contamination during petfood production
32
What must be done for patients with hepatic lipidosis? What is the ideal plan for refeeding?
The key to managing feline is to provide nutrition and stop the catabolic process
In addition, treat underlying disease, correct dehydration, manage hepatic encephalopathy (if present) and infection
Placing a feeding tube is almost always required in these cases; starting to feed at 25% RER in the first day, increasing gradually as tolerated to full RER
Dietary protein should not be restricted unless there are signs of hepatic encephalopathy
Energy is key as it is important to reverse the negative energy balance and stop the catabolic state
Ideally avoid high fat food; however, energy intake is more important
Potassium may be decreased due to low intake
Address refeeding complications if occur
33
What is the role in FIC as components of urethral plugs?
FIC cats you may want to put them on a diet that is preventative
34
What is the pancreas? What is its endocrine and exocrine function? What cells / enzymes are secreted?
Endocrine function: insulin, glucagon, somatostatin:
The Endocrine Pancreas (Islets of Langerhans):
- α cells – secrete glucagon – 15-20% of total islet cells
- β cells – secrete insulin and amylin – 65-80% of total islet cells
- δ cells – secrete somatostatin - 3-10% of total islet cells
- PP cells secrete pancreatic polypeptide – 3-5% of total islet cells
- ε cells – secrete ghrelin - \< 1% of total islet cells.
Exocrine function: Digestive enzymes (amylase, lipase, trypsin...)
- Secretion of digestive enzymes
- Secretion of bicarbonate in pancreatic juice
- Secretion of colipase that facilitates the action of pancreatic lipase
- Secretion of intrinsic factor (dog vs. cat) for absorption of cobalamin
- Secretion of bacteriocidal peptide
35
What are calcium oxalate?
- Oxalates typically come from plants
- some can be formed by compounds in the body.
- Non soluable cystals in water
36
How to achieve intentional weight loss?
• Step 1: Determine BCS, ideal BW
• Step 2: Determine current intake
(kcal)
• Step 3: Calculate RER= BW(kg)0.75 X70
• Step 4: Select diet
• Step 5: Calculate new daily energy
intake
• Check that protein intake is sufficient
• Step 6: Weigh every two weeks
• Bodyweight monitoring is crucial
• Step 7: adjust intake to reach desired
weight loss rate (1-2% BW per week in
dogs is typical)
- Remember to include treats.
- For weight loss, you can use the current RER in dogs, or 80% RER in cats OR decrease current intake by 20%
• Check that protein intake is sufficient
- Monitor body weight
37
Are there genetic tests for urolithiasis?
Yes, and there a may be some benefit to putting them on a diet that prevents urates.
38
What are the important parts of creating a nutritional support plan?
Meeting the energy needs- meeting RER is typically our goal
Achieving and maintaining ideal bodyweight/ BCS/ muscling Meeting nutrient requirements
Addressing electrolyte shifts
Addressing specific metabolic problems (HE, CKD, pancreatitis etc)
39
What would be the best option for a patient with prolonged anorexia and diagnosed idiopathic megaesophagus?
Best would be to place a gastrostomy tube and provide a liquid diet . This is so we can prevent chance of regurgitation as well as to control the speed of feeding and bypass the esophagus entirely. Make sure diet is highly digestible, short transit time, (low fiber, low fat), caloriclly dense (lower volume), and complete and balanced diet (for growth in this case).
40
When should a patient be offered parenteral nutrition?
A good option for patients that cannot tolerate enteral feeding
◦ Severe pancreatitis
◦ Not stable for anesthesia
◦ GI obstruction/ dysfunction
◦ Temporary support
41
What are concurrent diseases associated with diabetes?
Obesity is associated with an increased risk
for a variety of diseases in dogs and cats,
including:
• Neoplastic disease (chronic inflammation)
• Pancreatitis
• Diabetes mellitus
• Hyperlipidemia
• Dermatological disease (folds)
• Renal disease
• Urinary disease
• Cardiovascular/pulmonary disease
• Orthopedic disease
42
Based on a survey by the association of pet obesity prevention in 2018, what percentage of dogs are overweight? Cats?
56% of dogs are overweight or obese
59% of cats are overweight or obese
43
What are the predisposition for struvites?
- Obesity (more skin folds/ micro environment, tend to empty bladder less, higher risk of compounds precipitate.
- Sex (more common in females, proximity between anus and vulva)
- Anatomical (hooded vulva)
- Endocrinopathy (diabetes Mellitus, Cushings, glucosuria,
- Immunosuppression
- Dermatological disease
Anything that predisposes to UTI
Cats: unsure why?
44
What are cystine urolitiasis?
Cystine is disulfide AA
- Normally reabsorbed in the PCT, therefore genetic defect in the reabsorption mechanism is responsible.
45
How do you diagnose pancreatitis?
Diagnosis can be challenging
Medical history
Serum pancreatic lipase
immunoreactivity (PLI)
Abdominal US
Histopathology
46
What is
Hematuria, pollakiuria, stranguria, periuria?
Hematuria- blood in urine
Pollakiuria- often urination (more incidences of urination)
Stranguria - painful or strenuous urination
Periuria- urination in inappropriate location.
47
How to determine if a pet is obese?
BCS
- Cats 5/9 is ideal
- Dogs 4-5/9
- Every point difference is 10% shift in weight.
Most used scale is purina bcs scale (9 point scale)
48
What is the link between obesity and CKD in humans? In dogs?
• In people = significant risk factor for development of
glomerulosclerosis & failure
• Degree of obesity also correlates with degree of proteinuria in people
In Dogs?
• Associated with mild hypertension in dogs
• Increased HR & increased Na+ resorption from renal tubules
• Glomerular hyperfiltration & renal hypertension, damage to parenchyma
49
What must you monitor with Parenteral nutrition?
Magnesium, potassium and phosphorous: Within 24 hr of initiating PN, then EOD
BUN & albumin: Within 24 hr of initiating PN, then EOD Thiamin injection; if lack of B-vitamins in solution/ concern of Refeeding Syndrome
Thoracic radiographs: If signs of respiratory disease develop during administration
Triglycerides: If hypertriglyceridemia or lipemia is present
Blood culture: If evidence of sepsis
Blood glucose every 4 hours If hyperglycemia is present (\>300 mg/dL) consider reducing rate, add insulin, or reduce dextrose in solution.
50
What is relative supersaturation?
- Computer technique
- precipitate vs. Stay in solution
Based on thermodynamic behavior
- concentration of solute compound
- ph
- temp
-interaction with other compounds
Supersaturated: high risk
Meta stable: possible
Unsaturated: unlikely to form
51
What is copper storage disease?
Dietary copper reduction/restriction indicated in these cases May get reduction of copper absorption with long-term
ingestion of increased zinc (unreliable)
Copper is essential, so must also avoid over-restriction
Negative clinical consequences of deficiency (i.e. anemia)
52
What is the mechanism of allopurinol and how it prevents urate stone formation?
Xanthine oxidase is inhibited by allopurinol -\> so it prevents stones, but it can cause xanthine stones ( if given too much)
53
What are potential diets that can be used for hospitalized patients?
Commercial veterinary diets: canned or liquid
Commercial human diets: liquid (may not be balanced for dogs and cats!)
Home-prepared die
54
What tends to be found in lower quantities in liver diets for both cats and dogs?
Dog hepatic diets: relatively low protein, low copper, low
purine
Cat hepatic diets: not available, use renal diets
55
What is important about protein reduction in patients with CKD?
Reduce bioavailable phosphorus…
• Reduce azotemia/uremia
• BUN is only a marker (other uremic toxins too)
• Proteinuria
• Independent of CKD/IRIS stage
• Reduction based on
• UPC/diet history!
• Response…
• Must provide enough digestible protein
56
How can you change dietary precursors?
Struvite- combination of ammonia and phosphate-\> diet with less of these Precursors would be ideal
- in struvite acidify urine
57
What is glutamine? Arginine? Where is fat absorbed and what does it stimulate/ cause?
- Glutamine: fuel source for mucosal lymphocytes
- Arginine: metabolized to NO
- Fat: absorbed through the lymphatics, stimulates CCK, peptide YY, GLP-1
- Slows GI motility
- Butyrate: fuel source for colonocytes, anti
inflammatory
- Fiber: soluble and insoluble
58
What are the common uroliths?Less common?
Struvite and calcium oxalate (cats calcium oxalate) dogs (struvite)
Urate, cystine, silicate, ect
59
When is it ideal to fast a patient? What is the new recommendations in regards to pancreatitis and severe enteritis?
- NPO may be necessary in cases where uncontrolled vomiting is present or high risk of aspiration
- BUT Early enteral feeding is beneficial even in conditions where ‘NPO’ was traditionally recommended
- pancreatitis (Qin et al. 2002)
- severe enteritis (Mohr et al. 2003)
60
What are the risk factors for CKD?
Risk factors for CKD:
• Age (estimated that up to 33% of cats above 13 years have
CKD)
• Body condition
• Hyperlipidemia
• Acute kidney injury
• Vaccination?
• Dietary??
61
What is important about potassium in dogs with renal disease?
• Dogs with renal disease -\> Can be
• Normokalemic, hypokalemic,
hyperkalemic
• ACE-inhibitors may predispose to K+ retention…
• Canine renal diets
• Typically normal to decreased in K+
content
• Look at product guides for K+
concentration
• Important to choose best option for individual patient
• May need custom home-cooked formulation for severe hyperkalemia or refusal to eat appropriate diet
62
What are the energy requirements for orphaned puppies? How can you feed them? How often must they be fed? What else must you do to take care of them?
Age (weeks) -MER (kcal/kg/d)
0-1 : 140
1-2 : 150
2-3: 190
3-4 : 200
weaning: 130
• Treatment:
• Bottle/Dropper feeding
• Tube Feeding
• 5-8 fr catheter
• measure nose to last rib and mark tube • feed slowly (2 minutes) • 6-8 feedings a day best (4 may suffice) • massage perineal region with moist cotton ball
MER (kcal/kg/d) 140 150 190 200 130
63
What are diet options for patients with CKD? What resource should not be recommended?
Commercial
• Custom formulated home-cooked diet
• Consult veterinary nutritionist
• Do NOT used recipes on-line or in books…
64
What is needed for maternal antibody transfer? When does it begin? What is the trend of fetal to maternal abs?
* transport requires a healthy placenta
* Begins at 17 weeks (humans) increases with gestation
* By week 40 (humans): IgG(fetal)\> igG (maternal)
65
What must you do with PPN to meet energy requirements?
Must use higher fat solutions, which can cause issues with hyperlipidemia, or other issues with lipid metabolism. Studies also show risk for immune dysfunction in higher fat diets.
66
What is the correlation between excess weight and musculoskeletal disease?
• Osteoarthritis is more prevalent in
overweight dogs compared to lean
littermates (Kealy et al. 1992)
• Overloading the joints is the main driver
of clinical signs of OA in dogs
• Hormonal imbalances due to obesity such
as increase IGF-1 and decreased GH may
also contribute to OA
67
What are the kinds of feeding tubes and how are they placed?
Feeding tubes types include:
1. Nasoenterel: small lumen, temporary, no anesthesia or incision required
2. Esophagostomy tube: larger lumen, can be long-term, requires anesthesia and incision
3. Gastrostomy tube: Larger lumen, long-term, requires anesthesia and incision
4. Jejunostomy tube: long-term, requires anesthesia, diet- liquid and highly digestible
68
What are comorbidities that have growing evidence in regards to CKD?
• Evidence accumulates for proteinuria and hyperlipidemia
being comorbidities
• Unknown whether treating one disorders impacts the other
69
What percent of dogs meet 95% of the resting energy requirements while hospitalized
under 30%
- 0.95XRER met only 27% of the time
70
What are some different histories prior to gi incidence and what it will indicate?
History of fat intolerance? Try low fat
History of ‘ingredient sensitivity’? Try novel/ hydrolyzed protein.
Bland diet improvement?/ more small bowel- Try highly digestible
High fiber improvement/ more large bowel - try high fiber.
71
What is the role of protein in liver disease?
Supports liver regeneration
Dysfunctional liver (or bypassing in portosystemic shunt)
increased NH3 -\> HE
Protein reduction indicated in cases of hepatic encephalopathy
but otherwise not desired… unfortunately,
hepatic diets are low protein
still want to feed as much as tolerated by
individual
72
How frequent are complications with feeding tubes?
Overall complications are common (up to 77%), but most of them are minor
73
Can food cause CKD?
- May be related to form of phosphorous, and Ca:P ratio
• A need to establish a safety limit for phosphorous
• Acidifying diets, limited in potassium, can also lead to CKD
(Dow et al. 1987)
74
What can be the results of adverse reactions to food?
Inappropriate immune response to dietary antigen
Local cell mediation inflammation, may lead to IBD
Local antibody production (non-IgA). IgE may lead to mast cell stimulation
Systemic IgE production (dermatological signs? Other)
75
What is important about protein quality of patients with CKD?
Highly digestible
• Protein quality (AA profile)
• Less oxidation of AA -\> less
uremic toxins
• Less undigested protein
reaching the lower GI tract
76
What level of IgG in a puppy is considered deficient? What puppies are more sensitive to deficiency? What is the issue with milk replacers?
* Puppies w/ IgG below 230 mg/dl are deficient= increased 9X risk for mortality
* Large breed puppies appear more sensitive
* The proportion of IgA increases with time.
* IgA have a role in mucosal immunity
* Milk replacers can provide many nutritional needs; however, they do not provide immunity
77
What are potential causes of Dysorexia Anorexia relating to CKD?
- Primary disease/ concurrent disease
- gastritis/ enteritis.
- Uremic toxins
- Hormonal changes
- Anemia
- Dehydration, electrolyte disorders, metabolic acidosis.
- Stomatitis/ oral ulcerations, altered smell
- Unpalatable diet, Food aversion, Medications, Hospitalization.
78
What is canine plasma transfusion? Can it be used for IgG transfer?
* Use of IV transfusion in neonates is done in people
* Oral and Subcutaneous administration has been used with variable success in terms of IgG transfer
* However, there are other benefits on growth and health
79
What are the other hunger hormones?
Other hunger hormones include
cortisol and orexin
80
What is important to know about formulas?
• Use a reputable product/brand
• Even the best products are not equal to natural bitch/queen milk, so a foster is always
preferred
81
Why is obesity considered an inflammatory condition?
• Other adipokines such as TNF-α and IL-
6 promote inflammation • Therefore chronic obesity is an inflammatory condition
82
What is the cause of lymphangiectasia? What is the potential consequences of it? What is the treatment?
Can be a result of mucosal inflammation, extraluminal obstruction, intraluminal adhesions
Leads to panhypoproteinemia, hypocholesterolemia, lymphopenia
Treatment:
Fat restriction- relieves lymphatic pressure
Medium chain triglycerides- generally not recommended
Elemental diets- temporarily
83
What hormones suppress hunger?
Multiple hormones suppress hunger
including leptin, insulin, CCK, GLP-1
and more
84
What is feline hepatic lipidosis? What cats does it commonly occur in? What is the pathophysiology of the condition?
Imbalance between peripheral fat stores mobilized to the liver, de novo synthesis of fatty acids and hepatic use of fatty acids
The fat accumulation overwhelms the hepatocytes and impairs liver function
Inadequate energy intake can induce hepatic lipidosis in cats
The degree of energy restriction needed to induce HL was
identified to be between 50% and 75% of the cat’s resting energy requirement
Commonly occurs in overweight cats that are dysrexic due to concurrent disease
Peripheral tissue lipolysis is stimulated by catecholamines, adrenaline and noradrenaline during fasting
Lipolysis is inhabited by insulin
85
What are some exocrine pancreatic diseases?
EPI- Exocrine pancreatic insufficiency
- pancreatitis
86
What possible factors are involved in urolith formation?
PH, mineral concentration of urine, inhibitors and promoters of urolith formation.
87
How can you provide nutritional management of pancreatitis?
Parenteral nutrition allows to provide the body with energy
without pancreatic stimulation
When no more vomiting, offer water
Gradual feeding: increase calories to full RER
Fat restriction- Dogs \< 15% ME fat, \< 25% ME fat in cats?
Chronic management/ recovery from acute pancreatitis: Diet history is KEY !!!
causative episode identified (treat, trash), possibility to feed
previous diet, unless chronic pancreatitis has resulted.
88
Important image
89
How can you confirm tube placement in patients?
Can be difficult! Direct visualization:
◦ Endoscopically placed
◦ Surgically placed
◦ Fluoroscopically placed Radiographs
◦ May provide limited information if tube ends in the esophagus Injection of water/ air through the tube may help (coughing/ borborygmus)
90
What are the benefits of CPN feeding? Where is the catheter placed in the animal?
- Requires central vein access (through jugular or femoral veins)
- Allows feeding a higher osmolarity solution (up to 1400 mOsm/L)
- Allows for a highly concentrated solution, lower volume, or for a low- fat solution if desired
91
Why is the ingestion of maternal milk important in the first 24 hours after birth?
* In the first 24 h after birth, the newborn must ingest immunoglobulin-rich colostrum which provides passively acquired immune protection throughout the neonatal period
* Once the gastrointestinal tract matures, IgG can no longer transverse the intestines
92
What should you avoid in term of components of treats to prevent Calcium oxalates?
Increased vitamin C
Increased Calcium
Includes glycine
93
When should you consider a feeding tube? How do you select the right kind of tube?
When to consider a feeding tube?
◦ Failure to meet RER
◦ Patient unwilling to consume appropriate diet
◦ Need to provide many oral medications How to select the right type of tube?
◦ Type of food to be provided
◦ Length of time tube will need to be maintained
◦ Need for anesthesia
◦ Need for incision
◦ Desire to bypass the airways, mouth, esophagus, stomach, duodenum
94
What is the length of embryonic development in humans? Dogs? Cats? Chickens, Horses? Elephants?
Humans: 280 days
Dogs: 63 days
Cats: 62-72 days
Chickens: 21 days
Horses: 330-345 days
Elephants: 22 months
95
Is there a benefit to Omega -3 PUFAs in CKD? How can it help?
• Marine sourced (fish oil, krill, algae)
bioavailability
• EPA (eicosapentaenoic acid)
• DHA (docosahexaenoic acid)
• Incorporated into cell membranes -\> compete
with Omega-6
• Produce less inflammatory eicosanoids
• May reduce renal interstitial fibrosis, slow GFR decline
• Improve survival
• Lower glomerular capillary pressure, decreased inflammation
96
Where does each tube terminate/ bypass?
Tube selection and where the tube terminates may also be impacted by what we want to bypass
- Naso-enteric or nasogastric tube: does not bypass the airways or most of the GI
- Esophageal feeding tube- bypass the mouth, upper airways
- Gastric tube- bypass the esophagus
- J tube- bypass the esophagus, stomach, pancreas, duodenum
97
How common is CKD in cats?
1/3 of cats above the age of 15 suffer from chronic renal
disease
98
What are diet options for pets with cystine urolithiasis?
```
Commercial ( Vegetarian diet RC or Urinary UC ( low in Cystine as well as purine)
Home cooked ( custom formulated)
```
99
What is occurring in this image?
Immature cataract caused by canine milk replacer.
100
What does a high folate and low cobalamin suggestive of?
Folate supplementation [in patients with chronic enteropathy] Small intestinal bacterial overgrowth (SIBO)/ dysbiosis
Exocrine pancreatic insufficiency
All of the above may be possible
All of the above may be possible
101
What are some causes of mega esophagus?
- Myesthenia Gravis, idopathic, vascular abnormalities, ect.
102
What are the concerns associated with protein reduction?
Concerns with palatability or decreased intake
• Decreased E intake -\> loss of BCS
• Decreased protein intake below MR -\> muscle
loss, hypoalbuminemia
• Less aggressive if only reducing phosphorus…
• Generally more aggressive/restrictive with
• Stage 3/4 (azotemia/uremia)
- Proteinuria
103
What is important to remember about treats?
* Treats can be incredibly important to owners and to their pets
* Treats are allowed, but have to be included in the overall intake calculations
* Treats should not exceed 10% of the daily energy intake
* Low calorie treats allow increasing the number of treats that can be given per day
104
What is the potential drawbacks to assisted/ force feeding?
Assisted/forced feeding
◦ Aspiration
◦ Food aversion
◦ Trauma
Works well in rabbits and rodents
105
Can you dissolve calcium oxalate?
No you cannot in dogs or cats
106
What are lite foods? Are they weight loss food? What can they do?
• Lite food is NOT weight loss food
• Lower caloric density
• "lite" or "low calorie" dry dog food
cannot contain more than 3100
kilocalories per kilogram
• Canned foods contain much more
moisture, so the maximum allowable
calories are even lower 900 kcal/kg • Can help avoid overfeeding and
maintain weight post weight loss
107
What are the other crystals that can be found in the urine? What is the treatment for them?
Crystals: Silicate, calcium phosphate/ brushite, calcium carbonate.
- Dilution is the solution, limiting intake of urolith components.
108
What are the nutition requirements during lactation of both dogs and cats?
* 5-10% increase in BW pre-breeding to post whelping
* More not necessary due to capacity for increased food intake
* Obesity at whelping may predispose to dystocia
* Nutrient requirement is proportional to milk • Production energy costs may reach 4-8X RER (depending on # puppies)
* At peak bitch’s milk production may reach 8% BW = to average dairy cow
* Bitch milk is higher in fat and protein than cow milk
* Free feed during lactation- high protein, high fat diet
* Typically recommended using puppy diet ad lib or to maintain BCS
* Don’t forget water!
109
What are the appetite stimulant medications?
• Mirtazapine (antidepressent)
• Capromorelin
• Ciproheptidine
• (Valium)
- midazolam
• (Propofol)
110
How to unclog a feeding tube?
In vitro study-
Water is at least as effective as soda, cranberry juice
Water + ¼ tsp pancreatic enzyme and 325 sodium bicarbonate most effective (Parker and Freeman 2013)
111
What forms uroliths?
Uroliths form with sustained alterations in urine that promote supersaturation of certain compounds.
Once crystals form they can become stones.
112
What is important about potassium in cats with renal disease?
Cats -\> more prone to hypokalemia
- Signs: plantigrade ( neuro signs appear in cats)
• Whole body potassium depletion
• Feline renal diets typically supplemented with K+
• May also need to supplement even more
• Cats can develop hyperkalemia (rare)
• Home-cooked renal diet only good option
113
Why is it important to recognize obesity?
- Obesity has a lower longevity ( 2 years less than the control in the study)
- There is also earlier signs of aging and age related disease ( such as osteoarthritis)
114
What percentage of food consumption increase should you see for a queen in gestation? Pre-weaning ? reconstitution of reserves?
Gestation : 30-70% increase
Pre- weaning: 100-300% increase
Reconstitution of reserves: intake will decrease rapidly between week 7-11 back to maintenance.
115
What is hyperimmune egg powder?
Hyperimmune egg powder
• Hens vaccinated against canine microbes
• The yolk is rich in canine antibodies
• May improve growth
116
How do antioxidants benefit CKD patients?
• Renal oxidative stress (ROS)
• Possible contributor to progression
• May trigger fibrosis or glomerulosclerosis
• Scarce data on antioxidant use in cats & dogs
• Vit E, carotenoids, lutein may slow GFR decline
in dogs…
117
What is important to remember about fish oil? What can it help?
- Fish oil does improve inflammation. It can help alot in dogs with orthopedic disease.
- Products vary considerably in quality,
concentration, purity, and concentration of
fat-soluble vitamins (Vit D)
• Products that undergo third party QC are
recommended
• The amount may be considerable [310 mg
\*BW^0.75]
118
What is FGF-23's role in P regulation and how does it interact with Klotho?
FGF-23 reduces P in the serum by increasing renal secretion and decreasing
intestinal absorption
• FGF-23: The N‐terminal peptide binds to tissue receptors, and the C‐terminal
binds to Klotho.
119
What are metabolic implications found in obese animals?
* Altered lipid metabolism
* Changes in membrane fluidity
* Microbiome differences?
120
What is the goal with reducing phosphorus in stage 3/4 kidney disease? What should we decrease phosphorus to?
Phosphorus restriction
• More severe restriction to
deal with hyperphosphatemia
-\> decreased below NRC RA
• Stage 2 (late)
• Stage 3/4
121
When is a pet obese?
A body condition score 8/9 or 9/9 is considered obese and corresponds to 30% excess body weight.
122
What is heterologous immunity?
Heterologous immunity- the induction of an immune response to an unrelated pathogen/antigen upon exposure to a different pathogen/antigen.
- would not protect against canine specific pathogens
123
When we have kidney disease what is occuring in terms of phosphorus?
- decrease 1,25 vitamin D
- increase phosphate
- Decrease in calcium
This increases PTH levels
FGF-2 is link between phosphate load and decreased 1,25 vitamin D levels
This decreased calcium levels cause increased PTH secretion, increased PTH synthesis, and increased cell proliferation
124
What is Klotho's role in longevity?
More klotho-\> longer life
125
What is the outcome of weight loss as a treatment for musculoskeletal disease?
A decrease in bodyweight in obese
dogs by 11-20% provides a significant
improvement in force plate analysis ( measures how much weight they are placing on their joints) ( they will place more weight on joints when less painful)
(Burkholder et al. 2000)
• Improved locomotion can be visually
assessed in a weight loss of 6%,
improved Force plate measurable at
9% (Marshall et al 2010)
126
What is important to monitor in neonates post birth? What is the rate of mortality? when do deaths normally occur? What are concerns for neonates? When could these issues occur?
• Mortality varies between species and
breeds, but can reach 10-30%
• About 1/3 of deaths occur in the first
week, and ~2/3 in the two weeks after
• Important to diagnose problems early
Monitor
• Activity
• weight gain
• body temp
• hydration
• stool quality
• muscle tone
• Hypoglycemia, Hypothermia, Dehydration
• Time period- first week especially first 3
days (in toy breeds risk may be for
longer)
127
What maternal antibody is transferred across the placenta? What is the neonatal receptor that transports IgG?
* Of the five antibody classes, only significant amounts of IgG are transferred across the placenta
* transport of IgG is carried out by the neonatal Fc receptor (FcRn)
128
How do you feed the reproducing queen? Lactation? Pregnancy?
• Queens should be kept at an ideal BCS
• Excess body fat may result in decreased
conception rates and increased risk of dystocia
• Low BCS could risk fewer kittens, poor kitten body condition score, poor conception rate
• During pregnancy queens increase in bodyweight is almost linear
• Different from dogs
• Energy requirements increase and peaks at 6-7
weeks (1.6 RER at breeding- 2 RER at parturition)
• Lactation: All kittens should nurse within 6-8 hours of
birth
• Energy requirements for the queen peak 6-8 weeks
after parturition (2-6 RER)
129
What is urate urolithiasis?
With liver disease, protein metabolism can be affected
Decreased conversion of uric acid to allantoin
As a result, uric acid is excreted instead of allantoin
Uric acid can form crystals and stones
130
What other supplements may help in management of orthopedic disease?
Glucosamine - Limited proof
Chondroitin S
EPA and DHA- studies showing this is helpful.
Green Lipped Muscle - sourced from new Zealand.
131
What are the most common food sensitivities in dogs?
Chicken Beef Pork Fish Turkey
Beef is number one
- followed by chicken in dogs, and fish in cats.
132
What is their a higher risk for with PPN? What factors must we be conservative with and mindful of?
Higher risk for phlebitis
◦ Max mOsm/L is 700
Must be mindful of :
◦ pH
◦ Flow rate
133
Can diet cause hypercalcemia?
- Some anecdotally recommend feeding a diet with moderately reduced calcium and vitamin
D in addition to added
insoluble fiber for all-cause
hypercalcemia
• High dietary calcium on its
own does not appear to be a
cause of hypercalcemia
• Some cats with CKD may
develop hypercalcemia due to
excessive phosphorus
restriction
134
What is the potential predispositions in cats for calcium oxalate?
Neutered male
Older adults
Persian, himalayin
Upper urinary ( usually nephroliths are calcium oxalate )
135
what happens when a patient has 50% or more excess?
The Healthy Weight Protocol/ Morphometric System allows determine the adiposity of patients with a BCS exceeding 9/9
136
How is immunity transferred to offspring?
* Transfer of immunity from mother to offspring:
* transplacental immunity
* colostral immunity
137
What is pancreatitis?
Inflammation of the acinar tissue of the pancreas
Involvement of pancreatic enzymes that exacerbate the
inflammation and tissue damage
Can be acute or chronic
Variable severity
138
Is chronic GI signs easily treated?
No, not every patient responds to the same thing and make judgements/ decisons based on history and the patient. There is no fix all, and it requires alot of trial and error
139
Why is nutrition important in regards to hospitalized patients?
Prognosis of frail, muscle wasted patients is poor
140
What are the benefits of canine plasma transfusion in neonates?
* oral plasma supplementation (twice within the first 8 hr of life and since Day 2 of life, every 2 days until 56 days)
* greater weight gain, increased intestinal microbiota diversity
141
What are causes of hypercalcemia, what is the prognosis? When are clinical signs typically seen?
Hypercalcemia can be the result of dietary, metabolic,
neoplastic, renal, and idiopathic causes in dogs and cats
• In cats, idiopathic hypercalcemia is most common
• The degree of hypercalcemia and its chronicity impacts
prognosis
• clinical signs of hypercalcemia are usually most severe when the
increase in calcium is rapid
• Most often, clinical signs are noted when usually serum total calcium is higher than 14.0 mg/dL and ionized calcium is greater than 6.5 mg/dL (1.6 mmol/L)
• If serum total calcium increases to 16.0 mg/dL or if ionized calcium increases above 7.5 mg/dL (1.9 mmol/L) -\> require hospitalization and immediate care
142
What can be said about older dogs prognosis that have a higher initial bcs and vomiting at admission? What about dogs that consumed RER and had higher initial BCS at admission?
Older patients, higher initial BCS and vomiting at admission were associated with a decrease of BCS status during hospitalization
Dogs that consumed their energy requirements, and had a higher initial BCS had lower odds of dying
143
What are the potential causes of an AKI in a patient?
Acute kidney failure can be secondary to CKD but can also occur as a result of another primary cause:
* Toxicity
* Infectious disease
* Neoplasia
* Trauma
* Heat stroke/ dehydration etc.
144
When should we start restricting phosphorus?
```
Stage 2 (early)
• Stage 1? (no clear evidence, still makes sense to avoid a higher phosphorus
diet when possible…)
```
145
Which of the following hormones promotes hunger? Where is it secreted from?
Ghrelin
- Ghrelin is a hormone secreted from
the enteroendocrine cells in the
stomach and small intestines and
acts on cells in the pituitary and the
thalamus to increase food intake
146
What is IBD? Is IBD a specific disease? What is its characteristics? What must you rule out?
IBD is a histopathological definition; often misused to describe all-cause chronic enteropathy
Not a single entity
Characterized by infiltration of immune cells to the lamina propria
Rule outs- parasites, bacterial enteritis/ dysbiosis, dietary intolerance, neoplasia
147
How can you achieve dissolution of struvites?
Medical management
- treat UTI
- treat predispositions
Diet strategies
- dilution
- Precursors
- composition
Monitoring
- culture
- imaging ( you should see rather quick decrease in size of urolith)
- failure (make sure were successful or know if we are not)
148
How should we administer Parenteral nutrition?
Dedicated line/lumen
- Aseptic placement Catheter- maintain clean area, cover/bandage
-Do not disconnect line if possible (walk dogs with line connected)
- Cover if B vitamins added
Replace bag every 24-48 hours
149
What are the different complications associated with feeding tubes?
Erythema
Cellulitis
Early removal
Tube clogging/coiling/migration
Infection of stoma
Vomiting, coughing, sneezing
Diarrhea
150
What is a cutaneous adverse food response?
The most common presentation for a dog or cat with cutaneous adverse food reaction (CAFR) is nonseasonal pruritus, although other syndromes such as otitis externa and gastrointestinal (GI) signs may also be present (indistinguishable from atopy)
151
Should you restrict phosphorus if patient is not hyperphosphatemic?
yes. Compensatory mechanism. Negative indications for having high PTH, so though it is not problematic, likely will cause other issues over time.
152
What are important points to remember/ tips for nutritional management of an AKI?
• The optimal nutritional management of acute kidney injury patients that
do not have an underlying CKD is not determined
• Emphasis should be given to them receiving adequate caloric intake, and if there are electrolyte shift, these should be corrected
• Long-term management may depend on regeneration of kidney function
• It may not always be needed or advised to start with a renal diet while hospitalized
• This may cause food aversion (stress, noise, nausea) for the food
153
What are potential causes of orthopedic disease?
• Puppies until the age of 6 months are unable to regulate calcium absorption. This can result in excess bone mineralization • Excess vitamin D, excess phosphorus or
deficiency or a skewed Ca:P ratio may all
result in orthopedic disease
• Large breed dogs are more sensitive to excess calcium compared with small breed dogs.
• AAFCO maximum Ca for large breed
puppy is 4.5 g/1000 kcal whereas small
breed puppies its 6.25 g/1000 kcal
• Expedited growth and weight gain may also predispose dogs to orthopedic disease
154
How do you diagnose stones?
Crystalluria- be careful with over interpreting ( sometimes there is crystals that form when urine sits around, also you may not have an issue with certain small amounts of crystals )
Ultrasound - shadowing, sand, grit, etc.
Radiographs -not all uroliths are radiopaque
- Struvite and calcium oxalate are radiopaque
- Urate, xanthine, cystine are not (often)
Contrast radiographs
Urolith mineral analysis
155
What are the risk factors for dogs for pancreatitis?
Breed
Diet history
Obesity
Drugs
Toxins
Pancreatic ischemia, trauma
Hyperlipidemia
Hypercalcemia
156
How do you compound Parenteral nutrition?
Aseptic/sterile procedure (lipid solution has highest risk for contamination) Order of mixing-
◦ 1. AA
◦ 2. Lipid
◦ 3. Dextrose
Important to maintain pH (dextrose has low pH) Temperature Light affects stability of B vitamins (not really of AA)
157
Why do we prefer enteral feeding?
Feeding the enterocytes
◦ The enterocytes depend on food in the lumen of
the gut for nutrition
◦ Glutamine is used as fuel for gut enterocytes and lymphocytes
◦ Glutamine is also used for purine synthesis
Healthy enterocytes are vital to maintain gut barrier and prevent villus atrophy
158
What are the commercial diets with restrictions of copper? What are the other treatments of copper hepatopathy?
Only commercially available diets restricted in copper are
therapeutic liver diets (Hill’s l/d, Royal Canin Hepatic)
Home-cooked diet formulation may be option in these cases
Avoid high copper foods such as internal organs, seafood, mushrooms etc
Can be with treatment with chelation, and with zinc
Zinc induces the synthesis of metallothionine, a protein that binds copper in the enterocytes and renders it unabsorbable (and possibly detoxifies the liver too)
159
How can you dissolve urate urolithiasis?
Urinary dissolution
dec precursors ( decrease purine consumption, avoid high purine foods (liver, organ meats, ect), use low purine foods ( dairy, egg, some vegetable based)
Make urine more alkaline
- accomplished with reduced protein/ vegetarian diet
Dissolution protocols: only successful with non- liver disease urate
- allopurinol: be careful of inducing xanthine uroliths.
160
How can you treat refeeding syndrome?
Treatment:
1. Slow feeding rate
2. Correct electrolyte abnormalities
3. Thiamin supplementation
161
What does the resting energy requirements helping the body achieve? Is it better to feed more to patients ?
Accounts for energy needed for homeostasis in a thermoneutral environment Energy needed for basic metabolic processes: protein turnover, ATP requiring pumps, etc.
Not necessarily helpful to feed more
162
What are dietary prevention strategies for calcium oxalates?
Moistures
Precursors
- balanced diet ( moderate calcium)
- Low oxalate intake
- investigate supplements and treats ( some can contribute/ be very important sources of oxalate)
Conditions: ideally don’t acidify the urine ( too acidic will promote ca++ oxalates.
163
What is the issue with eliminating/ reducing cystine and methionine? How can you prevent issues?
The issue is that these are essential for taurine synthesis. You can supplement taurine if you are concerned there is not enough.
164
What are potential signs of an adverse food response?
erythema, pruritis, otitis, redness, ear infections ( even chronically) red papules on skin, (thorax and abdomen)
165
What is the etiology of hypoglycemia, hypothermia, dehydration? What are the clinical signs? treatments?
Etiology:
• Decreased food intake
• High requirements, low reserves
• Low environmental temperature
• Disease (diarrhea)
Clinical signs:
• initially- vocalizing, active
• with time- sluggish, cool (below 94 F)
• poor skin turgor
• often rejected by bitch
Treatment:
• increase core temperature slowly to 94-98 F
• correct low BG
• correct dehydration (1 ml/30g BW)
166
What is secondary obesity?
While obesity is the result of energy intake vs. energy expenditure, there are
several endocrine diseases that negatively affect metabolism and can increase the
risk for obesity:
• Hypothyroidism (dogs)
• Cushing’s disease (hyperadrenocorticism)
167
What are complications with parenteral nutrition?
Metabolic complications are relatively common
◦ Hyperglycemia
◦ Hyperlipidemia
◦ Hyperammonemia
◦ Electrolyte shifts Mechanical complications Septic complications- 0-8%
168
What commercial diets can be given to patients with EPI?
THIS IS NOT NEEDED TO BE MEMORIZED, JUST AN FYI
Commercial diets:
- Hill’s Prescription Diet i/d
- Purina Veterinary Diet EN
- Royal Canin Digestive Low Fat (dogs)
Home cooked diets:
- May be more digestible
- Need to be complete and balanced
169
What is the organ that is most affected by nutrition? What do the enterocytes rely on within the intestinal lumen for sustenance? What is the importance of protein, and what is produced as a result that is essential?
The organ system most affected by nutrition
The enterocytes rely on nutrients in the intestinal lumen
- Protein: source of essential amino acids, dispensable amino acids for oxidation, AA and
energy for microflora
- Key for hormone stimulation (insulin, IGF-1, GLP-2, CCK)
antigenicity
170
What are portosystemic shunts?
Congenital or acquired vascular abnormalities in the portal vascular system
Congenital shunts are common in certain breeds including Yorkshire Terriers
Decreased portal perfusion and decreased liver mass permits encephalogenic material to bypass the
liver
Protein is typically metabolized to ammonia and then detoxified to urea in the liver, however its possible that heme, RNA and other nitrogenous products also
contribute to clinical signs of hepatic encephalopathy
171
What is considered low level nutritional intervention?
Low level intervention:
◦ Offer food for voluntary intake
◦ Switch foods as possible (dry/wet/flavor)
◦ Offer food in a quiet environment/away from cage/change
bowl/food temperature/mix with palatants ◦ Address health factors that could contribute to dysrexia
◦ Dehydration
◦ Pain
◦ Reduced mentation
172
What is the treatment of exocrine pancreatic insufficiency?
Treatment: Enzyme supplementation
1 Enzyme preparations
2 Raw fresh pancreas
173
What is refeeding syndrome? When does it occur? What can be seen occurring metabolically and why?
- Animals with prolonged anorexia (longer than 4 days) are at risk of refeeding syndrome
- For example, a young healthy dog with foreign body GI obstruction that resolves
- Can be severe enough to be life threatening
- During prolonged fasting, hormonal and metabolic changes are aimed at preventing protein and muscle breakdown
- Muscle and other tissues decrease their use of ketone bodies and use fatty acids as the main energy source
- This results in an increase in blood levels of ketone bodies, stimulating the brain to switch from glucose to ketone bodies as its main energy source
- The liver decreases its rate of gluconeogenesis, thus preserving muscle protein
- During the period of prolonged starvation, several intracellular minerals become severely depleted
- However serum concentrations of these minerals (including phosphate) may remain normal
- This is because these minerals are mainly in the intracellular compartment, which contracts during starvation
- In addition, there is a reduction in renal excretion
174
What are the clinical signs of pets with GI disease?
Loss of appetite - or ravenous appetite
Weight loss
Abdominal pain/discomfort (can have gas pain/ discomfort, gi distention)
Small bowel diarrhea
- Voluminous
- Low urgency
- No mucus
- No tenesmus
Large bowel diarrhea
- Low volume
- Mucus
- High urgency
- Tenesmus
175
What are the Metabolic implications of obesity?
Adipose tissue is active and secretes
hormones called adopokines.
176
What should you tell owners in terms of GI diets?
Be prepared, the first one we try may not be the fix all one.
177
What are some dangers of an unbalanced diet in neonates that cause cataracts?
Deficiencies: Vitamin A, Vitamin E, Riboflavin, Calcium, Tryptophane, Methionine, Arginine, Cystine
Excess: Glucose, lactose, galactose, xylose
178
What is important about giving feeding instructions to owners?
- Include a goal for main meal,
supplements (ie fish oil), treats
- Provide a gram amount- much more
accurate than cups
179
How should you feed a pregnant dog?
Gravid uterus may impair gastric filling
• Feed several smaller meals
• Feed high energy food (4.0 kcal/g)
• Feed high protein food (7g protein/kg BW or about 25% crude protein dry matter)
• Requirements for fatty acids, calcium, phosphorous and certain amino acids increased after day 40
• Typically- feed an ‘all-life stages’ or puppy food
180
What is liver disease? What is a common cause for liver disease?
Liver disease causes altered protein, carbohydrate and fat metabolism
Vitamin deficiency is common with liver disease
B vitamin supplementation may assist with energy metabolism
Vitamin C is produced by the liver and is an important anti-oxidant
Vitamin E is an antioxidant and can be helpful when there is oxidative damage (for example, copper storage disease)
Vitamin K is stored in the liver and can rapidly deplete
Synthesis by bacteria may be reduced due to dysbiosis
181
What is B12 and Folate?
Cobalamin (B12):
- Absorbed in the distal small intestine (specifically in the ileum)
- Values below the control range:
- EPI & bacterial overgrowth in the small intestine diseases affecting the distal small intestine (such as IBD)
Folate (B9) :
- Absorbed in the proximal small intestine
- Values above the control range:
- bacterial overgrowth in the small intestine Values below the control range:
- disease affecting the proximal small intestine
182
When do energy requirements increase in dogs? What BCS should you feed a bitch to? What RER should a whelping bitch receive?
• 15- 20% gain in BW prior to whelping
• 5% fetal mass developed by 40 days
• Therefore, energy requirements do not
increase until day 40
• begin to increase food intake @40d so at
whelping bitch receives 1.25 X MER
• Feed to BCS 5
183
What occurs between glucose, electrolytes, and other important vitamins during refeeding syndrome?
- Rapid increase in glucose -\> insulin increase - Na-K pump is coupled to sodium glucose transporter -\> high insulin-\>hypokalemia
- Phosphorous is shifted intracellularly for ATP
- Magnesium is shifted intracellularly as it is a cofactor for enzymes that participate in glycolysis
◦ Hypomagnesemia may cause GI, muscle and cardiac
abnormalities
◦ Magnesium is important to prevent passive potassium membrane leakage
- Thiamin is important for CHO metabolism
184
What should you feed through a G tube?
1. Complete and balanced diet for growth
2. Highly digestible
3. Calorically dense (lower volume)
4. Short GI transit time
1. Low fiber
2. low fat
5. Affordable
6. Easy to prepare
Ideal is not canine recovery diet. Its a homemade diet which is in the image
185
What is copper associated hepatopathy?
May be hereditary in certain breeds (Bedlington Terriers,
Labrador)
Defect in biliary copper excretion
May also be due to excessive dietary intake of highly bioavailable copper
Copper form in petfood was previously cupric oxide which has low bioavailability, it was since changed to copper sulfate and copper chelate forms that are more bioavailable
186
What is failure of passive transfer?
* Failure of passive transfer (FPT) is not a disease, but a condition that predisposes the neonate to the development of disease
* In domestic large animals, the placenta prevents transmission of immunoglobulins from the dam to the fetus in utero
* Neonates that do not nurse on colostrum in time, develop susceptibility to disease
187
What is the difference between acute and chronic colitis?
Acute
Caused by ingestion of foreign material, specific pathogens
Changes in intestinal peristalsis
Lack of evidence-based approach for management
Highly digestible diet/fiber responsive?
Prebiotics?
Chronic
Same reasons/management as acute
+ Food antigenicity
Novel protein
Omega-3
188
How can you dilute urine to prevent stones?
Increase water intake: Add water fountains, higher sodium diets, wet food, protein content decrease.
Protein is metabolized to urea, which is concentrated in renal medulla. Low protein = medullary washout. Urine doesnt get as concentrated.
189
Why are newborn puppies highly dependent on their mothers? What percentage of IgG is obtained by placental transfer? How is the remainder obtained?
• Newborn puppies are highly dependent on their mothers
• Unable to walk
• Unable to hear/see
• unable to regulate body temperature
• Unable to spontaneously urinate and defecate
• Ineffective immune system
• Only 1-7% of the IgG obtained by passive transfer are by
placental transfer • The rest are through colostrum
190
Is high dietary phosphorus safe in adult animals?
While calcium is tightly regulated, phosphorus regulation is not as
tight
• Meaning, calcium is usually kept in a tight range in the
blood/plasma, whereas
phosphorus has a wider range
• Phosphorous in foods can be
organic (from fruit, vegetables,
grains, meat) or inorganic
(phosphoric salts)
• Highly bioavailable phosphorous have been found to damage the kidneys in rats
• In current guidelines, there is no maximum P in cats
191
What are some of the adverse food responses?
Food allergens: glycoproteins 10,000-60,000 Da (10-60 kDa)
Type I hypersensitivity suspected Immediate IgE, mast cell degranulation Types III and IV also possible
Pathogenesis not well known
Gut-T cells homing to skin?
Cutaneous sensitization to food
Genetic predisposition: IgE production
Breed: Beagle, boxer, cocker spaniel, WHWT
192
What urine concentration should we be shooting for in dogs and cats when diluting their urine? How much is our initial moisture intake goal.
- Dog \< 1.020
- Cat \< 1.025
Goal: 85%
Monitor serial USG at home ( with strips/ refractometer)
Can mix can food 1:1 with H2O or 1:5 H2O with dry food.
193
How can you dissolve stones?
Struvite, urate, cystine
- Via nutritional/ medical therapy
194
What is Klotho?
Klotho is a transmembrane protein that acts as a coreceptor for FGF-23 in the
kidney
195
What is the risk factors for cats for pancreatitis?
Idiopathic ++
Toxins
Pancreatic trauma
Hyperlipidemia
FIP
Inflammatory GI and liver disorders (« triad disease »)
196
What is the discharge rate for an animal with voluntary food intake? Low BCS? Ideal body weight/ overweight? What is associated with more severe disease?
93% of animals with voluntary food intake were discharged
73% low BCS 84.7% for those at an ideal BCS or overweight
[However- low BCS may also be associated with a more severe disease]
197
What are different nutrient strategies utilized for patients with chronic enteropathies?
Fiber supplementation (soluble fiber as prebiotics, insoluble helps motilityconsistency)/probiotics (adding fiber can decrease digestibility, so it can worsen maldigestive disorders)
Provision of antioxidants
Correction of hypomagnesemia, supplementation of vitamin K
Moderate fat/ fat restriction- may improve clinical signs in several ways
Omega-3 PUFA High digestibility
Reducing antigenicity
Novel protein: diet Hx!
Hydrolyzed protein
198
What should you be looking for when completing a nutritional assessment?
1. Screening- is there a nutrition related risk factor?
◦ A. disease with nutrition related management
◦ B. prolonged dysrexia
◦ C. patient unable to consume food/ unlikely to be able to feed
◦ D. poor body condition
◦ E. poor muscling
2. Extended nutritional assessment
199
What happens if you do not feeding orally? What are the potential complications?
Intestinal mucosal hypoplasia or atrophy may occur
This may lead to several complications:
- GI dysbiosis
- Bacterial translocation
- Decreased digestive function
200
What are nutritional management strategies for EPI?
* Controversial
* Need for high digestibility?
* Fat content?
* Fiber restriction?
* Monitor B12 as needed
201
What factors should be considered when selecting a diet?
Select the right diet for the specific patient! Macronutrient composition
Electrolytes
Caloric density
Tube clogging
Ease of feeding
202
What are the types of parenteral nutrition?
- CPN= Central parenteral nutrition (i.e jugular)
- PPN= Peripheral parenteral nutrition (i.e cephalic)
203
What are the nutritional requirements of neonates?
• Milk contains all the energy and
other nutrients necessary for growth
during the first 3 weeks of life
• Low concentrations of some
minerals (Fe,Cu, Zn etc) are
compensated for by body stores
and the addition of solid food
during weaning
204
What causes struvites?
UTI (dogs)
Urease producers
- Staphylococcus , proteus, klebsiella
Can be sterile ( cats)
Ammonia pushes pH up, which pushes urine towards supersaturated range.
Ammonium is also a component of struvite, so this can increase cause
205
What else can treat leishmaniasis?
Allopurinol
206
What are the outcomes of CKD?
Dehydration (secondary to polyuria)
• Renal Secondary Hyperparathyroidism
• Hyperphosphatemia
• Azotemia/uremia
• Electrolyte & acid/base imbalances
• Hypertension
• Renal hypoxia and/or renal oxidative injury
• Loss of body condition and muscle…
207
What are essential nutritional factors for CKD?
• Maintain hydration & body
condition
• Phosphorus
reduction/restriction
• Protein –reduction?
• Address electrolyte
abnormalities
• Address acid/base
disturbances
• Sodium content
• Antioxidants
• Omega-3 PUFAs (marine
sourced)!
208
What IRIS stage has seen improvement with diet?
Benefits for kidney diets have been shown from IRIS CKD 2 and above; therefore, many would not change the diet in stage 1
209
What acid base issue can occur with CKD? Why? What is the potential treatments for this condition?
Metabolic acidosis can result from CKD
• Increases muscle catabolism • Disrupts intracellular metabolism
• Bone mineral dissolution?
Treatment :
• Provide alkalinizing agents in diet OR supplement
• Bicarbonate, carbonate, citrate
• Beware potassium…
210
Can you use food allergy testing to determine what your animal is allergic to? What can be used? what is a food trial?
While some companies offer “food allergy testing” using serum, saliva, or even hair clippings, the only valid diagnostic test is an elimination diet trial
Single protein single carbohydrate
Novel ingredients (diet history!)
There are a number of veterinary therapeutic diets that can be used for diet trials and long-term management. Home-cooked diets using novel foods are another
option
211
When are puppies weaned? How should moms diet change? How should you wean puppies? Following the correct weaning procedure will prevent what in bitches?
* 6 to 8 weeks of age
* Decrease Mom’s food intake 50%
• Remove pups during the day for 1-3 days before removing them
completely
* DON’T limit water intake
* This procedure allows monitoring of pups for adequate food intake
* Helps prevent mastitis in the bitch
212
Why is malnutrition such a common issue in hospitalized patients?
1. Poorly written orders (22%)
2. NPO per doctor (34%)
3. Patient not eating (44%)
213
What breeds have predispositions (dogs) that have calcium oxalates?
- miniture schnauzer, lasapzo ,……\*\*\*
214
What is colostrum? How do young animals receive and use colostrum?
• Colostrum is the antibody-rich fluid produced from the mother's mammary glands during the first day or two after
birth
• Young animals can absorb antibodies intact for the first couple of days following birth
• Colostrum production is influenced by maternal hormones which support the development of the mammary gland
at late gestation
215
What are strategies to work on dissolution of cystine urolithiasis?
- Urine alkalization
- 2- MPG (used)
- Urine dilution
- Potassium Citrate
- takes about 1-2 months
- prevention is very important
- Diet must be low in cysteine and methionine intake ( methionine converts to cystine)
216
What are the risks of overfeeding?
Risks of overfeeding:
◦ Hyperglycemia- negative prognostic indicator
◦ Increased CO2 production
217
How much should we feed patients with prolonged dysrexia?
Starting feeding with 25% of RER in patients with prolonged dysrexia may help decrease the risk for metabolic complications
218
What is hepatic encephalopathy?
Hepatic encephalopathy is the term used to describe neurological signs that result from liver dysfunction
These are typically vague cortical signs: confusion, staring into space, seizures
Often these occur after a meal
219
What are the diagnostic signs of protein losing nephropathy? How is it treated?
Diagnostic signs:
• Elevated UPC
• Rule out non renal causes
• May lead to hypoalbuminemia, loss of ATIII (prevents hypercoagulation, so these patients may be hypercoaguable) • A negative prognostic indicator; regardless of azotemia
• Treatment:
• Dietary protein restriction = decrease renal blood pressure, GFR
• Omega-3 supplementation
220
What was the outcome of the study of experimentally induced obesity in dogs
Experimentally induced obesity in dogs
• increased mean arterial pressure, increased plasma renin -\> altered
function & architecture
• Bowman capsule expansion, glomerular cell proliferation,
thickening of glomerular & tubular basement membranes,
increased mesangial matrix
• Changes in Bowman’s capsule -\> pathologic
proteinuria?
221
What mechanisms are there to help reduce phosphorus in the blood?
When phosphorous is high, there are several mechanisms including PTH to help reduce it
• Hyperphosphatemia upregulates a factor called fibroblast-growth factor-23 (FGF-23) from the bone
• This factor reduces activation of vitamin D to calcitriol in the kidney
• Reduces P absorption form the GI tract
• Primary action- joins with a factor called Klotho to increase P excretion in the kidney
222
When does total food intake plateau in puppies? What are the rules of thumb for estimating energy intake during growth? When do puppies have a higher risk of weight gain?
* Rules of thumb for estimating energy intake during growth:
* 2 X MER for weaning to 1/2 adult BW
* 1.5 X MER for 1/2 - 3/4 adult BW
* 1.2-1.0 MER for 3/4 to 1.0 adult BW
* Often total food intake plateaus between 4 and 5 months
• Once neutered, higher risk of weight gain
223
Who is most likely to get Exocrine pancreatic insufficiency?
Dogs \> Cats
- Breed disposition (German Shepherd, Chow, Collie
224
What are other diet related dermatological diseases?
Zn responsive dermatosis
Vitamin A deficiency
Protein malnutrition
Copper deficiency
Tyrosine deficiency
225
What is associated with fast growth post weaning in puppies? How can you prevent it? What dogs are more at risk?
Fast growth is associated with increased risk of skeletal disease in large breeds
* Maintain at BCS of 4/9
* Especially in large breeds
- Use growth curves to monitor puppies development and monitor for weight gain/ obesity
226
What are the pro's and cons of a kidney friendly commercial therapeutic diet?
• Many options
- Look at product guides
• Differences between diets may make some better fit
than others
• Different stages, differences in electrolytes, fat content, etc.
• Multiple options for palatability/variety
Be aware that many are high(er) in fat
• May be contraindicated for pancreatitis, hyperlipidemia, etc
- Some multi-function diets now available
• Hydrolyzed/renal diet (adverse food reactions/renal
disease)
227
What are the implications of liver disease?
The liver gets much of its nutrient supply from the portal vein (rather than from an artery)
The specific nutrient requirements of dogs and cats with liver disease are currently unknown
228
What are some of the mechanisms that contribute to a reduction of insulin response and eventually to diabetes mellitus?
What do they cause?
• Reduced expression of insulin signaling molecules in skeletal muscle
• Downregulation of a major insulin-responsive glucose transporter (GLUT4) in
adipocytes
They cause:
- These decrease insulin-stimulated glucose transport and metabolism in
adipocytes and skeletal muscle
- Impaired suppression of hepatic glucose output
- The increased demand for insulin secretion can result in amyloid deposition in the pancreas and decrease in the functional secreting tissue
229
Is there a benefit to using nutrition to help with dermatological disease?
The right diets, nutrients, and sometimes nutritional
supplements can have a significant benefit in
improving or resolving certain skin disorders
Some supplements may include fatty acids and zinc
High quality/digestibility protein
230
What is fibroblast growth factor 23?
FGF‐23 is a factor synthesized and secreted by bone cells (fibroblasts)
231
Is there a correlation between PTH and Creatinine?
yes there is.
Much higher PTH at high creatinine levels.
232
What are the top 3 causes of pruritis?
Flea allergic response
Food allergy
Atopy
233
How do you discontinue parenteral nutrition in patients? What is the concern with stopping cold turkey?
Discontinuing PN
Usually discontinue in parallel to patient consuming food or fed through tube Wean gradually Abrupt d/c is may lead to serious complications!
◦ While PN is provided, insulin is increased
◦ Abrupt stop = glucose is not provided= insulin still high = hypoglycemia
234
Why must we calculate protein requirements ?
Calculating protein requirements:
• Avoid protein malnutrition due to
energy restriction
Dont need to remember:
• The protein requirement for an adult
dog is 3.28 g BW(kg)0.75
• The protein requirement for an adult
cat is 4.96 g BW(kg)0.75
235
What are hydrolyzed protein diets?
Protein size reduction discourages IgE
crosslinking -\> mast cell activation
Theoretically, protein source irrelevant:
chicken, soy with starch
Helpful when novel foods fail or have been
already tried
Why can it fail? Theories
Hydrolysis not small enough
Bell distribution of protein sizes
IgG may be more relevant
Size of glycoprotein can matter
Purina HA 11.7 kDa or lower
Ultamino has 99% of peptides below 6 kDa
236
What causes EPI? What are the signs, diagnostic values, ect?
May be a result of pancreatitis
Loss of pancreatic tissue mass
deficiency in digestive enzymes (lipases, amylase, chymotrypsin, trypsin, etc…)
Signs: diarrhea, steatorrhea, weight loss, ravenous appetite, coprophagia
Diagnosis: Low serum TLI
Many times accompanied by dysbiosis
Bacteria may use cobalamin and produce folate
Cobalamin also requires pancreatic intrinsic factor for absorption
The result- high folate, low cobalamin
237
What are potential contributing factors to adverse reactions to food?
Potential contributing factors:
Bacterial enterotoxins
Parastism
Malnutrition
238
What are some causes that induce catabolic cytokines? What is the result?
Causes:
- Actions of cytokines catabolic hormones
- Severe injury, trauma, sepsis, burns, cancer, critical illness.
- Decreased calorie and nutrient intake
Results:
- Malnutrition
- Negative nitrogen balance and muscle catabolism.
- Decreased healing, depressed immune function, increased intestinal permeability, increased morbidity and mortality.
- Alterations in carbohydrate, lipid, and protein metabolism.
239
What are the signs of uroliths?
Some are asymptomatic
Lower urinary signs including, urinary incontinence, hematuria, dysuria, pollakiuria, periuria, stranguria.
Can cause urinary obstruction.
240
What are the desired characteristics for diets when it comes to calcium oxalate predisposition
Calcium -\> moderate
Phosphorus -\> moderate ( to bind some of the calcium/ good Ca++/Phos balance)
Vitamin D: moderate (not enough for Toxicity / not too low)
Oxalate: lower/ reduced
Vitamin C -\> should not be high, can be metabolized to oxalate
Vit B6 should also be limited because they can form oxalates as well
241
What is the diagnosis of copper hepatopathy?
Diagnosis: Clinical signs indicative of liver disease (jaundice, ascites, HE etc), elevated liver enzymes
Definitive diagnosis is done with a liver biopsy and
quantification of copper
Important to differentiate between primary copper
accumulation and secondary copper increase due to chronic
inflammation
242
What is important when feeding any patient?
Monitoring ( Monitor patient response)
243
What is the cause of urate urolithiasis?
Breed dispositions -\> genetic abnormalities
Problems with purine metabolism ( Nucleic acid)
- Dalmatians, English bull dogs, Yorkies, others
- Siamese, Egyptian may
Liver disease
- decreased conversion of urine acid to Allintoin
