- Improving both clinical condition and quality of life
- Prolonging survival time
- Slowing the progression of renal disease
Once chronic kidney disease has been diagnosed, it is recommended:
- Stop any drugs with certain or potential nephrotoxicity;
- Identify and treat any concurrent disease influencing renal function and determining renal damage. In some patients, other pathologic conditions (such as endocrinopathies) can make difficult either staging renal disease and setting an adequate therapy;
- Investigate all causes leading to renal damage and, if possible, treat it. Sometimes, a renal biopsy can be useful to evaluate histologic lesions; in case of proteinuria, results of renal biopsy can provide a specific diagnosis and therapy;
- To apply a conservative approach of clinical conditions associated to kidney failure such as metabolic, acid-base and electrolytic imbalances. Therapy is addressed to correct hydration and mineral disorders, acid-base alterations and nutritional impairments. Patients benefit from symptomatic treatment improving their quality of life although azotemia is not significantly modified as this is undoubtedly just one of the factors contributing to the clinical picture of renal patients.
As general recommendations, clinically stable dogs and cats affected from CKD should undergo a clinical examination and laboratory evaluations based on their IRIS stage (www.iris-kidney.com)
- every 12 months in IRIS stage 1
- every 6 months in IRIS stage 2
- every 4 months in IRIS stage 3
- every 6-8 weeks in IRIS stage 4
Clinical Evaluation– Other than general and particular clinical examination, a special attention goes to the nutritional condition of the patient, determined by body weight, Body Condition and Muscle Condition Score (available both for dogs and cats at WSAVA). Nutritional status of patients affected by CKD is related to risk of developing uremic crisis and mortality: bad nutritional condition is associated to higher risk of uremic crisis and mortality for renal related causes. Blood pressure is determined too and hypertensive patients are put under treatment.
Laboratory exams– Once CKD has been diagnosed, Veterinarian proceeds to request the laboratory exams useful to identify concurrent pathologies known to determine renal damage or the progression of kidney disease. After the initial evaluation of a complete blood count, biochemistry and urinalysis (included UPC) the Veterinarian will be requesting further exams based on patient’s laboratory results and clinical history such as exams for infectious disease, endocrinopathies, ect.
Below are IRIS stages and most common disorders by stage (modified from Polzin, 2006 and 2019)
|Clinical signs||IRIS stage|
|Anorexia and weight loss||3-4|
*although it is possible to identify hypertensive patients in any stage of the disease, the prevalence of hypertension increases with increasing of IRIS staging
NEW Hill’s ActivBiome+ Technology in Prescription Diet Gastrointestinal Biome Manages Gastrointestinal Health in Cats and Dogs
The gastrointestinal tract is inhabited by communities of microorganisms essential to host health. These microorganisms, including desirable and undesirable bacteria, are referred to as the micriobiome and the exact population of micoorganisms is unique to each host.
Bacteria in the microbiome are functionally and compositionally diverse, allowing contribution to energy homeostasis, metabolism, gut epithelial cell health, and immunologic activity. This population is not static and can change to due to medications, such as antibiotics, environmental factors, disease states and dietary influences. Additionally, it is common to see dysbiosis (imbalance in the gastrointestinal microbiome) in chronic GI disease in cats and dogs.
Over the past several years, Hill’s has focused heavily on studying the microbiome, characterising bacterial populations of the gastrointestinal tract of cats and dogs. Most critically, Hill’s has performed analyses to understand the functions of those bacteria in the gastrointestinal tract.
Hill’s has found that a pet’s gastrointestinal health can be impacted by ActivBiome+ Technology, a blend of synergistic prebiotic fibres that works with with each pet’s unique gastrointestinal microbiome.
Hill’s Prescription Diet Gastrointestinal Biome contains ActivBiome+ Technology. This is a proprietary blend of synergistic prebiotic fibres that works with, and is utilised by, each pet’s unique bacteria in the large intestine allowing the beneficial bacteria to flourish and produce postbiotics (metabolic products of microbial metabolism) to help the host. By promoting the growth of desirable bacteria, it also helps to reduce the growth of potentially undesirable bacteria and their metabolites. The fibre sources in ActivBiome+ Technology were selected because they have multiple functions and have fibre bound polyphenols. The bacteria ferment the fibres and produce gut-nourishing compounds, as well as release and activate antioxidant and anti-inflammatory polyphenols. These postbiotics benefit the gut, as well as other organs and tissues.
How does ActivBiome+ Technology improve Gastrointestinal Health?
A series of studies at Hill’s Pet Nutrition Center (PNC) were conducted demonstrating how ActivBiome+ Technology works and clinically showed improvements when this synergistic blend of prebiotic fibres was added to certain foods. Both dogs and cats showed improvements in markers of gastrointestinal microbiome health. Dogs also showed improvements in stool quality.1,2
One canine feeding study evaluated the benefits of the ActivBiome+ Technology in healthy dogs (n=16) and in dogs with chronic, recurrent enteritis or gastroenteritis (n=16) in a randomised, cross-over design study. ActivBiome+ Technology was added to either a hydrolysed meat food (Food A, Fig 1) or grain-rich food (Food B, Fig 2) and fed over a 56 day period. All dogs had significant improvements in stool quality, including those with chronic enteritis/gastroenteritis, when given food that included the ActivBiome+ Technology fibre blend.2 ™
Active Biome+ Technology Improved Stool Quality in All Dogs
Figures 1 and 2 illustrate the changes in stool quality among all dogs consuming this fibre blend. By the end of 4 weeks, the stool quality score of the dogs with chronic enteritis/ gastroenteritis had improved to the point that they were no longer significantly different from the healthy dogs.
Additionally, a significant increase in beneficial bacteria taxa (e.g. Lachnospira sp, Fig 3) and a decrease in harmful bacteria taxa (e.g. Desulfovibrio sp.) was observed. This positive change in the microbiome also leads to an increase in the production of helpful postbiotics. ActivBiome+ Technology significantly increased faecal levels of certain polyphenols and short-chain fatty acids (SCFA’s, Fig 4). The SCFA’s help reduce faecal pH, creating an environment that favours the growth of beneficial bacteria in the host. Potentially harmful postbiotics (faecal polyamines such as putrescine, spermidine) were also measured and were reduced by the addition of ActivBiome+ Technology2.
Similar to studies performed with dogs, the feline research done at the PNC on 28 healthy cats showed that ActivBiome+ Technology helped create a more positive gastrointestinal microbiome environment. There was a significant increase in beneficial bacteria. There was also a significant increase in key postbiotics, such as SCFA’s (acetic & propionic acids) from fibre fermentation and a decrease in fatty acids (isobutyric, 2-methylbutyric, & isovaleric acids) from protein breakdown. Increased stool moisture and decreased pH were also achieved whilst maintaining acceptable stool scores1.
NEW ActivBiome+ Technology has been proven to provide
numerous benefits in cats and dogs.
- Nourishes the pet’s individual gut microbiome and promotes beneficial bacteria
- Activates the microbiome to release and convert fibre bound polyphenols into more potent anti-inflammatory and antioxidant postbiotics
- Increases short-chain fatty acid production to nourish colon cells
- Promotes healthy stool quality in healthy dogs and dogs with enteritis2
Dr Andrei Timen , senior president of AMVAC
Pamas Trading is one of the best veterinary distribution company in Romania. Their portofolio for small animal consists in pet food , diets and medecines very usefull for clinicians. We have a very good cooperation and every year new products are offered on vet market. I believe in this partnership and hope that our relation will be better every year.
Dr Raluca Zvorasteanu
We have been working with Pamas for many years. The portfolio of products offered by them meets our standards and that of our clients. As professionals we want to offer only what is best to increase the quality of animal life. Together with Pamas we managed to raise the standards, offering treatments with the latest generation products. Collaboration with them is a flexible one, being prompt and attentive to our requirements as veterinarians
Clinica Veterinara Ortovet
During our collaboration, Pamas provided us with a wide range of products, which we have used with good results in the treatment and care of our patients. We enjoy an efficient communication, the Pamas team giving us prompt and appropriate answers to our needs.
Thank you, Pamas!
The Ortovet team
Dr Simon Corneliu, Tazyvet Clinic
I like the collaboration with the company Pamas because it is a company with good management.
It has good products which then become a brand under their distribution.
Always looking to distribute good and niche products.
They have flexible payment terms and are prompt in delivery.
It encourages and facilitates young doctors in the exchange of experience with other clinics.
I wish them success in what they do and keep it that way.
Dr Ina Dragomir
In the more than 4 years of collaboration, Pamas has shown me that it is a company I can rely on, with a wide portfolio of products and seriousness in the delivery of orders. Also, the team from which it is formed and that broke my threshold in the cabinet is cooperative, united and very serious. At the same time, all its members proved to be jumping, understanding and always funny. I hug you PAMAS!
Dr Matei Alexandru
We have been collaborating with Pamas company for over 7 years. During this time we managed to create a strong connection based on professionalism and mutual trust. All the problems that have appeared over the years have been solved in a professional and equitable manner for both parties. I have recommended and I will continue to recommend my colleagues to collaborate with Pamas Trading for the quality of the products and for the short delivery time.
Dr Sonia Pintece
The Pamas Trading Company is very professional, they pay attention to our needs, the delivery is fast and they have good prices. Pamas Trading and Dr. Luba Ganceva by ”Learn and Travel” program made possible my externship to Central Vet Clinic – Sofia, Bulgaria and for that I would like to say : ” Thank you!”.
Dr Mirel Marafet
I have been working with Pamas for over 5 years, during which time it has proved to me that it is a company I can rely on. I hug you and wish you Happy Holidays PAMAS
Author: H.P. Meyer, DVM, PhD, Dipl-ECVIM-CA
Director, Professional & Veterinary Affairs, Hill’s Pet Nutrition
Co-author: Iveta Becvarova, DVM, MS, Dipl-ACVN
Director, Global Academic & Professional Affairs, Hill’s Pet Nutrition
It has long been accepted that canine atopic dermatitis (CAD), much like human atopic dermatitis is underpinned by dysfunction of the patients’ adaptive immune response. Specifically, inappropriate production of immunoglobulins and activation of an inflammatory response as a result of sensitisation to environmental allergens. However, newer research into the pathophysiology of the condition has also discovered an important deficiency in the skin of patients with CAD. It has been suggested that dogs have reduced skin barrier function allowing increased allergen permeation (1). These two mechanisms are not mutually exclusive and it is possible that both play a role in the development of atopy. The abnormal presence of allergens that have permeated the epidermis may be a potential trigger for cell sensitisation during development of CAD.
Structural changes in the skin of atopic dogs are notably a reduction in the intercellular lipid layer with disorganised lipid lamellae (1). Studies also show differences in the barrier function of skin in atopic and non-atopic patients (2). Transepidermal water loss (TEWL) has been used as a measure of skin barrier function to demonstrate this effect. A study using an experimental model of CAD showed increased TEWL assumed to be as a result of altered skin barrier function in patients with an experimental model of atopy (2). This finding has also been noted in dogs with naturally occurring AD (3). Importantly, in both of these studies the changes in barrier function could be measured in both lesional and non lesional skin.
This improved understanding of affected skin barrier function whether cause or consequence is highly relevant to the management of CAD. These deficiencies have been shown to be present both in lesional and non lesional skin and structural changes are constant and present both during and between episodes of clinical signs. The International Task Force on Canine Atopic Dermatitis (4) has recommended a gold standard approach to management of CAD, which is to use more aggressive therapy for periods of clinical signs or atopic flares in addition to long-term maintenance therapy between flares that aims to reduce the incidence and severity of clinical episodes. One of the big considerations for clinicians when selecting such long-term management therapies for CAD patients is interventions with mild or no side effects. Use of carefully selected nutrients that can support the skin and coat could fit this brief. Considering the importance of maintaining barrier function as well as tempering the inflammatory response to allergens there are nutrients that may play an important role in these areas of recent interest.
Nutrients of interest in CAD
There are two nutrients to consider that can be utilised for their effects on cell sensitisation and cell activation during the induction and effector phases of CAD. The first is the use of egg, which has multiple potential benefits, including antioxidant and immunomodulatory properties (5,6). The immunomodulatory benefit of egg has been explored in skin sensitisation in dogs (7). Three groups of dogs were exposed to a novel antigen (keyhole limpet hemocyanin (KLH) in weeks 9 and 11 of a controlled food trial. The three groups were a control food, the control food and prednisone (at 2.2mg/kg bodyweight orally per day) and a food containing egg. An intradermal skin test (with KLH) was performed at week 12 and the results were as follows: both the prednisone treated group and the egg fed group had statistically significant reductions in the immediate and delayed-type (cell-mediated) hypersensitivity reactions compared to the control group. This response was similar between the egg and prednisone groups. These results support the findings that egg have immunomodulating properties (5,6), in particular in reducing allergen-induced hypersensitivity reactions. This nutrient may be of use when considering a food for patients with CAD.
The other important nutrient group to consider are polyphenols, which are sourced from plant ingredients such as green tea, herbs and green vegetables. Polyphenols do also have strong antioxidant properties. Antioxidants are beneficial in foods for patients with CAD as it is a markedly inflammatory condition. Supplementation can support the patient’s own antioxidant defences in the face of free radical cellular injury caused by inflammation. Polyphenols, like egg, have also been shown to have specific effects tempering cell-mediated immune responses. Notably, they may inhibit antigen presentation, T cell cytokine release, B cell IgE production and mast cell degranulation (8-13). Use of these ingredients in pilot feeding studies of botanicals, containing polyphenols and antioxidants, in CAD has yielded reductions in levels of IL-31, IL-12p40 and other cytokines as well as reduced itching, hair loss and erythema (14).
Image 1. Fast and simple completion of the CADESI-4 skin scoring for CAD in the ‘Atopy Index’ APP developed by Hill’s. Download in your phone’s APP store .
Following the identification of impaired barrier function in patients with CAD, studies have been conducted to identify nutrients to support the skin barrier. A key area has been to target the deficiencies noted in the intercellular lipid layer. A major component of this layer is ceramide; lower ceramide levels have been identified in the stratum corneum (SC) of patients with CAD compared to normal dogs (15,16). Oral supplementation of polyunsaturated fatty acids (PUFAs) appears to support improvement in at least some of these structural changes. One study found supplementation of AD dogs with PUFAs resulted in increased ceramide content in the SC and improved organisation of lamellae in the SC to be comparable to that of normal dogs (17).
PUFAs have been widely trialed in both research and clinically as a management strategy for CAD for their anti-inflammatory effect and to nourish the skin and coat. The benefits of using PUFAs as an anti-inflammatory are through a reduction in production of pro-inflammatory eicosanoids and a reduction in stimulation of inflammatory cells. (18). This effect is largely mediated through Ω-3 PUFAs in contrast to the epidermal barrier support described above which is considered to be a factor of total Ω-6 intake.
This requirement for both Ω-3 and Ω-6 fatty acids can complicate the interpretation of research findings in relation to PUFAs. Further work is required to completely understand PUFAs in this regard. From the current literature it is advisable to consider both the level of Ω-3 and Ω-6 PUFAs and their ratio to one another for optimum support. A low Ω-6 to Ω-3 ratio is considered anti-inflammatory, with an inclusion of sufficient total Ω-6 for skin barrier support. For this reason their inclusion in a complete food rather than supplementation on top of the patient’s own food will give better control.
To complete the review of nutrients there are also macro and micro nutrients that can be added to the food and optimised for skin and coat support. These nutrients are applicable to all dogs not just patients with CAD. Protein, vitamins A and E, Ω-3 and Ω-6 fatty acids, zinc and copper all contribute to maintenance and repair of skin and coat. These benefits are well described in more detail in nutrition texts (19).
Figure 1. Median (range) dermatological scores in 20 dogs with CAD at baseline and at 4 and 8 weeks after being put on a dietetic food indicated for CAD. * p<0.05 vs. baseline.
To assess the holistic impact of the discussed nutrients a study was conducted using a food indicated for patients with CAD. The food is a complete canine food optimised for skin support to include zinc, copper, antioxidant vitamins E and C and also containing egg, polyphenols and supplemented with both Ω-3 and 6 PUFAs. The study was constructed as an open label non-controlled feeding study of adult dogs with pre-existing AD. Patients were included on the basis of presenting with 5 or more of Favrot’s criteria for the diagnosis of AD (20). The dogs could be maintained during the study on standard therapy for AD including allergen avoidance, allergen-specific immunotherapy, symptomatic anti-inflammatory therapy and antimicrobial therapy as long as drugs, doses, and frequency of administration remained constant from the time of previous food administration through to completion of the study . Dogs were excluded on the basis of untreated infectious or parasitic dermatitis or concurrent skin or major systemic conditions. Also dogs were excluded if they had been fed with either food or supplements with high levels of Ω-3 fatty acids in the 12 weeks preceding the study. Dogs using oclacitinib were also excluded from the study.
The owners were instructed to feed the dogs the food exclusively for 8 weeks and discontinue all any homeopathic remedies and other supplements. The dogs were assessed at 0, 4 and 8 weeks and at each assessment the attending vet completed a dermatological evaluation based on the Canine Atopic Dermatitis Extent and Severity Index (CADESI) (21) and owners completed an evaluation form at each visit and gave their opinion on their dog’s quality of life, skin and coat appearance, and food acceptance. The CADESI-4 scoring system is an important tool to provide an objective assessment of the situation and to monitor progress. Hill’s has developed a simple in-clinic APP to facilitate CADESI-4 scoring completion, storage and visualisation to the pet owner. It can be downloaded via your app store on your mobile phone (Image 1).
20 dogs were included in the data analysis, 28 dogs were excluded prior to this due to various medication and supplement changes or missing data and 3 were excluded due to food refusal. For the analysed patient group both mean BCS and mean weight were stable during the study. The results shown below show the median dermatological scores for the dogs decreased significantly at both 4 and 8 weeks when compared to the baseline (Fig 1).
Owner assessments also showed significant improvements at the end of the study compared to baseline in the following categories: scratching, licking, scratching of ears, disruption to the family redness of skin and overall condition of skin and hair coat (Fig 2).
Figure 2. Owner assessments (Least square mean (range); Scale from 0 (not present) – 10 (always present) of various skin parameters in 20 dogs with CAD at baseline and at 4 and 8 weeks after being put on a dietetic food indicated for CAD. * p<0.05 vs. baseline
Overall food acceptance was good with 90% of dogs eating the food for the entire study duration. Many dogs had to be excluded due to medication changes. The number that started and stopped medication was almost equal during the study removing selection bias towards milder or more severe cases. This results suggest use of these nutrients in a complete food shows improvement from both an owner perspective and in reducing dermatological scores for patients. The application of a food designed for use in patients with AD to reduce the inflammatory response, support skin barrier function and optimise skin and coat health could be considered as part of a multimodal approach to managing the patient with AD. Particularly considering that nutrition can be used simply on a daily basis both during and between clinical flares with no adverse effects to the patient.
Associations , we are in contact:
SRVO Romanian Society of Veterinary Orthopeady
Clinic which we are in contact:
Central Vet Clinic
Saint Antim veterinary center
Vet Medical Assistance
Vet Center Otopeni
Vet Medical Center
Robert and Oana Popa veterinary Clinic
Veterinary Practice Novak – Denis and Nikoleta Novak
Ivavet- Dr Ivan Jevtic
Tommy VeterinaryClinic -Dr Goran Tomisic
Dr Ivan Rakic
Dr Eugen Sefer
Petcode – Ankara, Dr Ates Barut
PatiSev Veterinary Clinic- Dr Gizem Taktak
Ares Veterinary Clinic , Istanbul
Tilia Veterinary Clinic Istanbul
Cat Hospital Ankara
Anipoli Veterinary Clinic Istanbul
HappyPets Veterinary Clinic Mugla
Kreszinger Veterinary Clinic – Dr Lea Kreszinger
Veterinary Clinic More – Dr Emil Ofner
Veterinary Clinic Vevita- Dr Ana-Maria Bljaic
” Citta di Pavia ” Veterinary Clinic