Case of the month: pancreatitis and renal disease in a Dachshund + two recipes

Updated: Mar 4

This month I wanted to talk about nutritional management of two diseases that we see very commonly. A 9-year-old female spayed Dachshund was referred to us for a nutrition consult, as the referring veterinarian had correctly decided that there was no commercial therapeutic diet (available in Australia) to suit this patient's needs.


Commercial renal diets are too high in fat, and low fat gastrointestinal diets are too high in phosphorus (and potentially protein). The owner had a preference to use turkey in one of the recipes, and also mentioned that the dog really enjoyed different kinds of fish. The nutritional goals for this patient were, therefore, to create a low fat, moderate to low protein, phosphorus-restricted diet, enriched with mixed fermentable fibre, antioxidants, and omega-3 fatty acids.


Tuna canned in springwater can be a good addition to renal diets. It is low in phosphorus, rich in omega-3 fatty acids and has a strong flavour, which can be used to increase the appeal of the carbohydrate component of the diet. Small tuna species like Skipjack are increasingly fished using sustainable methods, and since it's a small, fast-growing species, it's not high in mercury like larger tuna species.

Unfortunately, it can be a challenge to create highly palatable recipes when both fat and

protein restriction are required. By necessity, these recipes contain mostly carbohydrate.

It is therefore important that for these cases, we make sure that the carbohydrate component of the diet is as tasty as possible. Sometimes we do this by using vegetables like sweet potato and pumpkin, and sometimes we add some homemade broth to the recipes, to add as much flavour as possible.


Phosphorus restriction is an uncontroversial goal for all renal diets, for both dogs and cats. Phosphate retention is the initiating factor for the development of many of the complications observed in chronic kidney disease, such secondary renal hyperparathyroidism, and bone and cardiovascular diseases. Many studies have demonstrated that dietary phosphorus restriction slows decline in renal function and increases mean survival time in dogs (and cats) with chronic kidney disease.


Phosphate retention can cause renal secondary hyperparathyroidism, which has a wide range of detrimental effects.

Protein restriction is a more debated goal, and will the sole topic of an upcoming blog post. To summarise, there are three main reasons why restriction of dietary protein for renal patients is recommended:

1) Protein-rich ingredients are a source of non-protein nitrogenous compounds such as urea, which may advance the onset of uraemia.

2) Feeding excessive protein can decrease its digestibility. This may increase fermentation of protein by gastrointestinal microflora. End-products of bacterial protein fermentation include uraemic toxins like p-cresyl sulfate and indoxyl sulfate, which can worsen renal toxicity by increasing oxidative stress and accelerating skeletal muscle atrophy.

The paper by Fernandez-Prado et al. (2017), "Nutrients Turned into Toxins: Microbiota Modulation of Nutrient Properties in Chronic Kidney Disease" provides an excellent overview of this topic.

3) Proteinuria has been shown to have a highly detrimental effect on the kidney. Protein overload of tubular epithelial cells and intrarenal activation of complement can cause infiltration of inflammatory cells and injury to the surrounding interstitial cells, leading to the development of glomerulosclerosis. Excessive albuminuria may also lead to increased renal oxidative stress, which can cause progressive nephron damage. Many studies have demonstrated that decreasing the magnitude of proteinuria by reducing dietary protein intake slows down the progression of nephron loss.


Fat restriction for dogs with a history of pancreatitis is another controversial topic. There is a lack of convincing research on the relationship between dietary fat and pancreatitis in dogs; important precipitating factors may include hypertriglyceridaemia, obesity or a sudden increase in dietary fat. Given the absence of evidence, we typically opt for a conservative amount of dietary fat. However, we try to avoid very severe fat restriction, given that dietary fat increases the energy density of the meals and often improves palatability (which can be vital for patients with a poor appetite). It may be the case that occasional feeding of high fat treats or snacks is a much more critical risk factor, so we recommended that the owners of this dog strictly adhere to the recipes.


A recent study on pancreatitis found that just being present at a social event like a party or barbecue increased the dog's risk of developing pancreatitis.

The remaining three goals for this patient were enrichment of the diet with fermentable fibre, omega-3 fatty acids, and antioxidants. Supplementation with omega-3 fatty acids has been shown to lower glomerular capillary pressure, reduce proteinuria and slow decline in glomerular filtration rate. Fish oil is often the best thing to add to the diet to provide EPA and DHA; in this case, it was important to use a very concentrated product, to provide maximum enrichment with omega-3 fatty acids, but minimal excessive fat.


Fermentable fibre is also desirable in renal diets. Both animals and humans with chronic kidney disease often exhibit changes in the gut microbiota and increased gut permeability, which may be due to excessive luminal urea and its breakdown product, ammonia, reducing epithelial tight junction proteins in the colon. Dietary supplementation of fermentable fibres like wheat dextrin has been shown to decrease colonic pH and improve gut barrier function, which may reduce translocation of harmful bacterial products and metabolites, decreasing inflammation in the kidneys.


Finally, we typically try to include a range of different vegetables and sometimes a vitamin E supplement, to enrich the diet with vitamin C, vitamin E, beta-carotene, lutein and alpha-lipoic acid. Several studies have demonstrated that addition of dietary antioxidants reduces the magnitude of renal glomerulosclerosis and interstitial fibrosis, regardless of dietary polyunsaturated fatty acid ratio.


Green leafy vegetables, carrots, pumpkin, sweet potato, capsicum, and broccoli are all excellent sources of beta-carotene, vitamin C and alpha-lipoic acid.

Phew. Lots of goals to consider. For this dog, we formulated two recipes - one was a turkey and white rice based recipe with additional vegetables like cabbage, kale and broccoli. The second recipe contained canned tuna and salmon, with rice, carrot, red capsicum and pumpkin. To these recipes we also added the required supplements to produce a balanced diet (with the exception of phosphorus restriction), and to achieve the goals described above. The owner transitioned the dog on to the new diet very gradually, to minimise the risk of gastrointestinal upset, and so far, the recipes have been a big success. As this dog's renal disease progresses we will aim to further reduce phosphorus and protein, while still maintaining palatability and food intake. A delicate balancing act!


February 2022 update


Since writing the post above, we have received thousands of emails from dog owners trying to find diet options for their own dog with pancreatitis and kidney disease. Unfortunately, there is still a lack of commercial fat-restricted renal diets, especially in Australia and New Zealand. Many of these dog owners do book in a consult and personalised therapeutic recipe formulation with us. This is our preferred option, so we can ensure that the recipes are appropriate for the individual dog's medical needs, and also their ingredient 'likes' and 'dislikes'.


However, we understand and appreciate that many owners (for a range of reasons) are not in a position to be able to go ahead with a consult (either with us, or another veterinary nutritionist). Given the lack of commercial options, I would like to help all owners have access to a well-formulated homemade therapeutic diet, appropriate for dogs with kidney disease and a history of pancreatitis. I have therefore decided to include, as part of this post, two recipes which dogs owners around the world should be able to use. A few very important points: 1) Please talk to your local vet before changing your dog's diet. It is really important to get your vet's input. You can show your vet this blog post and the recipes and ask for any comments or thoughts. For all the vets out there: the recipes are suitable for patients with IRIS stage 2 or early stage 3 chronic kidney disease and a history of pancreatitis. They are not suitable for dogs with severe hyperlipidaemia, or lymphangiectasia - an ultra-low fat diet may be more appropriate in these cases. Both recipes are suitable for patients with or without proteinuria and/or hyperphosphataemia. Dogs with advanced kidney disease (late IRIS stage 3 or stage 4 CKD) may benefit from a more protein-restricted diet; please discuss this with your vet.


2) You must follow the recipes, exactly as they are, without substituting, changing, or omitting any of the ingredients or supplements. I can't stress this enough - if you leave out supplements, or change doses or amounts, you will negate the benefits of a therapeutic diet. You might cause severe deficiencies or considerable harm to your own dog. If your dog won't eat the diet, including all ingredients and supplements, then these recipes are not for you, unfortunately. You are welcome to contact us and book in a consult for some personalised recipes.


Both recipes are for 1-kilogram batches of prepared food - you can make up as many batches as you like, depending on the size of your dog and how much you want to feed per day. The goals for both recipes were restricted protein and phosphorus, and restricted fat, with added omega-3 fatty acids, taurine, fibre and antioxidants. Please be sure to monitor your dog's body weight regularly, to ensure he or she is eating enough. It is important that dogs with CKD being fed a low protein diet consume enough calories per day, in order to prevent loss of muscle mass.


Here are the recipes; I have tried to keep them quite simple so people around the world have access to the ingredients, and also to make them as practical as possible. You will notice that the amount of meat (relative to the vegetables) is low - this is not a mistake, it is just the reality of formulating a low protein homemade diet for dogs with kidney disease.




Recipe One: Chicken and egg with rice, pumpkin, broccoli and spinach


Required ingredients:


110 grams of raw skinless and boneless chicken thigh

40 grams of mashed hard-boiled egg (white and yolk, but no shell)

440 grams of cooked white rice (medium or short grain preferred)

125 grams of raw pumpkin or butternut squash (peeled)

100 grams of raw green beans (fresh or frozen)

80 grams of raw broccoli (fresh or frozen)

80 grams of raw spinach, silverbeet, chard or kale leaves (fresh or frozen)

3/4 (three quarters) teaspoon of cold-pressed safflower oil or walnut oil

1/4 (one quarter) level teaspoon of iodised table salt


Required supplements (per 1-kilogram batch):


Nordic Naturals omega-3 pet liquid: 6 mL

Now Foods psyllium husk powder: 5 grams

Now Foods taurine (1000 g) capsules: 1 capsule (contents only)

Now Foods Daily Vits multi vitamin and mineral capsules: 1 capsule (contents only)

Now Foods calcium carbonate powder: 1 1/2 (one and a half) level teaspoons

Country Life choline tablets: 3 tablets (crushed)

Solgar zinc picolinate (22 mg) tablets: 1/2 (half) tablet (crushed)



Preparation instructions:


Please use a digital kitchen scale and measuring spoons to measure all quantities very accurately. This is very important. Do not estimate amounts.

  1. Cook the white rice in water until very soft (overcooked), according to the manufacturer's instructions (you will likely need about 160 grams of uncooked rice). Allow to cool slightly, until warm, then weigh out the required amount (440 grams).

  2. Steam or microwave the chopped pumpkin, green beans, broccoli and spinach until very soft, then allow to cool and mash together.

  3. Weigh out the required amount of raw chicken thigh (110 grams), then gently pan-fry it in a non-stick pan until cooked. Dice or shred very finely, then set aside.

  4. Hard-boil one large egg, then allow it to cool and remove the shell. Mash the white and yolk together, then weigh out the required amount of cooked egg (40 grams).

  5. Combine the cooked white rice with the mashed hard-boiled egg, cooked mashed vegetables, and finely diced cooked chicken thigh, and mix very thoroughly.

  6. Add the iodised salt, safflower or walnut oil, psyllium husk powder, and fish oil, and mix again.

  7. Just before serving, add the taurine capsule (contents only), Now Foods Daily Vits capsule (contents only), calcium carbonate powder, zinc tablet (half a tablet, crushed to a powder) and choline tablets (3 tablets, crushed to a powder).

  8. Be sure to mix together all the ingredients very well. The diet can be refrigerated or frozen until needed. When defrosting the food, do not heat it to a high temperature, just warm it gently and slowly, or defrost it in the fridge.


This recipe has 18.6% calories from protein, 18.2% calories from fat and 63.2% calories from carbohydrate (be aware, this is not the same as 'dry matter basis' or 'as fed basis'). It has 0.65 g phosphorus per 1000 kcal ME, and an omega-6 to omega-3 ratio of 2.3.

Here are the links to the supplements you will need to purchase to make Recipe One:


Nordic Naturals omega-3 pet liquid:

https://www.nordic.com/products/omega-3-pet/

Available via NZ Health Store (https://www.nzhealthstore.co.nz/) for NZ and Australian clients. Order the liquid, not the capsules. The medium to large-breed dog product is more economical. Store in the fridge to minimise odour and prolong the shelf-life. If clients in Australia are not able to order this, please substitute PAW Blackmores fish oil 500: veterinary strength: (https://www.blackmores.com.au/products/pet-health/joint-care/paw-fish-oil-500-veterinary-strength)

Now Foods psyllium husk powder:

https://au.iherb.com/pr/now-foods-psyllium-husk-powder-12-oz-340-g/8934

Now Foods taurine (1000 mg) capsules:

https://au.iherb.com/pr/now-foods-taurine-double-strength-1-000-mg-100-veg-capsules/15787

Now Foods calcium carbonate powder:

https://au.iherb.com/pr/now-foods-calcium-carbonate-pure-powder-12-oz-340-g/480

Solgar zinc picolinate (22 mg) tablets:

https://au.iherb.com/pr/solgar-zinc-picolinate-100-tablets/10035

Country Life choline tablets:

https://au.iherb.com/pr/country-life-choline-100-tablets/1631

This supplement is occasionally out of stock; if it is, please sign up for notifications and order as soon as possible.


Now Foods Daily Vits multi vitamin and mineral capsules:

https://au.iherb.com/pr/now-foods-daily-vits-multi-vitamin-mineral-120-veg-capsules/86755

Please be careful to purchase the capsules (exactly as per the link above), and not the tablets.




Recipe Two: Beef and sardines with pasta, sweet potato, zucchini and kale


Required ingredients:


90 grams of raw, very lean beef mince (ground beef) with 5% fat

30 grams (drained weight) of sardines, canned in spring water

350 grams of cooked plain pasta (penne, macaroni, risoni etc)

350 grams of raw orange or purple sweet potato (washed, but not peeled)

90 grams of raw zucchini/courgette (fresh or frozen)

65 grams of raw spinach, silverbeet, chard or kale leaves (fresh or frozen)

1 1/4 (one and a quarter) teaspoons of cold-pressed safflower oil or walnut oil

1 gram (1 medium pinch) of iodised table salt


Required supplements (per 1-kilogram batch):


Nordic Naturals omega-3 pet liquid: 5 mL

Now Foods psyllium husk powder: 5 grams

Now Foods taurine (1000 g) capsules: 1 capsule (contents only)

Now Foods Daily Vits multi vitamin and mineral capsules: 2 capsules (contents only)

Now Foods calcium carbonate powder: 1 1/2 (one and a half) level teaspoons

Country Life choline tablets: 2 tablets (crushed)



Preparation instructions:


Please use a digital kitchen scale and measuring spoons to measure all quantities very accurately. This is very important. Do not estimate amounts.

  1. Cook the pasta in water until very soft (overcooked), according to the manufacturer's instructions (you will likely need about 145 grams of uncooked pasta). Allow to cool slightly, until warm, then weigh out required amount (350 grams).

  2. Steam or microwave the chopped sweet potato, zucchini and kale until very soft, then allow to cool and mash together.

  3. Weigh out the required amount of raw beef mince (90 grams), then gently pan-fry it in a non-stick pan until cooked.

  4. Combine the cooked pasta with the canned sardines (30 grams), cooked mashed vegetables, and cooked beef mince, and mix very thoroughly.

  5. Add the iodised salt, safflower or walnut oil, psyllium husk powder, and fish oil, and mix again.

  6. Just before serving, add the taurine capsule (contents only), Now Foods Daily Vits capsules (2 capsules; contents only), calcium carbonate powder, and choline tablets (2 tablets, crushed to a powder).

  7. Be sure to mix together all the ingredients very well. The diet can be refrigerated or frozen until needed. When defrosting the food, do not heat it to a high temperature, just warm it gently and slowly, or defrost it in the fridge.


This recipe has 18.5% calories from protein, 17.3% calories from fat and 64.2% calories from carbohydrate (be aware, this is not the same as 'dry matter basis' or 'as fed basis'). It has 0.58 g phosphorus per 1000 kcal ME, and an omega-6 to omega-3 ratio of 2.8.



Here are the links to the supplements you will need to purchase to make Recipe Two:


Nordic Naturals omega-3 pet liquid:

https://www.nordic.com/products/omega-3-pet/

Available via NZ Health Store (https://www.nzhealthstore.co.nz/) for NZ and Australian clients. Order the liquid, not the capsules. The medium to large-breed dog product is more economical. Store in the fridge to minimise odour and prolong the shelf-life. If clients in Australia are not able to order this, please substitute PAW Blackmores fish oil 500: veterinary strength: (https://www.blackmores.com.au/products/pet-health/joint-care/paw-fish-oil-500-veterinary-strength)

Now Foods psyllium husk powder:

https://au.iherb.com/pr/now-foods-psyllium-husk-powder-12-oz-340-g/8934

Now Foods taurine (1000 mg) capsules:

https://au.iherb.com/pr/now-foods-taurine-double-strength-1-000-mg-100-veg-capsules/15787

Now Foods calcium carbonate powder:

https://au.iherb.com/pr/now-foods-calcium-carbonate-pure-powder-12-oz-340-g/480

Country Life choline tablets:

https://au.iherb.com/pr/country-life-choline-100-tablets/1631

This supplement is occasionally out of stock; if it is, please sign up for notifications and order as soon as possible.


Now Foods Daily Vits multi vitamin and mineral capsules:

https://au.iherb.com/pr/now-foods-daily-vits-multi-vitamin-mineral-120-veg-capsules/86755



Again - please include all ingredients and supplements exactly as per the recipe. Don't change anything. I understand it does look like an overwhelming number of supplements. Do keep in mind that while the initial cost of purchasing all the supplements may be quite high, many of them last for a long time, so the day-to-day cost is much more reasonable.


Dogs are not generally as fussy as cats, however we still strongly recommend a gradual transition to a new diet over 7-10 days minimum. This will help to reduce the risk of any mild gastrointestinal signs due to a sudden change in diet.


I hope these recipes are helpful, and that your dog enjoys them. If you really have no luck with these, or your dog loves kangaroo, or pork, or other proteins, we can formulate personalised recipes for you - there is more information on our referral process here:

https://www.veterinarynutritiongroup.com/for-veterinarians




Medical disclaimer: All content and media on this website is created and published online for informational purposes only. It is not intended to be a substitute for professional advice from your pet's veterinarian. Always seek the guidance of your veterinarian with any questions you may have regarding your pet's medical condition/s. Never disregard the advice of your veterinarian, or delay in seeking it, because of something you have read online. If you think your pet may have a medical emergency, call your veterinarian immediately, or visit the nearest emergency hospital or clinic.