Clinical progression of cats with early-stage chronic kidney disease fed diets with varying protein and phosphorus contents and calcium to phosphorus ratios

Background Dietary protein and phosphorus (P) restriction is the mainstay for nutritional management of chronic kidney disease (CKD). However, adequate restriction levels for cats with early CKD remain unclear. Objectives To investigate responses in cats with early CKD to varying dietary protein, P, and calcium (Ca) : P ratio. Animals Nineteen research colony cats with International Renal Interest Society stages 1-2 CKD. Methods In an opportunistic longitudinal case study, cats were fed a low protein (59 g/Mcal), low P (0.84 g/Mcal) dry diet (LP-LP; Ca : P = 1.9) for 18 months and later transitioned onto a moderate protein (76-98 g/Mcal), moderate P (1.4-1.6 g/Mcal) dry-wet diet regimen (MP-MP; Ca : P = 1.4-1.6) for 22 months. Fold-changes in serum creatinine, total Ca (tCa) and P (primary outcomes) and fibroblast growth factor 23 (FGF23) were assessed by linear-mixed models. Results While feeding LP-LP, mean serum creatinine decreased (0.87-fold, 95% confidence interval [CI] 0.81, 0.93, P < .001) to within reference range after 6 months, while increases in total Ca (tCa; 1.16-fold, 95% CI 1.11, 1.22, P < .001) and FGF23 (2.72-fold, 95% CI 1.72, 4.31, P < .001), but not in P (1.03-fold, 95% CI 0.945, 1.124, P = .94), were observed after 17 months. On MP-MP, mean creatinine, tCa and P remained within reference ranges and did not significantly change (P = .11, P = .98, and P = 1, respectively), while FGF23 significantly decreased (0.58-fold, 95% CI 0.36, 0.95, P = .02) after 22 months. Conclusions and Clinical Importance Cats with early CKD developed hypercalcemia after long-term feeding of a highly P-restricted diet. Increasing dietary P and reducing Ca : P ratio maintained renal markers, while improving Ca-P balance. Cats with early CKD could benefit from moderately protein- and P-restricted diets.