kidney disease in dogs and cats - illinois state veterinary medical … · 2019. 12. 11. ·...

Kidney Disease in Dogs and Cats:How to Make the Most from an Early Diagnosis

Robert M. DuFort, DVM, DACVIM, FMS III

2 © 2017 IDEXX Laboratories, Inc. All rights reserved.

Key learning objectives

o To show why the IDEXX SDMA® Test is a more reliable indicator of kidney function than traditional diagnostics.

o To emphasize that clinical information and diagnostic results need to be evaluated together to determine if acute kidney injury (AKI) or chronic kidney disease (CKD) is present.

o To review what next steps should be taken when kidney disease is diagnosed.

o To review the International Renal Interest Society (IRIS) CKD guidelines.

o To highlight the benefits of diagnosing kidney disease earlier and more reliably.


Limitations of traditional kidney diagnostics

Creatinine• Late marker• Impacted by other

factors including muscle mass

BUN• Late marker• Impacted by other

factors including diet, liver disease

GFR• Expensive• Not practical • Rarely done in practice

UPC• Urine test• False positives with UTI• Can be normal with

kidney disease

Microalbuminuria• Urine test• False positives• Not specific for

kidney

Specific Gravity • Urine test• Later marker• Impacted by other factors and

other diseases (e.g. diabetes)

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=WzZO0sCQAsHWtM&tbnid=PX-xx97YxA6XbM:&ved=0CAUQjRw&url=http://www.bodypartchart.com/product/cat-anatomy-labeled/&ei=lGeqUu-rNMPtkQeYrYHQCw&bvm=bv.57967247,d.eW0&psig=AFQjCNGnqB5MIDmFRfjlHnOicHGd2iHSyQ&ust=1386985733127417

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=WzZO0sCQAsHWtM&tbnid=PX-xx97YxA6XbM:&ved=0CAUQjRw&url=http://www.bodypartchart.com/product/cat-anatomy-labeled/&ei=lGeqUu-rNMPtkQeYrYHQCw&bvm=bv.57967247,d.eW0&psig=AFQjCNGnqB5MIDmFRfjlHnOicHGd2iHSyQ&ust=1386985733127417


o SDMA = Symmetric dimethylarginineo Methylated form of arginine in intracellular proteins of

all nucleated cellso Released into circulation when intracellular proteins are

processedo Stable production of SDMA is part of daily cell activityo Excreted by the kidneyso A proven renal biomarker that that has been shown to

correlate with glomerular filtration rate (GFR) in humans, dogs, and cats

What is SDMA?

Now available from IDEXX Reference LaboratoriesAvailable in late 2017 in-clinic on IDEXX Catalyst® platform


SDMA is more sensitive: SDMA increases earlier than creatinine.

Why is SDMA more reliable than traditional diagnostics?

Sources1. Nabity ,MB, et al. Symmetric dimethylarginine assay validation, stability, and evaluation as a marker for the early detection of chronic kidney disease in dogs. J Vet Intern Med. 2015;29(4):1036–1044.2. Hall JA et al. Serum concentrations of symmetric dimethylarginine and creatinine in dogs with naturally occurring chronic kidney disease. J Vet Intern Med. 2016;30(3):794–802.3. Hall JA, et al. Comparison of serum concentrations of symmetric dimethylarginine and creatinine as kidney function biomarkers in cats with chronic kidney disease. J Vet Intern Med. 2014;28(6):1676–1683.


SDMA is more specific: Creatinine is impacted by lean body mass but SDMA is not.

Source: Hall JA, Yerramilli M, Obare M, Yerramilli M, Melendez LD, Jewel DE. Relationship between lean body mass and serum renal biomarkers in healthy dogs. J Vet Intern Med. 2015;29(3):808–814.

Source: Hall JA, Yerramilli M, Obare E, Yerramilli M, Yu S, Jewell DE. Comparison of serum concentrations of symmetric dimethylarginine and creatinine as kidney function biomarkers in healthy geriatric cats fed reduced protein foods enriched with fish oil, L-carnitine, and medium-chain triglycerides. Vet J. 2014;202(3):588–596.

Why is SDMA more reliable than traditional diagnostics?


How do I know it is accurate?

Over 40 peer-reviewed

publicationsEndorsement by

IRISHuman field takes interest in SDMA

“Creatinine is so 1950s.”


…is for all patients in all cases.

…results are clinically actionable.

…increases with active and acute kidney injury.

…allows for early diagnosis and management of CKD.

IDEXXSDMA®

Test

When should you run SDMA on your patients?


Why should you run SDMA in all patients?

In time, at least 1 in 3 cats1 and 1 in 10 dogs2 will develop some form of kidney disease in their lifetime.

Sources1. Lulich JP, Osborne CA, O'Brien TD, Polzin DJ. Feline renal failure: questions, answers, questions. Compend Contin Educ Pract Vet. 1992;14(2):127–153.2. Brown SA. Renal dysfunction in small animals. The Merck Veterinary Manual website.

http://www.merckvetmanual.com/mvm/urinary_system/noninfectious_diseases_of_the_urinary_system_in_small_animals/renal_dysfunction_in_small_animals.html. Updated October 2013. Accessed August 2, 2016.

Because kidney disease is common!


When do we diagnose dogs and cats with kidney disease?

Preventive screensduring wellness visits

Preanesthetic screening

Diagnostic testing for clinical signs of kidney disease

Diagnostic testing for clinical signs of other illnesses

During evaluation for and treatment of hyperthyroidism

Case study: Molly


Can we diagnose Molly with CKD?

Need clinical information!o Signalmento Clinical signs: appetite, weight

loss, vomiting, polyuria/polydipsia (PU/PD)

o Duration of clinical signso Physical examination findings:

hydration status, renal palpationo Documentation of azotemia

previouslyo Need urinalysis!o Exposure to medications, toxinso Exposure to and protection

from infectious diseases


Molly

Presenting reason: Ovariohysterectomy (OVH)

Historyo Healthy, from breeder at 2 monthso Indoor/outdoor Pacific Northwest

suburbo Vaccinations complete, including

leptospirosis and rabies o Using Revolution®, recently added

Comfortis®

o Kirkland Signature® puppy foodo Occasional household urinary

accidents

7-month-old, intact female shih tzu


Physical examinationo Bright, alert, responsive,

hydratedo Temperature, pulse,

respiration normalo Body condition score 5–6/9 o Weight of 6.6 lb (3 kg)

Diagnostic plano Complete blood count (CBC) o Chemistry panel including the

IDEXX SDMA Test

Molly’s physical examination


SDMA reference interval in puppies is higher than in adults

SDMA units = µg/dLPuppyhood depends on breed and size.


What should be done now?

Delay spay and follow the IDEXX SDMA Test diagnostic algorithm


www.idexx.com/sdma

IDEXX SDMA® Test diagnostic algorithm

http://www.idexx.com/sdma


IDEXX SDMA® Test diagnostic algorithm


Kidney disease probable: Follow IMM protocol


What if Molly’s SDMA result had been 18 µg/dL?


Look for other evidence of kidney disease

Consider other evidence of kidney disease:o Inappropriate urine specific gravity (USG) of <1.030 in a dog or <1.035 in a cato Active urinary sediment—particularly casts, white blood cells, or bacteriao Proteinuria or urine protein:creatinine (UPC) ratio >0.5 in a dog or >0.4 in a cato History of weight loss, decreased appetite, polydipsia, polyuriao Physical examination findings, such as palpable kidney abnormalities o Creatinine, BUN, and/or phosphorus above reference intervalo Creatinine increasing within reference intervalo Anemiao Other diagnostic findings (abnormal kidney imaging, unexplained hypertension)


Kidney disease probable: Follow IMM protocol


Molly’s diagnostic assessment

AssessmentKidney disease probable – act immediately!

Differential diagnoses Acute kidney injury versus chronic kidney disease

o Etiologies• Infectious: pyelonephritis, leptospirosis, Lyme

disease• Familial: renal dysplasia • Toxic: jerky treats, grapes, raisins,

medications• Glomerulonephritis• Tubulointerstitial disease• Nephrolithiasis • Neoplasia


Molly: Investigate

• Urine culture and MIC susceptibility

• Infectious disease testing (Lyme disease, leptospirosis, ehrlichiosis, FeLV, FIV, FIP, toxoplasmosis)

• Diagnostic imaging (stones, pyelonephritis)

• History/possibility of toxin exposure?

• History/exposure to potentially nephrotoxic drugs?

• Hydration status• Blood pressure• Urine protein:creatinine

ratio• Thyroid status

To identify an underlying cause, perform:For confounding conditions, asses:


Molly’s ultrasound

Findingso Kidneys both slightly smallo Mild bilateral renal pelvic

dilation o Renal cortices are mildly

thinned

Conclusionso Renal dysplasiao Concurrent pyelonephritis

August 2015

Right kidney

Left kidney

Pelvic dilation

Pelvic dilation


Molly

Urine culture and MIC susceptibility o Not performed and Molly was

treated empirically o Best practice to confirm

infection and choose appropriate long-term antibiotic


Molly: Manage

• Underlying disease if identified

• Clinical dehydration• Persistent

hypertension• Persistent proteinuria• Hyperthyroidism

• Feed kidney-supportive diet

• Provide fresh, clean water sources

• Discontinue all potentially nephrotoxic drugs if possible

• Provide intravenous fluids, before, during, and upon recovery

• Provide oxygen, before, during, and upon recovery

• Maintain and monitor blood pressure and body temperature

• Analgesia use narcotic for pain management,

Treat appropriatelyProvide kidney support immediately

Adjust anesthesia protocols


Anesthetizing Molly for her spay

Ensure adequate oxygen delivery to the kidneys o Maintain perfusion

• Intravenous (IV) fluids o Maintain oxygen-carrying capacity

• Supplemental oxygen o Prevent hypothermia

• Active warming deviceso Monitor

• Blood pressure, heart rate and rhythm, oxygenation, ventilation, and body temperature

Avoid potentially nephrotoxic drugs o Buprenorphine for analgesia Photo courtesy of Dr. Jennifer Hess, DVM, DACVA


Molly: Monitor

Monitor as indicated Recheck in 2 weeks

• Kidney function has returned to normal

• Monitor confounding conditions and other underlying disease if present

Underlying or confounding disease identified

Underlying or confounding disease not identified

SDMA returns to normal• If SDMA and creatinine

are stable, chronic kidney disease (CKD) is diagnosed

• Initiate appropriate treatment based on International Renal Interest Society (IRIS) CKD staging

SDMA remains increased but stable

• If SDMA and/or creatinine are increasing, consider ongoing, active kidney injury

• Perform additional diagnostics to determine cause and to guide treatment

SDMA continues to increase


Molly: Monitor

Left kidney Right kidney


Molly: Monitor

Monitor as indicated Recheck in 2 weeks

• Kidney function has returned to normal

• Monitor confounding conditions and other underlying disease if present

Underlying or confounding disease identified

Underlying or confounding disease not identified

SDMA returns to normal• If SDMA and creatinine

are stable, chronic kidney disease (CKD) is diagnosed

• Initiate appropriate treatment based on International Renal Interest Society (IRIS) CKD staging

SDMA remains increased but stable

• If SDMA and/or creatinine are increasing, consider ongoing, active kidney injury

• Perform additional diagnostics to determine cause and to guide treatment

SDMA continues to increase

Pyelonephritis successfully treated, but Molly has renal dysplasia so she does have CKD


Staging Molly’s CKD Using the IRIS CKD Staging Guidelines


Treat based on IRIS CKD staging

What are the benefits of diagnosing kidney disease earlier and more reliably?


o Find active and potentially reversible disease.o Treat confounding conditions.o Prevent acute on chronic kidney injuries.o Better detect and co-manage concurrent diseases.o Easier treatment so that pets live longer, happier lives.o Delay progression of CKD and increase survival time by using the

IRIS CKD staging and treatment guidelines.o Monitor closely and intervene earlier with appropriate treatment as

disease progresses.

The benefits of diagnosing kidney disease earlier and more reliably


Find active and potentially treatable diseaseInfectious disease Pyelonephritis

Pelvic dilation

Urinary stone


CKD is irreversible and often progressive

Important to determine if active injury is present that could potentially be treated and reversed!


Reese Ayers visit observations

Presenting reason: Annual check up

History : Doing well

Physical examination: Unremarkable

Wellness diagnostic results• Creatinine 2.1 mg/dL• BUN 39 mg/dL• USG 1.018• Urinalysis: >100 WBC/hpf, marked

bacteria

IDEXX SDMA: 19 µg/dL

16-year-old, spayed female, DSH


Staging Reese’s CKD Using the IRIS CKD Staging Guidelines


Investigate: Urine culture and susceptibility

Reese Ayers: Preventive care visit

Manage: Clavamox® 62.5 mg BID for 1 month

Investigation that should have been considered o Abdominal ultrasoundo Blood pressure measurement


SDMA declined19 15

Monitor: 1 month rechecko Urine culture negativeo SDMA improved

Reese Ayers: Follow-up visit


Staging Reese’s CKD Using the IRIS CKD Staging Guidelines


Reese Ayers: Wellness visitDiagnosiso Suspect pyelonephritis o Active injury superimposed on CKD

(i.e. acute on chronic disease)

Long-term managemento Treat for IRIS stage 2 CKD including feeding a

kidney therapeutic diet.o Recheck urine culture monthly for 3 negative

consecutive months.o Then recheck minimum database and urine

culture every 3 months.

Why does SDMA matter to Reese?o Increased SDMA led to diagnosis and

treatment for suspect pyelonephritis and improvement in kidney function.




disease progresses.



Diagnose and treat confounding conditions

Dehydration Proteinuria Hypertension

Urine protein to creatinine ratio:

> 0.5 dog

> 0.4 cat




disease progresses.



Prevent acute on chronic kidney injuries

Photo courtesy ofTanya Duke-Novakovski BVetMed MSc DVA DACVAA DECVAA

Adjust anesthetic protocols

Use with caution any potentially nephrotoxic drugs and monitor

Correct prerenal and postrenal abnormalities as they arise




disease progresses.



Presenting reason:Biannual wellness visit

Additional history:Possible weight loss but eating well

Physical examination:• Slightly thin with low body condition

score (BCS) 2.5 of 9• Tachycardic; heart rate 240 bpm• Palpable thyroid nodule

Baxter: Wellness visit14-year-old, neutered male domestic shorthair


Clinical impact of increased SDMA:o Increased SDMA led to diagnosis of kidney disease prior

to treatment of hyperthyroidism.o Methimazole dose adjustments made to avoid hypothyroidism. o Baxter’s kidney function was monitored closely during treatment.o Baxter treated appropriately for IRIS CKD stage 3 because of the

disproportionately high SDMA.



o Kidney disease is common in cats with hyperthyroidism.1

o Hyperthyroidism can mask kidney disease.1,2,3

o Creatinine affected by decreased muscle mass and hyperfiltration.1

o SDMA not impacted by muscle mass and is a more sensitive biomarker.4,5

IDEXX SDMA® Test is a more reliable test for detecting kidney disease in hyperthyroid cats

Sources:1. Williams T. Chronic kidney disease in cats with hyperthyroidism. Clin Brief. 2015;Sept:10–12. http://www.cliniciansbrief.com/article/chronic-kidney-disease-cats-hyperthyroidism. Accessed October 9, 2017.2. Mooney CT, Little CJ,.Macrae AW. Effect of illness not associated with the thyroid gland on serum total and free thyroxine concentrations in cats. J Am Vet Med Assoc. 1996;208:2004–2008.3. Peterson ME, Peterson ME. Hyperthyroidism in cats: what’s causing this epidemic of thyroid disease and can we prevent it? J Feline Med Surg. 2012;14:804–818.4. Hall JA, Yerramilli M, Obare E, Yerramilli M, et al. Comparison of serum concentrations of symmetric dimethylarginine and creatinine as kidney function biomarkers in healthy geriatric cats fed reduced protein

foods enriched with fish oil, L-carnitine, and medium-chain triglycerides. Vet J. 2014;202(3):588–596.5. Hall JA, et al. Comparison of serum concentrations of symmetric dimethylarginine and creatinine as kidney function biomarkers in cats with chronic kidney disease. J Vet Intern Med. 2014;28(6):1676–1683.


oKidney disease is common in cats with hyperthyroidism.

• occur in 15%–49% of hyperthyroid cats.2

oHyperthyroidism is common in older cats. • Up to 10% of cats in North America >10 years.1

oHyperthyroidism can mask kidney disease.

Better co-manage concurrent diseasesincluding hyperthyroidism

Sources:1. Peterson ME, Peterson ME. Hyperthyroidism in cats: what’s causing this epidemic of thyroid disease and can we prevent it? J Feline Med Surg 2012; 14: 804–818.2. Williams T. Chronic kidney disease in cats with hyperthyroidism. Clin Brief. 2015;Sept:10-12. http://www.cliniciansbrief.com/article/chronic-kidney-disease-cats-hyperthyroidism.

Accessed: June 30, 2016.


Presenting reason:Overall healthy but a little weight loss

Physical examination:• Slightly thin with body condition

score (BCS) 4 of 9• Rest of physical examination

unremarkable

Jasper: Annual visit9-year-old, neutered male Siamese


Jasper: Annual visit9-year-old, neutered male Siamese

30


Investigation:• Radiographs:

Bilateral nephrolithiasis with left kidney decreased in size

• Ultrasound: No evidence of obstruction

• Urine culture: negativeDiagnosis: Chronic kidney disease with nephrolithiasis

RKDLKD

Spleen

LKD

9-year-old, neutered male SiameseJasper: Annual visit


Jasper: Annual visit

Clinical impact of increased SDMA:

o Increased SDMA led to diagnosing Jasper with nephrolithiasis.

o Owners instructed to monitor for sudden change in appetite, behavior, or urinary habits.

o Management to focus on preventing additional uroliths from forming and preserving right kidney function:

• Renal therapeutic diet.• Water intake encouraged.• Recheck in 3 months and then twice

yearly with blood testing and radiographs.

9-year-old, neutered male Siamese


Max: Preventive care visit

SNAP® 4Dx® Plus Test: Positive for Ehrlichia

6-year-old, neutered male goldendoodle


Dogs exposed to Lyme and Ehrlichia have an increased risk of developing CKD and should be screened at least annually

New research based on 846,626 dogs with a least one IDEXX test result for vector-borne diseases, creatinine, and SDMA confirms the importance of comprehensive annual screening.

Source: Data on file at IDEXX Laboratories, Inc. Westbrook, Maine USA

300%Increased risk CKD

Exposure to Ehrlichia

43%Increased risk CKD

Exposure to Lyme


Max: Preventive care visit6-year-old, neutered male goldendoodle


Max: Preventive care visit

Clinical impact of normal SDMA:o Increased confidence that

kidneys are currently functioning well

o Owners instructed on clinical signs to watch for

o Annual monitoring to allow for early intervention if kidney disease develops

6-year-old, neutered male goldendoodle


Zeke: Wellness visit

Presenting reason: Biannual wellness visit

Additional history: Possible weight loss, eating well, increased vocalization

Wellness diagnostic resultso Creatinine 0.9 mg/dLo BUN 37 mg/dLo T4 9.0 µg/dLo USG 1.016

SDMA: 15 µg/dL

14-year-old, neutered male, domestic shorthair


Staging Zeke’s CKD Using the IRIS CKD Staging Guidelines


Manageo Methimazole 2.5 mg BID

Monitor: 1 month rechecko Renal parameters increasedo Iatrogenic hypothyroidismo Reduce methimazole to 2.5 mg once daily

Zeke: Wellness visit14-year-old, neutered male, domestic shorthair

Reese


Staging Zeke’s CKD Using the IRIS CKD Staging Guidelines


Zeke: Wellness visit

Diagnosiso Hyperthyroidismo Chronic kidney disease

• IRIS CKD stage 2

Long-term managemento Aim to keep euthyroido Concurrent management of CKDo Monitor every 3 months

Why does SDMA matter to Zeke?o Increased SDMA led to close

monitoring of his kidney function during treatment for hyperthyroidism

14-year-old, neutered male, domestic shorthair




disease progresses.



Easier treatment so that pets live longer, happier

VS.




disease progresses.



Study: Earlier diagnosis and treatment may slow rate of progression and increase lifespan

Source: Grauer GF. Early detection of renal damage and disease in dogs and cats. Vet Clin North Am Small Anim Pract. 2005;35:581–596.

100

0

Ren

al fu

nctio

n (%

)

Time

T1Untreated disease

T2Later diagnosis,

treatment

T3Early diagnosis,

treatment

b

a


IRIS stage 2b* 3 4Medial survival (days)

1,151 778 103

Range (days) 2–3,107 22–2,100 1–1,920

Survival time in cats by IRIS stage

n = 211 cats*2b = Creatinine of 2.3–2.8 mg/dL (203–249 µmol/L)

Source: Boyd LM, Langston C, Thompson K, Zivin K, Imanishi M. Survival in cats with naturally occurring chronic kidney disease (2000-2002). J Vet Intern Med. 2008;22:1111–1117.


The only therapy shown to improve survival and quality of life in both cats and dogs with CKD is…

therapeutic renal food.

Delay progression of CKD and increase survival time by using the IRIS CKD staging and treatment guidelines


Renal therapeutic diets are more than just controlled protein

ProteinPhosphorus

N-3 FA

Acid - Base

Potassium

Tastier options now available!




disease progresses.



Monitor closely and intervene earlier with appropriate treatment as disease progresses


o IDEXX SDMA Test is a more reliable:• Increases earlier than creatinine.• Not impacted by lean muscle mass.

oClinical presentation should be considered.o Investigate to determine if AKI or CKD.oThere are benefits to diagnosing kidney disease early.oEarlier treatment is easier and outcomes are better.

Key takeaways


Thank you!


Information in these materials is subject to change without notice. Companies, names, and data used in examples are fictitious unless otherwise noted. No part of this document may be reproduced or transmitted in any form or by any means, electronic, mechanical, or otherwise, for any purpose, without the express written permission of IDEXX Laboratories, Inc. IDEXX Laboratories, Inc. may have patents or pending patent applications, trademark, copyrights, or other intellectual or industrial property rights covering this document or subject matter in this document. The furnishing of these materials does not give a license to these property rights except as expressly provided in any written license agreement from IDEXX Laboratories, Inc.

Any recommendations contained in these materials are intended to provide general guidance only. As with any diagnosis or treatment, you should use clinical discretion with each patient based on a complete evaluation of the patient, including physical presentation and complete laboratory data. With respect to any drug therapy or monitoring program, you should refer to product inserts for a complete description of dosages, indication, interactions, and cautions. For more specific information on IDEXX products and services, please refer to the appropriate operator guides, terms of sale, product inserts, and other materials.

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kidney disease in dogs and cats - illinois state veterinary medical … · 2019. 12. 11. ·...

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