kidney disease in dogs and cats - illinois state veterinary medical … · 2019. 12. 11. ·...
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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.
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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)
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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
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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.
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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?
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How do I know it is accurate?
Over 40 peer-reviewed
publicationsEndorsement by
IRISHuman field takes interest in SDMA
“Creatinine is so 1950s.”
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…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?
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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!
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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
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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
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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
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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
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SDMA reference interval in puppies is higher than in adults
SDMA units = µg/dLPuppyhood depends on breed and size.
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What should be done now?
Delay spay and follow the IDEXX SDMA Test diagnostic algorithm
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www.idexx.com/sdma
IDEXX SDMA® Test diagnostic algorithm
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IDEXX SDMA® Test diagnostic algorithm
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Kidney disease probable: Follow IMM protocol
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What if Molly’s SDMA result had been 18 µg/dL?
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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)
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Kidney disease probable: Follow IMM protocol
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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
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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:
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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
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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
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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
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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
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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
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Molly: Monitor
Left kidney Right kidney
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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
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Staging Molly’s CKD Using the IRIS CKD Staging Guidelines
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Treat based on IRIS CKD staging
What are the benefits of diagnosing kidney disease earlier and more reliably?
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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
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Find active and potentially treatable diseaseInfectious disease Pyelonephritis
Pelvic dilation
Urinary stone
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CKD is irreversible and often progressive
Important to determine if active injury is present that could potentially be treated and reversed!
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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
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Staging Reese’s CKD Using the IRIS CKD Staging Guidelines
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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
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SDMA declined19 15
Monitor: 1 month rechecko Urine culture negativeo SDMA improved
Reese Ayers: Follow-up visit
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Staging Reese’s CKD Using the IRIS CKD Staging Guidelines
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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.
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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
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Diagnose and treat confounding conditions
Dehydration Proteinuria Hypertension
Urine protein to creatinine ratio:
> 0.5 dog
> 0.4 cat
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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
52 © 2017 IDEXX Laboratories, Inc. All rights reserved.
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
53 © 2017 IDEXX Laboratories, Inc. All rights reserved.
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
54 © 2017 IDEXX Laboratories, Inc. All rights reserved.
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
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Baxter: Wellness visit14-year-old, neutered male domestic shorthair
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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.
Baxter: Wellness visit14-year-old, neutered male domestic shorthair
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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.
58 © 2017 IDEXX Laboratories, Inc. All rights reserved.
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.
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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
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Jasper: Annual visit9-year-old, neutered male Siamese
30
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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
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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
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Max: Preventive care visit
SNAP® 4Dx® Plus Test: Positive for Ehrlichia
6-year-old, neutered male goldendoodle
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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
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Max: Preventive care visit6-year-old, neutered male goldendoodle
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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
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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
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Staging Zeke’s CKD Using the IRIS CKD Staging Guidelines
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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
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Staging Zeke’s CKD Using the IRIS CKD Staging Guidelines
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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
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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
73 © 2017 IDEXX Laboratories, Inc. All rights reserved.
Easier treatment so that pets live longer, happier
VS.
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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
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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
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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.
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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
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Renal therapeutic diets are more than just controlled protein
ProteinPhosphorus
N-3 FA
Acid - Base
Potassium
Tastier options now available!
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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
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Monitor closely and intervene earlier with appropriate treatment as disease progresses
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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
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Thank you!
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