EARLY DIAGNOSTIC AND PROGNOSTIC MARKERS OF CHRONIC KIDNEY DISEASE (CKD) IN CANINE AND FELINE PATIENTS

SUMMARY Chronic kidney disease (CKD) is a clinical syndrome with a high prevalence both in human and veterinary medicine. Being able to formulate an early diagnosis of CKD can allow veterinarians to introduce a dietary and medical therapy, which can dramatically reduce progression towards end stage renal disease (ESRD)1. At the same time, strong evidences of a deep relationship between heart and kidney in the progression of CKD in humans, have led to a greater attention towards potential markers of prognosis and negative outcome of the disease, even in small animal population. The present research project has been organized in two sections2,3. FIRST SECTION The aim of the first part of the study has been to validate a glomerular filtration rate (GFR) method, at a low number of plasma samples, through the plasma clearance of iohexol in both CKD and clinically healthy cats. MATERIALS AND METHODS - After the owners’ informed consent, 53 clinically healthy and 14 CKD cats have been submitted to a first blood sample (0) and to an eight-hour clearance study. Iohexol (Omipaque® 300 mgI/ml) has been intravenous injected at the dose of 64.7 mg/kg body weight. Heparinised blood samples have been taken at 5 and 30 minutes and 1, 2, 4, 6 and 8 hours from the completion of iohexol injection. Plasma has been obtained and each sample has been stored at -20 C° till extraction process and HPLC analysis. Pharmacokinetic analysis has been performed through the software Easy Fit® for Macintosh (Istituto Mario Negri, Milano, Italia) and, for each subject of HC and CKD group, plasma concentration of iohexol/time curves have been analyzed through a non-compartimental kinetic model. Then, a pharmacokinetic analysis has been carried on after the application of simplified models (Model A, Model B, Model C and Model D) with a lower number of blood samples. Statistical analysis has been performed by using the software GraphPad Prism 4 for Macintosh, USA. RESULTS – t-test analysis (p<0.05) between GFR of CH and CKD patients has shown a significant difference between the two groups of subjects, not only for reference method (p=0.003), but also for Model A (p=0.0005), Model B (p=0.01), Model C (p=0.001) and Model D (p=0.004). Pearson correlation analysis (p<0.05) between each simplified model and reference method has shown a positive linear correlation with vey high values of Pearson r and R2. CONCLUSIONS - The present study has validated a safe, simple and accurate three-sample HPLC method (5’ – 30’ – 1 hour) for the determination of GFR through the plasma clearance of iohexol in feline patients. This model represents an attractive and cheap alternative to cumbersome plasma clearance methods, with a dramatic applicatory potential in different clinical settings. SECOND SECTION The aim of the second part of the study has been to assess serum ionized calcium, total calcium, calcium corrected for albumin (cCaAlb), calcium corrected for total proteins (cCaPt), Ca x P product (Ca x P), cardiac troponin I (cTnI), C-reactive proteine (CRP) and α-tochopherol in CH and CKD canine patients at different stages of the disease. MATERIALS AND METHODS – serum ionized calcium, total calcium, cCaAlb and cCaPt have been determined in 301 CKD and 125 CH patients, while Ca x P, cTnI, CRP and α-tochopherol have been assessed in 13 IRIS 1, 7 IRIS 2, 13 IRIS 3 and 11 IRIS 4 subjects. Ionized calcium has been determined through a selective ion method (STAT PROFILE® pHOx Plus, GEPA, Milano, Italy), cTnI through an immunometric method (IMMUNOLITE 2000® Immunoassay System), CRP through an immunometric method (RANDOX immunoturbidimetric kit for CRP, Vet Med Lab, IDEXX, Germany) and α-tochopherol through HPLC (Chromosystems-Diagnostic Kit HPLC & LC/MS, Munchen, Germany). Statistical analysis has been performed by using the software GraphPad Prism 4 for Macintosh, USA. RESULTS – One-way ANOVA has reported a significant difference (p<0.0001) in ionized calcium concentration among CH, IRIS 1, IRIS 2, IRIS 3 and IRIS 4 and χ2 analysis has shown a significant difference (p<0.0001) in the number of patients with hyper, hypo and normocalcemia according to the progression of the disease. One-way ANOVA among CH subjects and IRIS 1, IRIS 2, IRIS 3 and IRIS 4 patients has reported a significant difference in the mean value of Ca x P (p<0.0001). No significant correlation has been found between Ca x P and plasma creatinine in any of IRIS classes. The number of patients with Ca x P above 70 mg/dl has been reported to increase significantly (p<0.0001) with the severity of CKD, as well as the number of dead patients (p<0.0008). Finally, Kaplan-Meier survival curve has shown a significantly higher percentage of survival (p<0.0002) of CKD patients with Ca x P below 70, compared to patients with Ca x P above 70. One-way ANOVA among CH subjects and IRIS 1, IRIS 2, IRIS 3 and IRIS 4 patients has reported a significant difference in the mean value of cTnI (p<0.02). No significant correlation has been found between cTnI and plasma creatinine in any of IRIS classes. The number of patients with cTnI above 0.20 ng/ml has been reported to increase significantly (p<0.0001) with the severity of CKD, as well as the number of dead patients (p<0.02). Finally, Kaplan-Meier survival curve has shown a significantly higher percentage of survival (p<0.0002) of CKD patients with cTnI below 0.20 ng/ml, compared to patients with cTnI above 0.20 ng/ml. One-way ANOVA among CH subjects and IRIS 1, IRIS 2, IRIS 3 and IRIS 4 patients has reported a significant difference in the mean value of CRP (p<0.0001). No significant correlation has been found between CRP and plasma creatinine in any of IRIS classes. The number of patients with CRP above 9.7 mg/l has been reported to increase significantly (p<0.0001) with the severity of CKD, as well as the number of dead patients (p<0.0009). Finally, Kaplan-Meier survival curve has shown a significantly higher percentage of survival (p<0.001) of CKD patients with CRP below 9.7 mg/l, compared to patients with CRP above 9.7 mg/l. One-way ANOVA among CH subjects and IRIS 1, IRIS 2, IRIS 3 and IRIS 4 patients has reported a significant difference in the mean value of α-tochopherol (p<0.0002). A significant correlation (p=0.00) has been found between α-tochopherol and plasma creatinine in IRIS 2. The number of patients with α-tochopherol below 21.6 ppm has been reported to increase significantly (p<0.0001) with the severity of CKD. No significant difference in the number of survived and dead patients has been found between subjects with α-tochopherol below and above 21.6 ppm. Finally, Kaplan-Meier survival curve has shown no significant difference. CONCLUSIONS – The present study has demonstrated a significant increase in Ca x P, cTnI and CRP serum concentration according to the progression of CKD. Ca x P, cTnI and CRP have shown a prognostic, not IRIS stage-dependent, value and a significant correlation towards mortality. In CKD dogs, as well as in humans, alterations of calcium-phosphate metabolism, cardiovascular injury and inflammation seemed to play a significant role in the progression and negative outcome of CKD. No correlation has been reported between mortality and α-tochopherol, although a significant serum reduction with the progression of CKD has been shown

La Fortezza Nuova di Livorno: recupero funzionale del "parco urbano" e degli "spazi interi" restituiti alla Citta.

L'obiettivo della tesi di laurea è quello di restituire alla città di Livorno il suo monumento storico di maggior pregio, la Fortezza Nuova, oggi solo parzialmente fruibile dopo molti anni di chiusura al pubblico

Metodo semplificato per la valutazione della velocità di filtrazione glomerulare (GFR) tramite clearance plasmatica dello ioexolo

Riassunto La velocità di filtrazione glomerulare (GFR) indica la velocità con cui si forma il filtrato glomerulare per passaggio dal plasma attraverso i glomeruli renali e permette una valutazione quantitativa della funzionalità renale sia nell’animale sano che nel malato. Essere in grado di stabilire una diagnosi precoce di disfunzione renale è importante sia per il paziente che per il proprietario, in quanto può aiutare a formulare una prognosi a lunga scadenza e a fornire tempestivamente una terapia medica di sostegno per la funzionalità renale. È, infatti, la diagnosi precoce degli stadi subclinici o borderline di insufficienza renale a costituire la sfida maggiore nella pratica veterinaria delle patologie renali. I parametri che vengono comunemente analizzati (creatinina e urea plasmatica, peso specifico urinario) non appaiono alterati finché una buona parte della funzionalità renale non è ormai perduta (circa il 67%). Lo ioexolo è un mezzo di contrasto non ionico a bassa osmolarità che può essere utilizzato per determinare il GFR sia nell’uomo che negli animali. Lo ioexolo può essere utilizzato come marker per la determinazione del GFR in quanto presenta un’eliminazione esclusivamente renale. Scopo di questo studio è stato di valutare metodi semplificati per la determinazione dell clearance plasmatica dello ioexolo nel cane. Sono stati effettuati prelievi di sangue in 35 cani prima dell’inoculazione dello ioexolo e 5, 15, 30, 45, 60, 90, 180, 240, 300, 420 minuti e 24 ore dopo tale iniezione. La concentrazione plasmatica dello ioexolo è stata determinata usando un metodo HPLC. La clearance è stata calcolata dividendo la dose inoculata per l’area sottostante la curva di eliminazione plasmatica, stabilita tramite un modello bicompartimentale. La clearance è stata normalizzata per la superficie corporea. Il valore di clearance ottenuto mediante undici prelievi è stato utilizzato come riferimento per la valutazione di metodi semplificati. Sono stati sperimentati quattro modelli a cinque prelievi, basati su un modello bicompartimentale. È stata effetuata un’analisi di regressione lineare tra il metodo di riferimento e i metodi semplificati. Tutte le combinazioni hanno rivelato una buona correlazione con il metodo di riferimento. Il metodo migliore tra le metodiche a cinque prelievi è stato il modello basato su prelievi a 5, 15, 60, 90 e 180 minuti. Si può concludere che la clearance plasmatica dello ioexolo può essere ottenuta mediante cinque prelievi con un accettabile margine di errore

Assisted feeding through an oesophagostomy tube in patients with chronic kidney disease and uraemic syndrome: impact on body condition score, renal function and survival

La dietoterapia rappresenta il primo strumento terapeutico nel paziente in presenza di danno renale acuto e malattia renale cronica. Tuttavia la maggior parte di tali pazienti non è in grado di alimentarsi volontariamente e nel quantitativo adeguato ai propri fabbisogni. Obiettivo del presente studio è di valutare BCS, parametri di funzionalità renale e sopravvivenza in pazienti in crisi uremica sottoposti o meno ad alimentazione assistita. Lo studio è stato condotto su quattordici cani con pregressa CKD e in fase di riacutizzazione o scompenso. Sette pazienti sono stati gestiti mediante impiego di feeding tube (FT), 7 mediante terapia medica tradizionale (GC). Per ciascuno dei due gruppi, BCS, creatinina, urea, e fosforo sierici e sopravvivenza, sono stati valutati a T0 e ad uno (T1) e due mesi (T2). I dati sono stati elaborati statisticamente. Il GC presentava una differenza significativa di BCS (p=0,04), creatinina (p=0,001), urea (p=0,005) e fosforo (p=0,04) a diversi controlli. Il FT presentava una differenza significativa di BCS (p=0,03), valori sierici di creatinina (p=0,006), urea (p=0,0001) e fosforo (p=0,02) ai diversi controlli. Il FT mostrava una sopravvivenza alla crisi uremica maggiore (p=0,01) del GC. Le evidenze del presente studio riportano un significativo miglioramento di BCS, parametri di funzionalità renale e sopravvivenza nei pazienti gestiti con feeding rispetto agli altri. Il feeding tube sembra rappresentare un ausilio terapeutico estremamente utile nella gestione medica del paziente in crisi uremica.Introduction – A renal diet is a fundamental part of the medical management of patients with acute and chronic kidney disease. Unfortunately, most patients are not able to eat a sufficient amount of a renal diet to achieve an adequate calorie intake. The aim of this study was to evaluate the Body Condition Score (BCS), renal function and survival rate in a group of uraemic patients managed with a feeding tube and compare the findings with those in a comparable group managed without a feeding tube. Materials and Methods – Fourteen dogs with acute-on-chronic kidney disease formed the study population. Seven dogs were managed with the use of a feeding tube (FT group) and seven were managed without a feeding tube (control group). BCS, serum creatinine, urea and phosphate concentrations and survival rate were evaluated in both groups at time 0 (T0), after 1 month (T1) and after 2 months (T2). Data were analysed statistically. Results – There were significant differences in BCS (p=0.04), creatinine (p=0.001), urea (p=0,005) phosphate (p=0.04) at the different time points in the control group. The FT group also had significant difference in BCS (p=0.03), creatinine (p=0.006), urea (p=0.0001) and phosphate (p=0.02) at the different time points. The survival rate was higher in the FT group than in the control group (p=0.01). Discussion – The results of the present study show significant improvements in BCS, renal function and survival in patients managed with a feeding tube, compared to those in which a feeding tube was not used. A feeding tube seems to be a very useful therapeutic instrument for the management of patients with uraemic syndrome

Evaluation of urinary γ-glutamyl transferase and serum creatinine in non-azotaemic hospitalised dogs

Urinary and blood biomarkers for diagnosis of acute kidney injury (AKI) in hospitalised dogs were evalueted. This prospective study included 97 dogs, classified according to the International Renal Interest Society classification into no AKI and AKI grade 1 (48-hour increase in serum creatinine≥0.3 mg/dl and/or urinary production &lt;1 ml/kg/hour for at least six hours). A total of 62 of 97 dogs (64 per cent) were classified as AKI 1. A statistically significant difference was found between no AKI and AKI 1 in urine protein to creatinine ratio, urinary γ-glutamyl transferase (uGGT) and uGGT/cu (P&lt;0.0001). Thirteen of 97 dogs (13.4 per cent) that developed increased creatinine and change in AKI grade showed high mortality (n=9/13; 69.2 per cent). The receiver operating characteristic (ROC) curve analysis of uGGT/cu index as a marker for AKI grade 1 had an area under the ROC curve of 0.78; optimal cut-off point was 57.50 u/g, with sensitivity and specificity of 75.4 per cent and 75.6 per cent, respectively. Overall intensive care unit mortality was 23.7 per cent (23/97), 13.4 per cent (13/97) of which died during hospitalisation and 10.3 per cent (10/97) within 28 days after discharge. uGGT is an acceptable marker for distinguishing between AKI 1 and no AKI

Clinical utility of urine kidney injury molecule-1 (KIM-1) and gamma-glutamyl transferase (GGT) in the diagnosis of canine acute kidney injury

The aim of the present study was to evaluate the sensitivity and specificity of urine KIM-1 and urine GGT for the detection of naturally-occurring AKI, compared to healthy control dogs, dogs with stable chronic kidney disease (CKD), and dogs with lower urinary tract disorders (LUTD). The study included AKI grade 1 (n = 21), AKI grade 2 to 5 (n = 11), stable CKD (n = 11), LUTD (n = 15), and healthy dogs (n = 37). Urine KIM-1 (ng/mg) and GGT (U/l) were normalized to urine creatinine (uCr). Statistically significant difference in KIM/uCr (p = 0.0007) and GGT/uCr (p &lt; 0.0001) was found among the study groups. Area under the curve (AUC) for KIM-1/uCr and GGT/uCr as predictors of AKI was 0.81 and 0.91 respectively. Values of KIM-1/uCr of 0.73 ng/mg and of GGT/uCr of 54.33 showed the best combination of sensitivity and specificity (75% and 75.6%; 85.7% and 89.1% respectively). A significant positive correlation (p &lt; 0.0001) between KIM-1/uCr and GGT/uCr was found. Both urine KIM-1/uCr and GGT/uCr seemed to be potentially good markers for the diagnosis of AKI. Dogs with AKI showed significantly higher levels of urine KIM-1/uCr and urine GGT/uCr, compared with healthy dogs. Caution should be used in the evaluation of elevated urine KIM-1/uCr and GGT/uCr in dogs with pre-existing CKD and/or LUTD. Urine KIM-1/uCr and GGT/uCr might have a significant clinical utility, as complementary test, particularly in diagnosis early, non-azotemic stages of AKI

Evaluation of a prognostic scoring system for dogs managed with hemodialysis

Objective: To investigate prognostic models in a cohort of dogs with acute kidney injury (AKI) and acute on chronic kidney disease (AKI/CKD) managed by hemodialysis. Design: Retrospective study from July 2011 to November 2014. Setting: University Veterinary Teaching Hospital. Animals: Forty dogs with historical, clinical, imaging, and laboratory findings consistent with AKI or AKI/CKD managed with intermittent hemodialysis were included. Interventions: Scoring system models previously established by Segev et&nbsp;al for outcome prediction in dogs with AKI were applied to all dogs. Results: Models A, B, and C correctly classified outcomes in 68%, 83%, and 85% of cases, respectively. In our cohort Model A showed sensitivity of 58% and specificity of 86%, Model B showed sensitivity of 79% and specificity of 87%, Model C showed sensitivity of 86% and specificity of 84%. The presence of anuria (P &lt; 0.0002), respiratory complications (P &lt; 0.0001), disseminated intravascular coagulation (DIC) (P = 0.0004), grade of AKI (P = 0.0023), pancreatitis (P = 0.0001), and systemic inflammatory response syndrome (SIRS) (P = 0.0001) was significantly higher in nonsurvivors compared with survivors. Conclusions: In our cohort of patients, Segev's model C showed the best sensitivity and specificity for predicting prognosis, while model A had lower sensitivity. In our cohort of dialysis patients, the presence of respiratory complications, DIC, SIRS, and pancreatitis at hospitalization, were correlated with a poor prognosis

Urinary Cytology: Potential Role in Canine Urinary Tract Infections

The diagnosis of urinary tract infections (UTIs) requires a concomitant evaluation of clinical signs and urine culture, which is of fundamental to start an appropriate antibiotic treatment. Several factors, such as subclinical bacteriuria or pre-analytical errors, may make the interpretation of urine culture difficult. The aim of the study was to evaluate the association between the finding of neutrophils and bacteria in unstained and stained canine urine sediment and the presence of clinical signs and positive urine culture. Urine samples from 35 dogs with clinical signs of UTI and 55 asymptomatic dogs with risk factors for UTI were prospectively collected by cystocentesis, divided into three aliquots, and submitted for: (1) physical and chemical Dipstick analysis and unstained urinary sediment (casts, crystals, bacteria, leucocytes, cells, parasites); (2) stained urinary sediment (extra/intracellular bacteria, degenerated and non-degenerated neutrophils); (3) qualitative and quantitative urine culture and antimicrobial sensitivity-test. The association between unstained and stained findings of urinary sediment and urine culture was tested. Sensibility, specificity, and positive/negative predictive values in diagnosing positive urine cultures of bacteria at unstained and stained evaluation were compared. Both wet-mount bacteriuria and the cytological presence of intracellular and extracellular bacteria, neutrophils, and degenerated neutrophils were successively associated with positive urine culture (p &lt; 0.001). The presence of intracellular bacteria was the only independent predictor of positive urine culture. Total bacterial count did not differ significantly between symptomatic and asymptomatic dogs. Detection of extracellular and intracellular bacteriuria at stained urinary sediment significantly improved the sensibility of predicting positive urine culture. Cytologic evaluation of urinary sediment may be helpful in detecting signs of active inflammation, thus enhancing the clinical relevance of a positive urine culture

Alterations of selected serum biochemical and urinary parameters in dogs with chronic enteropathy

Background: No specific study on concurrent nephropathy has been conducted in dogs with chronic enteropathy (CE), except for soft-coated Wheaten Terriers. Moreover, limited information exists regarding the urinary profile in dogs with CE.Aim: To describe, compare, and discuss the alterations in selected serum biochemical and urinary parameters in dogs with CE.Methods: Multicentric retrospective study on dogs with CE diagnosed after exclusion of extra-gastrointestinal diseases. In addition, dogs with azotemia and lower urinary tract diseases were excluded. Information on canine chronic enteropathy clinical activity index (CCECAI) score, muscular condition score (MCS), presence of glycosuria, proteinuria [urine protein-to-creatinine (UPC) ratio &gt; 0.5], and/or cylindruria (&gt;1–2 casts/hpf) at diagnosis were gleaned from the medical records. Dogs were retrospectively classified as food-responsive enteropathy, immunosuppressant-responsive enteropathy, or nonresponsive enteropathy based on the presence of gastrointestinal histological inflammation and the treatment response. In addition, based on the serum albumin concentration (ALB), dogs were classified as having protein-losing enteropathy (PLE).Results: Ninety CE dogs were included. Fifty-two dogs had mild-to-severely decreased MCS and 38 dogs showed altered urinary parameters. No significant associations were found between CCECAI and altered urinary parameters. No significant association was found between PLE dogs and altered urinary parameters. PLE dogs showed higher prevalence of proteinuria than non-PLE dogs (p = 0.03; OR = 2.8; 95% CI = 1–6.8).Conclusion: Despite the presence of altered urinary profile in dogs with CE, further studies are needed to explore a possible link between gastrointestinal and renal inflammation