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My Dog's Kidneys Are Failing
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By Francesca Perondi 1 , Ilaria Lippi 1, * , Veronica Marchetti 1 , Barbara Bruno 2 , Antonio Borrelli 2 and Simonetta Citti 1
Received: September 4, 2020 / Revised: September 25, 2020 / Approved: September 29, 2020 / Published: October 1, 2020
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In patients with chronic kidney disease (CKD), certain ultrasound (US) abnormalities have been shown to correlate better than others with disease progression. The aim of the study was to evaluate the prevalence of the most common renal US abnormalities in dogs at different stages of CKD and to investigate their association with the CKD International Renal Interest Society (IRIS) stages. Clinical records and ultrasound reports of 855 dogs were retrospectively included. The most common renal ultrasound abnormalities are: increased cortical echogenicity, abnormal cortico-medullary junction (C/M) ratio, and pyelectasis. A statistically significant difference was found in the incidence of irregular margin, abnormal cortico-medullary junction, abnormal C/M, increased cortical echogenicity and pyelectasis for dogs at different IRIS stages. The number of dogs with more than one US abnormality increased significantly with progression of IRIS stage. In summary, increased cortical echogenicity, abnormal C/M transition, and pyelectasis were the most common US abnormalities in our CKD population. Although none of the US abnormalities were significantly more prevalent, the number of dogs exhibiting 3 US abnormalities increased significantly from IRIS 2 to IRIS 4. Renal US is an excellent diagnostic adjunctive test that should be used in conjunction with renal function parameters. Monitor the development of CKD.
Chronic kidney disease (CKD) is the most commonly recognized kidney disease in dogs and is defined as a structural and/or functional abnormality of one or both kidneys that persists for at least three months [ 1 , 2 ]. The International Renal Interest Society (IRIS) stages of CKD are based on the assessment of serum creatinine, balanced dimethylarginine (SDMA), proteinuria and blood pressure, facilitating diagnosis, prognostic assessment and treatment of the disease [1, 3]. Abdominal ultrasound (US) is routinely performed and recommended in animals with renal disease or when serum creatinine levels are elevated [4, 5, 6]. Ultrasound was the first imaging test to be used in human and veterinary patients with chronic renal failure [ 4 , 7 ]. Ultrasound characterization of chronic nephropathy is based on subjective criteria such as cortical echogenicity, kidney shape, kidney size, and internal architecture [ 4 ]. Increased cortical echogenicity and decreased corticomedullary differentiation have been reported as the most common symptoms of CKD in veterinary medicine [4, 6]. These changes indicate chronic and irreversible lesions of the kidney; However, both dogs and cats can have CKD without showing renal changes on ultrasound [6, 8]. In human medicine, simultaneous assessment of cortical echogenicity, renal volume and serum creatinine level have been evaluated to determine the chronicity of the disease . In human CKD patients, renal echogenicity correlates better with serum creatinine than other ultrasound parameters (length volume, parenchymal thickness, and cortical thickness) and appears to be a good parameter to assess renal function .
The aim of this study was to evaluate the prevalence of the most common renal US abnormalities in dogs at different stages of CKD and to investigate their association with CKD IRIS stages.
Between January 2013 and December 2019, the medical records of all dogs diagnosed with CKD at the Veterinary Teaching Hospital “Mario Modenato” of the University of Pisa were retrospectively evaluated. Inclusion criteria included documented history of CKD, laboratory findings consistent with CKD, and ultrasound examination. Diagnosis of CKD is based on a long history (more than 3-4 months) of azotemia, polyuria-polydipsia and inappropriate urine specific gravity. Registered dogs may or may not suffer from proteinuria and/or systemic hypertension. Exclusion criteria included history, laboratory, and/or ultrasound findings consistent with acute kidney injury (AKI). For each dog included in the study, data regarding history, physical examination, biochemical profile (serum urea, creatinine, total calcium, phosphate, calcium phosphate product) and US report were collected from the medical record. Dogs were classified according to the IRIS guidelines for CKD based on serum creatinine concentration as follows: stage 2, 1.4 to 2.0 mg/dL; step 3, 2.0 to 5.0 mg/dL; and stage 4, >5.0 mg/dL .
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An ultrasound system (Toshiba, Italy) with a microconvex (5–7.5 MHz) and linear (7–12 MHz) transducer (6–8 MHz) was used by two radiologists with 20 years of experience in renal ultrasound.
For each dog in the study, US reports and recorded images were reviewed for the following US findings [6, 8, 10].
Statistical analysis was performed using commercial statistical software (GraphPad Prism, 6 for Mac). Continuous variables were tested for normality with the Kolmogorov-Smirnov test. Descriptive statistics included means and standard deviations for normally distributed variables such as creatinine, urea, calcium, phosphate, and serum calcium-phosphorus concentration product (sCaPP) and means with minimum and maximum limits for non-normally distributed variables (age).
Chi-square test was used to compare the prevalence of one, two to three or more than three US abnormalities in different CKD IRIS stages.
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) showed renal mineralization of serum calcium phosphate product (sCaPP) in dogs, at different CKD IRIS stages. All data were considered statistically significant for a p-value <0.05.
A retrospective record review of our electronic medical database identified 865 dogs with CKD. Ten dogs with clinical, ultrasound, and laboratory signs of CKD IRIS stage 1 were excluded from statistical analysis due to small numbers (n = 10). A total of 855 dogs were included in this study. Of the 855 dogs enrolled, 337 dogs (39.40%) were in CKD IRIS stage 2, 295 dogs (34.50%) were in IRIS stage 3, and 223 dogs (26%) were in IRIS stage 4. By sex, 430 dogs (50.30%) were intact males, 35 dogs (4%) were castrated males, 240 dogs (28.20%) were intact females, and 150 dogs (17.50%) were females. Median age was 9 years (range 0.40–17 years). Mixed breeds (n = 258; 30%), Labradors (n = 70; 8%), German Shepherds (n = 46; 5.30%), Boxers (n = 34; 3.90%) and Golden Retrievers (n = 31; 3.50%). The mean values of serum creatinine, urea, calcium, phosphorus and sCaPP for each IRIS group are reported in Table 1.
The chi-square test showed a significantly different distribution of US findings of irregular margin, abnormal C/M shift, abnormal C/M ratio, increased cortical echogenicity and pyelectasis for dogs in different CKD IRIS stages. No statistically significant difference was observed in the prevalence of cysts, mineralization, infarct and perirenal effusion (Table 2).
For 6/10 ultrasound abnormalities (irregular margin, abnormal C/M shift, abnormal C/M ratio, increased cortical echogenicity, abnormal medullary echogenicity, and pylectasis) a significant increase in their prevalence was detected with progression of CKD stage. 2 ). Among the different CKD IRIS stages, the most common US abnormalities were increased cortical echogenicity, abnormal C/M transition, and pyelectasis (Figure 2).
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Chi square test showed a statistically significant difference in the prevalence of dogs with one, two to three or more three US abnormalities in different CKD IRIS stages (p = 0.0001). The number of dogs with more than one US abnormality increased significantly with progression of CKD IRIS stage (Table 3).
IRIS increased with progression of stage (p = 0.0001). Number of dogs showing renal mineralization in dogs with sCaPP > 70 mg
In our study, the number of US abnormalities increased significantly with the progression of IRIS stages; In IRIS stage 4, 60.5% of dogs showed more than three renal abnormalities, while 39.5% of dogs showed two or three abnormalities. The main US abnormalities in dogs and cats with chronic Nike disease are increased echogenicity, irregular rim, decreased or absent cortico-medullary differentiation, and decreased kidney size. These findings were overwhelming
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