Transcript Physiology - Woodley Equ

Woodley Equipment Company Ltd.
E.R.D.-HealthScreen® Urine Tests
Paul Lymer, B.Sc.
European Sales Manager
Woodley Equipment Company Ltd.
E.R.D.-HealthScreen® Urine Tests
What do you know about kidneys?
®
E.R.D.-HealthScreen
Test
What is its purpose?
Used to detect albumin in the urine
Urinary System
Kidney
What are the functions of the kidneys?
Regulate water and
soluble substances by:
• Filtering the blood
• Removing excess water and
waste from the blood (urine)
• Sending urine to the bladder
• Releasing hormones into the
blood
How does a normal kidney
handle albumin?
4 mg/dL albumin
goes in
2-3 mg/dL albumin
normally leaks
through
glomerulus and is
reabsorbed by the
proximal tubule
Russo et al 2002 AJKD 39:899
D’Amico and Bazzi 2003 Kidn Internt’l 63:809
<<1 mg/dL
albumin
comes out
The Glomerulus at work
The kidneys filter a dog’s or cat’s entire blood volume every 30 minutes.
Systemic Disease & Albuminuria
• Antigen-Antibody Complexes
• Vasculitis
• Hypertension
The most common protein associated with kidney damage is albumin.
1º Causes of 2º renal damage
• Inflammatory diseases
• Infectious diseases
• Metabolic diseases
• Neoplasia
• Hypertension
• Drugs
1º Causes of 2º renal damage
• Inflammatory diseases
• Metabolic diseases
• Infectious diseases
• Hypertension
• Neoplasia
• Drugs
– Dental disease
– Pyoderma
– IBD
– Immune mediated diseases
– Heartworm disease
– Tick-borne diseases
– Viral diseases
– Diabetes mellitus
– Hyperadrenocorticism
– Hyperthyroidism
Introduction to
E.R.D.-HealthScreen Urine
Test Technology
Microalbuminuria testing in Dogs and Cats
• Semiquantitative in-clinic test
(E.R.D.-HealthScreenTM Urine Tests)
• Species-specific monoclonal antibodies to albumin
• Detects as little as 1 mg/dl of albumin in the urine
• No maximum limit of detection
• Microalbuminuria: 1-30 mg/dl
3 Easy Steps
Dilute Sample
1.070
1.060
1.050
1.040
1.030
1.020
Sample
(1 mL)
Insert Device,
Wait 3 minutes
Read Results
Interpretation of Results
What Do You See?
Results
Bottom Band
Darker
Negative
Bands Equal
Low Positive
(~ 1 mg/dL)
Top band
Slightly Darker
Medium Positive
Top band
Much Darker
High Positive
Top Band Very
Dark, Bottom
Band Absent
Very High
Positive
Clinical Signs
Subclinical Disease
“Veterinarians should give more attention to the
detection, evaluation, monitoring, and treatment of
dogs and cats with proteinuria.”
Dr. George Lees in his introduction to
Small Animal Consensus Statement Draft on “Assessment
and Management of Proteinuria in Dogs and Cats”
ACVIM 2004
The Kidney as a “Sentinel”
Proteinuria/Albuminuria Detection
• Marker of systemic disease
– Inflammatory/Infectious
– Metabolic
– Neoplasia
Canine
Microalbuminuria
Prevalence Study
Prevalence of Microalbuminuria in Dogs
Owned by Veterinary Staff (n = 3041)
Relationship between age and percentage of dogs testing positive
on the E.R.D.-HealthScreen Urine Test, n = 3041.
Prevalence of Microalbuminuria in
Selected Age Groups of Dogs Owned
by Veterinary Staff (n = 3041)
Feline Microalbuminuria
Prevalence Study
• No appropriate cat models of renal disease
• Feline MA Study modeled after Canine Staff Testing Study
• Any cat, any age, any collection method, any health status
Cat’s Name
Age
Collection Method (circle one)
Presentation (circle one)
Medical History/Medications
Sex (circle one) M CM F SF
Expression
Well-pet exam
Cystocentesis
Neuter Dental
Breed
Litter Box
Medical Visit
Prevalence of Microalbuminuria in
Cats (n = 1243)
100
Percent Positive
90
80
Relationship between age and percentage of cats testing
positive on the E.R.D.-HealthScreen Urine Test, n = 1243
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 >19
Age, Years
Prevalence of Microalbuminuria in
Selected Age Groups of Cats (n =
1243)
Age Group
<3
3-5
6-8
9 - 11
12 - 15
> 16
# of Positives
40
46
41
45
83
50
Total # of Cats
361
228
184
180
213
77
Percent Positive
11.1%
20.2%
22.3%
25.0%
39.0%
64.9%
Increase in Prevalence
--
9.1%
2.1%
2.7%
14.0%
25.9%
Prevalence of Microalbuminuria in
Selected Age Groups of Cats
Proteinuria/Albuminuria Detection
• Marker of renal disease
Primary renal causes of albuminuria
• Antiglomerular basement membrane disease
• Renal inflammation
• Renal neoplasia
• Genetic renal disease
Genetic Renal Disease
Detection of Kidney Damage
100%
Early Detection
Capability
Conventional Testing
• Azotemia, isosthenuria
• Late-stage kidney disease identified
25-33%
0%
E.R.D.-HealthScreen™ Urine Test
• Identifies early renal damage
• Early treatment and preventive
measures can be initiated
Proteinuria/Albuminuria Detection
• Marker of disease progression/prognosis
“Proteinuria is associated with bad outcomes.”
(Lees, ACVIM 2004)
Proteinuria predicts reduced survival times in cats with
chronic renal failure.
(Syme, ACVIM Abstract 2003)
Proteinuria is associated with reduced survival times in
nonazotemic cats.
(Walker, ACVIM Abstract 2004)
The relative risk for uremic crises and mortality was approximately 3
times higher in dogs with UP/C ≥ 1.0 compared to dogs with UP/C
ratio < 1.0.
(Polzin, ACVIM Abstract 2004)
Proteinuria/Albuminuria Detection
• Treatment efficacy
Treatment Efficacy
• Humans
– Hypertension
– Diabetes mellitus
• Dogs and cats
– Anecdotal
• Lyme disease
• Heartworm disease
• Dental disease
• Hypertension
– Studies ongoing
When should you test for albuminuria?
• Breeds at risk for hereditary/familial renal disease (early age)
• Part of a prophylactic health maintenance program
– Dogs ≥ 6 years
– Cats ≥ 8 years
• Anytime you have reason to evaluate a CBC, serum biochemistry
profile, and UA
• Follow-up as indicated by previous results
E.R.D.-HealthScreen® Test Positive
All Positives
• Complete urinalysis
• Physical examination
Discretionary Testing
• CBC; Chemistry Panel
• Blood Pressure measurement
E.R.D.-HealthScreen® Test Positive
Low/Medium Positives
• Determine trend
• Repeat test twice at one-to-three month interval
Proteinuria/Albuminuria is significant only if it is persistent.
It is most significant when it is increasing.
E.R.D.-HealthScreen® Test
Positive
High/Very High Positives
• Run UPC to quantify amount of albuminuria
Recommendations for Monitoring
Microalbuminuria Stable or Decreasing
• Recheck patient every 6-12 months
– physical examination
– urinalysis + E.R.D.-HealthScreenTM Urine Test
– serum creatinine
Recommendations for Monitoring
Microalbuminuria Increasing
• Recheck patient every 3-6 months
– Physical examination
– Urinalysis + E.R.D.-HealthScreenTM Urine Test
– Serum creatinine
– Blood pressure
Other methods of detecting
albuminuria
Components of a Complete Urinalysis
• Physical Characteristics
• color, appearance, specific gravity,
and odor
• Biochemical Analysis
• pH, glucose, ketones, bilirubin, occult
blood, and protein
• Microscopic Analysis
• RBCs, WBCs, Casts, Crystals, and
Bacteria
• ± Culture
Urine dipstick
Dog
Cat
Sensitivity Specificity
54%
68%
60%
31%
If you exclude hematuria, pyuria and bacteruria:
Dog Specificity = 84%
Cat Specificity = 55%
Grauer ACVIM 2004
Screening tests for proteinuria:
Sulfosalicylic acid test
• Advantages
– Inexpensive
– Easy to use
– ↑ Sensitivity
• Disadvantages
– More labor/time compared with the
dipstick
– Subjective grading
– ↓ Specificity for albumin
Urine Protein/Creatinine Ratio
• Quantitative test for proteinuria
• Not as sensitive as SSA or MA
• Best for tracking progression of proteinuric patients
• Available at reference labs & on IDEXX VetTest® Chemistry
Analyzer
• Ratio > 1.0 Abnormal
• Ratio 0.5-1.0 Borderline (Abnormal?)
• Ratio < 0.5 Normal
• Individual patient variation
Urine protein-creatinine ratio
Specific Gravity vs. Urine Creatinine
n=593
1.070
2
R = 0.6942
Specific Gravity
1.060
1.050
1.040
1.030
1.020
1.010
1.000
0.0
200.0
400.0
600.0
Urine Creatinine (mg/dl)
800.0
UPC calculations
• Urine specific gravity____1.030____
• UPC = Urine protein/Urine creatinine
• Urine protein ____65___________
• Urine creatinine 1. 29.2 2. 228
• UPC 1. 2.2 2. 0.3
Urine Protein Detection Methods
• Dipstick
– Many false positives
• SSA
– More accurate than dipstick
– Subjective interpretation
• Urine protein/creatinine ratio
– Interpatient variation in urine creatinine at same specific gravity
– Quantitative
• Microalbuminuria
– E.R.D.-Healthscreen® Urine Test
– Most sensitive and specific of all methods
Level of Response
Response to Persistent Renal Albuminuria
Intervene
Monitor
Investigate
Investigate
Monitor
Monitor
Magnitude of Proteinuria
ACVIM 2004
Optimizing Proteinuria Testing
• Dipstick positives
– Sediment exam
• Dipstick negative or Dipstick positive with
negative sediment
– E.R.D.-HealthScreen® Tests
• Once patient is confirmed to have persistent
proteinuria
– Monitor trend with UPC (quantitative)
Competition