About

 me
• Graduated  University  of  Bristol
• PhD  (FIV),  residency  (Feline  Medicine)
Diagnosis  and  staging  of  renal   • RCVS  Specialist  in  Feline  Medicine
disease  in  cats • Love  first  opinion  and  referral  work
– University  and  referral  clinics
– Standard  first  opinion  vet  practices
Sarah  M.  A.  Caney  BVSc PhD  DSAM(Feline) • Founder  of  Vet  Professionals
RCVS  Specialist  in  Feline  Medicine – Publications:  books  for  sale
– Education:  CPD,  free  downloads
sarah@vetprofessionals.com – Clinics  and  research:  via  online  owner  questionnaires  
+  specialised clinics

ISFM  Consensus  Guidelines Lecture  plan

• Chronic  kidney  disease
– Very  common,    >  1/3  of  older  cats
• Diagnosis  is  not  always  straightforward
– Early  diagnosis  has  additional  challenges
• Assessment  is  complicated
– Many  potential  complications  of  CKD  
which  benefit  from  identification  and  
treatment

Download  your  copy  (free  access  to  everyone):  

http://jfm.sagepub.com/content/18/3/219.full.pdf+html

What  is  chronic  kidney  disease  

What  do  kidneys  do? (CKD)?
• Urine  production • Definitions
– Excretion  of  products  of  protein  catabolism – ‘Renal  insufficiency’:  loss  of  renal  concentrating  ability  
– Excretion  of  drugs,  toxins,  hormones (USG  <  1.035);  occurs  when  2/3  functional  nephrons lost
– Regulation  of  normal  hydration  status
– Regulation  of  normal  electrolyte  status – ‘Renal  failure’:  glomerular filtration  rate  (GFR)  no  longer   ‘CKD’
– Regulation  of  normal  acid-­‐base  status adequate  to  maintain  normal  excretory  function
• Regulation  of  blood  pressure (azotaemia and  USG  <  1.035);  
– RAAS  system occurs  when  >  ¾  functional  nephrons lost
• Production  and  activation  of  hormones

1
 Diagnosing  CKD How  can  early  diagnosis  improve  outcome?
‘Clinical  suspicion’ ‘Early  diagnosis’  (screening) • CKD  is  a  progressive  condition
– Compensatory  mechanisms  are  triggered  once  25%  of  
functional  nephrons  have  been  lost
• Activation  of  RAAS  to  maintain  GFR
History,  clinical  signs • These  mechanisms  help  to  support  GFR  and  excretory  function:  ‘short  
term  gain’
Physical  examination
Laboratory  tests – Ultimately  these  compensatory  mechanisms  are  damaging  
and  contribute  to  further  progression  of  disease:  ‘long  term  
pain’
• Glomerular  hypertrophy,  glomerular  hypertension,  proteinuria,  
inflammatory  cascades  and  nephron  loss…
Diagnosis  confirmed

Routine  screening:  what’s  recommended? Clinical  suspicion  of  CKD

• Cats  aged  up  to  7  years
– Annual  health  check  including  weight  check,  physical  examination
• Clinical  pointers
• Cats  aged  7  -­‐ 10  years  (Mature) – Older  cats   NB  many  cats  with  CKD  are  
– Annual  health  check:  add  BP  and  urinalysis www.icatcare.org
– Weight  loss free  of  clinical  signs
Wellcat for  life  recommendations
• Cats  aged  11  -­‐ 14  years  (Senior)
– Polydipsia
– Health  check  every  6-­‐12  months
– BP  check  every  6-­‐12  months – Polyuria
– Annual  urinalysis – Altered  kidney  size
– Annual  bloodwork
– Dehydration
• Cats  aged  15  years+  (Geriatric)
– Health  check  every  3-­‐6  months   – Systemic  
– 6  monthly  BP  and  urinalysis hypertension
– Annual  bloodwork

Assess  weight  and  %  weight  changes

%  weight  change:  =  
(difference  in  weight  ➗ original  weight)  x  100%
• Accurate  scales
• Weigh  and  BCS  on  every  visit
• Look  at  %  weight  changes
– <  5%  -­‐ ?  significance:  
monitor  (2-­‐4  weekly)
– 5-­‐10%  -­‐ significant:
action  should  be  taken 4  Kg  cat:
– >  10%  -­‐ serious! v3.9  kg  =  100g  loss  =  2.5%

10  stone,  140  Ib,  65kg  person: v3.8  kg  =  200g  loss  =  5%

v63.4  kg  = 1.6kg  (3.5  Ib) loss   =  2.5% v3.7  kg  =  300g  loss  =  7.5%
‘Cats  lost  a  median  of  8.9%  of  body  weight  in  the  12  months  
v61.8  kg  = 3.2kg  (7  Ib)  loss   =  5% v3.6  kg  =  400g  loss  =  10%
before  diagnosis,  but  weight  loss  was  already  present  3  years  
v60.1  kg  = 4.9kg  (10.5  Ib)  loss  =  7.5% before  diagnosis  and  accelerated  after  diagnosis  of  CKD.’
v58.5  kg  = 6.5kg  (14  Ib)  loss =  10%

2
 Sonny  -­‐ bodyweight Routine  urinalysis:  
make  the  most  of  any  opportunity  to  do  this!
• Lifestage preventive  medicine
– Annual  UA  in  cats  aged  7  – 10  years
Dental  Tx Weight – Six  monthly  in  cats  aged  11  and  over
6.2
• All  cats  undergoing  procedures  if  aged  7  years+
5.04 5.2
5.5 5.4 5.25 – eg dental  surgery
1 5.14
4.8
2
3
4.45
4.16 – Train  O  to  bring  in  samples  with  them
4
Weight   %  weight  loss • Urine  specific  gravity  (USG)  is  most  important
1.   6.2à5.0kg 18.7
2.   5.14à4.8kg 6.6 – Cheap,  quick,  easy
3.   4.8à4.45kg 7.3
– Can  be  done  in  the  absence  of  the  cat!
4. 4.45à4.16kg 6.5
• May  facilitate  early  diagnosis  of  CKD
JUL-­‐12
SEP-­‐12
NOV-­‐12
JAN-­‐13
MAR-­‐13
MAY-­‐13
JUL-­‐13
SEP-­‐13
NOV-­‐13
JAN-­‐14
MAR-­‐14
MAY-­‐14
JUL-­‐14
SEP-­‐14
NOV-­‐14
JAN-­‐15
MAR-­‐15
MAY-­‐15
JUL-­‐15
SEP-­‐15
NOV-­‐15
JAN-­‐16
MAR-­‐16
MAY-­‐16
JUL-­‐16
SEP-­‐16
NOV-­‐16
– Typically  USG  falls  before  
Weight azotaemia develops

Value  of  urinalysis  in  older  cats Urine  collection  in  cats:  how?
• USG  <  1.035  generally  considered  abnormal  and  should  prompt  
further  assessment • Cystocentesis
– History:  benign  reasons  for  reduced  USG?
• Free  catch
– Evidence  of  illness?  eg weight  loss
– Blood  profiles?  (rule  out  renal,  thyroid,  DM)
– Litter  tray,  midstream
• USG  helps  differentiate  pre-­‐renal  from  renal  disease • Catheter
– Information  on  severity  of  disease • Expressed
• Assessment  of  secondary  problems  in  CKD  cases
– Urinary  tract  infections
– Proteinuria
See  also  Free  Downloads  
• Diagnosis  of  other  disorders  eg diabetes  mellitus
on  free  catch  sampling  and  cystocentesis

Proteinuria  assessment:  why  and  how? Bacteriology:  C&S

• Proteinuria  is  a  marker  of  RAAS  activation
• Proteinuria  is  damaging  to  the  kidneys • Sample  required
• Proteinuria  assessment – Cysto preferred
– Cysto sample  preferred;  UPC  test  recommended
– Rule  out  UTI,  LUTD
• When  is  this  indicated?
– >  0.4  considered  proteinuric - USG  <  1.035  ?
– 0.2-­‐0.4:  borderline  proteinuria
- Signs  of  FLUTD  (especially  
• Approx half  of  CKD  patients  have  UPC  >  0.2 if  cat  >  10  years  old)
• Dipsticks  are  unreliable  for  proteinuria  assessment!   - UTIs  are  more  prevalent  in  
Diagnosis 6m 12m 18m
older  cats  and  in  those  with  
common  geriatric  conditions
Dipstick Negative Trace Trace Trace
- CKD,  diabetes  mellitus,  hyperthyroidism
UPC 0.03 0.05 0.18 0.43
0.54

3
Blood  pressure  assessment  is  essential Wellness  blood  profiles  in  older  cats
• Lifestage preventive  medicine
– Annual  blood  profile  in  cats  aged  11  years  and  over
• All  cats  undergoing  procedures  if  aged  7  years+
– eg dental  surgery
Download  the  free  guides  from  
– In  combination  with  urinalysis
www.vetprofessionals.com • Key  parameters  are  covered  by  pre-­‐GA  screen
– Proteins,  liver  enzymes,  urea,  creatinine,  glucose,  PCV
• Broader  profiles  are  great  if  possible
– Full  haematology,  serum  biochemistry,  Idexx SDMA,  total  T4
– Look  at  trends  in  results:  creatinine  >  140  abnormal  by  IRIS  
standards

How  can  we  assess  renal  function? A  note  on  BUN  and  creatinine
• Laboratory  tests • Insensitive markers  of  renal  function
– Ideally  GFR – Both  are  affected  by  ‘non-­‐renal’  factors
• Correlates  well  with  the  functional  renal  mass
• Assays  available  but  expensive,  multiple  samples  required  
– Creatinine
(iohexol clearance  assay),  not  needed  in  all  cases • Filtered  but  not  resorbed
– Laboratory  confirmation  of  CKD  – most  cases: • Constant  rate  of  excretion
ü Azotaemia • Levels  are  inversely  proportional  to  GFR
– Elevated  creatinine  (>  140  umol/l)  
ü Elevated  SDMA  (>  14  µg/dL)
– Urea  is  passively  resorbed after  filtration
ü Reduced  urine  specific  gravity  (USG) • Variable  rate  of  excretion
– 1.035  or  less • Levels  rise  disproportionately  in  dehydrated  cats  (slower  
ü Above  changes  have  been  present  for  several  weeks  or  longer flow  of  glomerular filtrate)
ü History  compatible  with  CKD

What  extra-­‐renal  factors  affect  BUN  and   IRIS:  International  Renal  Interest  Society
creatinine? IRIS  Stage Description Creatinine results
• Urea? • Creatinine? 0 At  risk  of  CKD <  140  μmol/l
– Post  prandial – Well  muscled  (Tom  cats) <  1.6  mg/dl
– GI  haemorrhage – Severe  exercise 1 Non-­‐Azotaemic <  140  μmol/l
– High  protein  intake   – Lab  artefact <  1.6  mg/dl
(polyphagic  cats)
(cephalosporins,   2 Mild  renal  azotaemia 140-­‐250  μmol/
– Catabolic  conditions
ketones) 1.6–2.8  mg/dl
– Severe  exercise
– (Post  prandial)
– Liver  disease 3 Moderate renal  azotaemia 251-­‐440  μmol/l
– (High  protein  intake) 2.9–5.0  mg/dl
– Low  protein  diet
– Non-­‐renal  polyuria – Poorly  muscled  (young  
4 Severe renal  azotaemia >  440  μmol/l
cats,  thin  cats)
– Anabolic  conditions >  5.0  mg/dl
Sub-­staging  according  to  blood  pressure  and  presence/magnitude  
of  proteinuria:  www.iris-­kidney.com

4
 How  does  SDMA  affect  staging? SDMA  interpretation  – IRIS  
• SDMA  (Idexx laboratories) www.iris-­‐kidney.com
– Serum  biomarker • Patients  with  creatinine <  140  µmol/l (<1.6  mg/dl)  
– Symmetric  dimethylarginine – SDMA  persistently  >  14  µg/dl  suggests  reduced  renal  function
– Released  during  protein  breakdown – Suggest  classifying  patient  as  IRIS  CKD  Stage  1

– Exclusive  renal  excretion:  levels  correlate   • Patients  with  creatinine  140  – 250  µmol/l  (1.6  – 2.8  mg/dl)  
closely  with  GFR – SDMA  ≥25  µg/dl  in  patients  with  low  body  condition  scores  may  
indicate  the  degree  of  renal  dysfunction  has  been  underestimated
– Levels  can  rise  as  early  as  once  25%  renal  function  lost – Consider  treating  patient  as  IRIS  Stage  3
– Levels  rise  on  average  once  40%  of  renal  function  lost • Patients  with  creatinine  251  – 440  µmol/l  (2.9  – 5.0  mg/dl)  
– Not  affected  by  muscle  mass – SDMA  ≥45  µg/dl  in  patients  with  low  body  condition  scores  may  
– More  reliable  indicator  of  early  renal  disease?  Detected  renal   indicate  the  degree  of  renal  dysfunction  has  been  underestimated
disease  on  average  17  months  earlier  than  creatinine  tests   – Consider  treating  patient  as  IRIS  Stage  4

– Launched  late  2015

– Normal  cats,  SDMA:  0  -­‐ 14  µg/dL

SDMA  -­‐ summary Why  make  an  earlier  diagnosis??

• Suggested  indications  
– Routine  annual  blood  sample  for  cats  aged  11  years  and  over • Earlier  intervention  is  possible…
– Old  thin  cats  – cats  with  poor  muscle  mass – Some  interventions  may  be  beneficial  for  IRIS  Stage  1  cats
– Cats  suspected  of  having  CKD – Many  interventions  are  beneficial  for  improving  both  quality  and  
length  of  life  in  patients  with  IRIS  Stage  2  CKD  and  above  
– Cats  known  to  have  CKD:  it  may  be  worse  than  it  appeared  on  
(yet  often  these  cats  have  no  clinical  signs!)
standard  urea/creatinine  assays
– Identify  complications  before  they  impact  on  the  patient
– Young  adults  with  genetic  predisposition  to  renal  disease
• Prevent/reverse  renal  secondary  hyperparathyroidism
– ?  Hyperthyroid  cats • Manage  systemic  hypertension  before  complications  occur
– ?  Cardiac  patients • Reduce  the  likelihood  of  acute  crises  needing  hospital  treatment  etc
– ?  Critical  care  patients – Develop  good  teamwork  with  the  carer,  educate  and  support  
• Interpret  SDMA  results  alongside  creatinine them  through  their  cat’s  diagnosis  and  treatment

IRIS  sub-­‐staging IRIS  sub-­‐staging

• According  to  proteinuria • According  to  arterial  blood  pressure
• Rule  out  pre-­‐ and  post-­‐renal  proteinuria SBP  mmHg Blood  pressure  sub-­‐stage Risk  of  future  target  
– UPC  <  0.2 Non  proteinuric organ  damage
– UPC  0.2  – 0.4 Borderline  proteinuric <  150 Normotensive Minimal
– UPC  0.4  – 2.0 Mild  to  moderate  proteinuria 150-­‐159 Borderline  hypertensive Low
– UPC  >  2.0* Severe  proteinuria 160-­‐179 Hypertensive Moderate
*Likely  to  be  primary  glomerular  disease,  no  need  to  confirm  
persistence  prior  to  starting  treatment ≥  180 Severely  hypertensive High
• Ideally  over  two  samples,  collected  over  2  weeks Hypertensive:  SBP  160-­‐179  mmHg  measured  over  1-­‐2  months
• Borderline  cases:  reassess  again  in  2  months
Severely  hypertensive:  SBP  ≥  180  mmHg  measured  over  1-­‐2  weeks

5
Checklist  for  assessment  of  CKD  cats Looking  for  an  underlying  cause
• Evaluate
q History • Aims – Signalment,  history
q Systolic  blood  pressure ü Stage  severity  of  CKD
– Blood  results,  urine  sediment  
q Physical  examination ü Identify  underlying  cause  of   and  bacteriology
q Urinalysis  including  USG,   CKD  if  possible • Infection,  inflammation,  
dipstick,  UPC,  sediment,  culture ü Identify  complications  of  CKD other  clues
q Haematology ü Identify  concurrent  disease • Where  possible
q Biochemistry  including  proteins,  
– Ultrasound  +/-­‐ radiography
urea,  creatinine,  electrolytes  
+/-­‐ T4 • Renal  structure,  size,  pelvis  
dilatation,  stones
q Imaging  (radiography,  
ultrasound) • Further  tests?
q +/-­‐ renal  biopsy – Renal  biopsy??

What  complications  of  CKD  are  important?

Functions  of  the  kidney
• All  patients  are  vulnerable  to  a  number  of  acknowledged   • Urine  production
complications…. – Excretion  of  products  of  protein  catabolism
– Excretion  of  drugs,  toxins,  hormones
– Regulation  of  normal  hydration  status
– Regulation  of  normal  electrolyte  status
– Regulation  of  normal  acid-­‐base  status
• Regulation  of  blood  pressure
– RAAS  system
• Production  and  activation  of  hormones

Complications  to  look  for…

Consequences  of  renal  disease

• Urine  production • Haematology

– Accumulation of  products  of  protein  catabolism – Anaemia,  inflammatory/infectious  disease,  dehydration…
– Accumulation of  drugs,  toxins,  hormones • Serum  biochemistry
– Dehydration – Dehydration,  hyperphosphataemia,  hypokalaemia,  
– Electrolyte  abnormalities hypoalbuminaemia,  hypercalcaemia,  concurrent  diseases…
– Acidosis
• Urinalysis
• Regulation  of  blood  pressure
– Systemic  hypertension – Reduced  USG,  bacterial  UTI,  proteinuria,  casts,  concurrent  
• Production  and  activation  of  hormones diseases…
– Anaemia,  renal  secondary  hyperparathyroidism • Other
– Metabolic  acidosis,  concurrent  disease  tests…

6
 Senior  clinics  for  diagnosis  of  CKD How  effective  is  the  Wellcat  protocol?
• Many  older  cats  will  have  clinical  or  subclinical  problems  
that  can  be  helped  by  us  – CKD  and  others! • 21  diabetic  cats,  21  control  cats
– CKD  estimated  to  affect  >  30%  of  Senior  and  Geriatrics • Study  assessing  ocular  manifestations  of  diabetes
– Owners  may  not  otherwise  bring  their  cats  to  see  us • Control  cats
• May  not  notice  changes  in  their  cat/s
– Not  diabetic
• May  not  realise significance  of  these  changes  if  seen
– Age-­‐matched:  10  – 18  years  old
• Clinical  signs  can  be  confusing  eg PU  may  manifest  as  periuria
• May  feel  that  these  are  just  changes  ‘to  be  expected  in  an   – Not  receiving  any  medication  for  at  least  one  month
older  cat’ – Not  known  by  the  owner  to  be  suffering  from  any  
• May  worry  that  nothing  can  be  done  to  help  their  cat symptoms  of  ocular  or  systemic  disease
• Earlier  diagnosis  helps  lead  to  a  better  treatment  outcome – Perceived  to  be  ‘completely  healthy’
• Healthier  cat  -­‐ happier  owner  -­‐ fulfilled  clinician!

Results Current  experience:  Inglis Vets

• Urine  specific  gravity
– Normal  (>  1.040)  in  a  third  of  cats • Cats  aged  7  -­‐10  years
– Abnormal  (<  1.035)  in  a  third  of  cats – Around  10%  of  those  invited  attended  ‘senior  checks’
– Borderline  (1.035-­‐1.040)  in  a  third  of  cats – Very  popular  with  owners
• Blood  pressure – 20%  of  cats  referred  on  to  vets  for  further  treatment/advice  
– Significantly  elevated  in  3  cats  (14%) (mostly  dental,  obesity  management)
• Further  investigations • Cats  aged  11  – 14  years
– 2  cats  hyperthyroid  (10%) – >  30%  of  cats  referred  on  to  vets  for  further  treatment/advice  
– 7  cats  (33%)  diagnosed  with  CKD (dental,  CKD,  hyperthyroidism,  hypertension,  etc)
• 1  cat  in  IRIS  Stage  3  CKD  (creatinine  283  μmol/l;  3.2  mg/dl) • Cats  aged  15  years  and  over
• 6  cats  in  IRIS  Stage  2  CKD
– >  50%  of  cats  referred  on  to  vets  for  further  treatment/advice  
All  of  these  cats  were  perceived  to  be   (dental,  CKD,  hyperthyroidism,  hypertension,  etc)
‘completely  healthy’  by  their  owners!

My  vision  for  the  future… Successful  integration  of  Wellcat  protocols

• Integrate  geriatric  care  into  your   • Include  BP  and  UA  screening  
practice tests  free  of  charge  (or  in  normal  fee)
• Make  it  normal  to   – Guarantees  good  uptake
– Follow  ICC’s  Wellcat guidelines – Helps  bond  and  educate  clients  
– Measure  BP  in  older  cats – Financial  gain  through  
– Assess  urine  samples  in  older  cats appropriate  use  of  follow-­‐up  
– Include  assessments  as  part  of  the   diagnostic  tests,  treatments  etc
annual  health  check  (ie offer  as   • Start  by  integrating  UA  
much  as  possible  included  in  your   screening
normal  prices!)
– Start  with  older  patients  (éage è éproblems!)
– See  old  cats  more  frequently

7
Successful  integration  of  Wellcat  protocols
• Consider…
– Client  evenings/open  days
– Owner  questionnaires  
(waiting  room)
– Ask  owner  to  bring  in  urine  sample
– Timetable  longer  appointments  for  
any  old  cat  coming  in
• Ideal  20  minutes  minimum
– Combined  Vet  and  Nurse  
appointments
• 20-­‐30  mins  with  VN:  history,  weigh,  BP,  eye  exam,  
Available  to  download  from  
urinalysis  then  10  mins  with  VS
www.vetprofessionals.com

Useful  resources
Thank  you  for  listening!

Websites:
https://www.vetprofessionals.com/site/
http://www.iris-­kidney.com
https://icatcare.org
https://www.idexx.com/small-­animal-­health/sdma-­home.html sarah@vetprofessionals.com