SD index for kidney disease

RE: SD index for kidney disease

Kate Richardson — Wed, 22 Jun 2016 14:33:33 GMT

Liked your post Martin Atkinson but disagree with [quote user="Martin Atkinson"] promoting treating renal failure with ACEi/Semintra before proteinuria.[/quote]

RE: SD index for kidney disease

Martin Atkinson — Wed, 22 Jun 2016 14:07:45 GMT

[quote user="robloxley"]it sounds like you are happy to wait until 75% of renal funtion is lost before detecting and addressing this? [/quote]No, there is a misunderstanding especially as I'm promoting treating renal failure with ACEi/Semintra before proteinuria.

What I intended to convey was that you are unlikely to have a cat presented with symptoms of CKD before 75% of renal function is lost as we all know we can function normally on one half of one kidney as there is so much reserve. Therefore you are unlikely to have the opportunity to test it until symptoms are present and then the normal renal parameters will be flagging up. I can only see SDMA being of value if you are routinely testing 'normal' animals say for a pre-surgical profile but given that we've established we are not going to intervene at this stage and all my at risk i.e. older cats are going to be on a partly protein/phosphate restricted diet anyway it seems superfluous.

The new IRIS guidelines show rises in SDMA as being parallel with creatinine in CKD so again how does this add value to the diagnosis?

I admit that I'm partially playing Devil's Advocate here but my mind is open, as you say I've embraced NT-proBNP with open arms (except the SNAP test!), I just need a bit more convincing before I can justify SDMA to my clients. Idexx may be adding it on to their profiles FOC but I don't send renal profiles to them and that seems like a bit of a cynical gesture to get a data base in clinical cases without doing their own research.

RE: SD index for kidney disease

Rob Loxley — Wed, 22 Jun 2016 13:49:03 GMT

[quote user="Martin Atkinson"]So unless we are going to perform SD as a regular routine screen from middle aged in all cats it is still of limited value[/quote]

Maybe that is worth considering?

Another thought - you seem keen on measuring proBNP in asymptomatic animals, in early intervention in cardiac cases, but it sounds like you are happy to wait until 75% of renal funtion is lost before detecting and addressing this? Our evidence base for intervention in such early stages is lacking, but as is much of our evidence for early intervention in cardiac disease?

RE: SD index for kidney disease

Martin Atkinson — Wed, 22 Jun 2016 09:07:11 GMT

[quote user="Kate Richardson"]Nothing at this stage, but you can start monitoring from this point onwards whereas you wouldn't have done otherwise. Lots of info to show early detection of a decline in HCT for example and interaction can be of benefit. UPC may be normal now, but will it still be in 6months time? Similar for BP etc [/quote]OK I'm off my Cardiopet SNAP high horse now.

Despite my reply to the OP about what we can do for cats with early CKD I am also struggling to see the advantage of SDMA. Yes its a valuable monitoring tool but if I was at the stage of monitoring renal function I'd already be taking regular samples in older cats to check the associated biochemistry/haematological parameters in-house which are much more valuable for assessing what intervention is required. If I had a younger cat with symptoms suggestive of renal disease I would expect to see blood test results which were consistent with renal disease. Yes I know that 3/4 effective renal function has to be lost before they become symptomatic and SDMA might alert me that things are not too rosy before that but I would have had no reason to test if the cat was asymptomatic so Catch 22. So unless we are going to perform SD as a regular routine screen from middle aged in all cats it is still of limited value.

RE: SD index for kidney disease

Kate Richardson — Tue, 21 Jun 2016 22:29:11 GMT

[quote user="Martin Atkinson"]

[quote user="Kate Richardson"]

Recent webinar said a negative pro BNP snap on pleural effusion would rule out cardiac cause. So useful from that point. Agree a positive doesn't help you as much, but if massively high then you could be fairly certain of a cardiac cause.[/quote]

Was this an Idexx webinar by any chance?!

Given Idexx's own guidelines for cats are: <100 pmol/l no cardiac disease; 100-270 cardiac disease unlikely but monitor; over 270 cardiac disease likely, a result of 170 tells you nothing other than its possible its cardiac disease but you have no idea how much over 170 it is. It could still be <270 = no cardiac disease! IME a cat with symptoms due to cardiac failure would have a NT-proBNP in excess of 350 and if its so bad there's an effusion very much higher, often into the 1000's but you would also have other clinical signs of heart failure.

What's more worrying is that when I called Idexx technical support no-one knew what the cut off point was for the SNAP test and someone had to go off and do some research to find out it is 170 pmol/l.

I don't think the SNAP has any value at all and all my tests are now sent to the lab for a quantitative result.

[/quote]

No not an Idexx webinar, ISFM one. I wouldn't use the snap test on a daily basis, only suggesting it may have a use in emergency situations.

[quote user="Rob Davis"]To be fair to Idexx, I was under the impression that they were including it in all their profiles at no extra cost.[/quote]

I didn't know that, so apologies to Idexx if that is true, however we don't use them so it would cost us extra.

[quote user="dachsie_4"]

Ok renal diet fair enough, but there's no protein urea, so semintra not really indicated, not able to get blood pressure on this cat, K normal, no anaemia.... I am aware of all these guys in stage 2 onward, it deciding the difference between stage 0 and stage 1. the creatitine is normal as well. So if we are picking up kidney disease so much earlier want realistically can we do about it other than the diet.....

Monika

[/quote]

Nothing at this stage, but you can start monitoring from this point onwards whereas you wouldn't have done otherwise. Lots of info to show early detection of a decline in HCT for example and interaction can be of benefit. UPC may be normal now, but will it still be in 6months time? Similar for BP etc

RE: SD index for kidney disease

Martin Atkinson — Tue, 21 Jun 2016 18:52:52 GMT

[quote user="dachsie_4"]So if we are picking up kidney disease so much earlier want realistically can we do about it other than the diet.....[/quote]Now you phrase it like that then erm...not a lot especially as I will advise all older cats go on a senior diet which is protein and phosphate restricted anyway. However, I'm a believer in putting cats on ACEi, now Semintra, before they become proteinuric or at least when they are in the borderline 0.2-0.4 UPC range as I believe it is protective. This could start a whole new debate mind you as we've had this discussion before. And to put my money where my mouth is one of my old cats with stage 3 CKD which is not proteinuric is on benazepril - mind you he does also have a grade 2 systolic murmur and an NT-proBNP of >1500 and a VHS of 9.5.

RE: SD index for kidney disease

dachsie_4 — Tue, 21 Jun 2016 18:09:15 GMT

[quote user="Martin Atkinson"]

[quote user="dachsie_4"]

OK, so just to put the cat amongst the pigeons, so now we can stage the kidney disease, but what would be the treatment be other than phosphate binders??

Monika

[/quote]Erm....renal diet, ACEi/Semintra, anti-hypertensives (OK you need to measure BP for that), KCl for hypokalemia, treatment for anaemia - anabolics/Vit B12/EPO, additional fluid therapy with SC fluids - a skin button maybe??!!

[/quote]

Monika

RE: SD index for kidney disease

Rob Davis — Tue, 21 Jun 2016 12:42:50 GMT

[quote user="Kate Richardson"]Another Idexx wonder test, lots of promo to suck you in and spend money that isn't going to change what you do a massive amount[/quote]

To be fair to Idexx, I was under the impression that they were including it in all their profiles at no extra cost.

RE: SD index for kidney disease

Martin Atkinson — Tue, 21 Jun 2016 09:43:54 GMT

[quote user="Kate Richardson"]

Was this an Idexx webinar by any chance?!

I don't think the SNAP has any value at all and all my tests are now sent to the lab for a quantitative result.

RE: SD index for kidney disease

Kate Richardson — Mon, 20 Jun 2016 21:51:21 GMT

RE: SD index for kidney disease

Martin Atkinson — Mon, 20 Jun 2016 21:22:34 GMT

The problem with the SNAP test is that the positive is 170 which is useless. Given below 100 is normal and over 270 is abnormal with anything in between equivocal it doesn't actually tell you anything.

RE: SD index for kidney disease

Kate Richardson — Mon, 20 Jun 2016 19:51:27 GMT

[quote user="Martin Atkinson"]

[quote user="Kate Richardson"]Would I run it routinely- no. Another Idexx wonder test, lots of promo to suck you in and spend money that isn't going to change what you do a massive amount[/quote]You're becoming as cynical as me Kate.

But I hope you don't include NT-proBNP in the argument because in cats it is a very useful tool for monitoring cardiac disease. Just don't waste money on the SNAP test its worse than useless.

[/quote]

Probably. And no Pro BNP gets a thumbs up from me. I think the snap test may be useful bedside in cats with pleural effusion, run it on the effusion- a negative pretty much rules out a cardiac cause, whilst a positive means cardiac disease is a possible cause. But I would still want to get a value from the lab.

RE: SD index for kidney disease

Martin Atkinson — Mon, 20 Jun 2016 19:13:28 GMT

[quote user="dachsie_4"]

OK, so just to put the cat amongst the pigeons, so now we can stage the kidney disease, but what would be the treatment be other than phosphate binders??

Monika

RE: SD index for kidney disease

Martin Atkinson — Mon, 20 Jun 2016 19:08:58 GMT

But I hope you don't include NT-proBNP in the argument because in cats it is a very useful tool for monitoring cardiac disease. Just don't waste money on the SNAP test its worse than useless.

RE: SD index for kidney disease

Kate Richardson — Mon, 20 Jun 2016 19:03:04 GMT

My take on this test is that is useful where the diagnosis of kidney disease is equivocal ie early cases. For example, animals with weight loss but no biochem changes but with a USG in the borderline zone. In terms of treatment, nothing really changes, but it gives you an early heads up to start monitoring for secondary problems so BP/UPC/urine culture/HCT/potassium as well as urea/creat and phos levels.

Would I run it routinely- no. Another Idexx wonder test, lots of promo to suck you in and spend money that isn't going to change what you do a massive amount

RE: SD index for kidney disease

dachsie_4 — Mon, 20 Jun 2016 17:52:46 GMT

OK, so just to put the cat amongst the pigeons, so now we can stage the kidney disease, but what would be the treatment be other than phosphate binders??

Monika

RE: SD index for kidney disease

Martin Atkinson — Mon, 20 Jun 2016 15:03:42 GMT

[quote user="Catriona MacIntyre"] I refer to the IRIS algorithms quite a lot and had a quick look[/quote]I do as well but suddenly things have been shifted to the right: the recommended phosphate level has just got a lot higher which means loads of cats I've been giving phosphate binders suddenly don't need them anymore. Plus I can't really see the value of SDMA in cats in >stage 2 CKD if you're sure you have a CKD rather than trying to differentiate high crea & phos in a pre-renal azotaemia. And what I really find surprising is how in all of this no-one seems to worry about BUN. Yes the 'fashion' is to stage renal failure with creatinine rather than BUN but it is still a very useful prognostic indicator.

RE: SD index for kidney disease

dachsie_4 — Sun, 19 Jun 2016 17:50:11 GMT

Magic thank you. Will have a read before discussing results with owner

Thank you

Monika

RE: SD index for kidney disease

Catriona MacIntyre — Sun, 19 Jun 2016 16:55:50 GMT

Hi Monika

Diagnosis and staging seems to have got SO much more complicated since I qualified in 2001.

I think it's now suggested you blood sample on more than one occasion unless it's very clear. I refer to the IRIS algorithms quite a lot and had a quick look to see what they say about SD:

"A persistent increase in SDMA above 14 µg/dl suggests reduced renal function and

may be a reason to consider a dog or cat with creatinine values <1.4 or <1.6 mg/dl,
respectively, as IRIS CKD Stage 1."

There's a downloadable pdf file at http://www.iris-kidney.com/guidelines/staging.html

Hope that helps a bit

Catriona