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Urine Protein/Creatinine Ratio 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 <<1 mg/dL Russo et al 2002 AJKD 39:899 albumin D’Amico and Bazzi 2003 Kidn Internt’l 63:809 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 – Dental disease – Diabetes mellitus – Pyoderma – Hyperadrenocorticism – IBD – Hyperthyroidism – Immune mediated diseases • Hypertension • Neoplasia • Infectious diseases • Drugs – Heartworm disease – Tick-borne diseases – Viral diseases 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 Insert Device, Read Results Wait 3 minutes 1.070 1.060 1.050 1.040 1.030 1.020 Sample (1 mL) Interpretation of Results What Do You See? Results Bottom Band Negative Darker Bands Equal Low Positive (~ 1 mg/dL) Top band Medium Positive Slightly Darker Top band High Positive Much Darker Top Band Very Very High Dark, Bottom Positive Band Absent 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 Sex (circle one) M CM F SF Breed Collection Method (circle one) Expression Cystocentesis Litter Box Presentation (circle one) Well-pet exam Neuter Dental Medical Visit Medical History/Medications Prevalence of Microalbuminuria in Cats (n = 1243) 100 Relationship between age and percentage of cats testing 90 positive on the E.R.D.-HealthScreen Urine Test, n = 1243 80 70 60 50 40 Percent Positive 30 20 10 0 123456789101112131415161718>19 Age, Years Prevalence of Microalbuminuria in Selected Age Groups of Cats (n = 1243) Age Group # of Positives Total # of Cats Percent Positive Increase in Prevalence < 3 40 361 11.1% -- 3 - 5 46 228 20.2% 9.1% 6 - 8 41 184 22.3% 2.1% 9 - 11 45 180 25.0% 2.7% 12 - 15 83 213 39.0% 14.0% > 16 50 77 64.9% 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% Conventional Testing Early Detection • Azotemia, isosthenuria Capability • 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 Sensitivity Specificity Dog 54% 68% Cat 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 R2 = 0.6942 1.060 1.050 1.040 1.030 1.020 Specific Gravity 1.010 1.000 0.0 200.0 400.0 600.0 800.0 Urine Creatinine (mg/dl) 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 Response to Persistent Renal Albuminuria Intervene Investigate Investigate Monitor Monitor Monitor Level of Response 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.
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