Woodley Equipment Company Ltd. E.R.D.-HealthScreen® Urine Tests Paul Lymer, B.Sc. European Sales Manager Woodley Equipment Company Ltd.
Dec 30, 2015
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?
• Filtering the blood • Removing excess water and
waste from the blood (urine)• Sending urine to the bladder• Releasing hormones into the
blood
Regulate water and soluble substances by:
How does a normal kidney handle albumin?
4 mg/dL albumin goes in
2-3 mg/dL albumin normally
leaks through glomerulus and isreabsorbed by the
proximal tubule <<1 mg/dL albumin
comes outRusso et al 2002 AJKD 39:899
D’Amico and Bazzi 2003 Kidn Internt’l 63:809
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– Dental disease– Pyoderma– IBD– Immune mediated diseases
• Infectious diseases– Heartworm disease– Tick-borne diseases– Viral diseases
• Metabolic diseases– Diabetes mellitus– Hyperadrenocorticism– Hyperthyroidism
• Hypertension• Neoplasia• Drugs
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
1.070
1.060
1.050
1.040
1.030
1.020
Sample (1 mL)
Dilute Sample Read ResultsInsert Device,Wait 3 minutes
Interpretation of Results
Bottom Band NegativeDarker
Bands Equal Low Positive
Top band Medium PositiveSlightly Darker
Top band High PositiveMuch Darker
Top Band Very Very High Dark, Bottom PositiveBand Absent
What Do You See? Results
(~ 1 mg/dL)
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 toSmall 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
CanineMicroalbuminuriaPrevalence 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)
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 >19Age, Years
Perc
ent P
ositi
ve
Relationship between age and percentage of cats testing positive on the E.R.D.-HealthScreen Urine Test, n = 1243
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
E.R.D.-HealthScreen™ Urine Test• Identifies early renal damage• Early treatment and preventive measures can be initiated
Conventional Testing• Azotemia, isosthenuria• Late-stage kidney disease identified
100%
0%
25-33%
Early DetectionCapability
Proteinuria/Albuminuria Detection
• Marker of disease progression/prognosis
Proteinuria is associated with reduced survival times in nonazotemic cats. (Walker, ACVIM Abstract 2004)
“Proteinuria is associated with bad outcomes.” (Lees, ACVIM 2004)
Proteinuria predicts reduced survival times in cats with chronic renal failure. (Syme, ACVIM Abstract 2003)
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
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
Recommendations for Monitoring
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 SpecificityDog 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 Creatininen=593
1.000
1.010
1.020
1.030
1.040
1.050
1.060
1.070
0.0 200.0 400.0 600.0 800.0
Urine Creatinine (mg/dl)
Sp
ec
ific
Gra
vit
y
R2 = 0.6942
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
Lev
el o
f R
esp
onse
Magnitude of Proteinuria
Monitor
Investigate
Intervene
Response to Persistent Renal Albuminuria
MonitorMonitor
Investigate
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