A quick post on an important topic. It’s one of my soapbox topic, and when it was brought up in a rounds session today – I was reminded that I didn’t have this information online.
One of the early steps in investigating proteinuria and kidney disease is to evaluate for urinary tract infection. Urinalysis combined with urine culture are recommended to evaluate for bacterial infection. We know that blood and bladder infection (bacterial cystitis) can increase the urine protein/creatinine ratio (UP/C). However, vets often ask – by how much?
Don’t ignore proteinuria just because there are red blood cells or bacteria in the urine.
Don’t ignore proteinuria! If the UP/C is significantly increased in the face of blood-tinged urine or bladder infection, it should be rechecked after treatment. In some situations (ie: severe proteinuria), treatment may be initiated concurrently with treatment of lower urinary tract disease.
In July, 2020, we found that Cassie had severe protein loss in her urine. After watching her brother, aunt, uncle, and grandmother die of amyloidosis – I thought I knew how it would end. I told my parents (who are her primary owners) that if her UP/C was 13 or greater, we would not attempt treatment and she would be euthanized to prevent suffering.
Why 13? It is such an unlucky and arbitrary number, but it’s also the UP/C her brother had at diagnosis. Lou was only two years old and was dead 45 days later despite herculean efforts by modern medicine. That was where I drew my line in the sand.
Cassie’s UP/C that day was 12. I cried. I didn’t want to see another dog die from this disease. I didn’t want to be the one to push the plunger of euthanasia solution and close the eyes I knew so well and had held so closely. I brought her into this world, and I promised her that I would be the one to take her out of it.
But I also had promised that if the UP/C was less than 13 (which is was, but barely), then we would fight.
So we did. That day, after confirming in additional samples that the protein loss was real, we started her on telmisartan, colchicine, and clopidogrel.
Despite my grim predictions, and several back-slides along the way, her protein loss did improve. Medications were added and adjusted several times. She survived her spay surgery last February. Her UP/C has been normal now (< 0.3) for a few months. Her last UP/C value was 0.07 (a 99% reduction from her starting value). She is off medications except for a lower dose of telmisartan and colchicine. That is just shy of a year and a half after starting treatment.
Maybe it’s false hope, or maybe it truly is a remission, but she has given me a new perspective on this disease. I won’t be drawing any more lines in the sand. Her story isn’t over, and I hope it brings hope to anyone facing this disease in their dog.
In the light dying, we’ll rage and fight. Go kickin’ and screamin’ into that good night.
Yesterday, I was thrilled to see that our case series summarizing the kidney disease in 8 Bracchi Italiani was published online by the Journal of the American Veterinary Medical Association. To my knowledge, this is the first scientific publication documenting the kidney disease in this breed. Here is the link to the full document:
I wanted to provide the “TL;DR” (too long – didn’t read) abbreviated notes for quick reference here.
Amyloidosis is a diverse condition that can be localized (in one organ or part of the body) or systemic (throughout the body, or in many tissues).
It occurs when insoluble protein aggregates are deposited within tissue.
The kidney is the most common place of deposition in dogs, but it can be deposited in any tissue type.
Records and diagnostics were analyzed for 8 Bracchi with kidney disease confirmed on biopsy.
The dogs included in the study included 5 males and 3 females.
Their age ranged from 2-10 years, but the median age was 5 years.
The 8 dogs came from 4 distinct breeding lines and 4 were born outside the US; but there was common ancestry within 6 generations for all dogs.
The presenting symptoms were variable. The most common was inappetence. Increased thirst and urination, weight loss, weakness, cough and lameness were also seen.
All 8 dogs had protein loss in the urine (for the dogs with UP/C available, the median UP/C was 8.3).
Half of the dogs were azotemic (had increased kidney values on bloodwork) and the other half had normal Creatinine and BUN on bloodwork.
All of the dogs had low blood albumin concentrations.
The ultrasound reports from 5 dogs showed loss of normal layering of the kidneys (decreased corticomedullary distinction) in 4 dogs and ultrasound was reported normal in one dog.
6/8 dogs were diagnosed with glomerular amyloidosis of the kidneys. Of those dogs, 2/6 also had amyloid deposited in the renal interstitium.
The other two dogs had a non-amyloid disease. It’s unknown if these are unrelated forms of kidney disease or if they represent a spectrum of the same underlying disease.
The median survival time post-diagnosis (half lived longer, half did not survive that long) was 75 days.
7/8 dogs were euthanized from their disease, and one is still alive.
The dog that is still alive is managed on a telmisartan, moderate protein diet, omega-3 fatty acid supplement, and a probiotic.
Chronic inflammation often precedes the development of amyloidosis in Shar Pei, and it’s unknown if that’s also the case with the Bracco.
Due to the small number of dogs, further statistical analysis to correlate laboratory findings or patient factors with survival time wasn’t possible.
Clinical decline was often rapid once symptoms were noted, but earlier diagnosis may provide a window for disease management and longer survival.
Fibrosis (scarring) and cholesterol granulomas within a Bracco kidney.
A kidney biopsy is the process of taking a small piece of kidney tissue to look at under the microscope. This microscopic evaluation is performed by a veterinary pathologist. It allows for special stains to be applied to the tissue, which can help identify disease. For example, when Congo Red Stain is applied to the kidney, it stains a peach color when amyloid fibrils are present. The kidney biopsy works best when both kidneys are diffusely affected by disease (in other words – the whole kidney is affected). Otherwise, you may get a sample that doesn’t accurately represent the kidney’s health. Generally, amyloidosis affects both kidneys in this manner.
How is a kidney biopsy performed?
Kidney tissue can be evaluated while a dog is alive in order to obtain a specific diagnosis to guide therapy. This can be done surgically, laparoscopically, or ultrasound guided. The kidney tissue can also be evaluated post-mortem as part of a necropsy (animal autopsy). While the diagnosis will obviously not change the outcome for the deceased animal, it is helpful to obtain information for the breed and especially that dog’s close relatives who may be at an increased risk of kidney disease if a hereditary condition is found.
What are the benefits of kidney biopsy?
A kidney biopsy is the only way to evaluate the kidneys on a cellular level. It is generally the only way to reach a definitive diagnosis. This can provide information on the prognosis, treatment, and familial implications of disease.
What are the risks of kidney biopsy?
When performed by an experienced veterinarian, the risks of kidney biopsy are generally low. There is risk of bleeding from the biopsy site, obtaining a non-diagnostic or non-representative sample, and causing worsening of kidney disease. There is the standard risk associated with general anesthesia. It is important to discuss the risks/benefits of kidney biopsy with your veterinarian.
What is the associated cost?
Depending on the laboratory performing the testing and what tests are being run, the cost can vary significantly. In some labs, a single stain for Congo Red to screen for amyloidosis is less than $50. I generally recommend full evaluation of kidney tissue (which is can be $300-700, depending on the level of diagnostics needed, recommended lab is the International Veterinary Renal Pathology Service). There is also the cost to obtain the kidney tissue, which will be at the discretion of your veterinarian. Post-mortem evaluation generally costs less than pre-mortem evaluation (due to the costs associated with anesthesia, monitoring, imaging, and tissue collection).
Who can perform a kidney biopsy?
Post mortem kidney tissue can be collected by your local veterinarian and sent for evaluation. Ultrasound guided, surgical, or laparoscopic kidney biopsy often requires treatment with a veterinary specialist. The biopsy itself may be performed by an Internal Medicine, Surgery, or Radiology Specialist, among others – depending on the hospital protocols and what method is used for biopsy.
Who can evaluate a kidney biopsy?
The microscopic evaluation is performed by a board certified veterinary pathologist. I generally recommend the International Veterinary Renal Pathology Service. They provide excellent comprehensive and detailed reports with photos, and they are familiar with evaluating Bracco tissue for amyloidosis.
How do I plan for a post-mortem kidney evaluation?
Having a post-mortem kidney tissue evaluation can be a heart-wrenching and complicated process if not planned for. I recommend discussing your wishes with your veterinarian in advance. This allows them to have the materials needed to perform kidney tissue collection in a timely manner post-mortem. When faced with the loss of a beloved companion, the last thing we want to think about are the logistics and costs associated with kidney tissue evaluation. Planning ahead of time when your dog is diagnosed with kidney disease can help to streamline the process. Sometimes, our dogs get sick very rapidly and we cannot plan ahead. This is when I hope this website is helpful, to be a single source for resources and information. Your veterinarian will help you understand your options for post-mortem evaluation and guide you through the process.
More information on kidney biopsy is available on the Resources page.
Welcome to the Bracco Italiano Kidney Page. The goal of this blog and website is to provide a centralized location for educational information regarding kidney disease in the Bracco Italiano.
Bracchi Italiani have evidence of familial (hereditary) kidney disease, and the most common diagnosis is renal amyloidosis. Occasionally, other forms of kidney disease can be seen in the same family lines. It’s unclear if those dogs have a variation on the same disease process, or if their kidney disease may be unrelated.
The Top Three Points About Amyloidosis in the Bracco Italiano:
Kidney disease causing life-threatening protein loss in the urine can exist with normal kidney parameters (Blood Urea Nitrogen, Creatinine, SDMA) on bloodwork.
Many Bracchi have glomerular amyloidosis causing protein loss in the urine (proteinuria – which is best measured with a Urine Protein/Creatinine Ratio).
The published survival times for non-Shar Pei dogs with renal amyloidosis is grim (only 5 days in one study), but there is likely opportunity to manage this disease if diagnosed early. Routine screening of healthy dogs is an important part of this!
Please don’t hesitate to reach out if you have questions! I will try to update this blog with new information as it becomes available.
