Hematology. Chemistry AT HOME VETERINARY CARE. Patient: MAURICE GILLEN ( )

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1 Species: Canine Breed: Poodle Gender: Male Year of Birth: 2005 Client: GILLEN Requisition #: Accession #: L Account Code: Veterinarian: PATTERSON,BRAD Panel/Profile: SDMA Bile Acids (Single Sample) Add-on Thyroid Confirmation Panel with FT4ED-Canine Total Health Plus Hematology 7/2/2015 (Order Received) 3:55 PM (Last Updated) RBC M/µL Hematocrit % Hemogloin g/dl MCV fl MCH pg MCHC g/dl % Reticulocyte 0.7 % Reticulocyte K/µL WBC K/µL % Neutrophil 70.5 % % Lymphocyte 18.8 % % Monocyte 2.7 % % Eosinophil 8.0 % % Basophil 0.0 % Neutrophil K/µL Lymphocyte K/µL Monocyte K/µL Eosinophil K/µL Basophil K/µL Platelet K/µL Remarks SLIDE REVIEWED MICROSCOPICALLY. Chemistry 7/2/2015 (Order Received) 3:55 PM (Last Updated) Glucose mg/dl July 08, :32 PM Page 1 of 4

2 Chemistry (continued) BUN mg/dl Creatinine mg/dl SDMA BUN / Creatinine Ratio a ug/dl 11.3 Phosphorus mg/dl Calcium mg/dl Sodium mmol/l Potassium mmol/l Na / K Ratio Chloride mmol/l TCO2 (Bicaronate) mmol/l Anion Gap mmol/l Total Protein g/dl Alumin g/dl H Gloulin g/dl Al / Glo Ratio ALT U/L AST U/L L ALP U/L H GGT U/L Biliruin - Total mg/dl Biliruin - Unconjugated Biliruin - Conjugated mg/dl mg/dl Cholesterol mg/dl Amylase ,469 U/L Lipase U/L Creatine Kinase U/L Hemolysis Index Lipemia Index Bile Acids Preprandial / Random c d N N µmol/l July 08, :32 PM Page 2 of 4

3 Chemistry (continued) a Please note: the SDMA reference interval has een adjusted to 0-14 ug/dl ased on population analysis. SDMA is a new kidney function test. It increases earlier than creatinine in some animals with chronic kidney disease. Unlike creatinine, SDMA is not impacted y lean ody mass. SDMA and creatinine should e interpreted together, along with a urinalysis. For more information go to BOTH SDMA AND CREATININE ARE WITHIN THE REFERENCE INTERVAL which indicates kidney function is likely good. If SDMA and/or creatinine is at the upper end of the reference interval, early kidney disease cannot e ruled out. Evaluate a complete urinalysis to confirm there is no other evidence of kidney disease. Index of N,+,++ exhiits no significant effect on chemistry values. c Index of N,+,++ exhiits no significant effect on chemistry values. d In oth dogs and cats resting ile acids >7 umol/l or post prandial ile acid concentrations >15 umol/l are suggestive of liver malfunction ut does not indicate the nature of the anormality or whether the prolem is reversile or permanent. A liver iopsy may e warranted to further identify the underlying hepatopathy. Increased ile acids can e seen in diseases affecting hepatic circulation (i.e. liver shunts), cholestasis, or diseases associated with hepatocellular damage. Dehydration, hypovolemia, and chronic passive congestion have only a minor effect on ile acid levels. A normal ile acid level does not rule out a hepatopathy. Endocrinology 7/2/2015 (Order Received) 3:55 PM (Last Updated) Total T4 Free T4 y ED (ng/dl) Free T4 y ED (pmol/l) ctsh Thyrogloulin AA Screen a µg/dl L ng/dl L pmol/l L ng/ml 2.1 % Corrected Thyrogloulin AA c Not Indicated % a Interpretive ranges: <1.0 Low Normal >4.0 High Therapeutic Dogs with no clinical signs of hypothyroidism and results within the normal reference range are likely euthyroid. Dogs with low T4 concentrations may e hypothyroid or "euthyroid sick". Occasionally, hypothyroid dogs can have T4 concentrations that are low normal. Dogs July 08, :32 PM Page 3 of 4

4 Endocrinology (continued) with clinical signs of hypothyroidism and low or low normal T4 concentrations may e evaluated further y sumission of free T4 and canine TSH. A high T4 concentration in a clinically normal dog is likely variation of normal; however elevations may occur secondary to thyroid autoantiodies or rarely thyroid neoplasia. For dogs on thyroid supplement, acceptale 4-6 hour post pill total T4 concentrations generally fall within the higher end or slightly aove the reference range. Increased canine TSH values may occur in dogs with untreated primary hypothyroidism. Sick euthyroid dogs are expected to have low normal TSH concentrations. Secondary or tertiary hypothyroidism (pituitary or hypothalamic lesions) are reported to occur in less than 5% of hypothyroid dogs. c TgAA Screen Patient result 0-35% Corrected TgAA Patient result or N/I 0-25% Thyrogloulin Autoantiody Test Interpretation: TgAA Screen: Corrected TgAA: Negative <20% <10% Inconclusive 20-35% 10-25% Positive >35% >25% A negative TgAA Screen is normal; a Corrected TgAA is not indicated. If TgAA Screen is inconclusive or positive, a Corrected TgAA is performed to remove non-specific inding which may falsely increase the result. A negative Corrected TgAA is normal. A positive Corrected TgAA indicates the presence of autoimmune thyroiditis. TgAA are present in 60% of hypothyroid dogs. Dogs with normal thyroid function can have TgAA. Approximately 20% of these dogs will progress within one year to have additional clinical or laoratory anormalities consistent with hypothyroidism. July 08, :32 PM Page 4 of 4

5 SDMA (Symmetric Dimethylarginine) Interpretive Summary Description: Symmetric dimethylarginine (SDMA) is a new test to help evaluate kidney function in dogs and cats. It increases earlier than creatinine in some animals with chronic kidney disease. Unlike creatinine, SDMA is not impacted y lean ody mass. SDMA and creatinine should e interpreted together, along with a urinalysis. For additional information on using SDMA to diagnose kidney disease and monitor your patients, please go to: Normal SDMA (<14 µg/dl) Common Causes Normal SDMA with normal or low Creatinine o Normal kidney function is likely If SDMA and/or creatinine is approaching the upper end of the reference interval, early kidney disease cannot e ruled out. Evaluate urine specific gravity and urinalysis for proteinuria to help confirm there is no other evidence of kidney disease. Normal SDMA with high Creatinine o Dehydration SDMA may e less impacted y dehydration than creatinine. Assess hydration status and urine specific gravity for evidence of dehydration. In clinically dehydrated dog or cat, if urine is dilute, evaluate for extra-renal causes of polyuria. o Kidney disease is possile Determine if there is other evidence of kidney disease such as supportive history, anormal kidney palpation, inappropriate urine specific gravity, proteinuria and/or anormal imaging. Increased SDMA ( 14 µg/dl) Common Causes High SDMA with normal or low Creatinine o Renal Disease Early kidney disease is likely SDMA rises earlier than creatinine in early renal disease. In poorly muscled animals, creatinine may e a poor indicator of renal function and may not e increased even with more advanced disease. Infectious, inflammatory, toxic and ischemic renal diseases are most common. Evaluate for other evidence of kidney disease such as supportive history, anormal kidney palpation, inappropriate urine specific gravity, proteinuria and/or anormal imaging. High SDMA with high Creatinine o Renal Disease Kidney function is likely impaired Infectious, inflammatory, toxic and ischemic renal diseases are most common. Confirm that there is other evidence of kidney disease such as supportive history, anormal kidney palpation, inappropriate urine specific gravity, proteinuria and/or anormal imaging. Uncommon Causes High SDMA with high Creatinine o Renal Disease Congenital kidney disease, amyloidosis, and renal neoplasia are less common causes of renal disease. Generated y VetConnect PLUS: July 8, :32 PM Symmetric Dimethylarginine Page 1 of 3

6 o Dehydration SDMA may e less impacted y dehydration than creatinine. Assess hydration status and urine specific gravity for evidence of dehydration. Related Findings Renal disease o Increased BUN, creatinine and phosphorus SDMA can e increased prior to development of azotemia o Electrolyte anormalities, metaolic acidosis, hypo- or hypercalcemia o Mild to moderate nonregenerative anemia o Inappropriate urine specific gravity o Urinary casts, pyuria, hematuria, proteinuria, microaluminuria, glucosuria, acteriuria o Positive urine culture o Increased lood pressure o Protein losing nephropathy (glomerulonephritis or amyloidosis) Decreased alumin Increased urine protein:creatinine ratio High cholesterol in nephrotic syndrome o Positive PCR or serology for leptospirosis, Lyme disease, ehrlichiosis or other infections o Anormal kidney imaging findings such as anormal renal size and/or structure o History of kidney toxin exposure Additional Information Physiology SDMA is a molecule formed y post-translational methylation of the amino acid L-arginine in the nucleus of cells y the enzyme protein-arginine methyltransferase. o During protein degradation these methylated arginine molecules are released. o Biologically, SDMA is considered an inert molecule. SDMA is primarily ( 90%) eliminated y renal excretion, therefore lood concentrations are affected y changes in glomerular filtration rate (GFR) making SDMA a good marker for renal disease. SDMA is a iomarker for kidney function and has een shown to rise in proportion to creatinine and is inversely related to GFR (measured y iohexol clearance) in dogs and cats with kidney disease. SDMA increases earlier than creatinine in chronic kidney disease. o SDMA increases on average with 40% loss of kidney function versus creatinine, which does not increase until 75% of kidney function is lost. o In cats, SDMA increases on average of 17 months efore creatinine. o In dogs, SDMA increases on average of 9.5 months efore creatinine. SDMA is specific for kidney function. It is not impacted y various diseases including liver disease, Cushing s disease and heart disease, unless there is concurrent kidney disease SDMA is not impacted y lean ody mass. Reductions in lean ody mass occur with aging and chronic disease can lower creatinine concentrations, ut SDMA increases as kidney function declines with no correlation to lean ody mass. Week to week variaility of iohexol clearance, serum creatinine and SDMA are similar in dogs with stale renal disease Diagnostic Methodology No information is currently availale on how to interpret SDMA in species other than dogs and cats. SDMA is an immunoassay. SDMA is stale in serum at room temperature and when refrigerated for up to seven days. Generated y VetConnect PLUS: July 8, :32 PM Symmetric Dimethylarginine Page 2 of 3

7 References Braff J, Aguiar J, Yerramilli M, et al. Analysis of Serum Symmetric Dimethylarginine Concentration in Patient Samples Identified Through Retrospective Trending of Serum Creatinine. [ACVIM Astract U-43] J Vet Intern Med. 2014; 28(3): Braff J, Oare E, Yerramilli M, et al. Relationship Between Serum Symmetric Dimethylarginine Concentration and Glomerular Filtration Rate in Cats. J Vet Intern Med. 2014, Vol 28: Hall JA, Yerramilli M, Oare E, et al. Comparison of Serum Concentrations of Symmetric Dimethylarginine and Creatinine as Kidney function Biomarkers in Cats with Chronic Kidney Disease. J Vet Intern Med. 2014, Vol 28: Hall JA, Yerramilli M, Oare E, et al. Comparison of Serum Concentrations of Symmetric Dimethylarginine and Creatinine as Kidney Biomarkers In Healthy Geriatric Cats Fed Reduced Protein Foods Enriched with Fish Oil, L- carnitine, and Medium Chain Triglycerides. Vet J. 2014, Vol 202: Jepson, RE, Syme HM, Vallance C, et al. Plasma Asymmetric Dimethylarginine, Symmetric Dimethylarginine, L- Arginine, and Nitrite/Nitrate Concentrations in Cats with Chronic Kidney Disease and Hypertension. J Vet Intern Med Vol 22: Jewell DE, Fritsch D, Yerramilli M, et al. Feeding Reduced Protein and Phosphorus Food to Dogs with Naturally Occurring Renal Disease Reduces Serum Concentrations of Creatinine and Symmetric Dimethylarginine (SDMA). [ACVIM Astract NU-27]. J Vet Intern Med. 2014; 28(3): p Jewell DE, Yerramilli M, Oare E, et al. Foods with Controlled Protein and Phosphorus and Enhanced with Antioxidents Vitamin E and C Reduce Circulating Urea and Symmetrical Di-Methyl Arginine, and Increase Isosine in Dogs. [ACVIM Astract NM-10]. J Vet Intern Med. 2013; 27(3): p744. Jewell DE, Yerramilli M, Oare E, et al. Increasing Dietary Protein Concentration from 15% to 30% in a One Year Study Increases Glomerular Filtration Rate and Reduces Creatinine and Symmetrical Di-Methyl Arginine. [ACVIM Astract NM-9]. J Vet Intern Med. 2013; 27(3): p744. Naity MB, Lees GE, Boggess M, et al. Correlation of Symmetric Dimethylarginine with Glomerular Filtration Rate in Dogs with Chronic Progressive Renal Disease. [ACVIM Astract NU-11]. J Vet Intern Med. 2013; 27(3): 733. Yerramilli M, Yerramilli M, Oare E, et al. Symmetric Dimethylarginine (SDMA) Increases Earlier than Serum Creatinine in Dogs with Chronic Kidney Disease (CKD). [ACVIM Astract NU-42]. J Vet Intern Med. 2014; 28(3): Naity MB, Lees GE, Boggess M, et al. Week to Week Variaility of Iohexol Clearance, Serum Creatinine, and Symmetric Dimethylarginine in Dogs with Stale Chronic Renal Disease. [ACVIM Astract NU-14]. J Vet Intern Med. 2013; 27(3): 734. Padmanaahan M, Oare E, Yerramilli M. LCMS Method Development and Validation for a Potential Chronic Kidney Disease Marker Symmetrical Dimethyl Arginine. [ACVIM Astract NU-21]. J Vet Intern Med. 2013; 27(3): 736. Rentko V, Naity M, Yerramilli M, et al. Determination of Serum Symmetric Dimethylarginine Reference Limit in Clinically Healthy Dogs. [ACVIM Astract P-7]. J Vet Intern Med. 2013; 27(3): 750. Yerramilli M, Oare E, Relford R, et al. Staility of SDMA (Symmetrical Dimethyl Arginine) in Canine and Feline Serum and Plasma. [ACVIM Astract NU-25]. J Vet Intern Med. 2013; 27(3): 737. Last Updated 1/1/2015 Generated y VetConnect PLUS: July 8, :32 PM Symmetric Dimethylarginine Page 3 of 3