About IRIS
The IRIS Board made three significant changes to CKD Guidelines during 2014 and 2015. A summary of these new recommendations is presented here. The full version of 2015 Guidelines will be uploaded during our website relaunch by the end of 2015.
Substaging by Arterial Blood Pressure
We recommend replacement of the existing abbreviations for blood pressure substages (AP0-AP1) with descriptive terms as follows:
| Systolic blood pressure (mm Hg) | Diastolic blood pressure (mm Hg) | Risk of future target organ damage | BP substage | |
|---|---|---|---|---|
| Original | New | |||
| <150 | <95 | Minimal | AP0 | Normotension |
| 150 - 159 | 95 - 99 | Mild | AP1 | Borderline hypertension |
| 160 - 179 | 100 - 119 | Moderate | AP2 | Hypertension |
| >180 | >120 | Severe | AP3 | Severe hypertension |
Treatment of Proteinuria
We recommend that IRIS CKD Stage 1 patients with persistent proteinuria (UPC ≥ 0.5 for dogs or 0.4 for cats) are not only monitored and thoroughly investigated but also receive standard treatment for proteinuria as currently recommended for IRIS CKD Stages 2 to 4. This parallels the IRIS consensus statement on standard treatment for glomerulonephritis (J Vet Intern Med 2013;27:S27–S43).
Interpreting Blood Concentrations of Symmetric Dimethylarginine (SDMA) in CKD
SDMA concentrations in blood (plasma or serum) may be a more sensitive biomarker of renal function than blood creatinine concentrations. 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.
In IRIS CKD Stage 2 patients with low body condition scores, SDMA ≥25 µg/dl may indicate the degree of renal dysfunction has been underestimated. Consider treatment recommendations listed under IRIS CKD Stage 3 for this patient.
In IRIS CKD Stage 3 patients with low body condition scores, SDMA ≥45 µg/dl may indicate the degree of renal dysfunction has been underestimated. Consider treatment recommendations listed under IRIS CKD Stage 4 for this patient.
These comments are preliminary and based on early data from the use of SDMA in veterinary patients. We expect them to be updated as the veterinary profession gains further experience using SDMA alongside creatinine, the long-established marker in diagnosis and monitoring of canine and feline CKD.
IRIS Newsletter 2018
IRIS annual Board Meeting 2018
Thirteen members of the International Renal Interest Society met on September 3rd and 4th for the 2018 IRIS Board meeting in Rotterdam, The Netherlands.
Attendees at the 2018 IRIS Board meeting (from left to right): Toshifumi Watanabe, Harriet Syme, Jonathan Elliott, Reidun Heiene, Xavier Roura, Greg Grauer, Astrid van Dongen, David Watson, Larry Cowgill, Claudio Brovida, Scott Brown, Gilad Segev and David Polzin,. Hervé Lefebvre was absent from this meeting.
The annual meeting provided the opportunity for members to discuss and update existing Guidelines for staging and treatment of CKD and for grading AKI. In addition, elections were held for changes to the IRIS Board and membership of its various committees. Decisions were made regarding revision of existing IRIS website articles, and some new contributions were planned. These and other changes are detailed in the following sections.
Changes to the IRIS Board and Committees
This year one Board member retired, to be replaced by a new member in 2019.
This year David Watson announced his intention to step down from the IRIS Board by the time of the next Board meeting. David has been involved with IRIS since its inception in 1998. He has provided a voice of reason, experience and rationality, speaking up for what is practical and possible for the general practitioner. He has always contributed significantly to the editing of publications to make them concise, and accurate in the use of written English. We will miss all these attributes and his conviviality at the dinner table. A call for nominations for his replacement has been issued.
David Watson (second from the left) in conversation at dinner during the IRIS 2018 meeting in Rotterdam
This year was also saw a change in the position of Chair of IRIS, as the President Elect, Greg Grauer, assumed the presidency, while Xavier Roura was elected unanimously as the new President Elect.
At the same time, membership of the three committees responsible for the key activities of our Society was overhauled. For the next two years the organization is as follows:
Award Committee: Hattie Syme (Chair), Claudio Brovida, Greg Grauer, Toshifumi Watanabe
Project Committee: Gilad Segev (Chair), Larry Cowgill, Alexander Huettig, Hervé Lefebvre, Xavi Roura, Reidun Heiene
Website Committee: Jonathan Elliott (Chair), Scott Brown, Astrid van Dongen, David Polzin, David Watson (ending in 2018)
The 2018 IRIS Guidelines
Over the last two IRIS Board meetings, the breadth of kidney disease cases encompassed by IRIS CKD Stage 3 has been discussed and it was decided at the 2017 meeting to adjust the Staging Guidelines to make it clear that those cases that are demonstrating few clinical signs should be viewed as early Stage 3, where treatments aimed at slowing progression (as in Stages 1 and 2) would be the focus. Those that are showing many clinical signs of kidney disease are to be viewed as being in late Stage 3, where the focus of treatment shifts more towards symptomatic therapy to improve the quality of life of the patient, as in Stage 4. The guidelines on staging have also been updated to reflect the use of SDMA when viewed alongside creatinine to help identify cases where muscle wastage may mean that blood creatinine may be under-estimating the severity of the kidney disease.
The treatment guidelines have been updated to reflect the new published information on the use of antiemetic drugs to control nausea and vomiting in the cat. This information has been summarised in an educational article and the findings used to modify the recommendations. Mirtazapine has been shown to inhibit vomiting and improve appetite in cats with CKD and is now included in our treatment guidelines.
Furthermore, with the increased awareness and anecdotal evidence that some cats fed a phosphate-restricted diet can develop hypercalcaemia, an educational article has been produced reviewing our current knowledge of idiopathic hypercalcaemia in the cat and the approach to management that IRIS recommends should cats with CKD become hypercalcaemic (based on ionised calcium).
These changes to the Treatment Recommendations and Staging Guidelines were made during 2018. They were agreed at the IRIS 2017 Board meeting. Amendments to the treatment recommendations agreed at the IRIS 2018 meeting were to edit the document to make the full recommendations to be available under each stage so that cross referencing will not be necessary if a practitioner is looking for recommendations for a Stage 2 dog or cat (for example).
Educational Topics and Emerging Themes
Two new educational articles have been published on the IRIS website during 2018. The first deals with Renal Biomarkers and reviews recent published data on the many urinary and plasma biomarkers that are being researched to provide more sensitive indicators of Acute Kidney Injury (AKI). Definitive data are still lacking in veterinary patients but progress is definitely being made to enable practitioners to recognise low grade AKI more readily. The second article is on hypercalcemia and CKD. This is a relatively common problem – ionised hypercalcemia can occur in up to 30% of cats with CKD and 9% of dogs. Dr Henk van den Broek who completed his PhD on Bone and Mineral Disturbances in cats with CKD at the Royal Veterinary College in July 2018 reviewed this topic for IRIS, including his own studies that demonstrated a clear association between a diagnosis of CKD and the occurrence of hypercalcaemia in cats. This article discusses why theoretically feeding of renal diets might increase the risk of hypercalcaemia developing, how to assess calcium status of cats based on total calcium and provides practical advice as to what to do should this happen when a cat is transitioned on to a clinical renal diet.
Three new educational articles are planned to be uploaded to the IRIS Website during 2019. These include review of: (i) Bone and Mineral Disturbances in CKD; (ii) Differentiation between AKI and CKD, and (iii) The Clinical Pharmacology of Angiotensin Receptor Blockers. In addition, two new emerging theme articles are planned. The first, Stem Cell Therapy for CKD: What do we know?, is to be written by Dr Jessica Quimby, the 2018 IRIS Award winner, and will explain why there is excitement about the use of stem cells in the management of CKD for veterinary patients. The second article, Renal Fibrosis in Cats, will discuss the latest understanding of the molecular events leading to this pathological process and whether novel treatments may arise from this knowledge.
IRIS to partner with the UC Davis Hemodialysis Academy
Extracorporeal blood purification, which includes hemodialysis, hemoperfusion and therapeutic apheresis, is the process of purifying the blood of contaminants in patients with kidney failure, immune-mediated diseases, or other intoxications. Hemodialysis (the prototype therapy) has evolved considerably over the past 45 years, and now there is heightened worldwide interest and expansion of these therapies throughout the Americas, Europe, and Asia. However, the delivery of these is not readily mastered by the untrained, self-taught, or casual practitioner, and until recently there have been no training opportunities to promote safe, knowledgeable, and effective delivery of extracorporeal therapies. In 2014, Larry Cowgill (IRIS) established the UC Davis Hemodialysis Academy (in collaboration with Drs Cathy Langston, Carrie Palm, Sheri Ross, Mary Labato, Gilad Segev (IRIS), Thierry Francey, and JD Foster) to remedy the ongoing need for instruction in the foundations of extracorporeal therapies.
In September 2018, a partnership between IRIS and the UC Davis Hemodialysis Academy came into force, and in September, the 3rd Hemodialysis Academy commenced. Over the course of one year, the Academy is providing over 150 hours of web-based didactic instruction, case-based discussions, literature review, and virtual real-time extracorporeal experiences. Currently, 161 students from 24 countries are enrolled in the Academy. The Hemodialysis Academy extends the international, nephrology-directed educational mission of IRIS and affords expanded opportunities to facilitate ongoing and future initiatives in veterinary nephrology including the IRIS Extracorporeal Best Practices Guidelines Initiative, which is currently in progress. Upon successful completion and mastery of all didactic training and assignments, trainees are granted a Certificate of Achievement in Hemodialysis from UC Davis acknowledging competency in the principles of extracorporeal therapies.
The 2018 IRIS Award
A request for nominations and applications for the IRIS Award was circulated during the last quarter of 2017 (see boxed text below). This was request was circulated via the ESVNU website and a direct email to members of that group, as well as via the SVNU listserve.
Call for Nominations/Applications:
2018 IRIS Award in Veterinary Nephrology
The International Renal Interest Society (IRIS)* s pleased to invite nominations or applications for the 2018 IRIS Award. IRIS is an international organization supported by Elanco whose objectives are to advance veterinary nephrology and to help veterinary practitioners better diagnose, understand and treat kidney disease in cats and dogs. The IRIS Award (Value EURO 10 000) is granted to a promising individual for outstanding contributions to the field of veterinary nephrology. This award is made to a trainee or individual early in his/her research career for outstanding fundamental or clinical research performed in veterinary nephrology.
Qualifications:
Candidates for the IRIS Award must:
- be a veterinarian
- be in an early stage of career development and actively engaged in the field of veterinary nephrology for less than 7 years
- have conducted a single or series of research projects that have contributed significantly to the understanding, diagnosis, and/or treatment of kidney disease in dogs and/or cats.
- have research contributions published or accepted for publication in peer reviewed journals within the last 5 years (earliest publication date for consideration is 2013).
Nomination/Application Process:
Nominations/applications must accompany the completed Application Form, below, and must be submitted to the designated address by November 1, 2017. All nominations/applications will be reviewed and judged independently by the IRIS Board, composed of internationally recognized authorities from 10 different countries. The Awardee will be informed by January 15, 2018.
Prior to the release of the call there was discussion among the IRIS board about how to judge whether someone had been active in the field of nephrology (and thus qualify as an early career researcher) for less than 7 years. It was agreed that normally the 'start time' would be the time of a candidate's first publication in the field, although where the candidate subsequently interrupted their nephrology research (for example to complete clinical specialty training in the form of a residency, or for a career break to start a family) then the interval under consideration might actually be longer than 7 years.
In response to this call there were 2 excellent nominations for the award. Each member of the IRIS committee reviewed the application statement and CV for the candidates and the chosen winner was Jessica Quimby DVM, PhD, DACVIM.
Jessica Quimby's research has focused on improving diagnosis and management of cats with CKD. Over the 5-year period under consideration for the IRIS prize Jessica published over 25 articles with relevance to the field of nephrology.
While the work that Jessica has done on stem cell therapy as a potential treatment for CKD has attracted a lot of attention in the veterinary media, arguably her most important contributions have been in evaluating treatments that reduce patient morbidity, rather than trying to treat the disease per se. In particular, her meticulous evaluation of how we can improve appetite and reduce nausea in cats with CKD is especially noteworthy. Her work objectively evaluating some of the treatments that have been advocated for years without any real clinical proof of efficacy, has resulted in real changes to clinical practice.
The 2018 IRIS Award was presented at the ECVIM meeting in Rotterdam by IRIS Senior Vice-President Claudio Brovida. Dr Quimby gave an excellent IRIS Award Lecture summarising many of the excellent contributions she has made to feline nephrology.
2018 IRIS Renal Week was a Huge Success
The second biannual IRIS Renal Week symposium was held on the UC Davis campus on March 21-24, 2018 and was an unprecedented success. "Renal Week" has evolved over the past 14 years to be recognized internationally as the premiere educational offering for veterinary nephrology. IRIS assumed the leadership and became the official sponsor of "Renal Week" in 2015 as the program transitioned from New York City to UC Davis. Under the IRIS banner, "Renal Week" has become even more prestigious as an educational target for veterinary nephrology.
The program committee comprised of Drs. Cathy Langston, Larry Cowgill (IRIS), JD Foster, Jonathan Elliott (IRIS), and David Polzin (IRIS) designed a three and one-half day program packed with advanced topics in veterinary nephrology, sophisticated laboratories dealing with extracorporeal therapies and renal pathology, and a robust social agenda that kept the 177 international attendees intellectually stimulated and collegially interactive. Preceding Renal Week, 53 international attendees participated in an intense two-day Boot Camp with lectures and hands-on laboratories on extracorporeal therapies.
Thanks to very generous sponsorship (see below), we were able to provide 15 IRIS Renal Week Scholarships, which provided funding for registration to the Boot Camp and/or Renal Week in addition to a travel stipend to attend the meetings. IRIS is proud to include Renal Week as part of its educational offerings and encourage everyone to join the next IRIS Renal Week in March 2020.
IRIS Renal Week 2018 sponsors included: Platinum level – Boehringher Ingelheim, the Hemodialysis Academy, and Idexx Ltd.; Gold Level – Immutrix/Intrinsic; Silver level – CytoSorbents; Bronze level – Nephrology Knowledge, Kindred Biosciences Inc, Ceva Santa Animale, and Nestle Purina.
Introducing the IRIS Board President for 2018 - 2020
Dr. Grauer is a DVM graduate of Iowa State University. He completed his post-graduate training in internal medicine at Colorado State (internship, residency and MS degree). He is board certified by the American College of Veterinary Internal Medicine and has served as President and Chairman of the Board of Regents of the ACVIM. Dr. Grauer was a faculty member at the University of Wisconsin, School of Veterinary Medicine and Colorado State University, College of Veterinary Medicine prior to his appointment as the Jarvis Chair of Medicine in the Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University. He has received the SmithKline Beecham Award for research excellence in veterinary nephrology and he was appointed as a Morris Animal Foundation Fellow for his work on canine glomerular disease. Dr Grauer serves on the IRIS Board and is a past member of the Advisory Board of the North American Society of Veterinary Nephrology and Urology. He has authored or co-authored over 135 peer-reviewed articles and over 130 book chapters involving urinary tract disease of dogs and cats and is also one of the editors of the 2nd and 3rd editions of the British Small
Animal Association Manual of Canine and Feline Nephrology and Urology.