Guidelines

IRIS CKD Guidelines Updates 2014 - 2015
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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
OriginalNew
<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 Grading of Acute Kidney Injury (AKI)

Acute kidney injury (AKI) represents a continuum of renal injury from mild, clinically inapparent, nephron loss to severe acute renal failure. To emphasize the concept of AKI as a continuum, IRIS recommends that it be graded to accurately characterize the severity of the disorder. The IRIS AKI Grading scale (I-V) for dogs and cats is based on fasting blood creatinine determination and clinical parameters, such as urinary flow rate.

The development of this scheme was led by Dr. Larry Cowgill of the IRIS Board and was adopted by the IRIS Board, provisionally in 2012 and finally in 2013. The IRIS Board is now seeking feedback and recommendations for modifications from the American and European Societies of Veterinary Nephrology and Urology (ASVNU and ESVNU) and from the wider veterinary community.

The IRIS AKI Grading scheme is intended to aid the development of appropriate prognoses in patients with AKI. In the future, the Board intends to expand these guidelines to include recommendations for diagnostic testing and for treatment and monitoring of AKI, paralleling the widely accepted IRIS guidelines for Staging and Treatment of Chronic Kidney Disease (CKD).

» IRIS Guideline Recommendations for Grading of AKI in Dogs and Cats (2013)