Kidneydiseaseandthe Nexusofchronickidney Diseaseandacutekidneyinjury

Kidney Disease and the
N e x u s o f C h ro n i c K i d n e y
D i s e a s e an d A c u t e Ki d n e y In j u r y
The Role of Novel Biomarkers as Early and
Accurate Diagnostics
Murthy Yerramilli, PhD*, Giosi Farace, MSc, PhD, John Quinn, MS,
Maha Yerramilli, MS, PhD
KEYWORDS
Biomarkers Kidney Renal SDMA CKD AKI Diagnostics SDMA
KEY POINTS
Chronic kidney disease and kidney injury are interconnected; the presence of one is a risk
for the other.
It is necessary to develop species-specific and target organ–specific biomarkers that
result in sensitive and reliable diagnostic tests.
A combination of diagnostics that assesses kidney function and ongoing disorder (active
injury) will give practitioners a complete picture, allowing better patient management,
improved care, and better outcomes.
Symmetric dimethylarginine is a more reliable and earlier marker for chronic kidney dis-
ease than creatinine.
Kidney-specific clusterin, cystatin B, and inosine are all markers for the diagnosis of active
kidney injury in both cats and dogs.
KIDNEY DISEASE AND THE NEXUS OF CHRONIC KIDNEY DISEASE AND ACUTE KIDNEY
INJURY
The progression of chronic kidney disease (CKD) is characterized by continuously

advancing and irreversible loss of kidney function caused by loss of renal architecture
and individual nephrons characterized by progressive scarring that ultimately results in
structural damage to the kidney.1,2 General mechanisms include systemic and
glomerular hypertension, the renin-angiotensin-aldosterone system (RAAS), podocyte
Disclosure: The authors are employees of IDEXX Laboratories.

IDEXX Laboratories, Research & Development, 1-IDEXX Drive, Westbrook, ME 04092, USA
* Corresponding author.
E-mail address: [email protected]
Vet Clin Small Anim 46 (2016) 961–993

http://dx.doi.org/10.1016/j.cvsm.2016.06.011 vetsmall.theclinics.com
0195-5616/16/ª 2016 Elsevier Inc. All rights reserved.
962 Yerramilli et al
loss, dyslipidemia, and proteinuria. CKD is a silent disease that can remain asymptom-
atic until an advanced stage. Underlying CKD is one of the most important predictors
of vulnerability toward acute kidney injury (AKI) after exposure to risk factors such as
nephrotoxic drugs or major surgeries.
AKI is characterized by abrupt deterioration in kidney function and major causes
include nephrotoxic drugs such as nonsteroidal antiinflammatory drugs (NSAIDs)
and chemotherapeutics, infections, vasculitis, surgery, neoplasia, and blockage of uri-
nary tract by kidney stones. After AKI, renal function could be fully recovered in surviv-
ing patients; there could be incomplete recovery resulting in CKD; there could be
exacerbation of preexisting CKD, accelerating its progression; or there may also be
complete nonrecovery needing permanent renal replacement therapy.3–5
For a long time, CKD and AKI have been seen as two distinct diseases in isolation.
Lately, multiple epidemiologic and outcome analysis studies in humans have sug-
gested that the two diseases are not distinct entities but are closely associated and
interconnected with common risk factors and disease modifiers (Fig. 1). CKD is a
risk factor for AKI and vice versa. Persistent or repetitive injury over a period of time
could progress CKD.6–8 This latest understanding brings new perspectives to the
diagnosis and monitoring of kidney diseases, highlighting the need for a panel of
appropriate biomarkers that reflect functional as well as structural damage and recov-
ery, predict potential risk, and provide prognosis. The utility of these biomarkers
should go beyond diagnostic applications and provide insights into whether the dis-
ease is active (ie, continuously progressing) or pathologically stable. Such diagnostic
tools have the potential to change long-held clinical practice patterns and therapeutic
approaches, and help unravel elusive mechanisms concerning the nature of progres-
sive versus stable kidney disease. Early and accurate diagnosis could provide oppor-
tunities for timely and effective interventions and prevention of further disease
progression.
BIOMARKERS
A biomarker is defined as a physical, functional, or biochemical indicator of a physio-

logic or disease process that has diagnostic and/or prognostic utility with the ability to
Fig. 1. Nexus between CKD and acute kidney injury.

Kidney Disease and the Nexus of CKD and AKI 963
be measured accurately and reproducibly. The present role of biomarkers is rapidly

expanding beyond diagnosing progression and regression of diseases. Biomarkers
are becoming indispensable in accelerating drug discovery and development, in un-
derstanding the efficacy and toxicity of therapies, and in shortening the duration of
clinical trials by creating measurable and objective intermediate end points rather
than long-term hard end points such as survival time.9–12 The journey of a biomarker
from bench to clinic is long and difficult, as shown in Fig. 2.
There are a variety of biomarkers discovered and reported on regular basis, but very
few of them reach the clinics. There are several requirements and strict criteria that a
biomarker needs to meet to be an ideal marker and adopted into clinical practice.13
Some of these features are presented in Fig. 3.
CREATININE AS A KIDNEY FUNCTION BIOMARKER AND FALSE RESPONSES
Serum creatinine has been the standard-of-care test for kidney function and disease
for about 100 years. It is a breakdown product of muscle metabolism and correlates
with muscle mass.14–16 As a result, kidney function is overestimated in cachectic
low-muscled animals, whereas it may result in false diagnoses of kidney dysfunction
in heavily muscled animals. Creatinine metabolism must reach and remain at a steady
state to reflect kidney function, and this hampers detection of small losses of renal
function. In addition, differences that depend on gender, age, and race have been
observed in human patients. Because of these limitations, severe loss of kidney
Fig. 2. Journey of biomarkers from research laboratory to clinic.

Fig. 3. Characteristics of an ideal biomarker.
function may occur before significant changes in creatinine level are observed.17 How-
ever, trending within the reference range has been shown to improve the clinical per-
formance of creatinine measurements. There are also several issues associated with
the analytical measurement of the creatinine level using the Jaffe reaction, the most
commonly used method, including significant interference from endogenous com-
pounds, such as ascorbate, pyruvate, glucose, bilirubin, and ketoacids, that cause
overestimation of creatinine. Hemolysed samples can also cause issues because of
the increased release of the noncreatinine chromogens listed earlier.18 Lipemic and
icteric samples can interfere with the optical measurement and thus falsely lower
the creatinine result obtained. It has been shown that clinically relevant drug concen-
trations (eg, cephalosporins, aminoglycosides, trimethoprim, and phenacemide)
caused false increases in creatinine levels. The effect of these drugs was proportional
to the serum drug concentration and additive to the baseline concentration of serum
creatinine.19,20
It has also been shown that serum creatinine level increases after ingestion of
cooked meat products in humans and dogs, and that this increase occurs indepen-
dently of glomerular filtration rate (GFR).21,22 In dogs, serum creatinine concentrations
increased on average 0.4 mg/dL and were increased for several hours after feeding.
Most of the commercially available pet foods and treats contain cooked meats; hence
care should be taken in interpreting increased creatinine concentrations in nonstarved
animals.
There are multiple biological processes that affect creatinine concentrations inde-
pendent of kidney function, including hydration status, changes in tubular secretion,
and alterations in transport.17,23–27 In hypertonic dehydration, depletion of total
body water leads to hypernatremia in the extracellular compartment. This process
draws fluid from the intracellular compartment together with creatinine. Dehydration
therefore leads to increased circulating creatinine concentrations. Creatinine is mostly
eliminated when it passes from the blood into the urine through the glomerulus.
However, a significant percentage is secreted through the proximal tubule. In healthy

humans this has been estimated to account for 28% to 40% of total excreted creat-
inine. Tubular secretion of creatinine has been reported in the dog as well. There
are also some drugs that can influence biological processes that in turn could affect
creatinine concentrations independent of kidney function. The highly prescribed corti-
costeroid, prednisone, accelerates muscle metabolism, leading to increased creati-
nine concentrations.20 Also certain diseases, such as acute pancreatitis, seem to
nonspecifically increase creatinine concentrations, potentially caused by dehydration
and decreased blood flow.28,29
Even with all these significant limitations, creatinine assessment still remains the
standard of care for the evaluation of kidney function in both human and veterinary
medicine because finding new markers that offer significant performance improve-
ments compared with creatinine has proved to be extremely challenging. Instead of
moving toward new markers, human medicine has focused on the development of al-
gorithms (Cockcroft and Gault, Modification of Diet in Renal Disease [MDRD], Chronic
Kidney Disease Epidemiology [CKD-EPI]) that account for some of the gender and age
issues described earlier; however, there are some serious shortcomings of creatinine
that still remain unaddressed, highlighting the limitations of such approaches.17 No
such attempts have been made in veterinary medicine to derive even modest improve-
ments in the clinical performance of creatinine, leaving it as a poor biomarker for kid-
ney function in cats and dogs.
The frustrating inaccuracies associated with creatinine are a serious obstacle to the
qualification of new biomarkers when creatinine serves as the reference for compar-
ison. As an example, multiple studies involving biomarkers such as neutrophil
gelatinase-associated lipocalin (NGAL) in human medicine might have reached posi-
tive outcome had there been a true gold standard for AKI rather than defining AKI as
change in serum creatinine level.30 The dependence on creatinine sets up the new bio-
markers for poor accuracy and performance because of either false-positives (true
tubular injury but no significant change in serum creatinine) or false-negatives
(absence of true tubular injury, but increases in serum creatinine level) caused by pre-
renal issues or any of the several confounding variables that were discussed earlier. In
veterinary medicine, clinicians need to learn from these missteps taken in human med-
icine and need to be careful when evaluating new biomarkers for active kidney injury.
Rather than relying on creatinine, clinicians would be better served by focusing more
on the association between new biomarkers and clinical outcomes, treatments, and
reduction in adverse outcomes.
RENAL BIOMARKER DISCOVERY
Biomarker discovery is a complex and challenging process.31 The principal enabling

technology is mass spectrometry (MS) combined with disease-associated differential
analysis, a widely used approach in which statistically significant differences in the
expression of proteins or the production of metabolites between disease and control
cohorts identify potential biomarkers. Any biological fluids from clinically well-
characterized populations can be used in the discovery process. However, serum is
preferred because it is considered the most comprehensive circulating representative
of the proteome and metabolome of all body tissues and of both physiologic and path-
ologic processes. Also, the accessibility and vast clinical laboratory infrastructure that
is already in place for the analysis of serum once biomarkers reach the clinic makes it
the most suitable biological sample. However, this process needs to address the
complexity that comes from the presence of tens of thousands of proteins, peptides,
and metabolites with abundances spanning several orders of magnitude; for example,
from albumin to thyroxine.
The process and the work flow used in the discovery of the markers discussed in
this article is presented in Fig. 4. Serum and urine samples from clinically well-
characterized healthy and disease cohorts of dogs were analyzed using a combination
of advanced technologies and processes involving liquid chromatography mass
spectroscopy (LCMS), bioinformatics, and data analytics identifying differentially
expressed metabolites and proteins as potential biomarkers.
As examples, this research approach identified symmetric dimethylarginine (SDMA)
as an early marker for kidney function, along with urinary clusterin and cystatin B and
serum cystatin B and inosine as markers of active kidney injury. The biology and the
performance of these markers are discussed individually in this article.
KIDNEY-SPECIFIC BIOMARKERS
Biomarkers are not always specific to the organ of interest because some protein
markers are secreted by multiple tissues. As an example, clusterin messenger RNA
is ubiquitous in all animal tissues and is abundant in liver, stomach, brain, and testes.32
Similarly, NGAL is expressed and secreted by immune cells, hepatocytes, adipocytes,
epithelial cells, liver, lung, colon, and renal tubular cells in various pathologic states.33
Alkaline phosphatase is another example that is secreted by multiple tissues, and it is
used to assess liver function.34 However, the current diagnostic methods measure
both liver and bone alkaline phosphatase levels. These isoforms are both products
of the same gene, and the only difference is the posttranslational glycosylation, which
means that use of this marker to monitor either bone metabolism or liver dysfunction
can be compromised if a simple sandwich enzyme-linked immunosorbent assay
(ELISA) approach is adopted that measures all isoforms.
Hence it is important to measure proteins specifically from the target organ or dis-
order to avoid false diagnoses. This specificity could be accomplished by targeting
subtle differences such as posttranslational modifications (PTMs) that are specific
to the disease process in order to develop accurate diagnostics, as described later
for kidney-specific urinary clusterin (Fig. 5).
SYMMETRIC DIMETHYLATED ARGININE

Discovery
Symmetric dimethylated arginine (SDMA) and asymmetrical dimethylated arginine
(ADMA) were first isolated from human urine in 1970 by Kakimoto and Akazawa.35
They found that the excretion of these compounds was not from dietary sources
and thought it to be from an endogenous source. In 1992, Vallance and colleagues36
Fig. 4. Biomarker discovery workflow.

Fig. 5. Concept of organ-specific biomarkers.
reported an 8-fold increase in combined ADMA and SDMA levels in the serum
of hemodialysis patients. Marescau and colleagues,37 in 1997, reported that the con-
centrations of SDMA in both serum and urine correlated with the degree of renal insuf-
ficiency in nondialyzed patients with CKD and first suggested that serum SDMA was a
good indicator for the onset of renal dysfunction.
Biochemistry
Arginine is a conditional essential amino acid and most animals make their own. Post-
translational modification of protein arginine groups occurs in the mitochondria
involving the enzyme protein arginine methyltransferase, which results in 2 structural
isomers, SDMA and ADMA.38 N-monomethyl arginine (NMMA) is the intermediate
form of both dimethylated isomers; the structures of arginine and its methylated deriv-
atives are shown in Fig. 6. Arginine methylation primarily occurs in histones for the pur-
pose of transcriptional regulation. In general, asymmetric methylation of the arginine
(ADMA) activates transcription, whereas symmetric methylation (SDMA) is a repres-
sive signal.39 Proteolysis of these methylated proteins results in the release of
SDMA and ADMA into the cytoplasm and then from the cell into the circulation via
the y1 cationic transporters.40
Although ADMA has been shown to be an endogenous inhibitor of nitric oxide syn-
thase (NOS) and a marker for cardiovascular disease, SDMA does not interfere with
NOS activity36 or arginine transport at physiologic concentrations.41 Approximately
80% of circulating ADMA is eliminated through enzymatic pathways,42 making it a
poor marker for renal function. However, SDMA is strictly eliminated through the
Fig. 6. Chemical structures of arginine and its methylated derivatives.
kidneys by renal filtration and excretion, and so circulating concentrations are primar-
ily affected by changes in GFR and thus correlate with kidney function.43
Further evidence supporting that SDMA has no physiologic role was shown when
GFR, cardiac function, and blood pressure were found to be unchanged in mice
that received chronic infusions of SDMA for 28 days. Also, no renal histopathologic
changes were observed, thus strengthening the idea that SDMA does not play a
role in renal impairment.44
SYMMETRIC DIMETHYLATED ARGININE AS A MARKER FOR RENAL FUNCTION
SDMA was shown to correlate well with creatinine and renal insufficiency in a rodent
model using Sprague-Dawley rats and Swiss mice in which insufficiency was induced
by ligating branches of renal arteries or by removing the right kidney.45 In a similar
canine model in which dogs underwent either heminephrectomy or ligation of the
left renal artery and subsequent contralateral nephrectomy, circulating SDMA levels
were shown to increase as renal mass was reduced.46
SDMA was determined in a study of 257 people, consisting of healthy controls and
patients with CKD on dialysis and patients who had undergone kidney transplant.
SDMA levels were significantly increased in patients with CKD compared with the con-
trol population. Dialysis-dependent patients had even higher concentrations of circu-
lating SDMA, which returned to baseline posttransplant.47
Multiple additional studies have further established SDMA as a more specific, sen-
sitive, and accurate marker of renal function compared with serum creatinine.25,48–50
CORRELATION WITH GLOMERULAR FILTRATION RATE
GFR is the gold standard in determining kidney function in people and animals. How-
ever, GFR cannot be measured directly and instead is measured through the urinary or
plasma clearance of various small molecules, including inulin and iohexol. The plasma
clearance methods for determining a measured GFR (mGFR) require a bolus injection
of the small molecule and multiple, precisely timed measurements of the marker mole-
cule from blood collections documenting elimination of the marker, making the pro-
cess expensive and inconvenient. In human medicine, various formulas to account
for the impact of race and gender on the creatinine concentration are widely used
to calculate an estimated GFR (eGFR); however, they are not routinely used in veter-
inary practice.
Serum SDMA concentration has been shown to correlate well with mGFR in people,
establishing it as an endogenous marker of GFR. Studies comparing mGFR with
SDMA have included endogenous creatinine clearance, and inulin and iohexol clear-
ance.43,51 In 2006, Kielstein and colleagues43 provided an extensive summary of a
meta-analysis of 18 studies of SDMA predictions of kidney function involving 2136 hu-
man patients. SDMA concentrations correlated highly with inulin clearance as an es-
timate of mGFR.
The first evidence for using SDMA to assess renal disease in dogs using a remnant
kidney model was published in 2007 and showed a strong correlation of SDMA with
mGFR by inulin clearance.46 More recently, a linear relationship was shown between
GFR and SDMA levels in a population of cats52,53 and in carrier females and affected
males from a colony of dogs with X-linked hereditary nephropathy54 compared with
mGFR using iohexol clearance.
In another study involving client-owned cats with CKD, SDMA concentrations were
shown to increase and were correlated with serum creatinine.55 In addition, a study
evaluating hyperthyroid cats showed that SDMA level correlated better than serum
creatinine level with mGFR estimated by iohexol clearance before starting diet therapy
and at 6 months of follow-up.56
SYMMETRIC DIMETHYLATED ARGININE AS AN EARLY AND RELIABLE RENAL

BIOMARKER IN CATS AND DOGS
In cats53 and dogs,54,57 SDMA has been shown to be an earlier marker of kidney
dysfunction than creatinine, which is known to increase only after significant loss
of renal function. A recently published retrospective study in cats found that an in-
crease in SDMA above the upper reference limit of normal corresponded with an
average 40% loss in mGFR from baseline; however, in some cases changes in
mGFR as low as 25% were detected by increases in SDMA level. In this population
the increased SDMA level diagnosed CKD an average of 17 months earlier than creat-
inine.53 Fig. 7 shows a representative case of a cat from Hall and colleagues,53 in
which SDMA level increased above the upper reference limit 9 months earlier than
creatinine.
In this feline study,53 serum SDMA had a sensitivity of 100%, specificity of 91%,
positive predictive value (PPV) of 86%, and negative predictive value (NPV) of 100%
when using a 30% decrease from median mGFR (by iohexol) of colony cats as the
reference limit to confirm decreased renal function. The specificity and PPV of
SDMA were affected by what were considered as 2 false-positives. In both of these
cases, SDMA level was increased above the reference interval but mGFR was only
decreased by 25% below the median reference; this might mean that SDMA testing
was able to detect CKD even earlier in these cats. Meanwhile, in this same study,
serum creatinine had a sensitivity of only 17%, specificity of 100%, PPV of 100%,
and NPV of only 70%.
Fig. 7. The typical progression of SDMA and creatinine levels in a normal cat that developed
CKD. The red bars are the SDMA concentrations and the blue bars are creatinine. The line
represents the upper reference limit for both markers.
In a similar retrospective study in dogs with CKD, SDMA level increased an average
of 9.8 months earlier than serum creatinine and was significantly correlated with
mGFR. Fig. 8 shows one of the dogs from the study58 in which SDMA level increased
above the upper reference limit at least 20 months earlier than creatinine.
In a prospective study involving male dogs affected with X-linked hereditary nephrop-
athy and unaffected male littermates, SDMA remained unchanged in unaffected dogs,
whereas it increased during disease progression, correlating strongly with a decrease in
GFR in affected dogs. SDMA identified, on average, less than 20% decrease in GFR,
which was significantly earlier than recognized with serum creatinine.54
Preliminary results suggest that increased serum SDMA concentrations above its
upper reference limit and its ratio with creatinine may have prognostic value in dogs
Fig. 8. The typical progression of SDMA and creatinine levels in a normal dog that devel-
oped CKD. The red bars are the SDMA concentrations and the blue bars are creatinine.
The line represents the upper reference limit for both markers.
and cats with CKD.59 Results from the same study have also suggested that a new
biochemical pathway involving the enzyme AGXT2 may be resulting in discordance
between creatinine and SDMA clearance. The enzyme AGXT2 is a transaminase pre-
sent in glomeruli and catalyzes the conversion of glyoxylate to the essential amino acid
glycine. The enzyme uses beta aminoisobutyric acid (BAIB), which is a catabolic end
product of the pyrimidine degradation pathway, as an amine donor. Disorders such as
inflammation, fibrosis, and neoplastic infiltration can damage cells, resulting in the loss
of this enzyme, and as a result the enzyme substrates, glyoxylate and BAIB, accumu-
late in the kidney. Glyoxylate is converted to oxalate and can lead to the formation of
oxalate nephroliths, whereas BAIB is strongly cationic and can bind to the negatively
charged basement membrane, altering its polarity. Although the clearance of neutral
molecules such as creatinine is not affected by this change in polarity, the clearance
of SDMA, which is extremely cationic, is affected and this results in increased concen-
trations in circulation and thus may provide new diagnostic insights. However, these
findings are preliminary and require additional and detailed studies in a clinical
setting.59
SPECIFICITY OF SYMMETRIC DIMETHYLATED ARGININE AS A RENAL BIOMARKER
Multiple studies in different clinical scenarios have established SDMA as an extremely

specific and sensitive biomarker of renal function. A major shortcoming of creatinine
is its dependence on muscle mass, because it is the major metabolite of muscle
breakdown. As a result, its levels can be falsely increased in heavily muscled animals
and it can underestimate kidney function in these patients.60,61 In addition, cachectic
patients who are losing muscle mass or geriatric animals with low muscle mass may
have falsely low levels of creatinine, thus causing an overestimation of kidney
function.
In a prospective study of cats,60 the correlation of muscle mass with creatinine and
SDMA levels was investigated. GFR was determined in order to understand true kid-
ney function in these animals and changes in body mass and composition were
assessed by dual-energy X-ray absorptiometry, leading to the determination of total
mass, fat mass, and lean muscle mass. Cats were grouped into those less than
12 years old and those greater than 15 years old.
Table 1 shows that, as the cats aged, total lean muscle mass and GFR decreased in
group B compared with group A. Creatinine also decreased as the cats aged, even
though GFR decreased, meaning that creatinine level moved in the wrong direction,
showing that it is affected by decreased lean muscle mass. In contrast, SDMA level
increased, thus truly reflecting decreased renal function and signifying that it is unaf-
fected by changes in muscle mass.
In a similar prospective study of dogs, body composition was again determined
by dual-energy X-ray absorptiometry, and the correlations between lean mass,
creatinine level, and SDMA level were studied over 6 months (Fig. 9). Lean muscle
Table 1
Effect of lean body mass and GFR on creatinine and SDMA in cats
Total Muscle Creatinine

Group Age (y) GFR (mL/min/kg) Lean Mass (kg) Level (mg/dL) SDMA Level (mg/dL)
A <12 (n 5 11) 1.56 4.01 1.55 15.7
B >15 (n 5 10) 1.29 2.58 1.31 22.3
Fig. 9. The effect of lean body mass on creatinine levels in dogs. The box and whiskers cover
the 10th and 90th percentiles of the population at each lean body mass category with the
point representing the mean for each group. As the lean body mass increases, SDMA level
(box and whiskers on left hand side) is unchanged, whereas creatinine level (box and whis-
kers on right hand side) increases.
mass and age were significantly correlated with creatinine, whereas SDMA was
not.61
The population mean for SDMA in healthy humans,62 cats,53 and dogs54 is 9.6, 9.8,
and 9.6 mg/dL respectively. Considering the significant differences in size and lean
body mass, the virtually identical population mean concentrations further suggest
that SDMA is a true filtration marker uninfluenced by extrarenal factors such as age,
gender, and muscle. Note that Singer63 showed that the differences in GFR across
mammals are not significant when normalized to their metabolic rates.
Increased SDMA level reflects reduced renal function, so increased SDMA concen-
trations are found in multiple disorders when compounded by reduced renal function.
In a human acute inflammatory response model, SMDA levels were determined in
patients, without the confounding effects of multiple organ failure, and showed no sig-
nificant changes caused by inflammation.64 In patients with sepsis caused by lepto-
spirosis, studies showed no significant difference in SDMA levels compared with
those in patients without sepsis. Increases in SDMA levels only occurred when con-
current AKI was observed.65
Hepatorenal syndrome (HRS) is a major complication of end-stage cirrhosis in hu-
man patients and is characterized by functional renal failure. SDMA concentrations
were found to be elevated in these patients compared with those with cirrhosis but
there was no renal failure. Thus, renal dysfunction is a main determinant of increased
SDMA in patients with HRS, and SDMA level is not influenced by liver disease.66
Prolonged supplementation with L-arginine in women with preeclampsia produced
no changes in circulating SDMA concentrations.67 The authors have measured argi-
nine levels using LCMS in normal canine and feline populations and showed that
the SDMA is not affected by serum arginine concentrations (Fig. 10).
In human patients with stroke, SDMA was shown to be a highly sensitive and spe-
cific marker of renal function and a prognostic indicator of mortality.68 Increased
SDMA concentrations are associated with CKD and worse long-term prognosis in pa-
tients with myocardial infarction. Researchers concluded that SDMA accumulation
from reduced renal clearance reflects renal dysfunction. CKD is a known independent
risk factor for adverse outcome in cardiac patients. There is good correlation between
SDMA level and eGFR in this population. SDMA is a stronger predictor of cardiac
events exacerbated by renal dysfunction compared with serum creatinine–calculated
eGFR because SDMA level more accurately reflects filtration rate than serum creati-
nine level, and thus SDMA better identifies patients with a worse prognosis.69 The au-
thors have measured N-terminal pro–brain natriuretic peptide (NTproBNP) in nearly
300 dogs, including healthy and cardiac patients, and found no correlation between
the cardiac marker and SDMA (Fig. 11). Increased SDMA concentrations were
observed only in dogs that had compromised renal function.
The risk of CKD and AKI is a common problem in patients with cancer because of
the toxicity of the chemotherapeutics, which limits treatment. With the greater inci-
dence of cancer and particularly hematological malignancies, new therapies are being
developed with increased urgency. This work will undoubtedly lead to an increased
prevalence of kidney impairment and injury, which highlights the need for more effec-
tive and sensitive diagnostic biomarkers and tests. Although about 40% of human pa-
tients with lymphoma are known to have compromised kidney function, only 8% of the
affected patients are diagnosed by creatinine alone, whereas the remaining 32%
require biopsies70–73 for diagnostic accuracy. In France, the IRMA studies (Insuffis-
ance Rénale et Médicaments Anticancéreux [Renal Insufficiency and Anticancer Med-
ications]) studies have reported a prevalence of reduced GFR (<90 mL/min/1.73 m2) in
about 52% of a cohort of 5000 patients with different types of solid tumors. According
to the international definition and stratification of human CKD, the prevalence of
stages 3 to 5, excluding dialysis, was also high at about 12% in this population.74
There are several recognized causes of kidney impairment in cancer, including med-
ications, volume depletion, tumor lysis syndrome, obstruction, cancer infiltration, and
50 50
Cat Dog
45 45
40 40
35 35
Arginine, μg/dL
Arginine, μg/dL
30 30
25 25
20 20
15 15
10 10
5 5
0 0
0 20 40 60 80 100 120 0 20 40 60 80 100 120
SDMA, μg/dL SDMA, μg/dL
Fig. 10. Correlation between SDMA and arginine levels in cats and dogs showing that SDMA
level is not influenced by the circulating arginine concentration.
Fig. 11. Correlation between SDMA and NTproBNP levels showing that SDMA concentra-
tions are not dependent on circulating NTproBNP concentrations.
sepsis. The ineffectiveness of creatinine is likely caused by reduced production as a

result of cachexia, reduced protein intake, and medications to mention few. Although
such detailed information is nonexistent for veterinary patients at this time, there is no
reason to think the situation is any different.
It is possible that increased protein turnover in malignancies may lead to increased
production of dimethylarginines, including both ADMA and SDMA. However, in a
study that included different types of human hematological malignancies, ADMA but
not SDMA was shown to have significantly increased concentration in the population
with malignancies compared with the control group.75 Mean plasma levels of SDMA
were not different between the two groups (Table 2), further suggesting that any ob-
servations of increased SDMA levels in such disorders are likely caused by impaired
kidney function. This finding supports the hypothesis described earlier that, as cells
become malignant, increased protein turnover leads to increased ADMA production
as a result of transcriptional activation via asymmetric methylation of the arginine.
Despite a wealth of evidence over the last 45 years in the form of experimental and
clinical studies showing that SDMA level is a better measure of kidney function than
creatinine level, a lack of a convenient analytical method has slowed the routine
Table 2
ADMA and SDMA in control and human patients with malignancies
Mean Plasma Levels in Mean Plasma Levels

Analyte Group with Malignancies in Control Group P Value
ADMA (mmol/dL) 32 12.8 <.001
SDMA (mmol/dL) 10.7 9.6 .637
adoption of SDMA into clinics. Until recently, the measurement of SDMA level was
performed primarily using the expensive and complex technique of mass spectros-
copy. However, as of July 2015, a more convenient and accessible clinical chemistry
assay has been developed and marketed for routine veterinary diagnostics by IDEXX.
The International Renal Interest Society (IRIS) has recently recognized SDMA as a
biomarker for kidney function in dogs and cats.76
IMPACT OF EARLY NUTRITIONAL INTERVENTIONS
Early diagnosis of CKD allows the initiation of renoprotective interventions that could
potentially slow the progress or stabilize the disease. Dietary modifications are easy to
implement and have high pet owner compliance, and, so far, feeding renal diets to
cats and dogs with IRIS CKD stage 2 or higher has been considered the standard
of care with strong clinical evidence for its effectiveness. Proven dietary modifications
include decreased protein, phosphorous, and sodium, along with soluble fiber, omega
3 and 6 fatty acids, and antioxidants.2,77
A recent study of geriatric client-owned cats with early stage kidney disease,
consistent with IRIS CKD stage 1, found that cats that were given a renal diet were
more likely to maintain their serum SDMA concentrations than cats that continued
to consume foods of the owner’s choice. These results suggest that nonazotemic
cats with increased serum SDMA levels (early renal insufficiency) fed a food designed
to promote healthy kidneys are more likely to show stable renal function compared
with cats fed owner’s-choice foods. However, cats not receiving a renoprotective
diet are more likely to show progressive renal insufficiency.78
In a similar study involving geriatric dogs with kidney disease consistent with IRIS
stage 1, only dogs consuming the renal diet showed significant decreases in serum
SDMA and Cr concentrations (both P.05) across time. Compared with baseline,
dogs that received the renal diet for 6 months showed decreases in serum SDMA level
in 8 out of 9 cases, whereas of those that remained on owner’s-choice foods for
6 months, approximately 50% increased their serum SDMA and Cr concentrations.
These results suggest that nonazotemic dogs with early renal insufficiency and
increased serum SDMA level are more likely to show improved kidney function
when put on renal diets.79
URINARY CLUSTERIN
Clusterin, also known as apolipoprotein J, is a highly glycosylated extracellular chap-

erone.80–82 It is expressed from a broad spectrum of tissues and is part of many phys-
iologic processes, including sperm maturation, lipid transportation, complement
inhibition, tissue remodeling, membrane recycling, and stabilization of stressed pro-
teins, and is an inhibitor of apoptosis.83–91 Although urinary clusterin concentrations
are increased in kidney tubular damage, serum clusterin concentrations are affected
in several physiologic and pathophysiologic processes, including sperm develop-
ment, Alzheimer disease, atherosclerosis, and cancer.92–94 Urinary clusterin as a
marker of renal damage has been evaluated in a population of dogs with leishmani-
asis, in which a statistically significant increase in clusterin concentrations was
observed.95 A second study evaluated clusterin levels in beagles with AKI induced
by gentamycin, and the results showed a significant increase in clusterin concentra-
tions following the drug-induced injury.96
Clusterin exists in two forms: secreted and nuclear. Although secretory clusterin
delays apoptosis, nuclear clusterin triggers cell death. The secreted form consists
of two 40-kDa chains derived from a single polypeptide precursor, alpha (amino
acid residues 206–427) and beta (amino acid residues 1–205), which are connected by
5 symmetric disulfide bonds.97 The secreted form also undergoes significant PTMs,
including N-glycosylation. These PTMs are specific to the disease process and also
to the tissue of origin.
Urinary clusterin is part of the US Food and Drug Administration and International
Council on Harmonisation of Technical Requirements for Registration of Pharmaceuti-
cals for Human Use (ICH) renal biomarker panels for drug development and toxicity.98
A differential expression experiment consisting of healthy and kidney disease cohort
dogs as described earlier also identified clusterin as a marker of kidney injury.
There are several immunoassays that have been developed and marketed for
measuring clusterin levels in various body fluids, including plasma, serum, and urine.
Urinary clusterin has most characteristics required of a biomarker of kidney
damage or disease. It is expressed in urine at low to undetectable levels in the
healthy kidney, and its levels increase significantly in response to an injury. In addi-
tion, urinary clusterin levels have been found to decrease in response to recovery
from kidney injury.
Serum concentrations of clusterin (60–100 mg/mL) are 1000-fold higher than the uri-
nary concentrations (<100 ng/mL) in healthy humans and dogs. Contamination of a
urine sample with blood at levels as low as 0.2% (v/v) could lead to false-positives.
This problem is more acute in veterinary medicine, because of infection, trauma,
neoplasia, inflammation, and accidental contamination during catheterization and
cystocentesis, with recognition that 33% of canine and 54% of feline urine samples
submitted to a commercial reference laboratory have some level of blood contamina-
tion. The blood contamination brings nonspecific clusterin isoforms into the urine, and
hence it is important to ensure that only kidney-specific clusterin is measured.
To show the complications of false-positive results from contamination by nonspe-
cific clusterin, the clusterin concentration was determined in a control canine urine
sample using a commercial kit and then spiked with normal canine serum (0.002%
to 10% v/v). The resulting mixtures were analyzed and the results obtained are shown
in Table 3.
At contamination levels of more than 0.5%, the clusterin concentration is above the
upper reference limit of 70 ng/mL for the assay, resulting in a false-positive result.99
The urine from healthy canines was examined by urinalysis dipstick (IDEXX Labora-
tories) for the presence of blood. Urinary clusterin levels were measured using a
commercially available two-site immunoassay kit according to the manufacturers’ in-
structions (Biovendor Research and Diagnostic Products). As shown in Table 4,
Table 3
Negative impact on urinary clusterin quantitation when whole blood is spiked into control
urine as determined with a commercial assay
Sample Whole-blood Contamination (%) Clusterin (ng/mL)

Negative Urine 0 13.0
0.01-mL Spike 0.01 16.4
0.5-mL Spike 0.05 36.8
1-mL Spike 0.1 50.3
5-mL Spike 0.5 257.4
10-mL Spike 1 539.0
50-mL Spike 5 1321.3
100-mL Spike 10 2370.8
Table 4
Negative impact on urinary clusterin quantitation in normal canine urines contaminated with
whole blood as determined with a commercial assay
Sample Biovendor Clusterin Assay Urine Dipstick Blood Pad Result

1 <LOQ Negative
2 <LOQ Negative
3 29 Negative
4 <LOQ Negative
5 1045 3
6 1015 3
7 760 3
8 65,000 3
Abbreviation: LOQ, lower than the limit of quantitation.
healthy canines with no detectable blood in their urine had levels of clusterin within the
reference range (70 ng/mL); however, those having blood contamination (samples 5–
8) had clusterin levels 10 to 100 times above the normal reference range and would
result in strong false-positives.
To accurately measure the clusterin levels associated with active kidney injury it is
therefore necessary to measure only the kidney-specific isoform. An in vitro cellular
model was developed that mimics the proximal tubule using cultured canine kidney
cells. Stressing these cells with nephrotoxic gentamicin (Fig. 12) provided kidney-
specific clusterin mimicking the time-dependent in vivo physiologic response in a
dog given gentamicin. Meanwhile, the plasma isoform was purified from canine whole
blood. By screening with lectins, a family of proteins that recognize different sugar
moieties, the glycosylation pattern of the two isoforms was found to be different.
A sandwich format immunoassay was developed using the lectin that showed the
highest affinity for kidney-specific clusterin isolated from the in vitro model together
Fig. 12. Effect of gentamicin on the secretion of kidney-specific clusterin in a canine kidney
cell line (squares) and in vivo in a dog (diamonds).
with a-specific monoclonal antibody raised against clusterin. To show the specificity
of the kidney-specific clusterin immunoassay (KSCI), fresh whole blood or plasma
from a healthy dog was spiked into buffer and analyzed using both the KSCI and
the Biovendor assay.
As shown in Fig. 13, clusterin was detected at significantly high concentrations
in both matrices by the commercial assay but not the KSCI. Taking into considera-
tion that a high percentage of urine samples from healthy dogs and cats have
blood contamination, the only way to accurately measure clusterin level is to use a
KSCI.
Kidney-specific clusterin level was measured in urine from a canine gentamicin
model (Fig. 14) and the urines of dogs presenting to a clinic with inflammatory or
ischemic-induced active kidney injury (Fig. 15). In the model system, dogs were given
40 mg/kg gentamicin daily for 5 days. In this dog, serum creatinine was essentially un-
changed throughout the study, whereas kidney-specific clusterin level increased
rapidly, reaching 5 times baseline when dosing was stopped and peaked at 10 times
baseline at day 11. This finding shows that clusterin is an earlier and more sensitive
marker than serum creatinine for active kidney injury. In the patient samples there is
a clear separation between healthy patients and those diagnosed with active kidney
injury.
Preliminary results (not shown) have shown the feasibility of the current kidney-
specific urinary clusterin immunoassay for feline samples as well.
In conclusion, kidney-specific clusterin is a sensitive and specific marker for active
kidney injury in companion animals.
URINARY AND SERUM CYSTATIN B
The cystatins are a family of protein inhibitors of cysteine proteases and are ubiqui-
tous in mammals. They are composed of 3 main individual families, as shown in
Fig. 16.100 All these cystatins share high sequence homology and a common tertiary
structure of an alpha helix lying on top of antiparallel beta sheets. Cystatin C, the
3000
Blood KSCI
2500 Blood Commercial Assay
Serum KSCI
Serum Commercial Assay
Clusterin, ng/mL
2000
1500
1000
500
0
1000 2000 4000 8000 16,000 32,000 64,000 128,000
Diluon of Matrix
Fig. 13. Comparison of the performance of kidney-specific clusterin and commercial clus-
terin immunoassays when negative urine was spiked with whole blood and serum. The
blue (whole blood) and green (serum) lines are the results from the kidney-specific assay
and the red (whole blood) and black (serum) lines are the results from the commercial assay.
2 4000
1.8
3500
1.6
3000
Serum Creanine, mg/dL
Urinary Clusterin, ng/mL

1.4
2500
1.2
1 2000
0.8
1500
0.6
1000
0.4
500
0.2
0 0
–10 –5 0 5 10 15 20
Study Day
Creanine Clusterin
Fig. 14. Kidney-specific urinary clusterin level measured in a dog from the gentamicin model
study. Gentamicin was administered daily for 5 days at 40 mg/kg and serum and urine sam-
ples were collected daily for 15 days. The blue line is the serum creatinine level and the red
line is urinary clusterin.
most familiar of these proteins, along with cystatins D and S are 14 kDa, have 2 di-
sulfide bonds, and belong to family 2. Cystatin C is freely filtered through glomeruli
and is considered to be a marker for GFR.101 Kininogens are much larger and highly
glycosylated plasma proteins and are part of family 3. They are composed of a
single polypeptide chain and contain 2 inhibitory domains homologous to cystatins
of family 2. Kininogens are multifunctional and are involved in multiple biological pro-
cesses and disorders, including blood coagulation, acute phase response, and car-
diac disease.100
Cystatins A and B are members of family 1 and are small monomeric proteins of
around 11 kDa. They are not glycosylated and do not have the disulfide bridges
seen in larger family 2 and family 3 proteins. They also lack signal sequences and
so are generally intracellular proteins confined to the cell.100 Some cystatin B is pre-
sent in extracellular fluids, and it has been purified from human urine.102 Cystatin B
has been shown to inhibit members of the lysosomal cysteine proteinases, cathepsin
family, specifically cathepsins B, H, and L.100,103–105
Mutations of cystatin B have been found in progressive myoclonus epilepsy of the
Unverricht-Lundborg type (EPM1).106 EPM1 is a rare autosomal recessive disease that
results in neurologic dysfunction that leads to dementia, cerebellar ataxia, and
dysarthria.107,108
A differential expression experiment consisting of healthy and kidney disease cohort
dogs (as described earlier) identified several peptides from cystatin B in the disease
cohort. However, the UniProt (Universal Protein Resource) database109,110 describes
a protein that is truncated to 76 amino acids in the cat and 77 amino acids in the dog,
Fig. 15. Box and whiskers plot of kidney-specific urinary clusterin from clinically healthy
dogs (n 5 7) and dogs with diagnosed AKI (n 5 12), showing the ability of the biomarker
to differentiate the two populations.
compared with 98 amino acids in other mammalian species, including humans. The
missing 22 (cat) and 21 (dog) amino acids represent the N-terminus of the protein
and without the intact protein it is not possible to accurately measure concentrations
of cystatin B.
Canine cystatin B was purified from canine kidney cells and the full sequence was
determined by tryptic digestion followed by LCMS. Through this approach the
following sequence shown in Fig. 17 was identified. A recombinant protein was
Fig. 16. Cystatin superfamily. HRGP, histidine rich glycoprotein.

Fig. 17. Full amino acid sequence of canine and human cystatin B.
created using this sequence and was shown to be identical to native protein extracted
from canine kidney cells using LCMS.
Cystatin B is an intracellular protein and generally not freely circulating in large
concentrations. This finding was further confirmed when no protein was found in
the supernatant collected from stressed canine kidney cells. However, cystatin B
was purified from ruptured canine kidney cells. Therefore, any cystatin B that is
detected in serum or urine must result from the rupture and death of tubular
epithelial cells. In active kidney injury, apoptosis and necrosis of epithelial cells in
the proximal tubule is likely to result in increased serum and urinary cystatin B levels
(Fig. 18).
Nothing has been published linking cystatin B and kidney disease in companion an-
imals. A recent study in humans111 for the first time showed alterations in protease
profiles of urinary extracellular vesicles from patients with diabetic nephropathy,
resulting in the increase in cystatin B levels and showing a link between cystatin B
and kidney disease.
Monoclonal antibodies were raised against the recombinant canine cystatin B and
their specificity confirmed using Western blot analysis of purified native samples
(Fig. 19). A sandwich ELISA was also developed using these antibodies.
Cystatin B was measured using the ELISA in serum and urine from a canine genta-
micin model (Fig. 20) and the urines of dogs presenting to a clinic with inflammatory
or ischemic-induced active kidney injury (Fig. 21). In the model system, dogs were
given 10 mg/kg gentamicin every 8 hours until serum creatinine level reached
1.5 mg/dL. That point was reached on day 8; whereas serum cystatin B level was
increased over baseline on day 1. These preliminary results suggest that cystatin
B is an earlier marker than creatinine for active kidney injury. In the patient samples
with naturally occurring kidney disease there is a clear separation between healthy
patients and those diagnosed with active kidney injury. In most of the patients
with urinary tract infections (UTIs), cystatin B concentrations were similar to those
of healthy dogs.
The feasibility of this assay for feline samples has also been shown. From these early
results, cystatin B is emerging as a promising new marker for active kidney injury in
both serum and urine, which requires further detailed clinical field studies before the
marker can be available for routine use in the clinic.
Fig. 18. Potential mechanism of cystatin B release in AKI.

Fig. 19. Western blot of purified cystatin B from 3 different canine urine samples. Lane 1 is
the reference molecular weight ladder and lanes 2 to 4 are the canine urine samples. All 3
samples contain the cystatin B monomer, whereas the sample in lane 3 also has some dimeric
cystatin B.
SERUM INOSINE
Lately the role of adenosine metabolism, signaling, and receptor binding in processes
related to renal fibrosis and kidney injury, such as ischemia, hypoxia, and apoptosis,
has attracted substantial attention.112,113 ATP is the energy source of the cell, and its
levels decrease during cellular energy demand. ATP is sequentially hydrolyzed to ADP,
to AMP, and then to adenosine. The extracellular actions of adenosine are mediated
by the binding of the nucleotide to 4 types (A1R, A2aR, A2bR, and A3R) of G protein–
coupled adenosine membrane receptors.
It is suggested that endogenous adenosine is formed by renal tubular epithelial
cells.114 Inhibition of cellular uptake of adenosine increases the interstitial adenosine
concentrations, leading to decreased circulating concentrations and resulting in a sig-
nificant decrease in renal blood flow and GFR. This process suggests that the renal
hemodynamics depend on the adenosine concentrations in the interstitium. The inter-
stitial concentrations of adenosine are generally low but significantly increase during
hypoxia and inflammation through the hydrolysis of ATP and subsequent release
from injured or apoptotic cells.115
It has been shown in a canine hypoxia model that the accumulated interstitial aden-
osine is converted mainly into inosine by adenosine deaminase.116 Increased circu-
lating concentrations of plasma adenosine result in renal vasodilator response in
most parts of the renal vasculature, including larger renal arteries, juxtamedullary
90
80
70
Biomarker Concentra on 60
50
40
30
20
10
0
0 5 10 15
Study Day
Crea nine, mg/dL Cysta n B, ng/mL
Fig. 20. Kidney-specific serum cystatin B levels measured in a canine gentamicin model.
Gentamicin was given at 10 mg/kg every 8 hours until creatinine (blue) reached 1.5 mg/dL.
Kidney-specific cystatin B level (red) increased several days earlier.
afferent arterioles, efferent arterioles, and medullary vessels. However, the efferent
arteriole closer to the glomerulus responds to adenosine with vasoconstriction.
It was shown that adenosine is deaminated to inosine in the isolated basolateral
membrane (BLM) of kidney proximal tubules by adenosine deaminase. It further has
been shown that the inosine reduced Na1-ATPase activity significantly by inhibiting
the sodium pump mediated by the A1 receptor/Gi/cyclic AMP pathway. Our biomarker
discovery research has identified inosine as a biomarker for AKI through the differen-
tial expression technique described earlier in this article. The plasma and serum con-
centrations of inosine decreased rapidly and significantly following nephrotoxin
exposure in canine gentamicin (Fig. 22)117 and dichromate models of AKI (Fig. 23).
The results suggested that inosine is not only one of the most sensitive biomarkers
to injury but that it also responds to mark the recovery from the injury by the restoration
to the normal circulating concentrations. It is likely that injury to the tubular epithelial
cells by these nephrotoxins resulted in the loss of adenosine deaminase activity pre-
venting the conversion of adenosine to inosine, leading to depletion of circulating
inosine.
NEUTROPHIL-ASSOCIATED LIPOCALIN
Neutrophil-associated lipocalin (NGAL) (also known as 24p3, SIP24, lipocalin 2, or

siderocalin) is a 24-kDa protein that binds iron-containing ligands (siderophores). It
was originally discovered in human neutrophils,118 but is found in several different tis-
sues, including skin, alveolar and oral mucosa, adipose tissue, and proximal and distal
tubules.33 It is markedly induced in injured epithelial cells, including kidney, colon,
liver, and lung, and in neoplasia. Its primary function is not clear but is probably asso-
ciated with its ability to bind extracellular iron. It can bind siderophores produced by
Fig. 21. Box and whiskers plot of kidney-specific cystatin B levels measured in urines of dogs
that were diagnosed as either being healthy (n 5 14), having an AKI (n 5 16), or having a
urinary tract infection (UTI) (n 5 13). The plot shows that urinary cystatin B can differentiate
dogs with AKI from the healthy and UTI populations.
both prokaryotes and eukaryotes. The binding of prokaryotic siderophores elicits a

bacteriostatic effect by sequestering iron, whereas binding eukaryotic siderophores
helps shuttle iron across cellular membranes used in cellular proliferation and
differentiation.30
There is growing evidence and support for the use of NGAL as an AKI biomarker
within the human medical community, with several studies showing increased plasma
levels and serum and urinary NGAL concentrations in AKI events secondary to cardiac
surgery, contrast-induced nephropathy, and kidney transplant.30 In dogs, several
studies have found that NGAL concentration is increased in AKI earlier than serum
creatinine.119,120
Several potential issues have been noted for NGAL that could limit its adoption as a
kidney marker. It has been observed that NGAL seems to perform best in homoge-
nous patient populations with temporally predictable forms of AKI, and that there
are significant correlations with age and gender.30,33,121 Also, serum NGAL level has
been found to correlate with alanine transaminase, aspartate transaminase, choles-
terol, and high-sensitivity C-reactive protein. Circulating concentrations of NGAL
may also be influenced by coexisting conditions such as CKD, chronic hypertension,
systemic infections, inflammation, anemia, and hypoxia.122
Significant upregulation is observed in common inflammatory diseases such as
eczema, periodontitis, and ulcerative colitis, and in metabolic disorders such as
400
300
Serum Inosine, μg/dL
200
100
0
0 10 20 30 40 50 60
Day
Fig. 22. Serum inosine concentration in a canine gentamicin model. The dog was given
8 mg/kg gentamicin for the first 7 days of the study and then 10 mg/kg until serum creati-
nine level increased 50% from day 0; this occurred on day 16. The increasing and decreasing
concentrations of the biomarker during the study represent injury and recovery cycles.
obesity and type II diabetes in human patients. It is also overexpressed in several solid
tumor malignancies, including skin, thyroid, breast, liver, and stomach.33 In addition,
urinary NGAL concentrations also seem to be heavily correlated with serum creatinine
level, GFR, and proteinuria.122
180
160
140
Serum Inosine, μg/dL
120
100
80
60
40
20
0
0 12 24 36 48 60 72 84 96 108 120 132 144 156
Time, hrs
Fig. 23. Serum inosine levels measured in a canine dichromate model. The dog was given
dichromate before time 5 0 hours and samples were taken every 12 hours for 7 days. As di-
chromate was cleared from the circulation the biomarker concentration returned to base-
line, indicating recovery of kidney function.
OTHER RENAL BIOMARKERS
Several other novel renal biomarkers have been described in human medicine,
including cystatin C, kidney injury molecule-1, retinol binding protein, trefoil factor 3,
insulinlike growth factor binding protein-7, and tissue inhibitor of metalloproteinase-
2.123–125 However, there is very limited information about their applicability to veteri-
nary medicine at this time.
SUMMARY
Active injury and chronic disease are interconnected syndromes and not two distinct,
and different, entities (see Larry D. Cowgill, David J. Polzin, Jonathan Elliott, et al:
“Is Progressive Chronic Kidney Disease a Slow Acute Kidney Injury?,” in this issue).
Preexisting CKD is a risk factor for active injury and AKI is a risk factor for the initiation
and progression of CKD.
Creatinine has been the standard of care for the past 100 years but it is only relevant
after 75% of kidney function is lost, and it provides little information about ongoing
active injury in the patient. Therefore, there is a need in both human and veterinary
medicine for biomarkers that diagnose, predict risk and prognosis, and measure re-
covery following therapeutic interventions.
As described earlier, small molecules and protein biomarkers can be generated
from multiple tissues and metabolic pathways that have no involvement in kidney
disease, leading to potential nonspecificity issues. The only way to overcome this
problem is to develop analytical methods/tests that specifically measure bio-
markers generated by the kidney. It is also important that biomarkers are not influ-
enced by extrarenal factors such as age, gender, breed, muscle mass, and
hydration status.
Often decisions about the usefulness of biomarkers are made using reagents and
test kits that have been developed for human diagnostics and that may either have
poor reactivity toward the canine and feline markers or be overly affected by the sam-
ple matrices, leading to inaccurate clinical conclusions. Therefore, it is necessary to
develop species-specific diagnostic tests that provide accurate measurements for
veterinary patients.
As presented in this article, serum SDMA is an earlier biomarker than serum creat-
inine for diagnosing and monitoring CKD in cats and dogs on an average of 17 and
10 months, respectively, allowing more time for practitioners to positively intervene.
Further, unlike creatinine, SDMA is not influenced by muscle mass, age, and breed.
The commercially available IDEXX SDMA assay is specifically developed for veterinary
applications and validated for both cats and dogs.
This article presents multiple examples of this approach using advanced analytical
tools, including LCMS and bioinformatics, to identify canine clusterin and canine cys-
tatin B from well-characterized clinical samples and then obtain native proteins from
canine kidney cells. These purified proteins are then being used to develop kidney-
specific diagnostic assays.
The combination of diagnostics that assess kidney function (SDMA) and ongoing
pathology in patients (active injury markers) gives practitioners a complete toolkit to
better manage patients, improve care, and achieve better outcomes.
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Kidney Disease and the

The progression of chronic kidney disease (CKD) is characterized by continuously

Disclosure: The authors are employees of IDEXX Laboratories.

Vet Clin Small Anim 46 (2016) 961–993

A biomarker is defined as a physical, functional, or biochemical indicator of a physio-

Fig. 1. Nexus between CKD and acute kidney injury.

be measured accurately and reproducibly. The present role of biomarkers is rapidly

CREATININE AS A KIDNEY FUNCTION BIOMARKER AND FALSE RESPONSES

Fig. 2. Journey of biomarkers from research laboratory to clinic.

Fig. 3. Characteristics of an ideal biomarker.

However, a significant percentage is secreted through the proximal tubule. In healthy

RENAL BIOMARKER DISCOVERY

Biomarker discovery is a complex and challenging process.31 The principal enabling

SYMMETRIC DIMETHYLATED ARGININE

Fig. 4. Biomarker discovery workflow.

Fig. 5. Concept of organ-specific biomarkers.

Fig. 6. Chemical structures of arginine and its methylated derivatives.

SYMMETRIC DIMETHYLATED ARGININE AS A MARKER FOR RENAL FUNCTION

CORRELATION WITH GLOMERULAR FILTRATION RATE

SYMMETRIC DIMETHYLATED ARGININE AS AN EARLY AND RELIABLE RENAL

SPECIFICITY OF SYMMETRIC DIMETHYLATED ARGININE AS A RENAL BIOMARKER

Multiple studies in different clinical scenarios have established SDMA as an extremely

Total Muscle Creatinine

sepsis. The ineffectiveness of creatinine is likely caused by reduced production as a

Mean Plasma Levels in Mean Plasma Levels

IMPACT OF EARLY NUTRITIONAL INTERVENTIONS

Clusterin, also known as apolipoprotein J, is a highly glycosylated extracellular chap-

Sample Whole-blood Contamination (%) Clusterin (ng/mL)

Sample Biovendor Clusterin Assay Urine Dipstick Blood Pad Result

Abbreviation: LOQ, lower than the limit of quantitation.

URINARY AND SERUM CYSTATIN B

Urinary Clusterin, ng/mL

Fig. 16. Cystatin superfamily. HRGP, histidine rich glycoprotein.

Fig. 18. Potential mechanism of cystatin B release in AKI.

Neutrophil-associated lipocalin (NGAL) (also known as 24p3, SIP24, lipocalin 2, or

both prokaryotes and eukaryotes. The binding of prokaryotic siderophores elicits a

OTHER RENAL BIOMARKERS

2. Polzin DJ. Evidence-based step-wise approach to managing chronic kidney

59. Yerramilli M, Yerramilli M, Obare E, et al. Prognostic value of symmetric dimethy-

98. Available at: http://c-path.org/. Accessed September 3, 2016.

119. Segev G, Palm C, LeRoy B, et al. Evaluation of neutrophil gelatinase-associated

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