Review

J Vet Intern Med 1999;13:516528

Progression of Chronic Renal Disease in the Dog

Delmar R. Finco, Scott A. Brown, Cathy A. Brown, Wayne A. Crowell, Tanya A. Cooper, and Jeanne A. Barsanti
Progressive loss of nephron function may be caused by persistence of factors that initiated renal disease. However, newer studies suggest that nephron damage is self-perpetuating once renal mass is reduced to some critical level. Original theories on mechanisms of self-perpetuated nephron injury focused on intraglomerular hypertension and glomerular hypertrophy, but several other factors have now been incriminated, including tubulointerstitial responses, proteinuria, and oxidative stress. Studies of dogs with surgically reduced renal mass (remnant kidney model of chronic renal disease) have allowed investigation of the self-progression theory in this species. Use of this model eliminates pre-existing renal disease as a confounding factor. Data from these studies indicate that self-perpetuated renal injury is initiated when mild azotemia is induced (plasma creatinine concentration 2 to 4 mg/dL). Thus, with naturally occurring renal disease(s), it is likely that self-perpetuated nephron damage is occurring before or at the time when most cases of chronic renal disease are diagnosed. In dogs with remnant kidneys, loss of renal function often occurs at a linear rate over time, but non-linear patterns are common as well. The reciprocal of plasma creatinine concentration, which has been used to monitor rate of progression, is only a fair marker of renal function when compared to GFR. Thus, clinical results from creatinine measurements on cases of naturally occurring disease should not be interpreted too stringently. In remnant kidney dogs, the magnitude of proteinuria (UPC ratio) was not predictive of the rate in decline of GFR, casting doubt on importance of proteinuria in causing progression of renal disease. However, progressive increases in UPC may be a marker of an accelerated rate of renal injury. Self-perpetuation of renal injury in dogs could be the sole mechanism by which naturally occurring renal diseases progress. When more information is available on the rate of progression of naturally occurring diseases, it may become apparent whether factors initially inciting renal damage have an additive effect on rate of progression. Key words: Dog; Remnant kidney; Self-perpetuation.

linical impression suggests that naturally occurring chronic renal failure in the dog is a progressive malady, ending in uremia and death. This impression is so commonly accepted that documentation of this progression is strikingly meager. We are aware of only a single report, based on measurements of plasma creatinine concentration, that addresses the rate of progression of chronic renal failure in dogs.1 Knowledge about the progression of renal fail1 Homer Smith, an eminent renal physiologist of the past, made the following statements in his classic 1951 book16: This writer does not have much more condence in the white rat as an experimental animal for comparison with man than he does in the rabbit. It should be noted that the Wistar strain, for example, comes from the King A albino strain established by Helen Dean King at the Wistar Institute in 1904, and has been bred successively for 139 generations. Although in recent years it has been crossbred rather than inbred, the net biologic effect of selection within the strain for rapidity of maturation, size of litters, docility, etc. has not been evaluated. Had a sibling pair of H. sapiens or Canis familiaris been selected on a similar basis and inbred or narrowly crossbred for 139 generations (at 25 years to a generation, from 1525 BC) few students of physiology would expect them to react to stresses in a manner comparable to H. sapiens or Canis familiaris, both of which are generally represented in physiological investigations by mongrel individuals. From the Department of Physiology and Pharmacology (Finco, S.A. Brown, Cooper), Veterinary Pathology (C.A. Brown, Crowell), and Small Animal Medicine and Surgery (Barsanti), College of Veterinary Medicine, The University of Georgia, Athens, GA. Address correspondence to: Dr. Delmar R. Finco, University of GeorgiaCVM, Department of Physiology and Pharmacology, Athens, GA 30602-7389. Submitted January 27, 1999; Revised June 18, 1999; Accepted July 23, 1999. Copyright 1999 by the American College of Veterinary Internal Medicine 0891-6640/99/1306-0002/$3.00/0

ure is valuable for both prognostic and therapeutic purposes. Owners of dogs with chronic renal failure want information on expected lifespan and therapeutic measures that might increase lifespan while ensuring comfort for their pet. Efforts to slow progression of renal failure are a signicant part of its management, in view of the limited therapeutic options. Traditionally, the progression of chronic renal disease has been attributed to the persistence of the original cause or causes of renal damage. In dogs and other species, the causes often escape detection. Whether the cause is known or unknown, renal diseases often are categorized based on anatomic lesions to help us understand their pathogenesis. Dogs with severe glomerular lesions (glomerulonephritis or amyloidosis) usually have a marked proteinuria and some of these cases have been attributed to immunologic mechanisms.2 However, the etiology is entirely speculative for the more commonly encountered forms of chronic renal disease in dogs, in which tubulointerstitial lesions predominate and only mild to moderate proteinuria exists.3 Because of our ignorance, we may be lumping many diseases with different causes into one or a few categories, even though the progressions may be different when the causes are different. When the cause of disease is unknown and the disease is progressive, we might assume that the inciting factor has persisted. However, the natural history of many diseases includes periods of remission and exacerbation. These variations could explain changes in the apparent rate of disease progression, apart from the effects of any therapeutic or management measures taken. In the 1980s, a revolutionary theory was proposed that has fundamentally changed our perception of the mechanisms of renal disease progression. This theory postulated that when renal mass is reduced to some critical value, sub-

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sequent damage is a self-perpetuating phenomenon that continues even if the initiating cause(s) of renal dysfunction are eliminated.4 Since its proposal, the self-perpetuation theory has been examined exhaustively for its validity and potential mechanisms and for associated therapies that might modify the rate of disease progression. These examinations have been conducted primarily in certain strains of highly inbred rats, with the hope or assumption that information acquired from them applies to other species.1 Although most available data are from rats, some studies also have been performed in other species. This article summarizes information about the progression of renal failure that has been collected from species studied more extensively than the dog, then provides data gathered specically from dogs. We hope this information will help veterinarians understand progressive renal failure and improve the management of dogs aficted with it.

ProgressionRenal Disease versus Renal Failure

Progression of renal failure can be dened as the development or exacerbation of clinical signs or as directional changes in laboratory measurements consistent with a progressive loss of renal function. This broad denition is helpful for some aspects of clinical management but lacks the specicity required for analytical clinical judgements or investigation. Renal functions may be inuenced by extrarenal factors affecting renal hemodynamics or urinary outow, such as dehydration, cardiac insufciency, urinary outow obstruction, or adrenocortical insufciency. Therefore, changes in clinical signs and laboratory measures associated with declining renal function do not necessarily mean that the kidney has deteriorated structurally or in functional potential. A more restrictive evaluation separates factors into extrarenal and renal so that each is considered separately for diagnostic, therapeutic, and prognostic purposes. This review emphasizes renal factors involved in the progression of chronic renal failure, and that category will be referred to as progression of renal disease. When renal factors cannot be separated from extrarenal factors, the more general phrase progression of renal failure will be used.

appropriate test substance is the gold standard for monitoring progression of renal disease, but that method is too cumbersome for clinical usage. Plasma clearance techniques of measuring GFR have been used in clinical trials in humans; their potential use in dogs is mentioned subsequently. Among commonly used tests of renal function, blood urea nitrogen is well known for uctuating in response to extrarenal factors,5 so it should never be used for monitoring progression of renal disease. Plasma creatinine concentration, or its reciprocal, has been used extensively in studies of the progression of renal failure in humans. Although used sometimes, plasma creatinine concentration is generally not considered adequate for discriminating judgements for several reasons6: errors from tubular secretion of creatinine by humans, inuence of muscle mass on creatinine generation, the possibility of increased enteric degradation of creatinine as renal failure progresses, and the lack of specicity of the assay for creatinine.

Microscopic Evaluation Of Renal Tissue

In animal models of renal disease, development of renal lesions is a more sensitive indicator of renal disease than GFR measurement. However, in clinical patients, morphologic study is often not employed or is limited to a single needle biopsy obtained for diagnosis. Even in research studies, serial biopsies are seldom used because heterogeneous distribution of lesions makes it difcult to procure a representative tissue sample. In addition, serial biopsies induce parenchymal damage that may be difcult to differentiate from disease progression.7

Incidental Observations
A major study on progression of renal disease in humans, the Modication of Diet in Renal Diseases (MDRD) study, identied biologic events that were signicantly correlated with more rapid progression of renal disease in humans: hypertension and proteinuria.8

Factors and Mechanisms Involved in Progression of Renal DiseaseOther Species

Primary Disease
Even in humans, the species in which naturally occurring renal disease has been most widely studied, its primary cause often cannot be determined. However, a thorough anatomic characterization of renal disease exists in humans, and some correlations have been made between the anatomic classication of disease and the rate of its progression. When diseases are examined by both cause and anatomic classication, adult humans with diabetic nephropathy, polycystic disease, and glomerulonephritis are reported to have more rapid progression of renal disease than those with interstitial nephritis or glomerulosclerosis.9

Documenting Progression of Renal Disease

Destruction of renal parenchyma is accompanied by loss of function. Serial tests of renal function may be employed for detecting progression. This approach is valid if reliable tests are used and extrarenal factors are not contributing. Morphologic examination of kidney tissue at timed intervals is theoretically valid for monitoring progression but certain limitations exist.

Renal Function Tests

No test of renal function can distinguish progression of renal disease from progression of renal failure. Glomerular ltration rate (GFR) is considered the single most useful and most sensitive test of renal function overall; tests estimating or measuring GFR have been used extensively for monitoring. Measuring GFR by the urinary clearance of an

Self-Perpetuation
As previously indicated, this theory postulates progression of renal disease even when primary inciting disease is no longer a factor. The theory is based on studies in labo-

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ratory rats that underwent surgical reduction of renal mass, leaving them with a remnant kidney. This model is ideal for studying self-perpetuation, because preexisting renal disease does not complicate the process of progression. In addition, normal kidney tissue obtained during surgery is available to compare to the remnant kidney at the end of the study. The use of this model in rats has notably advanced our understanding of the progression of renal disease. The most important new recognition is that self-perpetuation of renal disease is a reality, at least in rats. In addition, several theories have been advanced and studied to explain the basis of that self-perpetuation. These studies have initiated a search for knowledge about the mechanisms of self-perpetuation, with the ultimate aim of slowing or eliminating injury by modifying the factors responsible. Glomerular hypertension. The glomerular hypertension theory of self-perpetuated renal damage attributes glomerular injury to increased intraglomerular capillary pressure. This theory has remained popular since its formulation in the early 1980s, when micropuncture studies in rats with reduced renal mass demonstrated increased glomerular capillary pressure associated with glomerular injury.10 Increased hydraulic pressure itself has been incriminated as the instigator of such injury, but a variety of factors may contribute to the overall process. Abnormalities in glomerular endothelial, epithelial, and mesangial cell morphology and function have been described. Mesangial matrix accumulation also occurs.1115 Glomerular hypertrophy. The capacity to generate new nephrons is lost before or soon after birth, so the kidney responds to injury and reduced function by hypertrophy and hyperplasia of cellular elements of the remaining viable nephrons. Hypertrophy is the predominant response, though hyperplasia also occurs in immature rats. Cells of all portions of the nephron undergo hypertrophy, resulting in increased glomerular volume, tubular diameter, and tubular length. These changes have been documented in a wide variety of species.16 Increase in functions of all segments of the nephron occur after hypertrophy; GFR is most frequently used to measure those functional consequences. The hypertrophy and accompanying increase in GFR that occur after renal mass reduction have traditionally been considered advantageous to the animal, but more recent evidence suggests that they may be harmful. A retrospective study of children with minimal-change nephrotic syndrome17 indicates that progression was associated with glomerular enlargement. In adult humans with focal glomerulosclerosis, glomerular hypertrophy was associated with mesangial expansion, interstitital brosis, and prevalence of glomerulosclerosis.18 In rat models as well, hypertrophy seems related to renal injury.19,20 However, some of these studies did not clearly establish that hypertrophy was responsible for the associated renal damage. Other studies did not demonstrate an adverse effect of hypertrophy when glomerular hypertension was prevented; in one study, hypertrophy actually prevented or ameliorated the early stages of glomerular injury.21 One school of thought is that glomerular hypertrophy accelerates injury from glomerular hypertension but is not injurious in the absence of glomerular hypertension.22

Tubulointerstitial injury. A growing body of evidence suggests a signicant role of the interstitium in the progression of renal disease. Tubulointerstitial changes may be the major determinant of progression of renal damage.2330 In humans with glomerulonephritis and other nephropathies, the severity of tubulointerstitial lesions is better correlated with decline in GFR and rate of renal disease progression than severity of glomerular lesions is. Previous thinking has emphasized the primary role of glomerular lesions in the progression of renal disease. However, more recent observations suggest not only that tubulointerstitial changes are a better predictor of progression but also that tubulointerstitial injury may be a primary factor in the events leading to progression. Proteinuria. Magnitude of proteinuria has been associated with rate of progression of renal disease in both humans and rats. In humans with nephrotic syndrome due to various glomerular lesions, progression of renal disease is more rapid than in patients without the nephrotic syndrome.31 The MDRD study of humans also found a positive relationship between severity of proteinuria and rate of loss of renal function in patients without nephrotic syndrome.8 In rats with remnant kidneys, measures that decrease proteinuria (low protein diets32 and administration of angiotensin-converting enzyme (ACE) inhibitors33) are associated with slower progression of renal disease. As with hypertrophy, proteinurias association with the progression of renal disease does not prove it is the cause rather than the effect. To determine whether proteinuria causes renal damage, several researchers have performed primary studies, which have also prompted review articles.3439 Examination of the evidence indicates that proteins may cause injury to both glomerular mesangial cells and proximal tubule cells. Mesangial cell injury has been attributed to components of LDL lipoproteins or their oxidation products, which may cause increased matrix production, act as chemoattractants for monocytes, and increase generation of growth factors that stimulate sclerosis. Several possibilities have been proposed for tubular injury. One theory is that tubular reabsorption of massive quantities of any type of protein passing the glomerular ltration barrier causes tubule cell damage by overload, swelling and rupturing the lysosomes. This damage mechanism may apply particularly to nephrotic syndrome, but it may not apply to diseases with only moderate proteinuria. Other theories attribute tubule cell injury and interstitial brosis to toxic effects of transferrin or iron, to lipoproteins, to fatty acids attached to albumin, and to cytokines and chemoattractants that accumulate in the area. Protein-loading studies have often used proteins foreign to the species injected, which may detract from applying these ndings to naturally occurring cases. Oxidative stress and hypermetabolism. Evidence has accumulated that reactive oxygen metabolites (ie, hydrogen peroxide, superoxide radicals, and hydroxyl radicals) mediate injury to several tissues, including the kidneys. Both glomerular and tubulointerstitial injury have been reported, and several mechanisms of injury have been postulated. Oxygen consumption per nephron is increased in rats with remnant kidneys, suggesting the potential for generating reactive metabolites. In addition, tissues from remnant kidney rats have increased lipid peroxidation and alterations in glu-

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tathione redox ratios. The ndings that supplementation with free-radical scavengers protects tissue from injury and that depleting antioxidants induces injury have both been considered supportive of the oxidative-stress theory.4043 Diets decient in antioxidants may have adverse renal effects (proteinuria, mild tubulointerstitial disease, and decreased GFR) by upregulating genes in cells of distal renal tubular epithelium that direct collagen synthesis and transforming growth factor1 production. Decient diets also cause increased renal mitochondrial production of hydrogen peroxide.41 In addition, reactive oxygen species may increase glomerular basement membranes susceptibility to proteolytic damage by inactivating proteinase inhibitors that normally prevent degradation of the glomerular basement membrane.44 Acidosis. Both extrarenal and renal effects have been attributed to metabolic acidosis that may accompany chronic renal failure. Acidosis was reported to accentuate progression of renal injury in remnant kidney rats by immunologic mechanisms via ammonium activation of the alternative complement pathway.45 However, another study did not conrm progressive renal injury due to metabolic acidosis in rats.46 Chronic mild acidosis in cats with remnant kidneys did not accelerate the progression of renal disease (Polzin D. Purina Nutrition Symposium, St Louis, MO, June 1998). The role of acidosis in causing kidney damage must be distinguished from its extrarenal effects. Substantial data from both humans and rats indicate that acidosis occurring during chronic renal failure is associated with biochemical events that result in tissue catabolism.4749 Progression of renal failure may occur by such extrarenal mechanisms. Other factors. Many other factors have been proposed to explain the self-perpetuation of renal damage. One hypothesis is that toxins of uremia result in renal damage in addition to adverse effects on many other organs.50 The list of factors considered to be uremic toxins is impressive,5153 but evidence of specic renal toxicity for most of these materials is sparse. Most evidence suggests that uremic toxins affect extrarenal tissues rather than causing renal injury. Several hormonal, paracrine, and autocrine factors have been identied that may help perpetuate renal injury once damage has been imposed. Endothelin, a potent vasoactive peptide, has been incriminated in rats because administration of an endothelin-receptor antagonist reportedly ameliorates disease progression in the remnant kidney.54 Androgens have been suggested as another factor, because males (both humans and some strains of rats) have a more rapid progression of renal disease.55 Castration of unilaterally nephrectomized male rats inhibits glomerular hypertrophy and proteinuria, lending support to this hypothesis.56 A role for angiotensin II and transforming growth factor in the progression of renal disease has been explored extensively.5761 Other cytokines have also been associated with renal injury at both glomerular and tubulointerstitial sites. However, it is not clear whether some of these factors are signicant in sustaining the injury, are merely observers, or actually help to resolve the injury. Other factors have been shown to inuence the progression of renal disease, including dietary

Fig 1. The relationship between GFR and 1/creatinine in 129 dogs with reduced renal mass. Although a linear relationship exists (R2 .84), 95% condence intervals predict considerable variation in GFR for any value of plasma creatinine concentration. Adapted from reference 64.

factors (eg, caloric intake, protein intake, and lipid intake), but considerable interspecies variability seems to occur.

Progression of Chronic Renal Disease in Dogs

Reliability of Methods Used to Monitor Rate of Progression
In research, urinary clearance of inulin is the gold standard for monitoring changes in GFR. We have compared simultaneous urinary clearance of inulin with exogenous creatinine clearance and found the latter to be a valid measure of GFR in dogs with reduced renal functions.62 Endogenous creatinine clearance also can be an accurate technique for measuring GFR in dogs if a creatinine-specic assay is employed.63 Unfortunately, the commonly used method of creatinine assay (kinetic Jaffe method) underestimates GFR by variable degrees due to variable proportions of creatinine to noncreatinine reactants in plasma (but not in urine).5 Clinically, plasma creatinine concentration is commonly measured to assess renal function as a crude estimate of GFR. We reported a comparison of GFR values (by exogenous creatinine clearance) with plasma creatinine concentration when both tests were conducted simultaneously on 129 dogs with reduced renal mass (Fig 1).64 Condence intervals derived from these data indicate that, in a population of dogs with reduced renal function, plasma creatinine concentration was a mediocre predictor of GFR. For example, a dog with a plasma creatinine concentration of 2.5 mg/dL could have a GFR between 0.64 and 1.44 mL/ kg per minute. Conversely, a dog with a GFR of 1.0 mL/ kg per minute could have a plasma creatinine value between 1.9 and 5.0 mg/dL. These wide ranges emphasize that plasma creatinine concentration (and its reciprocal) must be considered a crude estimator of GFR. When used clinically, plasma creatinine values or their reciprocals do not allow a specic value for GFR to be assigned. However,

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serial measurements from the same patient would be valuable for judging the progression of renal disease if intradog sources of error were consistent (See below). Plasma clearance tests have been used experimentally to measure GFR and are beginning to be used clinically as well. Iohexol has been tested extensively in humans and pigs, and it has been evaluated somewhat in dogs.6568 The relative ease of performing plasma clearance procedures, compared to urinary clearance procedures, makes them attractive. Renal scintigraphy also has been examined as a method for determining GFR in dogs, but that method does not lend itself to widespread use because of the equipment and radioactive materials it requires.6970 For both plasma clearance methods and renal scintigraphy, we have encountered major discrepancies between values provided for GFR and the actual GFR determined by urinary clearance methods. We do not consider either plasma clearance or renal scintigraphy methods acceptable unless each operator making the measurement has taken steps to validate its reliability. The method should be validated by comparing its results with GFR values obtained by classic urinary clearance measurements. Such measurements should be made in several dogs having a wide range of GFR values, and the two tests should be performed simultaneously or immediately after each other. Renal biopsy is used in dogs to provide anatomic data that may be helpful in establishing a prognosis. To our knowledge, no serial biopsy studies of dogs with either experimental or naturally occurring renal disease have been conducted to determine the value of tissue examination for monitoring the rate of progression of renal disease.

ProgressionThe Role of Primary Disease

As previously stated, the etiologies of naturally occurring chronic renal disease in dogs are almost always unknown, making routine categorization on the basis of etiology impossible. Anatomic classication of chronic renal disease of dogs is primitive compared to human nephrology and offers limited help in predicting progression based on the observed lesions. Currently, the rate of progression for various causes of naturally occurring chronic renal failure is an enigma, leaving us with no help in the prognosis of individual cases as they are managed. Only when more information is available on specic causes, or more meaningful histologic classication of renal disease can be correlated with rates of progression, will the primary diseases effect on the rate of progression be better understood. This scenario is predicated on the assumption that primary disease is a signicant factor in the rate of progression compared to self-perpetuated injury. On the other hand, current anatomic classication might be valid for predicting the rate of progression (even though it may lump many causes into one category such as chronic tubulointerstitial nephritis), if the kidneys limited ways of responding to injury lead to the same rate of progression regardless of cause. This concept has already been applied to the anatomic classication of chronic renal disease (ie, end-stage kidney). If this unifying hypothesis on the rate of progression were proved correct, then primary cause as

a factor in progression could become either immaterial or relevant only for its additive effect on self-perpetuated injury. Extending that speculation, if primary cause were only a transient event and self-perpetuation were the sole determinant of the rate of progression, then knowing the natural history of self-progression is even more relevant. Until we have enough information to characterize the progression of naturally occurring renal diseases in dogs, we will not be able to weigh the relative contributions of primary cause and self-perpetuation. It does seem reasonable to ask whether risk factors for self-perpetuation in other species, either proven or hypothesized, exist in dogs. Glomerular Hypertension. We are not aware of any published data from micropuncture studies on dogs with naturally occurring renal disease of any type. Dogs with renal mass reduced surgically by or more have glomerular hypertension.71,72 However, studies have not been conducted to demonstrate a cause-and-effect relationship between glomerular hypertension and renal damage in dogs. Systemic Hypertension and Its Relationship to Glomerular Hypertension. Some studies have demonstrated that dogs with chronic renal disease have elevated systemic blood pressure.73,74,75 One report indicates that blood pressure may be so severely elevated in some cases of naturally occurring canine renal disease that retinal detachment or damage to other organs occurs.75 However, one comprehensive study failed to document blood-pressure differences between dogs with renal failure and those without.76 We are aware of no reports on naturally occurring chronic renal disease in dogs that characterize systemic blood pressure on the basis of the diseases cause, anatomic classication, or stage within a classication system. Dogs with surgical reduction in renal mass have mild to moderate systemic hypertension.77 Renal autoregulation usually maintains normal glomerular capillary pressure, even with considerable uctuations in systemic arterial pressure. For this reason, systemic hypertension is not synonymous with glomerular hypertension. We are aware of no studies of naturally occurring renal disease in dogs in which renal autoregulatory mechanisms have been examined to determine whether normal responses are occurring. In the remnant kidney model of renal disease in dogs, renal autoregulatory mechanisms are blunted,78 which helps explain the presence of glomerular hypertension in this model of renal failure. Renal Hypertrophy. Hypertrophy of both glomerular and tubular portions of the nephron have been demonstrated in dogs with chronic renal failure diagnosed as chronic interstitial nephritis.79 Nephron hypertrophy in remnant kidney dogs is discussed below. Other Factors. In both naturally occurring and induced renal disease in dogs, little if any information has been published on the role of tubulointerstitial lesions, proteinuria, oxidative injury, acidosis, or circulation of metabolites unique to azotemia in the progression of disease. In naturally occurring glomerulonephritis and glomerular disease with a genetic basis, angiotensin-converting enzyme (ACE) inhibitors have been shown to have a benecial effect on both the rate of progression of renal disease and on the magnitude of proteinuria.80,81 However, angiotensin II may have many effects, including modifying growth-factor pro-

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duction within the kidney58 and modifying oxidative stress,82 which preclude assigning any benecial effect to either systemic vascular effects or to effects on proteinuria. Among the uremic toxins incriminated in progression of renal failure, parathyroid hormone has been examined for its effects in dogs with remnant kidneys; however, no benecial effect could be attributed to removing parathyroid hormone by parathyroidectomy.83

Self-Perpetuation of Renal Disease in Dogs The Remnant Kidney Model

Considering the almost complete lack of data related to progression of naturally occurring renal diseases in dogs, it seems presumptuous to endorse or eliminate from consideration any of these factors that have been studied in other species. Likewise, it seems prudent to acknowledge that future theories of self-perpetuation may identify mechanisms more important than those now popular. Although mechanisms responsible for progression cannot be condently identied for the dog, knowledge about selfperpetuation may provide data applicable to any naturally occurring case of renal disease. With any naturally occurring chronic renal disease, self-perpetuation may be the only factor operative if the primary renal insult is transitory. The remnant kidney model has been used in a variety of species to examine many aspects of renal disease and renal failure. We have used this model as an experimental tool to study effects of several dietary or therapeutic agents on progression of renal disease. A byproduct of these studies was the accumulation of data on dogs with remnant kidneys that allow us to characterize self-perpetuation of renal disease.
Fig 2. Changes in GFR following an 1112 reduction in renal mass (mean SE).83 The increase in GFR was greater when a 32% protein diet was fed (hollow circles) than when a 16% protein diet was fed (solid squares). When diets were switched at 7 months, protein effects were apparent; however, GFR was maintained in each group at 180% and 220% of original values, respectively.

fection and its prompt eradication led us to conclude that urinary infection was not a factor in any decrements in renal function. Diets fed to dogs varied with the study, but they were either commercial dog food or its equivalent or experimental diets altered for renal protection (low phosphorus, low protein). Thus, diets fed to these dogs were comparable to or more protective than diets typically consumed by dogs with naturally occurring renal failure when their disease is rst diagnosed.

Hypertrophy Response in the Remnant Kidney

Renal hypertrophy in dogs has been studied previously, but our studies were conducted over a longer time and with more mass reduction than other reports. In our studies, increments in GFR following reduction of renal mass were interpreted to indicate that hypertrophy had occurred. In 1 study of 1112 nephrectomized dogs, most hypertrophy occurred during the rst 3 months, but a further increase occurred between then and the end of this experiment at 7 months. Hypertrophy as measured both by measurement of GFR and morphometric studies was positively affected by protein intake (Fig 2).84 In dogs with 1516 reduction in renal mass that were studied for 2427 months, maximum GFR occurred in of the dogs between 6 and 9 months; some dogs had maximum GFR values even later (Fig 3). These ndings may have clinical ramications. The prolonged period over which hypertrophy occurred may provide hope for modest functional improvement over extended periods in cases of acute renal failure, if the primary disease is resolved. Secondly, when judging progression of chronic renal failure, we should understand that the level of function at any time may represent a balance between nephron destruction and nephron hypertrophy. Stable function could be due to the absence of destructive elements without hypertrophy, or alternatively, it could be due to continued destruction combined with sustained hypertrophy of residual tissue. We are unsure of the importance of this prolonged period of hypertrophy in cases of naturally occurring renal failure in dogs. However, data from our dogs

The Remnant Kidney Model of Renal Disease

To create this model, 1112 to 1516 of the left kidney is infarcted by selective ligation of branches of the left renal artery. The right kidney is later removed. This degree of reduction of renal mass results in mild azotemia (plasma creatinine concentration about 2 to 4 mg/dL) after compensatory hypertrophy occurs. The level of residual function is comparable to naturally occurring clinical cases diagnosed rather early in the course of renal disease. The massive destruction and removal of kidney tissue required to achieve mild azotemia is a testament to the amount of reserve that exists in kidneys. Data included in subsequent analysis were derived from dogs used in several published studies.8385 In all studies, in addition to blood hematologic and biochemical measurements, renal function was evaluated at intervals by measuring GFR through urinary clearance of exogenous creatinine or inulin. Kidney tissue obtained during the infarction procedure (preazotemia) was available for histologic comparison with tissue from the remnant kidney at the end of the study. Many dogs, although azotemic, completed the study and were subsequently euthanized while clinically normal. Other dogs were euthanized during the study because of progressive uremia. All dogs were carefully evaluated for urinary tract infection by serial urine cultures. Such infections were uncommon and were treated appropriately when detected. The low incidence of urinary in-

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Fig 3. Maximum hypertrophy as deduced from GFR measurements performed in 60 dogs at intervals after 1516 reduction in renal mass. Although maximum values were attained at about 4 months in most dogs, substantial numbers of dogs attained their highest GFR values later.

Fig 4. Declines in GFR consistent with self-perpetuation of renal disease in dogs with reduced renal mass. Of 60 dogs, only 8 maintained a GFR of 90100% of the maximum GFR observed; 47 of 60 had a decline in GFR of 20%. GFR measurements were performed at 4-month intervals over periods up to 27 months.

indicate that both renal damage and renal hypertrophy occur simultaneously, meaning that our demonstration of the magnitude and duration of the hypertrophy response as measured by GFR is a conservative estimate. Specic data have not been collected from dogs with remnant kidneys to determine whether hypertrophy is a risk factor for progression of renal disease.

Documentation of Self-Perpetuated Renal Damage

To determine whether self-progression occurs in dogs, GFR data were analyzed from 60 dogs studied for 2427 months after reduction of renal mass. Of the 60, 32 survived the study period and 28 were euthanized when they developed signs of uremia. As already indicated, development of uremia is evidence of progressive renal failure but not necessarily of progressive renal disease. Of the 28 dogs euthanized, the nal GFR from 10 dogs was excluded from data analysis because of severe signs of uremia and terminal oliguria that was unresponsive to uid therapy. We judged that prerenal factors could not be excluded as a cause of extremely low terminal GFR values in these 10 dogs and excluded the terminal values with the risk of underestimating the magnitude of self-perpetuation. Progression of renal disease was expressed as the nal valid GFR (last measurement in 50 dogs, penultimate measurement in 10 dogs) as a decimal fraction of the highest GFR measurement made during the study. The highest value occurred several months after reduction of renal mass, representing an increase in GFR associated with hypertrophy. Tabulations indicated that 47 of 60 dogs had decrements in GFR 20% during the study (Fig 4). These results support the hypothesis that renal disease is a self-perpetuating phenomenon in dogs, as in rats. When renal mass is reduced by the technique described, temporary occlusion of a branch of the renal artery causes color changes in the renal tissue that has been made ischemic. This color change helps us judge which branches

should be ligated to achieve the desired reduction in renal mass. However, ideal choices are not always available. In any population of dogs whose renal mass has been reduced by infarction, a range of initial GFR values will be obtained even when the same mass reduction is attempted in all dogs. We used this heterogeneity to examine the question of whether there was a relationship between the degree of mass reduction and the progression of renal disease. We found that the initial GFR in survivors (0.84 0.31 mL/ kg per minute) was not signicantly different (by 1-way ANOVA analysis) from the initial GFR in dogs that were eventually euthanized after developing uremia (0.79 0.26 mL/kg per minute). We also did not nd a signicant relationship between initial GFR and the percent decline in GFR, either in the entire population or when survivors and fatalities were considered separately. Other investigators have reported serial GFR measurements in dogs with substantially smaller reduction in renal mass. In one study, a reduction in renal mass was induced either by vascular ligation and nephrectomy (remnant kidney) or by renal trauma combined with bacterial infection. This reduction in renal mass was inadequate to cause sustained azotemia. The GFR measured at intervals of 4 years failed to detect a decline in renal function with this degree of renal mass reduction, but the dogs did develop renal lesions.86,87 In another study, dogs with 1112 reduction in renal mass had mild azotemia and developed renal lesions, but they did not have consistent decrements in renal function.88 In a study of aged dogs, unilateral nephrectomy at age 7.5 years did not result in a progressive decline of GFR over the subsequent 4 years, but renal lesions developed in these dogs as well.89 In the latter study, the experiments design did not allow separation of the effects of aging from those of renal mass reduction. From all the available data, it is apparent that a substantial reduction in functional renal tissue must occur for renal disease to be self-perpetuating in dogs. This raises the ques-

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Fig 5. Data from 2 dogs depicting intradog correlation between GFR and 1/creatinine. Although this correlation was excellent in some dogs (a), a very mediocre correlation occurred in others (b). These results suggest that plasma creatinine concentration must be interpreted with caution even from serial tests in the same dog.

tion of whether self-perpetuation is occurring in clinical patients when the disease is diagnosed. With 1516 reduction of renal mass, azotemia is only moderate (plasma creatinine 24 mg/dL) after renal hypertrophy has occurred. This level of azotemia or higher is often encountered in clinical patients at the time of initial diagnosis. Consequently, dogs diagnosed with naturally occurring renal disease when azotemia is mild to moderate are probably undergoing selfperpetuating renal disease, either as the only mechanism or in addition to the primary etiology.

Plasma Creatinine Concentration as a Predictor of GFRIntradog Correlation

Examination of the data in Figure 1 reveals that plasma creatinine concentration is a relatively poor predictor of GFR across a population of dogs (interdog variation), but some of the sources of variation are minimized in repeated sampling of the same dog. Our protocols included sampling for plasma creatinine concentration immediately before GFR measurements. We examined the statistical correlation between plasma creatinine concentration and GFR on dogs with a marked (40%) decrement in GFR over 1220 months (35 GFR measurements). Reliability of plasma Table 1. Repeatability of GFR measurements (mL/min per kg body weight) in normal dogs over a 27-day period when maintained under controlled laboratory conditions. Urinary clearance of exogenous creatinine was used to measure GFR.
Dog Day of Study 1 7 14 21 28 1 2.3 2.4 2.5 2.4 2.7 2 2.3 2.5 2.2 2.3 2.2 3 2.4 2.4 2.4 2.8 ND 4 2.3 2.4 2.4 2.3 2.3

creatinine concentration as a predictor of GFR was highly variable from dog to dog, with R2 ranging from .220 to .996 in 21 dogs. The mean R2 value for the group was .801 .219. In some dogs, plasma creatinine concentration was an excellent predictor of change in GFR (Fig 5a), whereas in others it was a poor predictor (Fig 5b). Whether the lack of correlation between GFR and plasma creatinine concentration was due to lack of specicity in creatinine measurements as a marker for GFR or due to variability in GFR measurement is arguable. However, under the conditions in our laboratories, sequential GFR measurements were very reproducible (Table 1), leading us to postulate that plasma creatinine concentration was the source of the inconsistency.

Relationship between Proteinuria and Progression of Renal Disease

In the 60 dogs that were studied for 2427 months, urine protein : creatinine measurements (UPC) were made at 4month intervals on samples obtained by urinary catheterization. Each dogs average UPC was computed. Values in survivors (2.08 1.78) were not signicantly different (P .076) from those in fatalities (2.98 2.07), with a statistical power of 70% to detect an effect. Likewise, terminal UPC values in survivors (2.76 2.07) were not signicantly different (P .148) from those in fatalities (3.84 3.32), although statistical power for this analysis was low (45%). We dened progression as the decrement in renal function computed by expressing the nal valid GFR as a decimal fraction of the highest GFR measurement made during the study. This measure of progression was tested for its correlation to the average UPC of each dog (Spearmans value), and the resulting value was signicant (P .014). We also determined the correlation between this measure of progression and the last UPC obtained, obtaining a nearsignicant value (P .087). The same comparisons were made separately for survivors and fatalities; in survivors, no signicant correlation existed between magnitude of

ND, not determined.

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Fig 6. Relationship between UPC and rate of progression of renal disease in 45 dogs with a progressive decline in GFR. The UPC values obtained before a decline in GFR (a) were not predictive of later progression (P .266). The UPC values obtained after detecting a decline in GFR (b) were numerically greater than before and related to the rate of decline in GFR (P .031, Spearmans test).

progression and average UPC (P .276) or last UPC (P .331). In fatalities, the magnitude of progression was signicantly correlated with both average UPC (P .048) and nal UPC (P .050). To examine the relationship between proteinuria and progression in another way, the rate of progression (rather than its magnitude) was computed. For each dog, the percent decline in GFR per month was computed [((highest GFR nal valid GFR)/highest GFR)/months of declining GFR] and the mean UPC was tabulated for the time before progression was detected. Likewise, mean UPC was computed for each dog during the period after progression was identied. In 45 dogs (47 of 60 dogs demonstrated progression; 2 of those dogs were excluded because of UPC outliers), the correlation between preprogression UPC and rate of eventual progression was not signicant (P .266, Fig 6a). There was a signicant correlation between rate of progression and UPC values after progression began (P .031, Fig 6b). Our data on the relationship between proteinuria and progression were limited by the 4-month intervals between UPC determinations. However, the results suggest that proteinuria increases in association with an accelerated rate of renal disease progression. The nonsignicant correlation between UPC measured before onset of progression and the rate of eventual progression suggests that proteinuria may be an effect of progression rather than its cause.

Pattern of Progression of Renal Damage

We examined the reciprocal of plasma creatinine concentration as a marker for rate of renal disease progression. According to the clearance formula, 1/creatinine is linearly related to GFR. Despite the limitations of creatinine for estimating GFR, this test is commonly used to monitor progression of renal failure in clinical patients. Sets of data from each of 27 dogs with remnant kidneys and clear evidence of self-perpetuating renal disease were evaluated to characterize the relationship of 1/creatinine to

time. The period of progression was dened as the time during which plasma creatinine concentration progressively increased. A statistical software program (SPSS version 8, SPSS Inc, Chicago, IL) was used to determine the best data t when plotting 1/creatinine versus time for each dog. Linear, log, quadratic, cubic, power, and exponential curves were examined for t. The number of creatinine observations per dog in this group was 11.9 5.1 (range, 524 samples taken at monthly intervals). For the 27 dogs, R2 values for a linear change in 1/creatinine ranged from .249 to .984 (mean .82 .17). These data indicate that considerable deviation from linearity and dog to dog variation exists in the rate of renal disease progression as judged by plasma creatinine concentration. A curve t of values using the cubic equation gave higher R2 values (as expected mathematically, because any deviation from perfect linearity would be accommodated more precisely), but no consistent pattern occurred. Good linearity sometimes occurred (Fig 7a), but patterns of terminal acceleration (Fig 7b), terminal abatement (Fig 7c), or deviations from linearity during the midpoint of the observation period were also noted. The GFR measurements made in our studies provided an opportunity to examine the progression pattern of self-perpetuating renal disease with more accuracy than plasma creatinine measurements. Data were analyzed from 18 dogs in which 4 to 6 GFR measurements had been made at 4-month intervals over 1624 months. Ten of these dogs survived the 24-month study period but had decrements in GFR; 8 were euthanized because of uremia. In the latter group, nal GFR determination was not used if it occurred within 1 month of euthanasia, a decision made to avoid extrarenal inuences on GFR that may have occurred during terminal uremia. For the complete group of 18 dogs, R2 values for linear regression had a range of .81 to .99 (mean .90), with excellent linearity in some dogs (Fig 8a). The best t of data and higher R2 values were obtained in all 18 dogs with cubic regression analysis, indicating that perfect linearity was the exception rather than the rule. Nevertheless,

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Fig 7. The change in 1/creatinine with time (dotted line, each point a plasma creatinine determination) in dogs undergoing substantial loss of renal function. In some dogs (a) the relationship was very linear (R2 .984), but a cubic model t better for other dogs. An apparent changing rate of progression with terminal acceleration (linear R2 .734, cubic R2 .891 [b]) and a terminal abatement of progression (linear R2 .923, cubic R2 .976 [c]) were among the nonlinear patterns observed.

Fig 8. The change in GFR with time (dotted lines, each point a GFR determination) in dogs undergoing substantial loss of renal function. Linear t of data was better for GFR determinations than for 1/ creatinine, lending support to the hypothesis that self-perpetuation of renal disease progresses at a constant rate (example shown in [a], linear R2 .994). However, variation in the rate of progression (linear R2 .830, cubic R2 1.00 [b]; linear R2 .934, cubic R2 .999 [c]) were also observed.

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curve ts by the cubic method did not have a consistent pattern (Fig 8b,c), indicating that GFR was not declining in any consistent manner. We interpret these results from GFR measurement to indicate that a fairly linear decline in renal function occurs with self-perpetuating renal disease, with the caveat that the last month of life was not included in our data from the 8 dogs that were euthanized. The GFR data indicates that although a general linear trend for progression of renal disease exists, considerable deviation from linearity is observed in some dogs. Because individual dogs in our studies were managed in the same way once experiments began (diet, parathyroid hormone status), the variation from linearity could not be attributed to changes in management practices. Discrepancies between GFR measurements and plasma creatinine measurements reect the failure of plasma creatinine concentration to consistently reect GFR, even in the same dog.

improvement associated with hypertrophy may compensate for increasing functional losses as the disease progresses. 4. Urinary protein excretion as measured by UPC may be a marker for identifying accelerated progression of selfperpetuating renal disease. It may not be an accurate predictor, however, of an impending accelerated rate of progression. 5. The pattern of self-progression of renal disease can be variable, but it is fairly linear over time unless complicated by other factors. Plasma creatinine concentration must not be interpreted too stringently as an indication of progression, considering its lack of precision in reecting GFR.

References
1. Allen TA, Jaenke RS, Fetteman MJ. A technique for estimating progression of chronic renal failure in the dog. J Am Vet Med Assoc 1987;190:866868. 2. Brown SA. Primary diseases of glomeruli. In: Osborne CA, Finco DR, eds. Canine and Feline Nephrology/Urology. Philadelphia, PA: Williams and Wilkins; 1995:368385. 3. Finco DR, Brown CA. Primary tubulo-interstitial diseases of the kidney. In: Osborne CA, Finco DR, eds. Canine and Feline Nephrology/Urology. Philadelphia, PA: Williams and Wilkins; 1995: 386391. 4. Hostetter TH, Olson JH, Rennke HG, et al. Hyperltration in remnant nephrons: A potentially adverse response to renal ablation. Am J Physiol 1981;241:F85-F93. 5. Finco DR. Kidney function. In: Kaneko JJ, Harvey JW, Bruss ML, eds. Clinical Biochemistry of Domestic Animals. New York, NY: Academic Press; 1997: 441484. 6. Gaspari F, Perico N, Remuzzi G. Measurement of glomerular ltration rate. Kidney Int 1997;63(Suppl):S151S154. 7. Osborne CA, Low DG. Iatrogenic lesions in serial renal biopsy samples. J Urol 1971;106:805810. 8. Klahr S, Levey AS, Beck GJ, et al. The effects of dietary protein restriction and blood pressure control on the progression of chronic renal disease. N Engl J Med 1994;330:877884. 9. Locatelli F, Manzoni C, Marcelli D. Factors affecting progression of renal insufciency. Miner Electrolyte Metab 1997;23:301305. 10. Anderson S, Brenner B. Progressive renal disease: A disorder of adaptation. QJM 1989;263:185189. 11. Schwartz MM, Bidani AK. Role of glomerular epithelial cell injury in the pathogenesis of glomerular scarring in the rat remnant kidney model. Am J Pathol 1993;142:209219. 12. Johnson RJ. What mediates progressive glomerulosclerosis? The glomerular endothelium comes of age. Am J Pathol 1997;151: 11791181. 13. Lee LK, Meyer TW, Pollack AS, et al. Endothelial cell injury initiates glomerular sclerosis in the rat remnant kidney. J Clin Invest 1995;96:953964. 14. Cortes P, Riser B, Narins RG. Glomerular hypertension and progressive renal disease: The interplay of mesangial cell stretch, cytokine formation and extracellular matrix synthesis. Contrib Nephrol 1996; 118:229233. 15. Schwartz MM, Evans J, Bidani AK. The mesangium in the long-term remnant kidney model. J Lab Clin Med 1994;124:644651. 16. Smith HW. The Kidney: Structure and Function on Health and Disease. New York, NY: Oxford University Press; 1951:476481. 17. Fogo A, Hawkins EP, Berry EP, et al. Glomerular hypertrophy in minimal change disease predicts subsequent progression to focal glomerular sclerosis. Kidney Int 1990;38:115123. 18. Lee HS, Lim SD. The signicance of glomerular hypertrophy in focal segmental glomerulosclerosis. Clin Nephrol 1995;44:349355. 19. Lafferty HM, Brenner BM. Are glomerular hypertension and

Microscopic Examination of TissueRemnant Kidneys from Dogs

Studies of remnant kidneys from dogs document the occurrence of histologic lesions. These lesions include mesangial cell proliferation, mesangial matrix accumulation, periglomerular brosis, tubulointerstitial inltration with mononuclear cells, interstitial brosis, and mineral deposition. These lesions are the same as those encountered in kidneys of dogs with the naturally occurring renal disease commonly described as chronic interstitial nephritis. Although empirical examination suggests that pathologists are unable to separate microscopic sections of remnant kidneys from kidneys of dogs with naturally occurring tubulointerstitial diseases, controlled comparison studies have not been reported. In studies of dogs with remnant kidneys, initial and terminal kidney samples have been analyzed but serial samples from the same dog have never been reported. Thus, although histologic examination is considered a more sensitive indicator of self-progression than function tests, its usefulness in documenting the rate of progression is unproven in this model.

Conclusions
Studies of dogs with remnant kidneys have added much to our knowledge about self-perpetuation of renal disease in this species. The information can be summarized as follows: 1. Self-progression of renal disease often occurs at a stage of renal function reduction at which mild to moderate azotemia exists. Consequently, self-perpetuating renal disease is likely to be ongoing when naturally occurring renal failure is rst diagnosed. 2. Despite the presence of only mild to moderate azotemia, severe reduction in numbers of functional nephrons have occurred at this early stage of disease. 3. The marked and prolonged period of hypertrophy that occurs after nephron numbers have been reduced masks the severity of functional tissue loss. Hypertrophy also makes it difcult to assess the progression of renal disease with functional measurements, because functional

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