Association of chronic enteropathy activity index, blood urea concentration, and risk of death in dogs with protein-losing enteropathy

In-hospital mortality in dogs with protein-losing enteropathy and associated risk factors

BACKGROUND

Risk factors associated with negative outcomes in dogs with protein-losing enteropathy (PLE) are well documented. However, mortality before hospital discharge and associated risk factors are not well described.

HYPOTHESIS/OBJECTIVES

Report the percentage of dogs with PLE that do not survive to hospital discharge and identify associated risk factors.

ANIMALS

One-hundred and seven dogs presented to a referral hospital and diagnosed with PLE caused by inflammatory enteritis, intestinal lymphangiectasia or both.

METHODS

Retrospective cross-sectional study assessing hospital records. Data on in-hospital mortality and cause were assessed, and presenting signs, treatments prescribed, neutrophil count, lymphocyte count, serum albumin, globulin, and C-reactive protein (CRP) concentrations, and histopathologic findings were compared between survivors and non-survivors.

RESULTS

In-hospital mortality was 21.5% with the most common causes including financial limitations, failure to improve and aspiration pneumonia. Factors associated with mortality during hospitalization included longer duration of hospitalization (P = .04), longer duration of clinical signs (P = .02) and an increase in serum CRP concentration after 1-3 days of in-hospital treatment (P = .02). Higher mortality was identified in Pugs (odds ratio [OR], 4.93; 95% confidence interval [CI], 1.41-17.2; P = .01) and was a result of presumptive aspiration pneumonia in 5/6 of these dogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

Protein-losing enteropathy in dogs has substantial mortality during hospitalization. Monitoring for improvement in CRP concentration after treatment during hospitalization may help predict survival to discharge. Pugs have increased in-hospital mortality because of aspiration pneumonia; measures to prevent, recognize, and promptly treat this complication may improve outcomes in this breed.

An undernutrition screening score for dogs with protein-losing enteropathy: A prospective multicenter study

BACKGROUND

The impact of undernutrition in dogs with protein-losing enteropathy (PLE) caused by inflammatory enteritis, intestinal lymphangiectasia, or both and which variables are most predictive of outcome are unknown.

OBJECTIVES

Develop an undernutrition screening score (USS) for use at the time of diagnosis of PLE in dogs, which is predictive of outcome.

ANIMALS

Fifty-seven dogs with PLE prospectively recruited from 3 referral hospitals in the United Kingdom.

METHODS

An USS based on the presence and severity of 5 variables: appetite, weight loss, and body, muscle, and coat condition and scored out of 15, with higher scores reflecting worse undernutrition, was calculated at the time of diagnosis. Follow-up information was obtained for at least 6 months.

RESULTS

Dogs that failed to achieve clinical remission within 6 months had higher USS at diagnosis compared with dogs that achieved remission (median, 7.5; range, 2-14 and median, 5; range, 0-14, respectively). The USS at diagnosis gave an area under the receiver operating characteristic curve (AUC) of 0.656 for predicting nonclinical remission within 6 months, whereas a score consisting of just epaxial muscle loss and coat condition resulted in a larger AUC of 0.728.

CONCLUSIONS AND CLINICAL IMPORTANCE

Of the 5 variables assessed in the USS, a combination of epaxial muscle loss and coat condition was most predictive of not achieving clinical remission within 6 months in dogs with PLE. Additional studies will help determine the effect of changes in USS and the 5 associated variables after diagnosis on outcome variables in these dogs.

Incidence of relapse of inflammatory protein-losing enteropathy in dogs and associated risk factors

BACKGROUND

Dogs with inflammatory protein-losing enteropathy (iPLE) that attain remission may be at risk of subsequent relapse.

OBJECTIVES

To determine the incidence of relapse of iPLE in dogs that have previously attained complete clinical and biochemical remission and identify associated risk factors.

ANIMALS

Seventy-five client-owned dogs diagnosed with iPLE.

METHODS

Medical records of dogs diagnosed with iPLE based on histopathology of intestinal biopsy specimens between March 2010 and March 2020 were retrospectively reviewed. Variables were recorded from the time of investigation at histopathologic diagnosis and subsequent follow-up information was obtained from the records of referring veterinarians.

RESULTS

Twenty-three dogs (31%) achieved sustained remission without documentation of relapse for at least 2 years. Nineteen dogs (25%) achieved remission, but then subsequently relapsed within 2 years of histopathologic diagnosis, and 33 dogs (44%) never achieved remission with disease-associated death occurring a median of 19 (range, 3-114) days after histopathologic diagnosis. Dogs that achieved remission and subsequently relapsed had significantly higher poor dietary compliance, as defined by frequent scavenging or changing from the recommended diet compared to dogs with sustained remission (P = .01).

CONCLUSIONS

Inflammatory PLE is associated with a high rate of relapse in dogs. Ensuring owners adhere to dietary recommendations might help prevent subsequent relapse in dogs with iPLE that attain initial remission.

A Preliminary Study of Modulen IBD Liquid Diet in Hospitalized Dogs with Protein-Losing Enteropathy

Modulen IBD is an enteral liquid diet that can induce remission rates similar to glucocorticoids in children with inflammatory bowel disease. The Modulen IBD liquid diet has not been previously investigated in dogs. Our study aimed to describe the use of the Modulen IBD liquid diet in hospitalized dogs with inflammatory protein-losing enteropathy (PLE), including its tolerance and effects on appetite and gastrointestinal signs, and laboratory parameters during hospitalization. Of the 14 dogs hospitalized for PLE that had an esophagostomy feeding tube placed at the time of endoscopy, 5 were eligible and prospectively enrolled. The Modulen IBD liquid diet was supplemented with whey powder isolate and a multivitamin/mineral blend to ensure the diet was complete and balanced for canine adult maintenance and had a macronutrient profile desirable for PLE. All five dogs tolerated tube feedings with the Modulen IBD liquid diet, allowing an increase of 75 to 100% of the resting energy requirement (RER) by day 3 to 4. The diet was administered without glucocorticoid in all five dogs. All five of these dogs had a resolution of anorexia allowing the voluntary intake of a commercial hydrolyzed protein diet prior to the use of glucocorticoids. Of these five dogs, three (60%) had stable or improved serum albumin concentrations (median % increase: 10.3, range: 0−31.1), four (80%) had improved or normalized serum globulin concentrations (median % increase: 12.9, range: 5.1−66.2) and four (80%) had improved or normalized serum cholesterol concentrations (median % increase: 31.5, range: 4.8−63) 2−3 days after initiating the diet. However, there were no significant differences in these selected biochemical parameters pre- and post-feeding with the diet (p > 0.080). In conclusion, the Modulen IBD liquid diet, fed via an esophagostomy feeding tube was well-tolerated in-hospital and resolved anorexia in all dogs and helped to improve selected biochemical parameters in some dogs. Further studies are needed to assess the long-term effects of feeding this diet on the rate of serum albumin increase and remission in dogs with inflammatory PLE.

2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 1- Defining populations at risk

OBJECTIVES

To expand the number of conditions and interventions explored for their associations with thrombosis in the veterinary literature and to provide the basis for prescribing recommendations.

DESIGN

A population exposure comparison outcome format was used to represent patient, exposure, comparison, and outcome. Population Exposure Comparison Outcome questions were distributed to worksheet authors who performed comprehensive searches, summarized the evidence, and created guideline recommendations that were reviewed by domain chairs. The revised guidelines then underwent the Delphi survey process to reach consensus on the final guidelines. Diseases evaluated in this iteration included heartworm disease (dogs and cats), immune-mediated hemolytic anemia (cats), protein-losing nephropathy (cats), protein-losing enteropathy (dogs and cats), sepsis (cats), hyperadrenocorticism (cats), liver disease (dogs), congenital portosystemic shunts (dogs and cats) and the following interventions: IV catheters (dogs and cats), arterial catheters (dogs and cats), vascular access ports (dogs and cats), extracorporeal circuits (dogs and cats) and transvenous pacemakers (dogs and cats).

RESULTS

Of the diseases evaluated in this iteration, a high risk for thrombosis was defined as heartworm disease or protein-losing enteropathy. Low risk for thrombosis was defined as dogs with liver disease, cats with immune-mediated hemolytic anemia, protein-losing nephropathy, sepsis, or hyperadrenocorticism.

CONCLUSIONS

Associations with thrombosis are outlined for various conditions and interventions and provide the basis for management recommendations. Numerous knowledge gaps were identified that represent opportunities for future studies.

Immunosuppressant-Responsive Enteropathy and Non-Responsive Enteropathy in Dogs: Prognostic Factors, Short- and Long-Term Follow Up

Simple Summary

Chronic intestinal inflammation in dogs is a challenging disease to manage. Most studies about prognostic factors and follow-up data are only available for small populations or with short-term follow-up. The aim of this study of 165 dogs with chronic intestinal inflammation was to identify clinical and haematological factors associated with mortality, clinical response and relapse, with long-term follow-up. Nine per cent of dogs did not respond to therapy at 1 month follow-up. Most dogs with chronic intestinal inflammation had a good clinical course in most cases, and the non-response or relapse rate was 9–11%. A reduction of body condition (loss of weight), lower serum albumin concentration and presence of lacteal dilatation on intestinal histology at diagnosis were identified as factors associated with a decreased response rate, higher mortality and lower chance of achieving long-term remission.

Abstract

A multicentre prospective study was performed to assess whether clinical, hematobiochemical, endoscopic and histopathological parameters were associated with mortality, clinical response and relapse of disease in short- and long-term follow-up of a total of 165 dogs with chronic inflammatory enteropathy, of which 150 had immunosuppressant responsive enteropathy (IRE), and 15 had non-responsive enteropathy (NRE) dogs. Clinical severity (CCECAI) was evaluated from presentation (T0) to 18 months (T18) from diagnosis. T0 body condition score (BCS), selected haematological parameters and endoscopic and histopathological scores were evaluated. Presence/absence of histopathological duodenal lesions was recorded. Responders were evaluated using CCECAI at T1. Relapse was evaluated from T3 to T18. Long-term responders included dogs who responded at T1 and showed no relapse. Dogs were divided into responders/non-responders, survivors/non-survivors and relapsed/non-relapsed. At T1, 15/165 dogs (9%) were considered NRE. Sixteen dogs (11%) were considered relapsed at T3, 8% at T6 and 10% at T12, and none of 96 dogs relapsed at T18. NREs showed significantly lower BCS than IREs. Non-survivors showed a significantly lower serum albumin concentration and BCS than survivors. Non-responders, relapsed or non-survivors had higher presence of lacteal dilatation compared to long-term responders. Dogs with IRE showed a good clinical course with a low relapse rate, with only a few dogs in the NRE group. Reduction of BCS, albumin and lacteal dilatation at diagnosis may be considered negative prognostic factors for response, mortality and long-term disease remission.

The effect of assisted enteral feeding on treatment outcome in dogs with inflammatory protein-losing enteropathy

BACKGROUND

The effect of assisted enteral feeding on treatment outcome in dogs with protein-losing enteropathy (PLE) is unknown.

OBJECTIVES

To determine if dogs with inflammatory PLE that had an enteral feeding tube placed had better outcome vs dogs with inflammatory PLE without a feeding tube.

ANIMALS

Fifty-seven dogs with inflammatory PLE.

METHODS

A retrospective study at a UK referral hospital identified dogs with inflammatory PLE using a standard diagnostic criterion. Positive outcome was defined as survival greater than 6 months or death unrelated to PLE and negative outcome as death related to PLE within 6 months of diagnosis. Several variables were assessed to identify factors for positive outcome using logistic regression.

RESULTS

Thirty-five (61%) and 22 (39%) dogs had a positive and negative outcome at 6 months, respectively. Of the 21 dogs that had a feeding tube placed within 5 days of gastrointestinal biopsy, 16 (76%) had a positive outcome and 5 (24%) had a negative outcome. Dogs treated with dietary treatment alone (P = .002) and dogs with an enteral feeding tube (P = .006) were significantly associated with a positive outcome. When stratified by treatment, assisted enteral feeding was significantly associated with a positive outcome in dogs treated with concurrent immunosuppressive treatment (P = .006), but there was insufficient data to evaluate dogs treated with dietary treatment alone.

CONCLUSIONS AND CLINICAL IMPORTANCE

Assisted enteral feeding in dogs with inflammatory PLE could be associated with improved treatment outcome, especially in those receiving immunosuppressive treatment, and should be considered in the treatment plan of these dogs.

Canine Protein Losing Enteropathies and Systemic Complications

Canine protein-losing enteropathies occur commonly in small animal practice, and their management is often challenging with a long-term survival rate of only about 50%. Recent studies have investigated prognostic factors that may determine outcome in individual cases. In particular, systemic complications such as hypercoagulability, vitamin D3 deficiency, and tryptophan deficiency may play an important role and should be investigated in severely affected cases in order to maximize outcome.

Dietary and Nutritional Approaches to the Management of Chronic Enteropathy in Dogs and Cats

Nutrition can influence those functions of the gastrointestinal tract that can be adversely affected in chronic enteropathy, such as microbiota, mucosal immune system, intestinal permeability, and motility. Diet serves as a possible risk factor in disease pathogenesis and as a target for treatment in chronic enteropathy. Malnutrition is prevalent in people with inflammatory bowel disease and negatively affects outcome. Approximately two-thirds of dogs with protein-losing enteropathy due to chronic enteropathy or lymphangiectasia are underweight. Commercial diets and home-prepared diets have been used successfully in the management of chronic enteropathy. Fat restriction is the main dietary strategy for intestinal lymphangiectasia.

The use of hydrolysed diets for vomiting and/or diarrhoea in cats in primary veterinary practice

OBJECTIVE

To describe responses of cats prescribed a hydrolysed diet with or without concurrent medication for chronic vomiting and/or diarrhoea of undetermined aetiology.

MATERIALS AND METHODS

Anonymised records of 512,213 cats under UK veterinary care in 2016 from the VetCompass database were searched using relevant terms for hydrolysed diets. The records of 5000 (90%) of 5569 cats with evidence of receiving a hydrolysed diet were randomly reviewed for gastrointestinal indication, prior and concurrent medication and response after hydrolysed dietary intervention. A poor response was defined as evidence of receiving antibiotic or glucocorticoid treatment for vomiting/diarrhoea at visits after the onset of the diet or death from gastrointestinal signs for at least 6 months follow-up.

RESULTS

Of 977 cats prescribed a hydrolysed diet for chronic vomiting/diarrhoea, 697 (71%) were first prescribed the diet without concurrent antibiotics or glucocorticoids while 280 (29%) first received the diet with these medications. Thirty-four per cent of cats in the former group and 61% in the latter had a poor response. Cats older than 6 years and cats prescribed antibiotic and/or glucocorticoid for vomiting/diarrhoea before and concurrently with the diet had higher odds of poor response.

CLINICAL SIGNIFICANCE

Although variations in our observations may reflect severity of signs or prescribing habits of primary-care veterinary surgeons, our study suggests there is merit in trialling a hydrolysed diet first as a sole therapy in cats with chronic vomiting/diarrhoea when diagnostic investigations do not reveal a cause, before resorting to antibiotic and/or glucocorticoid therapy for cases that respond poorly.

Clinical characteristics of dogs with food-responsive protein-losing enteropathy

Background

In dogs with protein‐losing enteropathy (PLE), data on the clinical characteristics of food‐responsive PLE (FR‐PLE) remain scarce.

Objective

To determine the clinical characteristics of FR‐PLE in dogs responsive to ultralow‐fat diet (ULFD) management.

Animals

Thirty‐three dogs diagnosed with PLE based on standard diagnostic criteria.

Methods

Retrospective review of medical records. Clinical findings were compared between dogs with FR‐PLE (FR‐PLE group) and those with immunosuppressant‐responsive PLE (IR‐PLE) or nonresponsive PLE (NR‐PLE) (IR/NR‐PLE group). The area under the curve (AUC) of a receiver operating characteristic curve was used to evaluate the ability of factors to differentiate the FR‐PLE and IR/NR‐PLE groups. Survival time was compared between the FR‐PLE and IR/NR‐PLE groups.

Results

Twenty‐three dogs responded to ULFD management and were diagnosed with FR‐PLE. The canine chronic enteropathy clinical activity index (CCECAI) was significantly lower in the FR‐PLE group than in the IR/NR‐PLE group (P < .001). The AUC of CCECAI for differentiating the FR‐PLE group was 0.935 (95% confidence interval [CI], 0.845‐1.000) with an optimal cutoff value of 8 (sensitivity, 0.826; specificity, 0.889). Survival times were significantly longer in the FR‐PLE group (median, not reached) than in the IR/NR‐PLE group (median, 432 days; P < .001).

Conclusions and Clinical Importance

Dogs that respond to ULFD management and are diagnosed with FR‐PLE are expected to have a favorable prognosis. Clinical scores, specifically the CCECAI, could be useful for differentiating FR‐PLE from IR‐PLE or NR‐PLE.

Association of chronic enteropathy activity index, blood urea concentration, and risk of death in dogs with protein-losing enteropathy

Background

Malnutrition is associated with increased risk of premature death in humans with inflammatory bowel disease.

Hypothesis/Objective

To determine if historical, clinical, and laboratory markers of malnutrition in dogs at the time of histologic diagnosis of protein‐losing enteropathy (PLE) caused by chronic enteropathy (CE) or lymphangiectasia are associated with increased risk of death.

Animals

Seventy‐one client‐owned dogs diagnosed with PLE.

Methods

The medical records were retrospectively searched for cases of PLE, diagnosed with CE or lymphangiectasia on the basis of histopathology of intestinal biopsies at a referral hospital. For each case, various variables at the time of diagnostic investigation were recorded and follow‐up obtained by telephone contact with the referring veterinarian.

Results

A multivariable cox model indicated that canine chronic enteropathy activity index (CCEAI) and blood urea concentration were significantly associated with death (P values <.01). For each unit increase in CCEAI, the hazard of death increased by 22.9% (confidence interval [CI]: 6.9%‐41.2%). Dogs with a CCEAI of ≤8 and dogs with urea ≤7 mmol/L survived 256 days longer (P = .001, CI: 106.7‐405.4 days) and 279 days longer (P = .009, CI: 70.0‐488.7 days) than those with a CCEAI of >8 and urea >7 mmol/L on average, respectively, when followed up for 647 days.

Conclusions and Clinical Importance

Increased CCEAI and blood urea concentration at the time of diagnosis might be predictive of death in dogs with PLE caused by CE or lymphangiectasia.