Increased insulin-like growth factor 1 concentrations in a retrospective population of non-diabetic cats diagnosed with hypertrophic cardiomyopathy

Evaluation of serum insulin-like growth factor 1 concentrations in non-diabetic cats with chronic kidney disease

Feline hypersomatotropism (HST) can develop in both diabetic and non-diabetic cats, but studies evaluating the prevalence of HST in cats without diabetes mellitus (DM) are lacking. The aims of the study were to evaluate circulating insulin-like growth factor 1 (IGF-1) in non-diabetic cats with chronic kidney disease (CKD), to assess whether there is a correlation between general test of renal function and IGF-1 concentration in cats with CKD, and to screen this population for the presence of HST. In this prospective study, one hundred fifty-four non-diabetic cats (n = 154) with CKD from referral centers in Buenos Aires (Argentina) were evaluated. Serum IGF-1 concentration was measured as part of the routine tests for CKD and compared with a healthy control group of 50 cats without CKD. The median serum IGF-1 concentration in the total population of cats with CKD was 500 ng/mL (range 34-1593 ng/mL). Median serum IGF-1 concentrations of cats with IRIS stage 1 (n = 13), stage 2 (n = 86), stage 3 (n = 40) and stage 4 (n = 15) of CKD were 230 ng/mL (range 58-951 ng/mL), 473 ng/mL (range 34-1456 ng/mL), 597 ng/mL (range 123-1593 ng/mL), 569 ng/mL (range 123-1045 ng/mL), respectively. None of the cats in the control group had IGF-1 concentration >1000 ng/mL (median 505 ng/mL, range 114-720 ng/mL). There was a positive linear correlation between serum IGF-1 and creatinine concentrations in cats with CKD (r= 0.22, 95% confidence interval 0.06-0.37 P=0.005). A proportion of 5.8% (95% confidence interval 2.7-10.8%) of non-diabetic cats with CKD had markedly increased IGF-1 concentrations (cut-off IGF-1 >1000 ng/mL). Pituitary enlargement was detected on computed tomography in 3/4 of these cases. Eighteen cats (11.6%) had serum IGF-1 concentrations in the "grey zone" between 800 and 1000 ng/mL. A small proportion of non-diabetic cats with CKD had an IGF-1 concentration in a range that is consistent with HST in diabetic cats. Likewise, the progression of CKD in cats without DM correlates with increases in serum IGF-1 concentrations.

Evaluation of potential novel biomarkers for feline hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most common cardiomyopathy in cats. The diagnosis can be difficult, requiring advanced echocardiographic skills. Additionally, circulating biomarkers (N-terminal pro-B type natriuretic peptide and cardiac troponin I) have several limitations when used for HCM screening. In previous work, we identified interleukin 18 (IL-18), insulin-like growth factor binding protein 2 (IGFBP-2), brain-type glycogen phosphorylase B (PYGB), and WNT Family Member 5 A (WNT5A) as myocardial genes that show significant differential expression between cats with HCM and healthy cats. The products of these genes are released into the circulation, and we hypothesized that IL-18, IGFBP-2, PYGB, and WNT5A serum RNA and protein concentrations differ between healthy cats, cats with subclinical HCM, and those with HCM and congestive heart failure (HCM + CHF). Reverse transcriptase quantitative polymerase chain reaction (RTqPCR) and enzyme-linked immunosorbent assay (ELISA) were applied to evaluate gene and protein expression, respectively, in the serum of eight healthy controls, eight cats with subclinical HCM, and six cats with HCM + CHF. Serum IGFBP-2 RNA concentrations were significantly different among groups and were highest in cats with subclinical HCM. Compared to healthy controls, serum IL-18 and WNT5A gene expression were significantly higher in cats with HCM + CHF, and WNT5A was higher in cats with subclinical HCM. No differences were observed for PYGB. These results indicate that further investigation via large scale clinical studies for IGFBP-2, WNT5A, and IL-18 may be valuable in diagnosing and staging feline HCM.

Increased insulin-like growth factor 1 concentrations in a population of non-diabetic cats with overweight/obesity

Feline hypersomatotropism (HST) is typically associated with diabetes mellitus (DM), whereas HST without concurrent DM has only been reported in a few cases. Weight gain may be observed in cats with HST. The aims of this study were to evaluate circulating insulin-like growth factor-1 (IGF-1) in non-diabetic cats with overweight/obesity, to screen this population for the presence of HST, and to assess whether there is a correlation between body weight/body condition score (BCS) and serum IGF-1 concentration in overweight/obese cats. In this prospective study, 80 overweight/obese cats from referral centers in Buenos Aires (Argentina) were evaluated. Serum IGF-1 was measured as part of the routine tests for overweight/obesity. Non-diabetic cats were included in the study if they had a BCS>6/9. Twenty-nine cats were classified as overweight (BCS 7/9), whereas 51 were classified as obese (BCS 8-9/9). Median serum IGF-1 concentrations of cats with BCS 7/9, 8/9, and 9/9 were 570 ng/ml (range 123-1456 ng/ml), 634 ng/ml (range 151-1500 ng/ml), and 598 ng/ml (range 284-2450 ng/ml), respectively. There was a positive linear correlation between serum IGF-1 concentrations and body weight (r= 0.24, 95% CI 0.01-0.44 P=0.03), and between IGF-1 and BCS (r= 0.27, 95% CI 0.08-0.44 P=0.004). In total, 8.75% (95% confidence interval 3.6-17.2%) of the cats with overweight/obesity had IGF-1 concentrations >1000 ng/ml. Pituitary enlargement was detected on computed tomography in 4/7 cases. These seven cats showed varying degrees of phenotypic changes consistent with acromegaly. A proportion of 8.75 % of overweight/obese non-diabetic cats from referral centers in Buenos Aires had serum IGF-1 concentration in a range consistent with HST in diabetic cats. Likewise, 5% of overweight/obese cats were likely to be diagnosed with HST, supported by evidence of pituitary enlargement. Serum IGF-1 concentrations were positively correlated with body weight and BCS in this population of cats. This study highlights the relevance of screening different populations of non-diabetic cats to increase the detection of HST/acromegaly.

Feline Comorbidities: Hypersomatotropism-induced diabetes in cats

PRACTICAL RELEVANCE

Diabetes mellitus is the second-most common feline endocrinopathy, affecting an estimated 1/200 cats. While the underlying causes vary, around 15-25% of cats with diabetes mellitus develop the condition secondarily to progressive growth hormone (GH)-induced insulin resistance. This typically results in a form of diabetes that is challenging to manage, whereby the response to insulin is very variable or high doses are required to achieve even minimal diabetic control.

CLINICAL CHALLENGES

Although uncontrolled chronic excessive GH may result in phenotypic changes that raise suspicion for acromegaly, many cats with hypersomatotropism (HST) do not have these changes. In these situations, a clinician's index of suspicion may be increased by the presence of less dramatic changes such as marked polyphagia, stertor or uncontrolled diabetes mellitus. The current diagnostic test of choice is demonstration of a markedly increased serum insulin-like growth factor 1 (IGF1) concentration, but some affected cats will have only a marginal increase; additionally, chronic insulin administration in cats results in an increase in serum IGF1, making the diagnosis less clear cut and requiring additional confirmatory tests.

EVIDENCE BASE

Over the past two decades, HST has increasingly been recognised as an underlying cause of diabetes mellitus in cats. This review, which focuses on diagnosis and treatment, utilises data from observational studies, clinical trials and case series, as well as drawing on the experience of the authors in managing this condition.

Method Validation and Establishment of Reference Intervals for an Insulin-like Growth Factor-1 Chemiluminescent Immunoassay in Cats

Previously, radioimmunoassay (RIA) has been the only assay to measure insulin-like growth factor-1 (IGF-1) to diagnose hypersomatotropism (HS). Due to radiation concerns, availability, and the cost of IGF-1 RIA, validation of assays for automated analysers such as a chemiluminescent immunoassay (CLIA) is needed. The aim of this study was to validate a CLIA for measurement of feline IGF-1 (IMMULITE 2000® XPi, Siemens Medical Solutions Diagnostics, Malvern, PA, USA) compared to IGF1 RIA, establish reference interval (RI), and determine a cut-off value for diagnosis of HS in diabetic cats. Validation of assay performance included precision, linearity, and recovery studies. Right-sided RI was determined using surplus serum of 50 healthy adult cats. Surplus serum samples of diabetic cats with known IGF-1 concentration with (n = 32/68) and without HS (n = 36/68) were used for method comparison with RIA. The cut-off for diagnosis of HS was established using receiver operating characteristic (ROC) analysis. The intra-assay coefficient of variation (CV) was ≤4.7%, and the inter-assay CV was ≤5.6% for samples with low, medium, and high IGF-1 concentration. Linearity was excellent (R2 > 0.99). The correlation between CLIA and RIA was very high (rs = 0.97), with a mean negative bias for CLIA of 24.5%. The upper limit of RI was 670 ng/mL. ROC analysis showed an area under the curve of 0.94, with best cut-off for diagnosis of HS at 746 ng/mL (sensitivity, 84.4%; specificity, 97.2%). The performance of CLIA was good, and the RI and cut-off for HS diagnosis established in this study allow for CLIA to be used in routine work-up of diabetic cats.

Hypersomatotropism and Other Causes of Insulin Resistance in Cats

True insulin resistance should be differentiated from management-related difficulties (eg, short insulin duration, inappropriate insulin injection, inappropriate storage). Hypersomatotropism (HST) is the number one cause of insulin resistance in cats, with hypercortisolism (HC) occupying a more distant second place. Serum insulinlike growth factor-1 is adequate for screening for HST, and screening at the time of diagnosis, regardless of presence of insulin resistance, is advocated. Treatment of either disease centers on removal of the overactive endocrine gland (hypophysectomy, adrenalectomy) or inhibition of the pituitary or adrenal glands by using drugs such as trilostane (HC), pasireotide (HST, HC) or cabergoline (HST, HC).

The Feline Cardiomyopathies: 3. Cardiomyopathies other than HCM

Practical relevance:

Although feline hypertrophic cardiomyopathy (HCM) occurs more commonly, dilated cardiomyopathy (DCM), restrictive cardiomyopathy (RCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), left ventricular noncompaction (LVNC) and cardiomyopathy – nonspecific phenotype (NCM; formerly unclassified cardiomyopathy) are all recognized in domestic cats.

Patient group:

Any adult domestic cat, of either sex and of any breed, can be affected.

Diagnostics:

The non-HCM cardiomyopathies are rarely suspected in subclinically affected cats, so most are first identified when a cat presents with signs of heart failure or systemic thromboembolic disease. The definitive clinical confirmatory test for these other feline cardiomyopathies is echocardiography.

Key findings:

‘Cardiomyopathy – nonspecific phenotype’ is a catch-all term that groups hearts with myocardial changes that either do not meet the criteria for any one type of cardiomyopathy (HCM, RCM, DCM, ARVC, LVNC) or meet the echocardiography criteria for more than one type. RCM is characterized by diastolic dysfunction due to fibrosis that results in a restrictive transmitral flow pattern on Doppler echocardiography and usually marked left or biatrial enlargement. DCM is characterized by decreased myocardial contractility and is rare in cats. When it occurs, it is seldom due to taurine deficiency. However, since taurine-deficient DCM is usually reversible, a diet history should be obtained, whole blood and plasma taurine levels should be measured and taurine should be supplemented in the diet if the diet is not commercially manufactured. ARVC should be suspected in adult cats with severe right heart enlargement and right heart failure (ascites and/or pleural effusion), especially if arrhythmia is present. Feline LVNC is rare; its significance continues to be explored. Treatment of the consequences of these cardiomyopathies (management of heart failure, thromboprophylaxis, treatment of systemic arterial thromboembolism) is the same as for HCM.

Conclusions:

While these other cardiomyopathies are less prevalent than HCM in cats, their clinical and radiographic presentation is often indistinguishable from HCM. Echocardiography is usually the only ante-mortem method to determine which type of cardiomyopathy is present. However, since treatment and prognosis are often similar for the feline cardiomyopathies, distinguishing among the cardiomyopathies is often not essential for determining appropriate therapy.

Areas of uncertainty:

The feline cardiomyopathies do not always fit into one distinct category. Interrelationships among cardiomyopathies in cats may exist and understanding these relationships in the future might provide critical insights regarding treatment and prognosis.