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Antithrombotic therapy. Hypercoagulability is a complication of protein losing glomerular diseases; thromboembolism occurs in up to 25% of these
dogs. Unfortunately, serum albumin concentrations, antithrombin activity, and UPC cannot be used in isolation to predict hypercoagulability in individual patients. Although unclear when to implement thromboprophylaxis, consensus recommendations call for the daily administration of low-dose aspirin (1-5 mg/ kg/day). Clopidogrel may be an effective alternative.
Antihypertensive therapy. All dogs with glomerular disease should undergo repeat measurement of systemic blood pressure and assessment of the patient for target organ damage. An ACEi is the first line antihypertensive agents and a calcium channel blocker (e.g., amlodipine besylate) is a second agent, when needed. Animals presenting with systolic pressures >200 mmHg or with evidence of target organ damage (e.g., choroidopathy) should be given both drugs because monotherapy with an ACEi is unlikely to provide adequate control. Because telmisartan may be as effective at lowering blood pressure as amlodipine, it may be adequate as a single agent in some animals. If renal function worsens after initiating treatment with one of these agents, the drug should be temporarily withdrawn and reinstituted at a lower starting dose.
Body fluid volume. Dogs with glomerular disease may have fluid excesses, deficits or maldistribution, which may need to be corrected if the dog has decompensated or is being prepared for anesthesia. Correcting body
fluid imbalances in dogs that are hypoalbuminemic from glomerular disease is a very difficult therapeutic challenge. Fluid therapy can exacerbate edema and hypertension and diuretics can exacerbate azotemia or uremia. As such, those who have experience and expertise in critical care are the best people to deliver these therapies to dogs with glomerular disease. Fluid therapy should be given only when needed to help control clinical signs or provide support to those dogs that have inadequate fluid intake.
Immunosuppressive Therapy
Immunosuppressive therapy should be considered
in dogs that have severe, persistent or progressive glomerular disease and ICGN documented via appropriate evaluation of a renal biopsy specimen. However, there are practical and medical reasons why a biopsy might not be performed. Sometimes veterinarians must decide about immunosuppressive therapy in dogs with glomerular disease absent a pathologic diagnosis. Immunosuppressive therapy should not be administered if there is any doubt that the proteinuria is of glomerular origin, administration of the specific drug is medically contraindicated, or there is a high index of suspicion that the dog has amyloidosis or a non-immune-mediated familial disease. Immunosuppressive drugs should
An Urban Experience
be considered absent a pathologic diagnosis when standard therapy has been implemented but azotemia
is progressive, serum creatinine is >3.0 mg/dL or serum albumin is <2.0 g/dL. The risks of this therapy need to be clearly understood.
The immunosuppressive protocol may vary based on severity of clinical signs and rate of progression of the glomerular disease. More aggressive protocols may be best for dogs with severe, rapidly progressive disease. The rapidity of which the drug becomes active is of less concern when the disease is more slowly progressive. Drugs to consider are glucocorticoids, mycophenolate, cyclosporine, cyclophosphamide, chlorambucil and azathioprine, alone or in combination.
Patients receiving immunosuppressive drugs should
be monitored for drug-specific adverse effects and therapeutic response. A therapeutic response is
a reduction in the magnitude of proteinuria with improvement/stabilization of renal function and increases in serum albumin. A reduction in proteinuria is a UPC
of <0.5 (complete response) or 50% reduction from baseline (partial response). Improvement or stabilization in renal function is a sustained reduction in serum creatinine to <1.4 mg/dL (complete response) or by > 25% of baseline (partial response). A meaningful increase in serum albumin is a sustained increase to >2.5 mg/
dL (complete response) or either to 2.0-2.5 mg/dL or by >50% of baseline (partial response). Secondary goals
of therapy include improved blood pressure regulation, resolution of edema, and stabilization of body weight.
If there are no unacceptable adverse drug effects, treatment should be continued for 8-12 weeks. If there is a partial or complete response, therapy should continue for at least 12-16 weeks. If there has not been a partial or complete responses by 8-12 weeks, the protocol should be changed or discontinued. If there is no response by 3-4 months, all immunosuppressive therapy should be discontinued, tapering as needed.
1. Consensus recommendations for standard therapy of glomerular disease in dogs. J Vet Intern Med 27:S27-S43, 2013.
2. Consensus recommendations for immunosuppressive treatment of dogs with glomerular disease based on established pathology. J Vet Intern Med 27:S44-S54, 2013.
3. Consensus guidelines for immunosuppressive treatment of dogs with glomerular disease absent a pathologic diagnosis. J Vet Intern Med 27:S55-S59, 2013.
4. Consensus recommendations for treatment of dogs with serology positive glomerular disease. J Vet Intern Med 27:S60-S66, 2013.

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