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REVIEW
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 1
Journal of Small Animal Practice (2020), 1–19
DOI: 10.1111/jsap.13237
Accepted: 10 September 2020
Canine leishmaniosis and kidney
disease: Q&A for an overall
management in clinical practice
X. R 1,*, O. C†, M. J. D‡, S. L. B§, C L W Ga
A. Z¶
*Hospital Clínic Veterinari, Universitat Autònoma de Barcelona 08193, Bellaterra, Spain
†Hospital Clínico Veterinario, Universidad CEU Cardenal Herrera 46115, Valencia, Spain
‡School of Veterinary and Life Sciences, Murdoch University 6150, Murdoch, Australia
§Laboratorio La Vallonea 20017, Milano, Italy
¶Dipartimento di Medicina Veterinaria, Università degli Studi di Bari “Aldo Moro” 70010, Bari, Italy
1Corresponding author email: xavier.roura@uab.cat
INTRODUCTION
Canine leishmaniosis (CanL) is a systemic zoonotic disease caused
by the protozoan Leishmania infantum (Paltrinieri et al.2010), i.e.
endemic in more than 70 countries (Solano-Gallego et al.2011).
There is evidence of spread to traditionally non-endemic areas such
as North America (Gaskin et al.2002, Duprey et al.2006) and, espe-
cially, northern European countries such as the UK (Teske et al.2002,
Shaw et al.2009, Geisweid etal.2012, Maia & Cardoso2015, Sil-
vestrini et al. 2016, Medlock et al.2018). Increases in the number
of CanL cases in the UK might well be associated with increased
importation of dogs into the UK, often involving dogs rescued from
southern or eastern Europe (Norman et al.2020, Traversa2020).
CanL is a common cause of glomerulonephritis (GN), which
can cause proteinuria and may progress to renal failure (Zatelli
et al.2003, Aresu et al.2013, dos Santos et al.2013, Koutinas
& Koutinas2014). Azotaemia due to renal impairment has been
described frequently in dogs with leishmaniosis and some dogs
may present with severe renal failure alone, which might ultimately
be fatal (Slappendel1988, Ferrer1992, Ciaramella etal. 1997,
Koutinas et al. 1999, De Freitas et al. 2012, Foglia Manzillo
etal.2013, Ribeiro et al.2013). However, whilst proteinuria is
commonly recognised at the time of diagnosis, renal azotaemia is
reported to be a rare clinical finding (Zatelli et al.2003, Planellas
et al.2009, Paltrinieri et al.2016, Meléndez-Lazo et al.2018).
The Canine Leishmaniosis Working Group (CLWG) was
formed in November 2005 to develop a science-based consensus
for management of CanL. Since then, several papers on diag-
nosis, clinical classification, treatment, prognosis and prevention
of the disease have been developed (Maroli et al.2010, Oliva
et al.2010, Paltrinieri et al.2010, Roura et al.2013). The aim
of the current manuscript is to explore the relationship between
Leishmania spp. infection and kidney disease in dogs and create
guidelines for veterinarians to assist with management of those
cases that develop renal disease. These guidelines are based on
existing references and/or the experience of the CLWG mem-
bers; however, veterinary clinicians should critically evaluate their
potential applicability when approaching cases of CanL.
DO ALL DOGS WITH LEISHMANIOSIS HAVE
RENAL DISEASE?
This depends upon the diagnostic criteria used to establish the exis-
tence or absence of renal disease. If the diagnosis was based exclusively
on the presence of azotaemia, the reported prevalence of kidney dis-
ease ranges between 5.9% (Meléndez-Lazo etal.2018) and 38.1%
(Koutinas et al.1999) whilst, if pathological renal proteinuria was
the criterion, then the prevalence would be approximately 50%
(Font1999, Cortadellas et al. 2006). If, however, diagnosed was
based upon diagnostic imaging, kidney biopsy or direct visualisa-
tion of the kidneys, prevalence rises up (Polzin et al.2005). In this
respect, several studies (Poli etal.1991, Nieto et al.1992, Palacio et
al.1997, Costa et al.2003, Plevraki etal.2006, Aresu et al.2013,
Braga et al.2015, Batista et al.2020) have reported almost all dogs
would be considered to renal disease. Therefore, veterinarians
should be aware that, whilst only about half of dogs with leishmani-
osis will have clinical evidence of renal disease based upon common
diagnostic criteria, almost all are likely to be affected in some way.
DO WE NEED TO EVALUATE THE PRESENCE
OF PROTEINURIA IN ALL DOGS WITH
LEISHMANIOSIS?
The answer to this question is yes, because, as discussed above,
approximately 50% of dogs may have clinicopathologically
aCanine Leishmaniosis Working Group collaborators: Nuncio D'Anna, Alexandra Fondati,
LuigiGradoni, George Lubas, Michele Maroli, Saverio Paltrinieri, Eric Zini.
http://www.bsava.com/
X. Roura et al.
2 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
detectable kidney disease at the time of diagnosis of CanL
(Font1999, Cortadellas et al.2006). The renal disease is primar-
ily of glomerular origin, usually involving different histopatho-
logical forms of GN, whilst renal amyloidosis occurs, only very
rarely (Poli et al.1991, Costa et al. 2003, Zatelli et al. 2003,
Plevraki et al. 2006, Saridomichelakis 2009). Initially, asymp-
tomatically infected dogs with renal involvement present with
moderate-to-severe proteinuria without azotaemia. As the dis-
ease progresses, tubulointerstitial lesions and azotaemia develop,
ultimately leading to end-stage renal failure, which remains the
most significant cause of death in CanL (Font1999, Cortadellas
et al.2006, Koutinas & Koutinas2014). Proteinuria is also an
important marker of the progression of kidney disease in dogs
with azotaemia and is associated with greater risk of development
of clinical signs and death (Jacob et al.2005). Therefore, in order
to establish an earlier diagnosis and improve the prognosis for
existing kidney disease, quantification of proteinuria should be
mandatory in all dogs with leishmaniosis.
IS THERE A REASON TO MEASURE BLOOD
PRESSURE IN DOGS WITH LEISHMANIOSIS?
Kidney diseases are the main cause of secondary systemic hyper-
tension in dogs, associated or not to leishmaniosis and differ-
ent studies report a prevalence of between 9 and 93% (Acierno
etal.2018). In these dogs, a sustained increase in systolic blood
pressure (SBP) may result in target organ damage affecting the
eyes, heart, brain and kidneys (Jacob et al. 1999 and 2003,
Cortadellas et al. 2006, Acierno et al. 2018). Furthermore, in
dogs with induced renal failure, the greatest SBP measurements
were associated with increased proteinuria, a greater reduction
in glomerular filtration rate (GFR) and increased severity of
renal injury (Finco2004). Therefore, the concurrence of kidney
changes and hypertension in dogs with leishmaniosis potentially
exacerbate pre-existing chronic kidney disease (CKD), increasing
the risk of mortality (Jacob et al.2003). Given that the preva-
lence of systemic hypertension in dogs with leishmaniosis is
reported to be between 29% (Braga et al.2015) and 62% (Cort-
adellas et al.2006), SBP should be measured in all CanL cases, in
accordance with the recommendations of the International Renal
Interest Society (IRIS2019) and other published guidelines (Aci-
erno et al.2018).
WHAT WE KNOW ABOUT THE INNATE IMMUNE
RESPONSE IN CANL?
The role of innate immunity in responding to canine infection
with Leishmania infantum has been investigated in recent years,
with a focus on the expression of the pattern-recognition recep-
tors, Toll-like receptors (TLR) involved in initial recognition of
microbial antigens by classical antigen presenting cells such as
dendritic cells or macrophages. Overall, disease progression in
leishmaniosis is associated with decreased expression of TLR,
suggesting that the parasite subverts innate immunity by down-
regulating expression of these molecules (Hosein et al.2017).
Gene expression studies of brain and splenic tissue from affected
dogs revealed organ-specific patterns of up- or down-regulation
of TLR-encoding genes (Grano et al. 2018). The association
between a susceptibility phenotype for CanL and single nucleo-
tide polymorphisms in genes encoding TLR has been investi-
gated, but the associations identified did not achieve statistical
significance (Soutter et al.2019). The role of neutrophils as early
effector cells in Leishmania infection has been explored by in
vitro studies of neutrophil function including phagocytosis, che-
motaxis and oxidative and non-oxidative intracellular pathways
(Pereira et al.2017). Neutrophil and macrophage recruitment to
infected tissue is enhanced by the effect of IL-17 produced by T
helper (Th) 1 cells (Toepp & Petersen2020).
In recent years, the involvement of acute phase proteins (APP)
in a wide variety of canine infectious, neoplastic, inflammatory
and immune-mediated diseases have been investigated. Acute
phase proteins provide another measure of an inflammatory
response in addition to traditional assessment of leucocyte counts
and profiles or the measurement of serum cytokine concentra-
tions (Ceron et al. 2018). The concentration of APP (includ-
ing C-reactive protein [CRP], haptoglobin ferritin and others)
is inevitably increased in CanL cases and correlates with the
severity of inflammatory disease, but do not contribute directly
to the immunopathogenesis of renal lesions in CanL (Ceron
etal.2018). Nonetheless, they can provide a measurable index of
the inflammatory response, charting progression and remission.
WHAT WE KNOW ABOUT THE ADAPTIVE
IMMUNE RESPONSE IN CANL?
The complex immunopathology of CanL has been studied exten-
sively and reviewed several times (Baneth et al.2008, Day2011,
Koutinas & Koutinas2014, Papadogiannakis & Koutinas2015,
Hosein et al.2017, Toepp & Petersen2020). The immunopa-
thology that occurs in this disease is a consequence of interactions
occurring between the Leishmania parasite, the sand fly vector
(specifically the immunomodulatory properties of its saliva) and
the local (cutaneous) and the systemic immune system of the
host. Genetic background (breed) of affected dogs may also influ-
ence the immune system (Quilez et al.2012, Hosein et al.2017).
Fundamentally, there are two well-recognised, polarised
adaptive immune responses that may be made to this infec-
tion (Day2011, Toepp & Petersen2020). It is these differing
immune responses that are thought to account for the variety in
pathological changes and associated clinical signs recognised in
dogs with overt clinical disease. In this respect, genetically resis-
tant dogs mount a robust Th1 immune response in which the
signature cytokine (interferon [IFN]-γ) produced by Th1 cells;
IFN-γ signals parasitized macrophages, enabling them to destroy
intracytoplasmic Leishmania amastigotes and, thereby, limiting
both the infection and associated inflammatory reactions which,
ultimately, limit the reservoir capacity of the infected dog. In
contrast, genetically susceptible dogs mount a systemic immune
response dominated by Th2 cells, regulatory T cells (Tregs) and
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 3
regulatory B cells (Day2011, Toepp & Petersen2020). The sig-
nature cytokines released by Th2 cells include interleukins (IL)-4
and IL-13, which promote “inappropriate” humoral immune
responses by B lymphocytes, accounting for hypergammaglobu-
linaemia, autoantibody production and formation of circulating
immune complexes. The activity of Tregs and regulatory B cells
(via the signature cytokine IL-10) downregulates the protective
Th1 immune response and accounts for the persistence and chro-
nicity of lesions and of the infectious status of the parasitized dog
(Day2011, Toepp & Petersen2020).
WHAT WE KNOW ABOUT THE
PATHOPHYSIOLOGY AND IMMUNOLOGY OF
ORGAN LESIONS ASSOCIATED TO CANL?
The pathological basis of the multisystemic lesions of CanL
therefore varies between target tissues. Granulomatous inflam-
mation in a spectrum of organs (e.g. skin, lymph nodes, bone
marrow, liver, intestinal tract) likely relates to the balance of
activity between Th1 effector cells and T and B regulatory cells
as discussed above. Depending upon the extent of the inflamma-
tion, organ function may be impaired (Day2011). A range of
tissue autoantibodies may be induced in dogs with leishmaniosis,
with possible mechanisms for their induction including poly-
clonal B-cell activation, inappropriate Th2-mediated activation
of autoreactive B lymphocytes, release of autoantigens following
tissue damage or molecular mimicry between parasite or sand fly
salivary antigens and host autoantigens (Day2011). The ensuing
plasma cell secretion of autoantibodies contributes to immune-
mediated haemolysis (Ciaramella et al.1997) and thrombocyto-
penia (Terrazzano et al.2006) and the production of antinuclear
(Lucena & Ginel 1998, Chaabouni et al. 2018), anti-histone
(Ginel et al.2008), anti-myofibre (Brandonisio et al.1990, Vam-
vakidis et al. 2000) and peripheral antineutrophil cytoplasmic
antibodies (Karagianni et al. 2012). In dogs with Leishmania-
associated pemphigus foliaceus, the pathogenesis likely involves
triggering of autoantibody, which binds to interepithelial desmo-
somal proteins within the epidermis. In human endemic pem-
phigus foliaceus (Fogo Selvagem) in Brazil, a sand fly salivary
antigen triggers production of immunoglobulin (Ig) G4 antibod-
ies that cross-react with desmoglein-1 (Qian et al. 2012), but
there is no evidence for such a mechanism in CanL.
As discussed in more detail below, the presence of excess cir-
culating antigen, antibodies specific for Leishmania bind to this
antigen and create immune complexes that can lodge on vascular
walls in regions of turbulent blood flow with endothelial dam-
age; these complexes trigger local complement fixation, neu-
trophil recruitment, vascular damage and local leakage of fluid,
proteins and inflammatory cells (Gizzarelli et al. 2020). In a
recent proteomic study the composition of circulating immune
complexes isolated from the blood of experimentally infected
dogs was explored; the constituents that were most represented
were molecules of the complement pathway and of the serpin
family (Cacheiro-Llaguno et al. 2020), the latter of which are
serine protease inhibitors involved in modulation of numerous
proteolytic cascades. The classical target sites for deposition of
such complexes in CanL are the renal glomerulus, the anterior
uvea, dermis, nasal mucosa and synovial membrane (Koutinas &
Koutinas2014). The chronic inflammatory state in CanL may
also lead to tissue deposition of reactive amyloid in some cases.
Tissue infiltration by lymphoid cells, indicative of cell-mediated
or cytotoxic immune reactions may also be part of the pathogen-
esis of some tissue pathology in CanL (Hosein etal. 2017). The
“interface dermatitis,” seen histopathologically in depigmenting
nasal lesions of dogs with leishmaniosis, is indistinguishable from
the reaction characterising discoid lupus erythematosus, suggest-
ing similar immunopathology in the infectious and idiopathic
immune-mediated diseases (De Lucia et al.2017).
WHAT WE KNOW ABOUT THE
PATHOPHYSIOLOGY AND IMMUNOLOGY OF
KIDNEY LESIONS ASSOCIATED WITH CANL?
The kidney lesions associated with CanL are described in more
detail below, but include chronic interstitial inflammation (asso-
ciated with local infection) and GN (leading to proteinuria or
nephrotic syndrome). A range of glomerular and secondary tubu-
lar lesions are recognised, including membranoproliferative GN
(MPGN), membranous GN and mesangioproliferative GN, pro-
gressing to interstitial fibrosis, glomerulosclerosis and end-stage
renal disease (Costa et al.2003, Aresu et al. 2013, dos Santos
et al. 2013, Esch et al. 2015, Wilson et al.2017). The major
cause of glomerular pathology in CanL is thought to be depo-
sition of preformed circulating immune complexes at different
levels of the glomerular unit; this is determined by the size and
charge (cationic) of the complex. In MPGN, immune complexes
deposit within the mesangium and on either or both the epithe-
lial or endothelial sides of the glomerular basement membrane
(GBM). This results in GBM thickening with proliferation of
mesangium and epithelial and/or endothelial cells. In membra-
nous GN, immune complex deposition occurs on the epithelial
side of the GBM, resulting in basement membrane thickening
without cellular proliferation or inflammation. In mesangiop-
roliferative GN, larger immune complexes deposit within the
mesangium, leading to cellular proliferation and accumulation of
mesangial matrix (Costa et al.2003, Aresu et al.2013, dos Santos
et al.2013, Wilson et al.2017).
Classically, immune complex disease is associated with deple-
tion of complement components and subnormal concentrations
of circulating complement factors (e.g. C3 and C4). However,
reduced concentrations of complement factors have not been
consistently demonstrated in dogs with immune complex GN
(Acierno et al.2006). Circulating immune complexes could be
detected in the blood of dogs with leishmaniosis (Brandonisio
etal.1990, Lopez et al.1996, Cacheiro-Llaguno et al.2020, Giz-
zarelli et al.2020) and, in one clinical case, haemodialysis was
used successfully as an adjunct to treatment of the disease (Baneth
etal.2018). Glomerular immunoreactants have also been dem-
onstrated in affected kidneys by immunofluorescence labelling
and by transmission electron microscopy (Aresu etal. 2013).
X. Roura et al.
4 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
Such glomerular immune complexes contain Leishmania anti-
gens, antibodies (generally of the IgG or IgM classes) and
complement molecules (specifically the third component of the
complement pathway, C3) (Costa et al.2003, Soares etal.2009,
Esch et al.2015). Immunoreactants may also be found within the
glomeruli of clinically normal dogs without renal disease and this
has been the case when control dogs were compared with dogs
with leishmaniosis in some studies (Soares et al.2009, Costa et
al.2010). In contrast to the data supporting the deposition of
preformed antigen in the glomerulus, there is no evidence for
the alternative mechanism of complexes forming locally between
Leishmania antigens, which deposits first and subsequently binds
(“captures”) circulating antibody. That said, it has been suggested
that histone proteins and anti-histone antibodies in dogs with
leishmaniosis might act in such a fashion (Ginel et al. 2008).
Similarly, there is no evidence that infected dogs with glomer-
ular disease have circulating tissue autoantibodies specific for
glomerular antigens that bind to their targets in situ and trigger
localised inflammation. In such cases, immunofluorescence label-
ling would reveal linear deposition of Ig or complement along
the GBM, which may, in time, become granular. Limited studies
have explored the transcriptional expression of other immunolog-
ically relevant molecules within the kidneys of dogs with clinical
leishmaniosis, including the induction of genes associated with
autophagy and formation of inflammasomes (Esch et al.2015).
The infiltration of CD4+ and CD8+ T lymphocytes into the
kidneys of dogs with visceral leishmaniosis has been evaluated,
together with the expression of adhesion molecules involved in
T-cell recruitment into tissues. CD4+ T cells generally predomi-
nate over CD8+ cells, but the pattern of CD4/CD8 infiltration
does not vary significantly with different forms of GN (Costa
etal. 2010). There was upregulation of intercellular adhesion
molecule (ICAM)-1 and P-selectin in the kidneys of infected ver-
sus control dogs (Costa et al.2010). In contrast, there was less
apoptosis and expression of tumour necrosis factor (TNF)-α in
the kidneys of infected versus control dogs (Costa et al.2010).
WHAT ABOUT CIRCULATING IMMUNE
COMPLEXES AND PRECIPITIN REACTIONS?
As described above, the nature of the individual immune response
determines whether the protozoan infestation will be controlled
(e.g. in the presence of a cell-mediated response) or whether the
dog will develop clinical signs due to the deposition of circulating
immune complexes (e.g. in case of a humoral response involving
the formation of antibodies) (Day1999, 2011). The presence of
antibodies and antigens alone is not sufficient to produce circu-
lating immune complexes since the latest have precise character-
istics in order to be soluble and to circulate in the bloodstream
(Lopez et al.1996, Day1999, Gizzarelli et al.2020). For example,
immune complexes that are too large are cleared by phagocytic
cells, whilst complexes that are too small are unable to activate
complement (Day1999, Noris & Remuzzi2013). Formation of
immune complexes is best understood by considering the classi-
cal precipitin reaction:
1. An excess of antibody over antigen in a sensitised individual
creates large immune complexes, which form at the site of
antigens exposure leading to localised inflammatory disease,
the Arthus reaction (Day1999, 2011).
2. An excess of antigen over antibody creates soluble immune
complexes of small dimensions, which are more likely to cir-
culate and deposit in the capillary beds of predilection sites
such as the skin, synovia, uvea and renal glomerulus. This
mechanism is the one, i.e. thought to underlie the patho-
genesis of immune-mediated GN (Poli et al. 1991, Nieto
et al. 1992, Costa et al. 2000, Zatelli et al. 2003, Aresu
etal.2007, 2013, dos Santos et al.2013, Esch et al.2015).
The deposition of circulating immune complexes also depends
on several factors including: the size of the complex, the nature
of the antigen (e.g. its chemical composition and charge), the
nature of antibodies (e.g. complement fixing antibodies), vas-
cular permeability and endothelial damage and blood pressure
and flow. With high pressure, turbulent flow and altered vascular
permeability, the soluble circulating immune complexes deposit
within the vessel wall, causing platelet aggregation and inflam-
mation mediated by extracellular degranulation of neutrophils
that cannot phagocytise the immune complexes (Day 1999,
Warren2006).
WHAT DIFFERENCES ARE THERE BETWEEN THE
PATHOPHYSIOLOGY AND IMMUNOLOGY OF
LESIONS IN THE KIDNEY AND OTHER ORGANS?
Although human patients with visceral leishmaniosis develop
renal lesions (Clementi et al.2011, Ortiz et al.2015) and kidney
pathology is known to occur in experimental infections of rodent
species (Prianti et al.2007), there have been relatively few detailed
studies of renal immunopathology in these species. In contrast,
the dog is regarded as a model for the likely changes occurring in
infected people (Esch et al.2015). Inflammation is reported in
the kidneys of people with visceral leishmaniosis and this is asso-
ciated with Leishmania amastigotes, immune complex deposition
and expression of adhesion molecules promoting T lymphocyte
recruitment (Clementi et al.2011, Ortiz etal.2015). Circulating
immune complexes of Leishmania antigens with immunoglobu-
lin and complement have been identified (Clementi et al.2011).
Human patients with visceral leishmaniosis also develop a spec-
trum of autoantibodies, including serum rheumatoid factor,
antinuclear antibodies, anti-smooth muscle and anti-platelet
antibodies; the antinuclear antibodies cross-react with Leishma-
nia antigens, suggesting molecular mimicry as an underlying
mechanism (Argov et al.1989).
The murine model of experimental infection with Leishmania
major in mice of different inbred strains was widely employed
in the 1980s to dissect the Th1 to Th2 paradigm in immunol-
ogy. BALB/c mice are susceptible to infection and mount a
classical Th2 immune response, whilst C57Bl/6 mice mount a
Th1 response and are of resistant phenotype (Sadick et al.1986,
Loeuillet et al. 2016); however, these studies did not focus on
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 5
renal immunopathology. Experimental infection of BALB/c mice
with Leishmania chagasi led to lesions consistent with mesangiop-
roliferative GN and IgG immune complex deposition; consistent
with findings in the dog (Prianti et al.2007).
WHAT PATHOLOGICAL PATTERNS IN THE
KIDNEY ARE ASSOCIATED WITH CANL?
The renal lesions observed in CanL are consistent with immune
complex-mediated glomerulonephritis (ICGN), suggesting an
immune-mediated pathogenesis (Marcussen et al. 1989, Poli
etal.1991, Nieto et al.1992, Costa et al.2000, Zatelli etal.2003,
Aresu et al.2007, 2013, dos Santos et al.2013, Esch et al.2015).
However, there is inconsistency in the published literature in
both the identification of a glomerular pattern of injury and in
the terminology used to classify ICGN (Poli et al.1991, Nieto
et al.1992, Costa et al.2000, Zatelli et al.2003). This as a con-
sequence of a poorly defined classification scheme for canine
glomerular disease and the traditional adoption of a human clas-
sification system that does not entirely apply to canines (see ques-
tions 8-10). The terminology and pattern definitions used in this
review are consistent with those of the most recent literature on
CanL (Cianciolo et al.2016, 2018).
MPGN is the most commonly reported glomerular pattern
of injury in CanL (Marcussen et al.1989, Poli et al.1991, Nieto
etal.1992, Costa et al.2000, Aresu et al.2007, 2013, dos Santos
et al.2013, Esch et al.2015), with the key features of MPGN
being mesangial-cell proliferation, mesangial matrix expansion,
endocapillary hypercellularity and GBM thickening. There is
both ultrastructural (e.g. transmission electron microscopy) and
immunofluorescence (e.g. labelling of renal biopsy tissues with
antibodies specific for canine IgG, IgM or complement C3, plus
conjugated to a fluorochrome) evidence of mesangial and mem-
branous immune deposits. According to the ultrastructural loca-
tion of the deposits in the GMB, lesions can be sub-classified as
MPGN (only sub-endothelial deposits) or MPGN with mixed
pattern (multiple membranous locations, including sub-endo-
thelial, intramembranous or sub-epithelial). Immune deposits
are mostly composed of IgG and IgM, whilst C3 and IgA are
reported less frequently (Poli et al.1991, Nieto et al.1992, Esch
et al.2015).
Other types of ICGN, such as mesangioproliferative GN and
membranous GN, are less frequently reported in CanL (Poli
etal.1991, Costa et al.2000, Zatelli et al.2003, Aresu etal.2013).
Mesangioproliferative GN is characterised by mesangial matrix
expansion and hypercellularity with no GBM thickening or endo-
capillary hypercellularity. Immune deposits are located exclusively
in the mesangium. In contrast, membranous GN is typically
defined by GMB thickening with no significant hypercellularity
and membranous deposits (sub-epithelial location).
According to the stage of the disease, there is variable degree
of tubulo-interstitial damage with fibrosis and lymphoplasma-
cytic infiltration. However, tubulointerstitial lesions are thought
to be secondary and are not observed without glomerular lesions,
which are considered to be the primary lesion (Zatelli et al.2003).
The lymphocytic population is dominated by CD4+ lymphocytes
(T-helper cells) (Costa et al.2000, 2010).
However, Poli et al. (1991) also reported the presence of
immune deposits on the tubular basement membrane, identi-
fied by immunofluorescence. This observation suggests that at
least part of the tubular damage might also have an immune-
mediated nature. Glomerular amyloidosis is reported sporadi-
cally, but its association with Leishmania infection is not proven
(George et al.1976, Poli et al.1991). Finally, intraparenchymal
macrophages with intracytoplasmic amastigotes and vasculitis
are uncommon findings in kidneys of dogs with leishmaniosis
(Swenson et al.1988, Pumarola et al.1991).
WHAT DIFFERENCES ARE THERE IN RENAL
HISTOPATHOLOGY BETWEEN DOGS AND BOTH
HUMANS AND RATS WITH LEISHMANIOSIS?
In both humans and dogs, leishmaniosis has a wide range of pre-
sentations (mainly visceral, cutaneous and mucosal) depending
both on the species of Leishmania involved and the host immune
response to the parasite. Visceral leishmaniosis in humans fre-
quently affects immune-deficient patients, e.g. those infected
with the human immunodeficiency virus or organ transplant
recipients (Clementi et al.2011, Vassallo et al.2014, Enriquez
et al. 2015, El Jeri et al. 2017). Visceral leishmaniosis is also
reported in association with other renal diseases such as those
occurring as part of systemic lupus erythematous, sicca syndrome
and diabetes (El Jeri et al.2017). Type III MPGN, amyloidosis
and acute interstitial nephritis with intralesional parasites are the
most common pathological findings in affected people (Vassallo
et al.2014, Enriquez et al.2015). However, tubular necrosis is
also described and thought to be secondary to the inflammation
and/or ischemia due to small vessel obliteration by Leishmania
parasites (Vassallo et al.2014).
WHAT DIFFERENCES IN CLINICAL
PRESENTATION ARE THERE BETWEEN DOGS
WITH LEISHMANIOSIS WITH DIFFERENT
HISTOPATHOLOGICAL PATTERNS?
Renal lesions in CanL are mainly attributed to the deposition of
soluble circulating immune complexes within capillary beds of
the glomerular tuft, leading to ICGN (see question 11) (Mar-
cussen et al. 1989, Poli et al. 1991, Nieto et al. 1992, Costa
etal.2000, Zatelli et al.2003, Aresu et al.2007, 2013, dos Santos
et al.2013, Esch et al.2015). However, the clinical presentation
of dogs with GN can be extremely variable, mainly depending on
the stage of disease at diagnosis. Advanced GN, involving both
the glomerulus and the tubulointerstitial compartment, can be
characterised by severe proteinuria and renal failure, whilst the
same histological alterations at an earlier stage can lead to mild or
moderate proteinuria in the absence of renal failure. Regardless
of these general premises, the severity of proteinuria varies with
the different forms of GN, but it represents a marker identifi-
X. Roura et al.
6 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
able in all types of GN (Poli et al.1991, Costa et al.2000, Aresu
etal.2013).
MPGN is the most commonly reported glomerular pattern in
dogs with leishmaniosis (Marcussen et al.1989, Poli et al.1991,
Nieto et al.1992, Costa et al.2000, Aresu et al.2007, 2013, dos
Santos et al.2013, Esch et al.2015). MPGN is also characterised
by moderate proteinuria and is typically progressive and the over-
all renal prognosis is guarded-to-poor. No specific therapy has yet
been shown definitively to modify the natural course of MPGN
and data confirming efficacy of glucocorticoids, cytotoxic agents
or immunosuppressive drugs are absent.
Other types of ICGN are less frequently described in CanL.
These include mesangioproliferative GN and membranous GN
(Poli et al. 1991, Costa et al. 2000, Zatelli et al.2003, Aresu
et al.2013). Mesangioproliferative GN is characterised by mild
proteinuria, with many dogs being asymptomatic for years, never
developing renal insufficiency. Anecdotal evidence suggests that
dogs with mesangioproliferative GN have low risk of renal insuf-
ficiency, particularly those responding to antiproteinuric therapy.
In membranous GN, proteinuria is usually severe and the
most common clinical presentation is the nephrotic syndrome.
The clinical course of membranous GN is affected by several fac-
tors, but the stage of the disease at the time of diagnosis is fun-
damental. Unfortunately, with severe persistent proteinuria, the
renal damage is typically progressive and overall renal prognosis is
poor, with a large number of dogs developing end-stage renal dis-
ease (Benderitter et al.1988, Poli et al.1991, Costa et al.2000,
Aresu et al.2013).
HOW DO WE DIAGNOSE LEISHMANIOSIS IN
DOGS?
There is no perfect single test for CanL and, therefore, diagno-
sis will depend on the clinical decision of the veterinarian made
after evaluating a range of clinical and laboratory factors. The
likelihood of diagnosing leishmaniosis increases when a dog that
shows compatible clinical signs and laboratory alterations also
has a markedly positive antibody titre with serological testing
(e.g. IFA antibody titter ≥1/320 if the cut-off of the test is 1/40)
and when the parasite can be identified within tissue samples.
Therefore, veterinarians should use information from multiple
sources in order to make a diagnosis, including: clinical history,
physical examination findings, laboratory changes (e.g. haemato-
logical, biochemical and on urinalysis), tests to detect the para-
site [e.g. cytology, histopathology and polymerase chain reaction
(PCR)], tests that evaluate the immune response of the host (e.g.
serology) and response to treatment to support or refute the diag-
nosis of leishmaniosis (Paltrinieri et al.2010, Rodríguez-Cortes
et al.2010, Solano-Gallego et al.2011).
The main aim of diagnosis in dogs with compatible clini-
cal signs is to demonstrate a cause-effect relationship with both
pathological alterations and the presence of Leishmania parasites.
Without such confirmation, there is a risk of falsely concluding
that leishmaniosis is present, which can be problematic for dogs
living in areas endemic for the disease. In this situation, first-line
investigations should include both direct and indirect diagnos-
tic tests (Saridomichelakis et al.2005, Maia & Campino2008,
Paltrinieri et al.2010, Solano-Gallego et al.2011, De Tommasi
et al.2014). Direct tests involve identifying intralesional amas-
tigotes using cytology, tissue biopsy, immunohistochemistry or
PCR of injured tissues (if tissue damage is present) or cytology
and/or PCR of bone marrow or lymph node aspirates (if there are
no accessible lesions); indirect include qualitative and quantita-
tive serological assays.
In dogs without clinical signs, based on a complete physical
examination and a minimum database (e.g. haematological and
serum biochemical profiles and urinalysis), the first-line diagnos-
tic approaches should include specific indirect diagnostic tests as
quantitative serological assays. This is because of the poor sensi-
tivity of qualitative serological assays in ruling out potential infec-
tion with Leishmania (Solano-Gallego et al.2014). For screening
in areas endemic for CanL, this quantitative serology is best per-
formed between February and April; this is sufficient time after
the end of the last seasonal period, but before the beginning of
the Phlebotomus sand fly season. If indicated from the results of
serology, more accurate and specific direct tests should then be
performed including quantitative PCR assay on bone marrow or
lymph node aspirates or conjunctival swabs or blood; PCR is pre-
ferred because of its ability to detect the DNA of Leishmania and
thereby confirming the infection (Paltrinieri et al.2010, Solano-
Gallego et al.2011).
In both clinical situations, the use of vaccines for leishmani-
osis in southern Europe and in some Latin American countries,
known to elicit long-standing low-to-medium titre of antibodies
against Leishmania, may further complicate the interpretation of
serology in vaccinated dogs (Solano-Gallego et al.2017).
HOW SHOULD CANL BE CLASSIFIED FROM A
CLINICAL PERSPECTIVE?
In clinical practice, clinical staging is recommended in order to
establish proper management, treatment and prognosis in dogs
with leishmaniosis. The main aim is to decide whether the dog
is: (1) infected but healthy, (2) infected and sick for other reasons
or (3) infected and sick due to leishmaniosis. These distinctions
have become more complicated because vaccines are likely to
induce seropositivity. A correct clinical staging must be relevant
for the time of diagnosis, during the follow-up period and also to
help the clinician decide: (1) whether the dog should or should
not be treated for leishmaniosis; (2) whether the dog needs addi-
tional treatments depending on the clinical signs displayed and
(3) what is the clinical prognosis.
The two best-known clinical staging systems for leishmani-
osis in dogs are published, those produced by LeishVet (Solano-
Gallego et al.2011) and CLWG (Paltrinieri et al.2010, Roura
et al.2013). However, another classification of CanL based on
the severity of APP changes has been recently published (Ceron
et al.2018). A complete clinical and laboratory-based assessment
of each dog at the time of diagnosis, together with serological
responses and parasite detection, are necessary to characterise the
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 7
severity of disease and to assign the case to a clinical stage (Pal-
trinieri et al.2016, Ceron et al.2018, Meléndez-Lazo et al.2018,
IRIS2019). Following diagnosis, the dog should periodically be
re-evaluated and re-classified in line with disease progression or
regression (Oliva et al.2010, Paltrinieri et al.2010, 2016, Solano-
Gallego et al.2011, Roura et al.2013, Meléndez-Lazo et al.2018).
The CLWG system (Table1) classifies dogs as exposed, infected
and sick, with the latter being further classified by severity (Oliva
et al. 2010, Paltrinieri et al.2010, Roura et al. 2013). Exposed
dogs are clinically unremarkable, have a low-titre positive serology
and are negative either by PCR, by cytology or with both. These
dogs do not need treatment for leishmaniosis and have a favour-
able prognosis. Infected dogs are healthy or have clinical signs or
clinicopathological alterations associated with other causes, but
are positive either by PCR or cytology or both, based on samples
from bone marrow, lymph node, spleen, skin or peripheral blood.
These dogs only need treatment for clinical signs associated with
other diseases and the prognosis for leishmaniosis is favourable.
Sick infected dogs have clinical signs or clinicopathological altera-
tions associated with leishmaniosis. These dogs need treatment
for leishmaniosis and the prognosis is favourable-to-guarded.
Severely sick dogs show severe clinical conditions, e.g. severe pro-
teinuria associated with nephropathy, chronic kidney disease (e.g.
IRIS stages III and IV), ocular disease causing blindness or severe
joint disease impairing motility. These dogs could require immu-
nosuppressive drugs in addition to treatment for leishmaniosis
and their prognosis is guarded-to-poor.
WHAT DIFFERENCES ARE THERE AMONGST
DOGS WITH DIFFERENT CLINICAL AND
SEROLOGICAL STATUSES?
Dogs with different clinical and serological statuses differ in the
way they are treated and followed up. Seropositive dogs without
clinical signs or laboratory alterations associated with leishman-
iosis do not need treatment, even if they have a high positive
antibody titre. However, there are promising results with the use
of immunotherapeutic drugs, such as domperidone or nucleo-
tides, that modulate and activate the immune response so as to
prevent the development of clinical signs in this population of
dogs (Sabaté et al.2014, Hosein et al.2017, Segarra et al.2018).
Seropositive dogs require close follow-up to enable early detec-
tion of clinical signs or clinicopathological alterations compatible
with leishmaniosis (Oliva et al.2010, Solano-Gallego et al.2011,
2017). The intervals for follow-up should be shorter when the
antibody titre is higher especially when the dog is proteinuric,
because there is an association between high positive antibody
titre and the presence of clinical signs (Paltrinieri et al.2010,
2016, Pierantozzi et al.2013).
In contrast, although the other two groups of dogs with
clinical signs or laboratory alterations secondary to Leishmania
infection are seronegative, they should receive anti-Leishmania
treatment as soon as possible so as to obtain a better long-term
clinical response (Miró et al.2008, Oliva et al. 2010, Solano-
Gallego et al.2011).
HOW CAN WE DIAGNOSE RENAL DISEASE IN
DOGS WITH LEISHMANIOSIS?
The initial diagnostic investigation of renal disease in dogs with
leishmaniosis should include measurement of serum or plasma
creatinine (ideally assessed twice in a fasted, well-hydrated and
normotensive dog) and urinalysis [to include urine specific grav-
ity (USG), dipstick, urine sediment examination and urinary
protein-creatinine ratio (UPC)]. Depending upon the results
obtained, other diagnostic procedures may be indicated includ-
ing serum symmetric dimethylarginine (SDMA) concentration
or systolic blood pressure measurement. Once the evaluation is
completed, the dog should be classified according to the IRIS
staging scheme (Table2; IRIS2019).
TABLE 1. CLWG clinical stage of canine leishmaniosis
Stage Definition Description
A Exposed Clinically normal or have clinical signs and/or clinicopathological abnormalities associated with other disease(s).
Infection cannot be demonstrated by microscopy, culture or PCR and a specific antibody titter is positive. Such dogs
live or have lived during more than one ‘transmission season’ in a geographical region where sand flies are endemic.
B Infected Clinically normal or have clinical signs and/or clinicopathological abnormalities associated with other disease(s).
Parasites have been demonstrated by microscopy, culture or PCR and a specific antibody titter is negative or
positive to any extent.
C Clinically sick Dogs exhibit clinical signs and/or clinicopathological abnormalities associated with leishmaniasis. Infection is
demonstrated by microscopy, culture or PCR and by positive specific antibody titter, to any extent. Given the variable
clinical and clinicopathological expression of leishmaniosis, observed signs can differ from those commonly
described. Dogs with clinical signs and/or clinicopathological abnormalities associated with leishmaniosis and an
antibody titter ≥3 dilutions (IFA) or> 40% (ELISA) of the laboratory cut-off value can also be considered clinically
sick even if the parasite cannot be directly demonstrated.
D Severely sick Dogs with: (1) severe proteinuria (UPC> 3); (2) severe kidney disease (IRIS* stage 3-4); (3) severe ophthalmic disease
that can lead to functional loss and/or require immunosuppressive therapy; (4) severe joint disease leading to loss of
motor function and/or require immunosuppressive therapy and (5) severe concomitant disease(s).
Ea Unresponsive to
treatment
Dogs clinically unresponsive to recommended treatments of leishmaniosis.
Eb Early relapse Dogs with clinical relapse soon following cessation of recommended treatments of leishmaniosis.
CLWG Canine Leishmaniosis Working Group, ELISA Enzyme-linked immunosorbent assays, IFA Immunofluorescence assays, IRIS International Renal Interest Society, PCR Polymerase chain
reaction, UPC Urinary protein creatinine ratio. Adapted from Roura et al.(2013).
*IRIS stage of CKD in dogs (www.iris-kidney.com).
X. Roura et al.
8 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
Evaluation of proteinuria initially involves a dipstick test,
allowing semi-quantitative measurement of its magnitude.
Although, traditionally, cystocentesis samples were recom-
mended, so that protein contamination from the lower urinary
tract was avoided, voided samples are appropriate provided that
sediment is inactive (Beatrice et al.2010). In dogs, a negative
dipstick result indicates that the dog is probably non-proteinuric,
therefore eliminating the need for further determination of the
UPC. When the dipstick result is 30 mg/dL or above, pathologi-
cal proteinuria is suspected and quantification with UPC is indi-
cated (Zatelli et al.2010, Roura et al.2017). Ideally, pre-renal
and post-renal causes of proteinuria should be excluded before
measuring the UPC (Lees et al.2005, IRIS2019). However, this
is not always possible in dogs with leishmaniosis, because both
severe hyperproteinaemia (causing overload proteinuria) and
renal proteinuria can frequently coexist. To this end, proteinuria
should be re-evaluated after leishmanicide therapy. There may be
differences in UPC between samples obtained at home and those
obtained at the hospital (Duffy et al.2015), so samples should
always be obtained under the same conditions. The current rec-
ommendation is to consider that a dog is non-proteinuric when
UPC< 0.2, whilst those dogs with 0.2 ≤ UPC ≥ 0.5 are border-
line proteinuric and need to be re-evaluated within 2months.
Finally, dogs with a UPC> 0.5 are considered to be proteinuric
(Roura et al. 2017, IRIS2019). If proteinuria is persistent (e.g.
in three separate samples over a 2 to 3week period or docu-
mented on a pooled sample of three voidings) (Lees etal.2005,
LeVine etal.2010, Paltrinieri et al.2016), pre-renal and post-
renal causes of proteinuria have been excluded and the urine
sediment is inactive, then a UPC ≥ 2.0 usually is due to a glomer-
ular disease, whilst a UPC between 0.5 and 2.0 could indicate
either a glomerular or a tubular renal disease (Lees et al.2005).
That said, primary tubulointerstitial proteinuria has occasion-
ally been described in dogs with a UPC> 2.0, so this does not
necessarily preclude primary tubulointerstitial disease (Schneider
etal.2013).
In addition to UPC measurement, urine protein electropho-
resis using sodium dodecyl sulphate polyacrylamide gel (SDS-
PAGE), which separates proteins according to their molecular
mass, may help to determine whether proteinuria is of tubular
(e.g. low molecular weight proteins) or glomerular (e.g. inter-
mediate and high molecular weight proteins) origin (Zaragoza
etal. 2003, Zini etal.2004, Roura et al.2017). Results of SDS-
PAGE correlate well with histopathology of renal biopsy samples,
especially for the differentiation between glomerular and severe
tubulointerstitial damage (Zini et al.2004, Brown et al.2010).
A majority of dogs with leishmaniosis have a mixed glomerular
and tubular pattern, although pure glomerular proteinuria can be
seen in early stages (Zatelli et al.2003).
Different authors have investigated the usefulness of mea-
suring the activity of some urinary markers of glomerular
(IgG, c-reactive protein and ferritin) or tubular (N-acetyl-β--
glucosaminidase, γ-glutamyl transpeptidase, retinol-binding
protein and β-glucuronidase) damage in dogs with leishmaniosis
(Palacio et al.1997, Ibba et al.2016, Pardo-Marín et al.2017,
Paltrinieri et al. 2018). Although the results of some of these
studies are promising, more investigations are warranted before
such tests can be widely recommended.
Recently, serum SDMA has been investigated for early detec-
tion of decreased GFR in dogs with leishmaniosis; although mea-
suring SDMA could help, it did not increase diagnostic sensitivity
compared with UPC measurement (Torrent et al.2018, Giapit-
zoglou et al.2020). This is to be expected because proteinuria
is the first clinicopathological finding that indicates nephropa-
thy associated with leishmaniosis (Koutinas & Koutinas2014,
Paltrinieri et al.2016) and GFR is not usually decreased in the
initial stages of glomerular disease, instead being normal or
increased (Cortadellas et al.2008). Although this limits the use-
fulness of SDMA as an early indicator of renal disease in Can.
It might still be useful for detecting kidney dysfunction caused
by other pathogenic mechanisms. If the results of the laboratory
evaluation are all normal, the existence of renal disease might be
further investigated by performing kidney biopsy, although this
not always easily justified from a clinical perspective.
WHEN SHOULD RENAL BIOPSY BE
PERFORMED?
In general, renal biopsy is indicated a definitive diagnosis can
contribute to improve clinical management of the dog, thereby
improving outcome (Lees & Bahr2011). The main indication
for a kidney biopsy in dogs with leishmaniosis would be to inves-
tigate the existence of an active immune-mediated component
that could indicate therapeutic intervention with immunosup-
pressive drugs (IRIS Canine Glomerular Disease Study Group
et al.2013b). Additionally, in the presence of proteinuria, renal
biopsy can establish if a renal lesion not related to leishmaniosis
TABLE 2. IRIS stage of CKD in dogs
Stage Creatinine (mg/dL) SDMA (μg/dL) Description
1 <1.4 <18 No azotaemia
2 1.4-2.8 18-35 Mild azotaemia
3 2.9-5.0 36-54 Moderate azotaemia
4 >5.0 >54 Severe azotaemia
Sub-stage proteinuria (UPC) Nonproteinuric <0.2 Borderline proteinuric 0.2-0.5 Proteinuric >0.5
Sub-stage blood pressure (mmHg) Normotensive <140 Hypertensive 160-179 Prehypertensive 140-159 Severely
hypertensive ≥180
CKD Chronic kidney disease, IRIS International renal interest society, SDMA Symmetric dimethylarginine, UPC Urinary protein creatinine ratio. Adapted from IRIS(2019).
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 9
is present (Costa et al.2003, Zatelli et al. 2003, IRIS Canine
Glomerular Disease Study Group et al.2013b) a kidney biopsy
may help to establish if a renal lesion not related to leishmani-
osis is present. Nevertheless, this does not mean that renal biopsy
should be performed in all seropositive and proteinuric dogs. As
discussed previously, dogs with leishmaniosis and associated renal
disease should receive leishmanicide therapy and, when indicated,
renal treatment according to the severity of the disease. By itself,
the leishmanicide treatment can ameliorate the severity of renal
disease (Plevraki et al.2006, Pierantozzi et al.2013). Moreover,
standard therapy for renal disease (IRIS2019) can also help pre-
serve renal function and extend survival (Grauer et al.2000, Jacob
et al.2002, Cortadellas et al.2014, Zatelli etal. 2016). There-
fore, when an adequate response to these therapies is observed,
performing renal biopsies will probably not alter outcome. How-
ever, if there has not been an adequate response, renal biopsy
could be indicated especially if SDS-PAGE did not clarify the
origin of urinary proteins. It has been recommended that biopsy
should be considered when proteinuria is substantial (UPC ≥ 3.5)
in dogs already receiving standard therapy for glomerular disease,
if renal disease is progressive, if administration of immunosup-
pressive drug therapy is being considered or when the kidney
disease is not end-stage (IRIS Canine Glomerular Disease Study
Group et al.2013c).
Clinicians should also consider situations where renal biopsy
is contraindicated; examples include: dogs with IRIS advanced
stage 3 or stage 4 CKD where biopsy will probably not provide
any valuable information, concurrent coagulopathies, renal cys-
tic disease, moderate-to-severe hydronephrosis, pyelonephritis,
perirenal fluid, uncontrolled hypertension or severe anaemia.
Finally, the clinician should have access to a specialist renal diag-
nostic pathology centre that can perform electron microscopy
and immunofluorescence microscopy as well as light microscopy.
Several studies performed in dogs with glomerular disease have
shown that, although light microscopy leads to correct diag-
nosis in 73 to 77% of cases, immunofluorescence and electron
microscopy are required in the remainder, not least to confirm
of an immune-mediated component to the disease (Schneider
et al.2013, Cianciolo et al.2016, Aresu et al.2017). Therefore,
approximately one in four dogs could be erroneously classified if
only light microscopy is available, although this ratio could differ
in leishmaniotic dogs where minimal change GN is less frequent.
HOW SHOULD RENAL BIOPSY BE
PERFORMED?
Once it has been decided that renal biopsy could be of benefit in
a particular dog, the clinician needs to decide how to obtain the
sample and where to submit it for the histopathological examina-
tion. Different methods of obtaining kidney biopsies have been
described including percutaneous techniques (e.g. laparoscopy,
keyhole technique, ultrasound-guided or blind) and surgical
biopsy (Osborne et al.1996, Rawlings et al.2003, Vaden2004,
Vaden & Brown2017). A detailed description of these proce-
dures is outside the scope of these guidelines. Although, obtain-
ing kidney tissue is considered a safe and relatively low-risk
procedure, it is not exempt from complications that can be severe
(Vaden2004, Vaden et al.2005). Therefore, it is not advisable for
inexperienced operators to perform this procedure. Ideally, the
least invasive procedure capable of rendering satisfactory results
should be chosen, with ultrasound-guided needle biopsy produc-
ing satisfactory results in a majority of cases (Zatelli etal.2005,
Lees et al.2011, Crivellenti et al.2018). However, other methods
could be selected if preferred and if the benefits outweigh the
risks (Vaden et al.2005).
WHAT IS THE TREATMENT PROTOCOL FOR
KIDNEY DISEASE ASSOCIATED WITH CANL?
Any dog diagnosed with kidney disease should be classified and
treated following the IRIS recommendations (IRIS 2019), as
detailed in questions 21 to 25. This is also the case for dogs with
leishmaniosis, although clinicians have the advantage of know-
ing the cause of the renal disease (IRIS Canine Glomerular Dis-
ease Study Group et al.2013b). Treatment should be tailored to
each individual case and the risk: benefit ratio of each treatment
should be carefully considered (IRIS Canine Glomerular Disease
Study Group et al.2013b, Baneth et al.2018). However, when
leishmaniosis-induced kidney disease is identified, independent
of creatinine concentration, specific treatment for leishmaniosis
should be started immediately, either alone or together with the
standard treatment recommended for the IRIS (Table 2; Tor-
res et al.2011, IRIS Canine Glomerular Disease Study Group
et al.2013b, Pierantozzi et al.2013, Baneth et al.2018, Daza
González et al. 2019, IRIS 2019). Such dogs should then be
closely followed up to determine the efficacy of treatment (Fig1;
Segev et al.2008, Oliva et al.2010, Solano-Gallego et al.2011,
IRIS Canine Glomerular Disease Study Group et al.2013b).
HOW IS PROTEINURIA ASSOCIATED WITH CANL
TREATED?
Proteinuria associated with CanL requires different therapeutic
approaches, depending on the dog’s clinical condition and the
stage of disease (Fig1; Plevraki et al.2006, Oliva et al.2010,
IRIS Canine Glomerular Disease Study Group et al.2013b, Pier-
antozzi et al.2013, Cortadellas et al.2014, Proverbio etal.2016,
Zatelli et al. 2016, Daza González et al. 2019). In dogs with
UPC ≤ 3.0 and active leishmaniosis and hose that are sick or
severely sick (Table1; Paltrinieri et al.2010, Roura et al.2013),
should be given leishmanicide therapy and renal parameters
should be re-evaluated afterwards (Pierantozzi et al.2013, IRIS
Canine Glomerular Disease Study Group et al.2013b). If, at fol-
low-up and regardless of serum creatinine concentration, the dog
is still proteinuric (UPC> 0.5), therapy for proteinuria should
be administered (Plevraki et al. 2006, Pierantozzi et al. 2013,
IRIS Canine Glomerular Disease Study Group et al. 2013b,
Cortadellas etal.2014, Proverbio et al.2016, Zatelli et al.2016,
IRIS2019).
X. Roura et al.
10 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
A sequential treatment protocol thas been recommended
(Fig1) as follows: (1) identify and treat with a leishmanicide
drug plus allopurinol; (2) revaluate and stage renal disease after
finishing the leishmanicide treatment; (3) if proteinuria is not
controlled, continue with allopurinol and start a low-phosphorus
therapeutic diet alone or together with an angiotensin convert-
ing enzyme inhibitor (ACEi) such as enalapril or benazepril at
0.5mg/kg orally twice a day; (4) after 4 weeks of antiproteinuric
treatment, revaluate and restage renal disease; (5) if proteinuria is
still not controlled, increase the ACEi dose (maximum 2mg/kg
orally once a day) if it was not prescribed yet, add an angioten-
sin-receptor blockers (ARB) such as telmisartan (1mg/kg orally
once a day) or losartan (0.125-0.25 mg/kg orally twice a day) or
administer approximately 80 mg/kg orally once a day of poly-
unsaturated fatty acids (particularly an omega-3 fatty acid such
as eicosapentaenoic); (6) administer low-dose acetylsalicylic acid
canine leishmaniosis and UPC > 0.5
Active Leish Infection
and Stable Crea and UPC < or = 3*
LeishTx
After 3-7 days:
Control Crea +/-UPC
Stable Crea and UPC
Continue LeishTx Increased Crea
and/or UPC
Re-Consider LeishTx
(or Stop It)
Consider Prednisone
(evenat
antiinflammatory
dose: 0,7 mg/kg SID)
and recheck Crea
and UPC after 3-7
days
Reevaluate Crea
and UPC after
LeishTx
Restage based on
IRIS Staging System
and Consider
Antiproteinuric
Therapy, if needed
Active Leish Infection
and Increased Crea
and/or UPC
(during the last 5-7
days)
(with UPC < or = 3)*
Consider LeishTx
+
Consider Prednisone
(even at antiinflammatory
dose: 0,7 mg/kg SID)
Reduced Creatinine and UPC
Reduce Prednisone (one
week) and continue LeishTx
After 3-7 days:
Control Crea +/-UPC
Reevaluate Crea
and UPC after
LeishTx
Re-stage based on
IRIS Staging System
and Consider
Antiproteinuric
Therapy, if needed
Increased Crea
and/or UPC
Re-Consider LeishTx
(or Stop It)
Prednisone: to stop
it or increase dosage
up to
immunosuppressive
(dose: 1-2 mg/kg
SID-BID)
Non
Active
Leish
Infection
Consider
Antiproteinuric
Therapy
(renaldiet, ACEi,
ARB, omega3)
FIG 1. Flow-chart of clinical management of dogs with leishmaniosis and proteinuria (UPC> 0.5). Leish Leishmania spp., UPC urine protein creatinine
ratio, LeishTx leishmanicide treatment, ACEi angiotensin-converting enzyme inhibitors, ARB angiotensin-receptor blockers. *With UPC> 3, the
antiproteinuric therapy could also be instituted at the same time of leishmanicide treatment.
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 11
(1-5mg/kg orally once a day) or clopidogrel (1-3mg/kg orally
once a day) in all dogs when serum albumin persistently remains
below 2.0g/dL (<20 g/L).
Close monitoring of kidney function, blood pressure and
plasma potassium concentration are essential when administer-
ing high doses of an ACEi especially when combined with an
ARB requires.
Hypercoagulability is a potential risk in dogs with severe
persistent hypoalbuminemia (IRIS 2019), althought it cannot
always be predicted from the serum albumin concentration in
dogs with protein-losing nephropathy (White et al.2016).
These dogs with leishmaniosis and proteinuria could be
treated or not with this step-by-step protocol, depending on the
clinical evolution and severity of proteinuria (Zatelli et al.2016).
The approach to proteinuria described above can also be used in
dogs either exposed to or infected with Leishmania according to
the CLWG classification but who do not require leishmanicide
therapy (Table1; Paltrinieri et al.2010, Roura et al.2013). How-
ever, in sick or severely sick dogs in active leishmaniosis (Table1;
Paltrinieri et al.2010, Roura et al.2013) and UPC> 3.0 concur-
rent leishmanicide (Pierantozzi et al.2013, Proverbio et al.2016,
Daza González et al. 2019) and antiproteinuric therapy could
be considered, possibly even using all antiproteinuric treat-
ments at once (IRIS Canine Glomerular Disease Study Group
etal.2013b, IRIS2019).
DO ALL DOGS WITH LEISHMANIOSIS AND
KIDNEY DISEASE NEED ACEI?
Not all dogs with leishmaniosis and kidney disease need ACEi
(Plevraki et al.2006, Pierantozzi et al.2013, IRIS Canine Glo-
merular Disease Study Group et al.2013b, Cortadellas etal.2014,
Proverbio et al. 2016, Zatelli et al. 2016). For example, some
may have non-proteinuric renal disease or be dehydrated (IRIS
Canine Glomerular Disease Study Group et al.2013a, 2013b,
IRIS2019), whereas treatment with leishmanicides might lead
to a reduction in UPC< 0.5. In such cases, ACEi can still be
introduced if there is a subsequent increase in UPC or if systemic
hypertension is detected at follow-up examinations (see question
21).
In some countries, enalapril is the only ACEI registered for
the treatment of proteinuria in dogs, although others drugs from
the same class (e.g. benazepril) are likely to have the same effect.
For both drugs, 0.5mg/kg orally twice a day is most effective at
reducing the magnitude of proteinuria (Cortadellas et al.2014,
Zatelli et al.2016, IRIS2019, Keene et al.2019).
DO ALL DOGS WITH LEISHMANIOSIS AND
KIDNEY DISEASE NEED ANTIHYPERTENSIVE
THERAPY?
Not all dogs with leishmaniosis require antihypertensive therapy
and decisions on intervention should be made in accordance with
internationally accepted recommendations (Table2; IRIS2019).
Anti-hypertensive therapy is usually administered when there is
evidence of persistent SBP above 160 mmHg, given the risk of
further damage to the kidney, leading to the progression of renal
disease (Acierno et al.2018, IRIS2019). Any dog with leishman-
iosis and SBP> 160 mmHg needs therapy with antihypertensive
drugs in order to reduce blood pressure below this reference value
(Acierno et al. 2018, IRIS2019). Dogs with evidence of target
organ damage (e.g. eye, central nervous system or heart) should
be treated, even if persistent hypertension cannot be demon-
strated (Acierno et al.2018, IRIS2019).
Angiotensin converting enzyme inhibitors are the first choice
for the treatment of systemic hypertension in dogs but, if hyper-
tension cannot be controlled, the clinician should consider
increasing the ACEi dose, adding a calcium channel blocker
such as amlodipine (0.1-0.5mg/kg orally once a day) or adding
an ARB such as telmisartan (Acierno et al.2018, IRIS 2019).
If combinations of ACEi, amlodipine and ARB are used, close
monitoring of kidney function and blood pressure are required
given the risks of hypokalaemia and systemic hypotension (see
questions 20-22).
DO ALL DOGS WITH LEISHMANIOSIS AND
KIDNEY DISEASE NEED A RENAL DIET?
Nephropathic dogs with leishmaniosis can have proteinuria, azo-
taemia or both. In all of the above conditions, administration of
a low phosphorus therapeutic diet is recommended. Exceptions
are made for sick and severely sick dogs according to the CLWG
classification (Table1; Paltrinieri et al.2010, Roura et al.2013);
such dogs may not need dietary and, as described above (Pieran-
tozzi et al.2013, IRIS Canine Glomerular Disease Study Group
et al.2013b), are treated initially with leishmanicide therapy and
subsequently re-evaluated and staged according to the IRIS stag-
ing system (IRIS2019) (see question 21).
IS THERE ANY BENEFIT OF USING
GLUCOCORTICOIDS OR OTHER
IMMUNOSUPPRESSIVE DRUGS IN THE
MANAGEMENT OF DOGS WITH LEISHMANIOSIS
AND KIDNEY DISEASE?
Clinicians have long debated the use of glucocorticoids in CanL,
but robust evidence one way or another is lacking. Based upon
personal experience, some argue that they can ameliorate clini-
cal signs and improve outcomes (Bonavia et al.1995, Cortese
etal.2008). In contrast, others discourage their use given possible
because negative effects (Center et al.1987, Waters et al.1997,
IRIS Canine Glomerular Disease Study Group et al. 2013e).
Several studies have reported beneficial effects associated with
the use of glucocorticoids (mainly prednisone and predniso-
lone at variable doses) in dogs with leishmaniosis and clinical
presentations potentially caused by immune complex deposition
(Bergeaud1988, Blavier et al.2001, Cortese et al.2008, Sbrana
etal.2014). However, only two studies (Bergeaud1988, Bonavia
X. Roura et al.
12 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
et al.1995) evaluated dogs with renal disease and neither included
a control group, making it difficult to interpret the results. Other
studies have been small, including dogs with arthritis (Sbrana
etal.2014) and designed to evaluate the haemostatic function in
CanL (Cortese et al.2008), whilst one final study did not sup-
port the recommendation for using glucocorticoids in dogs with
leishmaniosis (Blavier et al.2001).
Nevertheless, evidence against the use of glucocorticoids
is also not strong. Adamama-Moraitou et al. (2005) discour-
aged the use of prednisolone, at an immunosuppressive dose,
in dogs with leishmaniosis given the risk of promoting parasite
replication by increasing serum iron concentration and decreas-
ing copper concentration. However, this did not actually occur
in any dog included in their study. In contrast, reactivation of
the disease after prolonged treatment with glucocorticoids has
been described in human patients and murine models (Rousseau
etal.1998, Ortiz et al.2015).
The IRIS group currently recommends using immunosuppres-
sive drugs in dogs with an active ICGN, which could be the case
in many dogs with leishmaniosis and renal disease (IRIS Canine
Glomerular Disease Study Group et al.2013b). This recommen-
dation is based on the prediction that suppression of humoral or
cell-mediated immunity and the associated glomerular inflamma-
tory response will favourably influence the progression, severity and
clinical outcome of the disease (Day1999, Noris & Remuzzi2013)
(see question 9). Ideally, this decision should be based on results of
a kidney biopsy (see question 18). However, if dogs are already
receiving standard therapy for glomerular disease, but they have
progressive increases in serum creatinine or evidence of rapidly pro-
gressive glomerular disease and no concurrent infectious disease has
been detected, then immunosuppressive therapy could be consid-
ered, even in absence of a histopathological diagnosis (IRIS Canine
Glomerular Disease Study Group et al.2013d, ).
Considering that severe complications are rare, current inter-
national recommendations are to use mycophenolate mofetil
(10mg/kg orally twice a day) as the first choice for dogs with
rapidly progressive glomerular disease, with cyclophosphamide
(50 mg/m2 orally once in 2 days) considered to be an alternative
when mycophenolate appears is ineffective (IRIS Canine Glo-
merular Disease Study Group et al.2013e). Although glucocorti-
coids are not recommended as sole treatment, due to slow onset
of action, an immunosuppressive dose of prednisolone (initially
2mg/kg orally once a day, then tapered) can be used in combina-
tion with these drugs (IRIS Canine Glomerular Disease Study
Group et al.2013e). Dogs with stable or slowly progressive dis-
ease (defined as minimally progressive proteinuria and azotae-
mia, with normo-albuminaemia or minimal hypoalbuminaemia)
and without evident oedema or clinical signs of uraemia, can be
treated with the above mentioned drugs or with drugs with more
delayed onset including chlorambucil (0.1-0.2mg/kg orally once
a day) alone or in combination with azathioprine (1-2 mg/kg
orally once a day) on alternating days or ciclosporin (5-10mg/
kg q12-24 h PO) (IRIS Canine Glomerular Disease Study Group
etal.2013e). In absence of adverse effects, at least 8 to 12 weeks
of therapy should be administered (IRIS Canine Glomerular
Disease Study Group et al.2013e).
It should be noted that these recommendations are based upon
evidence of efficacy in human patients (Emancipator1998) and
uncontrolled clinical experience in dogs (IRIS Canine Glomeru-
lar Disease Study Group et al.2013e). In fact, there is only a
single case report describing the use of mycophenolate in a
dog with GN of uncharacterised pathology (Banyard & Has-
sett2001). In contrast, it cannot be assumed that all proteinuric
dogs with leishmaniosis have ICGN. Although this may be true
for a majority of cases, the veterinary literature has described situ-
ations in proteinuric dogs with leishmaniosis in which immu-
nosuppressive drug administration would be contraindicated.
These include dogs with uncommon renal amyloidosis (George
et al.1976, Poli et al.1991) and those with chronic glomerulo-
sclerosis without immune complex deposits (Aresu et al.2013).
In summary, robust evidence supporting the use and dosage of
immunosuppressive drugs in the management of dogs with renal
disease secondary to leishmaniosis is lacking. The use of pred-
nisone or prednisolone at anti-inflammatory dosage (0.7mg/kg
orally once a day over a 3-10 days period) to reduce the renal
inflammation secondary due to deposition of immune complexes
and not to decrease their formation and circulation, is based only
on expert opinions (Fig1). Therefore, once the decision to treat a
dog with leishmaniosis with immunosuppressive drugs is taken,
the clinician should discuss with the owners the arguments for
and against the use of those drugs. Considering their potential
side effects, these agents should be administered cautiously,
adjusting doses and with close and careful monitoring (IRIS
Canine Glomerular Disease Study Group et al.2013b).
HOW SHOULD DOGS WITH LEISHMANIOSIS
AND KIDNEY DISEASE BE TREATED?
In dogs, the objectives of anti-Leishmania treatment are typically:
(1) to induce reduction in the parasite load in order to produce
clinical and clinicopathological improvement, (2) to restore nor-
mal immune function, (3) to avoid clinical relapses and (4) to
reduce the chance of further infection of sand flies (Gradoni
et al. 1987, Vouldoukis et al. 1996, Bourdoiseau et al. 1997,
Noli & Auxilia2005, Mateo et al.2009, Oliva et al.2010, Miró
etal.2011, Solano-Gallego et al.2011).
Given that the treatment of CanL is always a clinical decision,
the clinician must decide the best treatment in each case, based
on clinical presentation, published scientific evidence and owner
factors. However, for sick dogs with leishmaniosis (Table 1), the
combination of meglumine antimoniate at 50 to 100 mg/kg twice
a day or once a day SQ for 1month and allopurinol (10 mg/kg
orally twice a day or once a day with presence of xanthinuria, for
at least 12 months) is the most widely described and effective treat-
ment. If this treatment regimen is not possible, an alternative is a
combination of miltefosine (2mg/kg orally once a day for 28 days)
and allopurinol (Oliva et al.2010, Solano-Gallego et al.2011).
Several studies have demonstrated that all of these drugs can
improve and prevent progression of kidney disease in dogs with
leishmaniosis (Plevraki et al.2006, Torres et al.2011, Pierantozzi
et al.2013, Proverbio et al.2016, Paltrinieri et al.2018, Daza
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 13
González et al.2019) (see questions 20-21). However, to date,
there has been just one study of pathological renal damage, but
without clinical or clinicopathological alterations, induced by
meglumine antimoniate in dogs (Bianciardi et al.2009). In con-
trast, two recent studies have indicated no impact of meglumine
antimoniate treatment for CanL on kidney function on kidney
function (Daza González et al.2019, Kasabalis et al.2019). The
increase of azotaemia or proteinuria in some dogs treated with
meglumine antimoniate is most likely due to the kidney-specific
patho-mechanism of formation and deposition of immune com-
plexes than to nephrotoxicity of the drug (Koutinas & Kou-
tinas2014, Kasabalis et al. 2019) (see question 9). The routine
use of other protocols or drugs to treat leishmaniosis in dogs with
kidney disease is no longer recommended (Pineda et al.2017).
WHEN AND HOW DO WE NEED TO CONTROL
THE EVOLUTION OF LEISHMANIOSIS IN DOGS?
The ideal frequency, the tests used or the best protocol for man-
aging leishmaniosis in dogs with or without treatment has not
been defined (Paltrinieri et al.2016, Meléndez-Lazo et al.2018).
In general, dogs are followed according to their individual needs,
which are primarily driven by health status and clinicopathologi-
cal situation at the time of assessment.
In dogs that are exposed or infected (Table1), but not receiv-
ing treatment because there are no clinical signs or pathological
alterations, it makes sense to undertake a physical examina-
tion, minimum database (haematological and serum biochemi-
cal examinations and urinalysis) and serological testing every 6
to 12 months in order to confirm that retain the same clinical
classification. To interpret better the results of serology, testing
should be undertaken close to the beginning of the sand fly sea-
son (Oliva et al.2010, Roura et al.2013, Paltrinieri et al.2016).
In sick dogs without any renal changes or with kidney disease
IRIS stage 1 at the beginning of the treatment (Tables1 and 2),
it makes sense to undertake a physical examination, haemato-
logical and serum biochemical examination (that could include
protein electrophoresis and APP measurement, depending on
the clinician’s criteria) and urinalysis (especially USG and UPC)
(Pardo-Marín et al.2017, Ceron et al.2018) at the end of leish-
manicide treatment [1-7 days for meglumine antimoniate (Pier-
antozzi et al. 2013, Solano-Gallego et al. 2016); 3-4 weeks for
miltefosine (Proverbio et al.2016)] used. Later on, these assess-
ments, including quantitative serology for leishmaniosis, could
be repeated every 3 to 4months during the first year after leish-
manicide treatment. Subsequently, assessments (including real-
time qPCR) should be undertaken every 6 to 12 months for life,
to inform future decisions about clinical staging, treatment and
prognosis for each dog with leishmaniosis (Oliva et al. 2010,
Paltrinieri et al. 2010, Martínez et al.2011, Roura et al.2013,
Paltrinieri et al.2016). However, the schedule and the tests evalu-
ated in these controls could vary, depending on the health status
of the dogs and the clinical decisions of the clinicians.
In sick dogs with severe clinical signs (e.g. uveitis or kidney dis-
ease of IRIS stages 2-4) (Tables1 and 2), as well as the previously
described assessments, tests for secondary conditions should be
considered as per published recommendations (Oliva et al.2010,
Paltrinieri et al.2010, Roura et al.2013, Paltrinieri et al.2016).
When IRIS stages 2 to 4 are present, a further check should be
performed 3 to 5 days after starting meglumine antimoniate, to
evaluate for a possible worsening clinical status due to immune
complexes deposition and to determine the need for whether
adjustments to therapy are needed (see question 25 and Fig1).
WHEN AND HOW DO WE NEED TO CONTROL
THE EVOLUTION OF KIDNEY DISEASE IN DOGS
WITH LEISHMANIOSIS?
Most dogs that have been thoroughly evaluated and are consid-
ered to be free of renal disease at the time that leishmaniosis is
diagnosed do not to develop it (Planellas et al. 2009). There-
fore, no specific renal management is required beyond routine
monitoring for dogs with leishmaniosis. In contrast, renal func-
tion should be revaluated periodically in dogs with renal disease
require, so as to optimise the drugs and dosages that are requi-
ered (Roura et al.2013, IRIS Canine Glomerular Disease Study
Group et al. 2013a, IRIS Canine Glomerular Disease Study
Group et al.2013b). Although other alterations can be present,
the pillars of monitoring renal disease in dogs with leishmaniosis
are to control changes in proteinuria, azotaemia, hypoalbumi-
naemia, blood pressure and hyperphosphataemia. The following
recommendations only apply to dogs that are clinically stable and
are receiving ambulatory treatment; animals requiring hospitali-
sation because of their poor clinical condition require a different
monitoring protocol.
Although ACEi and ARB are considered safe when used in
stable dogs, they are not free of side effects, the most relevant of
which are hyperkalaemia, hypotension and reduction of GFR,
resulting in increases in serum creatinine concentration. The
authors advise that dogs treated with ACEi, ARB or their combi-
nation have creatinine, potassium and SBP reassessed within 5 to
7 days (even earlier for dogs at IRIS advanced stage 3 or stage 4)
of starting the treatment or when the dose is increased. Increases
of serum creatinine concentration of 0.5mg/dL (<45 μmoL/L)
and/or SDMA of <2μg/dL could be attributed to effect of the
ACEi and/or ARB on glomerular haemodynamics for dogs in
IRIS stages 1, 2 and 3, whilst greater changes suggest disease
progression and require treatment adjustment. However, any
increase in serum creatinine is considered unacceptable for dogs
in IRIS stage 4 (IRIS Canine Glomerular Disease Study Group
et al.2013a).
As a general rule, we recommend reassessing changes in pro-
teinuria, albumin, creatinine and phosphate concentrations every
4 to 6 weeks until values are stable or until the target value for
UPC and plasma phosphate have been reached (IRIS 2019).
Increases in serum albumin concentration and UPC reductions
suggest a positive response to therapy. However, since these
can also occur in dogs with progressive excretory failure, such
changes must be interpreted in conjunction with variations in
creatinine concentration (IRIS Canine Glomerular Disease
X. Roura et al.
14 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
Study Group et al.2013e). Subsequently, dogs at IRIS stages 1,
2 or early stage 3 are revaluated every 3 months for the first year
and thereafter every 6 to 12 months at IRIS stage 1, twice a year
at IRIS stage 2 and three times a year at IRIS stage 3. Dogs in
IRIS advanced stage 3 or stage 4 should be evaluated every 4 to
6 weeks. When assessing proteinuria, day-to-day variations in the
UPC should not be ignored, especially in dogs with UPC> 4
(Nabity et al.2007). In these cases, consideration should be given
to either averaging 2 to 3 serial UPC measurements or measur-
ing UPC in urine sample that has been pooled from 2 to 3 col-
lections (LeVine et al.2010). Moreover, the required percentage
of change to consider that variation in the UPC is significant
decreases with the severity of proteinuria. For dogs with massive
proteinuria (UPC> 12)> 35% change is required, whilst for dogs
with UPC close to 0.5, greater than 80% of change is necessary
(Nabity et al.2007).
Regarding serum phosphate concentration, the authors’ advice
is to follow the IRIS recommendations (IRIS2019). Initial SBP
monitoring is conducted 1 to 14 days after starting therapy
depending on the severity of hypertension, the IRIS stage of
CKD and dog stability. Dogs at IRIS stages 1 to 2 with mild
increase in SBP could be revaluated in 2 weeks, whilst unstable
hospitalised dogs at IRIS stages 3 to 4 need to be reassessed daily
(IRIS Canine Glomerular Disease Study Group et al. 2013a,
Acierno et al. 2018). Once the target SBP has been reached,
monitoring should occur at least every 3 to 6months (Acierno
etal.2018, IRIS2019).
In dogs that are put on immunosuppressive treatment, initial
assessments should be performed no later than 1 to 2 weeks after
initiation of the treatment and every 2 weeks thereafter for the
first 4 to 6 weeks of treatment. Subsequently, assessments are rec-
ommended at least every 4 weeks for the next 3months and then
at quarterly intervals until resolution of the disease (IRIS Canine
Glomerular Disease Study Group et al.2013e).
WHAT IS THE RELATIONSHIP BETWEEN
ALLOPURINOL TREATMENT, XANTHINURIA AND
KIDNEY DISEASE?
Allopurinol is a leishmaniostatic drug used in treating CanL for
long periods, usually at least 12 months, in order to maintain
reduced parasite load, avoid relapses and reduce the transmission
to people and other dogs (Plevraki et al.2006, Oliva et al.2010,
Miró et al.2011, Solano-Gallego et al.2011,Torres et al.2011,
Manna et al.2015). Traditionally, allopurinol was thought to be
safe for use in dogs, with long-term and even lifelong therapy
often required (Ginel et al.1998, Denerolle & Bourdoiseau1999,
Noli & Auxilia2005, Freeman2010). However, both allopurinol
resistance (Maia et al.2013, Yasur-Landau etal.2016) and xan-
thine urolithiasis (Koutinas et al.2001, Pennisi et al.2005,Torres
et al.2011, Torres et al.2016) can occur with prolonged therapy.
Urinary adverse effects of allopurinol can be detected as soon as
3 weeks post-treatment up to after 9 years of treatment, suggest-
ing issues with both short- and long-term use (Torres et al.2011,
Torres et al. 2016). Given that kidney mineralisation and xan-
thine uroliths are usually irreversible, can seriously impact kidney
function and this type of urolith cannot be dissolved medically,
closer follow-up is required, including urinalysis (at the begin-
ning of treatment and at the time of each follow-up assessment)
and abdominal ultrasound if xanthinuria is detected (Torres
etal.2016). In the presence of such urinary problems, the dose
of allopurinol should be reduced to 10mg/kg once a day or less
(Vercammen & De Deken1995, Manna et al.2015), water con-
sumption should be increased and low-purine diet fed in order
to maintain urinary xanthine concentration below its saturation
point (Osborne et al.2010) or to exchange allopurinol for nucle-
otides (Segarra et al.2017).
DO ALL DOGS WITH LEISHMANIOSIS NEED
TO RECEIVE LIFELONG LEISHMANICIDE OR
LEISHMANIOSTATIC DRUGS THERAPY?
Although CanL is considered to be a chronic disease, the major-
ity of dogs respond well to the recommended treatments and do
not require lifelong leishmanicide and/or leishmanostatic drugs
(Oliva et al.2010,Solano-Gallego et al.2011, Roura et al.2013).
Moreover, the occurrence of side effects or resistance asso-
ciated with the use of these drugs suggests that the treatment
should be suspended when the dog obtains the status of infected,
but clinically healthy dog (see questions 15, 16, 29 and 34).
However, some dogs could relapse although they had received
adequate treatment when clinicians: (1) withdraw allopurinol
or even (2) during the treatment with allopurinol. In the first
situation, a complete treatment needs to be reinitiated again; in
the second situation, the dog will again require treatment with a
leishmanicide drug such as meglumine antimoniate or miltefo-
sine. Furthermore, there are some dogs that, even when main-
tained on allopurinol treatment, need leishmanicide treatment
every 4 to 12 months in order to remain clinically stable. These
dogs have a guarded prognosis because their immunological
and clinical responses are inadequate (Oliva et al.2010,Solano-
Gallego et al.2011, Roura et al.2013).
DO ALL DOGS WITH LEISHMANIOSIS AND
KIDNEY DISEASE NEED LIFELONG RENAL
TREATMENT?
The answer to this question is clearly no since remission of renal
disease can occur in both proteinuric non-azotaemic and azotae-
mic dogs (Plevraki et al.2006, Pierantozzi et al.2013, Proverbio
et al.2016). For many practitioners, the general assumption is
that all dogs with leishmaniosis with renal disease have CKD.
However, in almost all cases, the initial diagnosis is based exclu-
sively on the results obtained after a single evaluation of the rou-
tine laboratory markers of renal function. Therefore, true severity
and irreversibility of renal disease cannot be estimated when the
disease is diagnosed. Treating the aetiological agent and provid-
ing therapy to support the kidneys can reduce the severity of the
injuries or even completely cure of the disease, especially where
Canine leishmaniosis and kidney disease
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 15
an early diagnosis has been made. Unfortunately, this is not the
case for all dogs and there will be some that progress to CKD,
requiring lifelong renal therapy and adjustment in treatment
(IRIS 2019). This fact highlights the importance of periodi-
cally monitoring renal function, as treatment requirements may
change with time.
WILL ALL DOGS WITH LEISHMANIOSIS AND
KIDNEY DISEASE DIE?
Many dogs with leishmaniosis and concurrent kidney disease
have both a normal quality of life and lifespan. Factors that most
influence both survival time and progression of the disease are
early diagnosis and an adequate therapeutic approach and moni-
toring scheme.
WHAT IS THE PROGNOSIS FOR DOGS WITH
LEISHMANIOSIS?
The prognosis of the disease varies depending on the clinico-
pathological situation and is, therefore, not the same for all dogs
with leishmaniosis. Nowadays, the prognosis for the majority
of cases is favourable, thanks to early diagnosis due to improve-
ment in diagnostic techniques and the use of more adequate
protocols to treat leishmaniosis (Solano-Gallego et al. 2011,
Roura etal.2013). Discussion with owners about the prognosis
for their dog with leishmaniosis can be difficult. The prognosis
depends on: the clinical staging at the time of diagnosis and at
each follow-up assessment; the severity of the clinicopathologi-
cal alterations that are present; the response to the treatment
and the number of relapses (Solano-Gallego et al.2011, Roura
et al.2013). While the prognosis for both exposed and infected
dogs is considered to be favourable, it is not the same if infection
progresses to overt disease. For clinically affected dogs undergo-
ing treatment, the prognosis varies from good-to-poor depend-
ing on many different factors, such as the severity of the clinical
signs. For example, the presence of uveitis carries a poor prognosis
for vision and the severity of kidney disease is clearly associated
with reduced survival (Finco et al.1999, Elliott & Watson2008,
Oliva et al.2010, Solano-Gallego et al.2011, Roura et al.2013,
IRIS2019). Prognosis also depends on the anti-Leishmania treat-
ment used, because clinical and laboratory alterations are more
stable and the prognosis is better on the long term when meglu-
mine antimoniate plus allopurinol treatment are used (Torres
etal.2011, Manna et al.2015). In contrast, the prognosis is very
poor in dogs with severe clinical signs of leishmaniosis with no
treatment (Dos-Santos et al.2008).
WHAT IS THE PROGNOSIS FOR DOGS WITH
LEISHMANIOSIS AND KIDNEY DISEASE?
Classically, the prognosis of dogs with leishmaniosis and kidney
disease was very poor because advanced renal disease was the
major cause of death or euthanasia (Mancianti et al.1988, Slap-
pendel1988, Ferrer et al.1995, Koutinas et al.1999). However,
in light of recent improvements in knowledge, diagnosis is often
made earlier and treatment options are better such that prognosis
is more favourable (Plevraki et al.2006, Torres et al.2011, Pier-
antozzi et al.2013, Cortadellas et al.2014, Proverbio et al.2016,
Zatelli et al.2016, Paltrinieri et al.2018).
For dogs with IRIS stages 1, 2 or early 3 CKD as well as
those with severe or progressive proteinuria, the prognosis
after treatment is generally favourable-to-guarded (Paradies
et al.2010, Torres et al. 2011, Rougier et al. 2012, Pieran-
tozzi et al.2013, Proverbio et al.2016, Pineda et al.2017).
However, dogs with advanced IRIS stage 3 or stage 4 CKD
or those with severe or progressive proteinuria, the progno-
sis after treatment is guarded-to-poor (Koutinas et al.1999,
Plevraki et al.2006, Planellas etal. 2009). When evaluating
the prognosis of dogs with leishmaniosis and associated renal
disease, the prognostic value of proteinuria needs to be con-
sidered after implementing the leishmanicide treatment (Kou-
tinas et al.1999, Plevraki et al.2006, Pierantozzi et al.2013,
IRIS Canine Glomerular Disease Study Group etal.2013b,
Proverbio et al.2016).
As a result, most experts recommend that dogs with leishman-
iosis and any renal alteration should be treated for leishmani-
osis with the same protocol as dogs without renal involvement
(see questions 20, 21 and 26), together with symptomatic and
specific renal treatment necessary for each IRIS stage (Elliott &
Watson 2008, IRIS Canine Glomerular Disease Study Group
etal.2013b, IRIS2019).
CONCLUSIONS
There is a growing international interest in CanL, because of the
geographical spread of the disease and because modern diagnos-
tic tests have allowed the identification of an increasingly large
number of dogs showing clinical signs, that in the past were not
identified or were identified late in the course of the disease. Sim-
ilarly, increased understanding and availability of diagnostics has
led to identification of more dogs with nephropathy associated
with leishmaniosis. Clinicians must be aware of this important
aspect of CanL and consider specific assessments of renal func-
tion at the time of initial diagnosis and staging and at the time of
periodic follow-up assessments over the life of those dogs. These
guidelines summarise the current state-of-the-art of knowledge
of the pathogenesis, clinical presentation, diagnosis, treatment,
long-term management and prognosis for CanL-associated renal
disease.
Acknowledgement
We thank Ecuphar Italia srl for its supports to scientific activity
of CLWG (https://www.gruppoleishmania.org/en). CLWG col-
laborators.
Conflict of interest
No conflicts of interest have been declared
X. Roura et al.
16 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
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