Veterinary Clinical Pathology ISSN 0275-6382
REVIEW ARTICLE
Renal biomarkers in domestic species
Jessica A. Hokamp, Mary B. Nabity
Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
Key Words
Cats, dogs, enzymes, kidney, SDMA
Correspondence
J.A. Hokamp, Department of Veterinary
Pathobiology, College of Veterinary Medicine
and Biomedical Sciences, Texas A&M
University, 4467 TAMU, College Station,
TX 77843, USA
E-mail: jhokamp@cvm.tamu.edu
DOI:10.1111/vcp.12333
I. Introduction
II. Renal Biomarkers: Blood
Endogenous markers of glomerular filtration rate (GFR)
a. Creatinine
i. Nephron Mass vs. Nephron Function
ii. Value of Population-Specific Reference Intervals
iii. Trending of Serum Creatinine
iv. Non-Renal Influences
v. Analytic Challenges
b. Symmetric Dimethylarginine (SDMA)
i. Background
ii. Measurement and Stability
iii. Reference Limit
iv. Non-Renal Influences
v. Renal Disease in Veterinary Medicine
Markers of altered metabolism
c. Fibroblast Growth Factor-23 (FGF-23)
i. Background
ii. Measurement, Stability, and Reference Range
iii. Non-renal Influences
iv. Renal Disease in Veterinary Medicine
III. Renal Biomarkers: Urine
Renal Protein Handling
28
Abstract: Current conventional tests of kidney damage and function in
blood (serum creatinine and urea nitrogen) and urine (urine protein crea-
tinine ratio and urine specific gravity) are widely used for diagnosis and
monitoring of kidney disease. However, they all have important limita-
tions, and additional markers of glomerular filtration rate and glomerular
and tubular damage are desirable, particularly for earlier detection of renal
disease when therapy is most effective. Additionally, urinary markers of
kidney damage and function may help localize damage to the affected
portion of the kidney. In general, the presence of high- and intermediate-
molecular weight proteins in the urine are indicative of glomerular
damage, while low-molecular weight proteins and enzymes in the urine
suggest tubular damage due to decreased reabsorption of proteins, direct
tubular damage, or both. This review aims to discuss many of these new
blood and urinary biomarkers in domestic veterinary species, focusing
primarily on dogs and cats, how they may be used for diagnosis of renal
disease, and their limitations. Additionally, a brief discussion of serum
creatinine is presented, highlighting its limitations and important consider-
ations for its improved interpretation in domestic species based on past
literature and recent studies.
Markers of Glomerular Damage/Dysfunction
a. Immunoglobulins
i. Background
ii. Measurement and Stability
iii. Values in Healthy Animals
iv. Non-Renal Influences
v. Renal Disease in Veterinary Medicine
1. Acute Kidney Injury (AKI)
2. Chronic Kidney Disease (CKD)
b. Additional Urinary Proteins Indicating Glomerular Damage/Dysfunction
i. Albumin
ii. C-Reactive Protein
Markers of Tubular Damage/Dysfunction
a. Retinol Binding Protein (RBP)
i. Background
ii. Measurement and Stability
iii. Values in Healthy Animals
iv. Non-Renal Influences
v. Renal Disease in Veterinary Medicine
1. AKI
2. CKD
d. Neutrophil Gelatinase-Associated Lipocalin (NGAL)
i. Background
ii. Measurement and Stability
(continued) (continued)
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
iii. Non-Renal Influences
iv. Renal Disease in Veterinary Medicine
1. AKI
2. CKD
e. Additional Urinary Proteins Indicating Tubular Damage/Dysfunction
i. Tamm-Horsfall Protein
ii. Cystatin C
f. Urinary Enzymes
i. Background
ii. Measurement and Stability
iii. Values in Healthy Animals
iv. Non-Renal Influences
v. Renal Disease in Veterinary Medicine
1. AKI
2. CKD
i. Cauxin
IV. Conclusions
V. References
Introduction
Urinalysis has contributed to medical diagnoses for
thousands of years. However, it was not until the
routine use of clinical chemistry approximately 50–
60 years ago that measurement of renal biomarkers
became commonplace in human and veterinary
medicine. This allowed for both an improved under-
standing of the renal system and ability to diagnose
renal disease. Historically, renal biomarkers have
focused on kidney function testing, and this is the
basis for current conventional tests in blood (serum
creatinine [sCr], urea or urea nitrogen [UN]) as
endogenous indicators of glomerular filtration rate
(GFR). We are increasingly recognizing the need to
identify renal disease at an early stage, when thera-
peutic options are most effective. While sCr and UN
play an important role in the diagnosis of kidney
disease, their limitations create poor confidence for
their use as early indicators of disease. New markers
of renal function aim to overcome these limitations.
In addition, there are now many urinary markers
that can detect kidney damage and help localize
that damage to the compartment of the kidney that
is affected.
Many excellent and comprehensive reviews of
renal biomarkers have been published focusing on the
human literature, with several recent reviews avail-
able in veterinary medicine.1–3 This review aims to
comprehensively summarize the field in veterinary
medicine, particularly focusing on recent advances in
renal biomarker research.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
Renal Biomarkers: Blood
Endogenous markers of GFR
Creatinine
Serum creatinine is the most widely used endogenous
marker for estimating GFR, and its metabolism, mea-
surement, and diagnostic significance in dogs have
previously been reviewed.4 While the present review
focuses primarily on new tests of renal function, it is
important to consider factors that can either enhance
or limit the clinical use of sCr in order to optimally help
clinicians and clinical pathologists interpret the value
of this conventional test. In particular, accurate inter-
pretation of the literature, population-specific refer-
ence intervals, trending of sCr, and consideration of
muscle mass influence and analytic variability are all
needed to best interpret sCr in dogs and cats. Of note,
although creatinine is referred to as sCr throughout
this manuscript, creatinine is also commonly measured
in plasma.
Nephron mass vs nephron function. It is widely accepted
that at least 75% of nephron mass must be lost before
sCr increases above the reference limit.4 The original
source for this statement likely originates from partial
nephrectomy studies in dogs. However, the statement is
often misinterpreted as 75% loss of renal function vs
mass. In partial nephrectomy studies, 3/4th loss of renal
mass corresponded to an approximately 50–60% or 35–
45% decrease in renal function based on inulin clearance
one month or 13 months post surgery, respectively.5,6
The much lower decrease in function as compared with
the percentage of nephron loss is due to compensatory
changes in remaining nephrons (ie, compensatory renal
hypertrophy).5,7 Furthermore, using an age- and
breed-specific reference limit (sCr ≥ 106 mmol/L or
1.2 mg/dL) along with frequent monitoring, adolescent
dogs with rapidly progressive kidney disease due to X-
linked hereditary nephropathy (XLHN) demonstrated
increased sCr after GFR had decreased an average of
48% (range 39–68%).8 Based on these studies, sCr can
be more sensitive for detecting decreased renal function
than has been historically assumed.
Value of population-specific reference intervals. While sCr
is not as poorly sensitive as generally believed, its
inability to consistently detect < 50% decline in kidney
function at least partly stems from reference intervals
that are overly wide for patients with low baseline
29
Renal biomarkers review
sCr. Since current methodologies are highly specific
for creatinine, the wide reference intervals largely
stem from biologic differences in sCr among individ-
uals. Serum creatinine has relatively high individual-
ity in dogs and cats9–11, meaning that variability
between individuals is much higher than the variabil-
ity observed within a single animal. Serum creatinine
is influenced by age12,13 and particularly by breed in
dogs14–19 and, to a lesser extent, in cats.20 It might
also be influenced by sex and the veterinary clinic
evaluating the patient.21 Therefore, sCr would bene-
fit from age- and breed-specific reference intervals,
ideally (although not practically) for every individual
instrument and laboratory.
Trending of serum creatinine. Small increases in sCr even
within the reference interval can reflect significant
decreases in GFR in an individual patient8, particularly
since variation in sCr within an individual healthy dog
or cat is minimal over weeks to months and even
years.4,9–11 In fact, the critical difference or reference
change value for detecting a significant increase or
decrease in sCr is only 23–27 lM/L (0.3 mg/dL) in
clinically healthy dogs10, and 17% (corresponding to
similar absolute values as in dogs) in clinically healthy
cats.9 Thus, the sensitivity of sCr for detecting early
kidney disease can be improved by evaluating serial
fasted sCr measurements in an individual animal
(trending) to look for increases that likely reflect wors-
ening renal function. This concept of detecting small
but clinically relevant increases in sCr is actively being
adopted in cases of acute kidney injury (AKI), illus-
trated by the International Renal Interest Society
(IRIS) Grading of AKI. In this grading scheme, an
increase in sCr ≥ 26 lmol/L (0.3 mg/dL) within a 48-
hour period is a criterion for identifying Grade I and
Grade II AKI (www.IRIS-Kidney.com). Furthermore,
in adolescent dogs with XLHN, trending of sCr detected
an average of 27% (range 5–49%) decrease in GFR.8
Despite heightened awareness of small, but clinically
relevant increases in sCr over a short time frame, more
recognition is needed with slowly progressive CKD, in
which small increases might occur over many months
or years.
Nonrenal influences. It is well known that an inherent
limitation of sCr is its dependence on muscle mass.
Serum creatinine can overestimate renal function in
cachectic, geriatric, and very young patients as well as
in small-breed dogs. Additionally, sCr increases might
be offset by ongoing muscle wasting in animals with
CKD and in elderly animals, as supported by a recent
30 Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
study of geriatric cats, where both sCr and GFR were
lower in cats > 15 years old as compared with cats
< 15 years old.22 Therefore, even careful monitoring
of sCr over time in an individual patient is an unreli-
able indicator of declining GFR if concurrent muscle
wasting is present. Additionally, as might be expected
with any endogenous marker of GFR, hydration and
blood volume status as well as urinary tract obstruction
or rupture can influence sCr. Particularly early on,
these changes do not necessarily reflect inherent kid-
ney function, further hampering the sensitivity and
specificity of sCr for kidney disease.
Analytic challenges. Finally, sCr is plagued by inconsis-
tencies in its measurement between instruments and
laboratories, which can result in markedly different
results. While most reference laboratory instruments
have excellent precision and provide results of similar
magnitude among instruments23, recent studies illus-
trate the high imprecision and bias possible with some
instruments and among different laboratories.23,24 In
normal to mildly azotemic samples, one study using
reference laboratories found differences of up to
40 lmol/L (0.45 mg/dL) in the same sample measured
by the same laboratory and up to 50 lmol/L (0.57 mg/
dL) among different laboratories, even when exclud-
ing 2 laboratories (out of 10) with extreme outliers.23
Larger differences were noted in moderately to mark-
edly azotemic samples: excluding outlier results from 3
laboratories, up to a 68 lmol/L (0.77 mg/dL) differ-
ence was observed within the same laboratory, and
117 lmol/L (1.32 mg/dL) difference between labora-
tories.23 A still larger variation in sCr measurement
was observed among 99 veterinary practices, where
results ranged from 80 to 200 lmol/L (0.9–2.26 mg/
dL) for a single sample spiked with 112 lmol/L
(1.25 mg/dL) creatinine.24
These results highlight that many instruments/
laboratories are performing below the total allowable
error (TEa) guideline for sCr (TEa ≤ 20%) set by the
Quality Assurance and Laboratory Standards Commit-
tee of the American Society for Veterinary Clinical
Pathology (ASVCP).25 Even with TEa ≤ 20%, analytic
variability alone (instrument precision and bias) could
account for an increase or decrease in sCr ≥ 18 mmol/
L (0.2 mg/dL) in normal to mildly azotemic samples,
which is approaching the critical difference for detect-
ing a significant change in sCr in clinically healthy dogs
and cats.9,10 To minimize this analytic variability, it is
particularly important that serial determinations of sCr
are measured on a single instrument that is subjected
to a strict quality assurance program.
Hokamp and Nabity
In summary, sCr can be a sensitive marker of
declining renal function if careful monitoring and/or
appropriate reference intervals are used in animals
with relatively stable muscle mass. However, because
of both inherent biologic and current analytic limita-
tions of sCr, additional endogenous markers of GFR
would aid in the early diagnosis of renal disease. Two
recently studied markers are cystatin C and symmetric
dimethylarginine (SDMA). An excellent recent review
of cystatin C is available.26 Therefore, only SDMA will
be further discussed below.
Symmetric dimethylarginine (SDMA)
Symmetric dimethylarginine is a methylated amino
acid (arginine) of similar size to creatinine (SDMA:
202 daltons [Da]; creatinine: 113 Da). Symmetric
dimethylarginine is formed by posttranslational
methylation of arginine by type 2 protein arginine
methyltransferases27, and it is released into circulation
following proteolysis. Symmetric dimethylarginine
was originally discovered 45 years ago in human
urine.28 Concentrations of Symmetric dimethylargi-
nine in protein fractions from various organs in rats
demonstrated SDMA to be highest in the brain and rel-
atively high in the liver, lung, kidney, spleen, and
small intestine as compared with heart, muscle, skin,
and blood.29 The kidneys are the major source of
SDMA excretion28,30–32, and SDMA does not appear to
be reabsorbed by the tubules for reutilization.28 Sym-
metric dimethylarginine was first shown to be
increased in human patients with CKD over 20 years
ago33; however, SDMA has only recently gained
prominence as an endogenous marker of GFR in peo-
ple34–36, correlating strongly with renal function based
on inulin clearance.36 Symmetric dimethylarginine
has largely been believed to be inert, reducing nitric
oxide synthesis indirectly by competing with L-argi-
nine uptake in cells.35,37 However, a recent study
demonstrated a direct effect of SDMA, in which
uncoupling of endothelial nitric oxide synthase
resulted in superoxide anion production in glomerular
endothelial cells.38 In addition, a recent review high-
lights several studies that support a proinflammatory
role of SDMA.39 However, chronic infusion of SDMA
in healthy mice had no evident effect on renal struc-
ture or function as well as cardiac function.40
Measurement and stability. Mass spectrometry is the gold
standard for SDMA measurement, as it uniquely and
accurately detects the molecule.41 However, recent
studies in people have used a commercially available
ELISA with at least one study demonstrating good
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
precision, although accuracy was not assessed.42 An
accurate and precise liquid chromatography–mass
spectrometry (LC–MS/MS) assay has recently been
developed for SDMA measurement in dogs and
cats.8,43 In addition, a high-throughput immunoassay
with similar performance to the LC–MS/MS method
has been developed and validated44, allowing SDMA
to become a standard analyte on chemistry panels
offered by IDEXX Laboratories, Inc. Symmetric
dimethylarginine is stable in canine and feline serum
and plasma for at least 7 days at room temperature,
and 14 days at 4°C and with up to 3 freeze–thaw cycles
(between 80°C and room temperature).8,45 While no
published studies are available regarding the long-term
stability of SDMA in frozen samples, anecdotal evi-
dence supports that it is stable for at least 5 years when
frozen at 20°C or 80°C (IDEXX, Laboratories, Inc.,
Personal Communication).
Reference limit. In clinically healthy animals, SDMA
concentrations are similar across studies and species,
despite differences in methodology and animal popula-
tions. Two studies in healthy human subjects deter-
mined the reference interval using LC–MS/MS as
0.32–0.65 lmol/L (6.5–13.1 lg/dL)46 and 0.225–
0.533 lmol/L (4.5–10.8 lg/dL).47 Using serum from
120 healthy adult dogs of varying ages and breeds, a
95% reference interval for SDMA was calculated as 6–
13 lg/dL48, and in both dogs and cats, the upper refer-
ence limit using the LC–MS/MS methodology was set
at < 14 lg/dl (0.69 lmol/L). Furthermore, a range of
7.3–12.4 lg/dL (0.36–0.61 lmol/L) was observed in
21 healthy geriatric cats in a recent study.43 However,
in juvenile dogs, SDMA might occasionally reach or
exceed the 14 lg/dL reference limit.8 In older studies
using high-performance LC, SDMA in healthy dogs
ranged from 0.22 to 0.61 lmol/L (4.4–12.3 lg/dL),49–
51
although values up to 14.1 lg/dL (0.7 lmol/L) were
observed in a group consisting of both healthy dogs
and dogs with mitral regurgitation.52
Nonrenal influences. Currently, SDMA’s rate of produc-
tion is thought to be relatively constant, although in
theory, altered arginine methylation and/or protein
breakdown could contribute to increased or decreased
serum concentrations. Furthermore, SDMA does not
appear to be highly protein bound53, and its clearance
is similar to that of creatinine, supporting that it is
freely filtered through the glomerulus.54 It is largely
renally excreted; however, hepatic clearance of SDMA
was observed in people55, and a small degree of uptake
by the gut was observed in rats.56 Unlike asymmetric
31
Renal biomarkers review
dimethylarginine (ADMA), which is largely degraded
by dimethylarginine dimethylaminohydrolase
(DDAH)57, enzymatic degradation does not seem to be
a major factor in SDMA elimination. However, some
degree of enzymatic degradation of SDMA is possi-
ble55,58, and in particular, alanine-glyoxylate amino-
transferase 2 (Agxt2), which is largely present in the
liver but also kidney, can metabolize SDMA.59 Sym-
metric dimethylarginine does not appear to be signifi-
cantly metabolized by renal tubules.30 No studies were
identified that determined whether or not SDMA can
be secreted from the tubules or reabsorbed for recircu-
lation, although these processes seem unlikely.28
Various studies, typically measuring SDMA as an
afterthought to ADMA, have found a variety of
external factors to show a lack of statistically signifi-
cant and/or clinically relevant influence on SDMA
concentrations in people or rats, including weight
loss60, inflammation61, diabetes62, and estrogen ther-
apy.63,64 Diet also does not appear to influence
SDMA in people, even with lysine and arginine load-
ing.28,65,66 Furthermore, SDMA in people is mini-
mally influenced by obesity67, gender, age68, and
polycystic ovary syndrome.69
In cats and dogs, several nonrenal influences have
been investigated. Notably, SDMA is not influenced by
muscle mass, the major nonrenal influence on sCr. In
healthy geriatric cats and adult dogs, SDMA did not
correlate with lean body mass.43,70 Furthermore, in
healthy growing dogs from 2 months to approximately
one year of age, SDMA did not correlate with age,
weight, or body condition score, whereas sCr strongly
correlated with these variables.8 Intriguingly, SDMA
did not increase as GFR (normalized to body weight)
decreased in these growing dogs.8 While this could
suggest a nonrenal influence on SDMA in adolescent
dogs, the normalization method for clearance tech-
niques needs further investigation in young, growing
dogs before ascribing clinical significance to stable
SDMA concentrations during growth. In addition, in
healthy dogs participating in a dietary trial (comparing
a renal diet with or without supplementation of L-car-
nitine and fish oil), SDMA significantly decreased over
6 months (from an average of 13.3 to 6.5 lg/dL).70
While the authors speculate that this decrease could be
due to improved renal function secondary to a dietary
effect, no clearance techniques were performed in
these dogs, and nonrenal causes for this decrease can-
not be ruled out.
In studies evaluating additional nonrenal vari-
ables in dogs, SDMA does not appear to be influenced
by breed, body size, sex, age (in adults), diurnal varia-
tion, white-coat effect, or short-term administration
32 Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
of angiotensin-converting-enzyme inhibitors.49,50,52
In one study, SDMA demonstrated a mild but statisti-
cally significant correlation with adjusted body weight
only when excluding creatinine as an explanatory
variable, and the authors speculated that this was due
to lower GFR in the larger dogs.52
Renal disease in veterinary medicine. Several recently
published studies of SDMA in dogs and cats have
shown strong evidence for SDMA as an endogenous
surrogate marker for GFR, particularly in animals with
renal disease. In dogs, SDMA correlated strongly with
inulin clearance in a partial nephrectomy model of
CKD (r = .851)51 and with iohexol clearance using
serial measurements in adolescent dogs with XLHN
(r = .95).8 In studies combining both healthy cats
and cats with CKD, correlations of SDMA or 1/SDMA
with iohexol clearance were r = .7943 and .8271,
respectively. These were similar to correlations of sCr
with clearance. Furthermore, in healthy geriatric
cats, the correlation of SDMA with iohexol clearance
was higher (r = -0.72) than that observed for sCr
(r = .50).22 Symmetric dimethylarginine correla-
tion with sCr was also strong in both dogs and
cats when including those with kidney disease
(r = .72–.95)8,43,71,72, whereas in clinically healthy
dogs and cats, the correlation between SDMA and sCr
was much lower (r = .32–.46).43,52,70
Importantly, SDMA appears to detect a decrease
in GFR prior to sCr when based on reference limits
in cats and dogs. In 21 geriatric laboratory cats with
naturally occurring CKD, SDMA increased by the
time azotemia (sCr > 2.1 mg/dL) developed in all
cats, and SDMA increased above its reference limit
an average of 17 months earlier (up to 48 months
earlier) than sCr.43 Symmetric dimethylarginine also
shows promise as a sensitive screening test for CKD
in cats. Using iohexol clearance to estimate GFR and
> 30% decrease from the median of clinically healthy
controls as the gold standard for decreased GFR,
SDMA had perfect sensitivity and negative predictive
value (100%), indicating that cats with SDMA
< 14 lg/dL did not have decreased GFR.43 Specificity
and positive predictive value (PPV) were slightly
lower (91% and 86%, respectively), due to 2 cases
where SDMA was mildly increased with a GFR only
25% lower than the median.43 However, this could
indicate that SDMA can detect < 30% decrease in
GFR in cats. In comparison, the upper reference limit
of sCr provided perfect specificity and PPV (100%),
indicating that cats with sCr above the reference
interval (sCr > 2.1 mg/dL) all had > 30% decline in
Hokamp and Nabity
GFR. However, sensitivity was quite poor (17%),
indicating that many cats with decreased GFR are
undetected when using this reference limit.43 Since
specificity and sensitivity depend on the reference
limit used, certainly use of a lower reference limit for
sCr would have improved its sensitivity in this study,
particularly since sCr in the clinically healthy cats
was ≤ 1.6 mg/dL.
In dogs with rapidly progressive CKD due to
XLHN, SDMA increased an average of 4–5 weeks prior
to an increase in sCr and decrease in GFR, based on
their respective reference limits.8 However, when
trending both sCr and SDMA in individual dogs,
SDMA increased an average of only 2 weeks prior to
an increase in sCr.8 Notably, SDMA identified ≤ 34%
(range, 6–34%) decrease in GFR when compared
with the GFR of unaffected, age-matched dogs in this
colony, regardless of whether the increase in SDMA
was based on the reference limit, trending, or compar-
ison with healthy controls. In some dogs, SDMA
increased even before iohexol clearance was below
that observed in unaffected, age-matched dogs.8 This
was in contrast to sCr, which detected a 5–68%
decrease in GFR.
In summary, SDMA appears to be a useful endoge-
nous marker of GFR and is particularly promising as a
screening test for early detection of decreased renal
function. Furthermore, because it is not influenced by
lean body mass and is less variable among different dog
breeds, SDMA could prove especially useful in those
patients with poor muscle mass or ongoing muscle loss,
where sCr would provide an unreliable estimate of
GFR. Further studies are needed in veterinary medi-
cine to determine possible extra-renal influences on
SDMA concentration.
Markers of altered metabolism
Fibroblast growth factor-23 (FGF-23)
Fibroblast growth factor-23 (FGF-23), recently
reviewed in dogs and cats with CKD73, is a phospha-
turic hormone that is secreted by osteoblasts and
osteocytes into the blood in response to increased
serum phosphorus.73–75 Fibroblast growth factor-23
results in increased urinary phosphorus excretion by
inhibiting sodium- dependent phosphorus reabsorp-
tion in the proximal tubule, and it decreases intesti-
nal reabsorption of phosphorus via diminished
calcitriol.73,76,77 Blood concentration of FGF-23 has
also been shown to increase as GFR decreases in
both people and cats.78 While studies in human
medicine have evaluated the pathogenesis of plasma
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
FGF-23 in CKD and secondary renal hyperparathy-
roidism, few studies are available in domestic ani-
mals, and these have focused on feline CKD in
geriatric (> 9 years) cats.78–80
Measurement, stability, and reference range. A human
FGF-23 ELISA has been validated for the detection of
plasma FGF-23 concentrations in cats, with acceptable
precision, reproducibility, and dilutional linearity.
Plasma FGF-23 was stable for up to 7 days at 22°C and
14 days at 20°C as well as up to 4 freeze–thaw
cycles.80 A reference range determined for geriatric
cats (56–700 pg/mL) was higher and broader than that
used in adult people, which could be due to subclinical
CKD in the cats used to establish the reference range,
diet, or species-specific factors.80
Renal disease in veterinary medicine. Plasma FGF-23 con-
centration was significantly increased at baseline in
geriatric cats that developed azotemia within the
following 12 months compared with those that
remained nonazotemic78, and plasma FGF-23
increased significantly with increasing IRIS stage of
CKD.80 Additionally, the presence of hyperphos-
phatemia was associated with greater plasma FGF-23
compared with normophosphatemic cats within the
same IRIS stage.80 Plasma phosphate concentration
was shown to be an independent predictor of FGF-23
concentration.80 Furthermore, plasma FGF-23 con-
centrations decreased significantly from baseline in
geriatric cats with stable azotemic CKD fed a reduced
phosphate renal diet for 4–8 weeks. This FGF-23
decrease was observed even in cats that were nor-
mophosphatemic (plasma phosphate ≤ 4.5 mg/dL),
although phosphate and PTH concentrations
remained unchanged.79 Hyperthyroid cats with azote-
mic CKD or that developed azotemia after becoming
euthyroid had significantly higher baseline plasma
FGF-23 than hyperthyroid cats that remained nona-
zotemic after treatment. However, after treatment for
hyperthyroidism, plasma FGF-23 increased both in
cats that remained non-azotemic and those that
became azotemic, and overall baseline plasma FGF-23
concentration was not a predictor for the develop-
ment of azotemia post treatment in hyperthyroid cats.81
Other renal biomarkers that have been evaluated
in the serum and plasma of domestic species include
cystatin C in dogs and cats82–90 and neutrophil gelati-
nase-associated lipocalin (NGAL)91–93 and homocys-
teine94–96 in dogs as endogenous markers of GFR, and
C-reactive protein97 and Big-Endothelin-194 as mark-
ers of inflammation in dogs (Table 1).
33
 34
Table 1. Summary of serum and/or plasma renal biomarkers in dogs and cats.

Location of Validation/ Values in Healthy Affected in AKI, CKD,

Renal Biomarker Production Type of Protein/Molecule Type of Biomarker Species Animals or Both Nonrenal Influences
Renal biomarkers review

226
Creatinine Muscle Cyclic derivative of creatine Endogenous indirect Dogs Dogs: 0.5–1.5 mg/dL Both Muscle mass; meat diet;
GFR marker Cats Cats: 0.8–1.8 mg/dL226 hydration status
(but depends on
breed/species/
instrument)
Cystatin C All nucleated cells LMW protein and Endogenous indirect Dogs96,227–229 Dogs: < 2.28 CKD: Dogs83,86–89,227–229, Obesity and weight
proteinase inhibitor GFR marker mg/L83,86–89,227–229 cats82,85,90 loss in dogs96
Cats82,84 Cats: < 1.95 (Presumably also AKI)
mg/L82,84,85,90
SDMA All nucleated cells Methylated amino acid Endogenous indirect Dogs8,44,45 Dogs and cats: CKD: Dogs8,51,
(arginine) GFR marker Cats43–45 < 14 µg/dL8,43,48–52 cats43,71,72
(Presumably also AKI)
FGF-23 Osteocytes and Phosphaturic hormone Marker of altered Cats80 Cats: 56–700 pg/mL80 CKD: Cats78–81 Dietary phosphorus;79
osteoblasts phosphorus hyperthyroidism81
metabolism
NGAL Neutrophils, kidney, LMW glycoprotein Endogenous indirect Dogs93 Dogs: < 21.2 ng/mL91–93 AKI: Dogs92,93 Inflammation230
bronchus, stomach, GFR marker CKD: Dogs91–93
small intestine,
pancreas, prostate
gland, thymus
C-reactive Hepatocytes Positive acute phase Inflammatory marker Dogs97 Dogs: 3.21 mg/L Renal diseases in dogs
protein protein (range: 2.09–8.60 (AKI vs CKD not
mg/L)97 specified)97
Homocysteine All nucleated cells Amino acid; Intermediate Endogenous indirect Dogs94–96 Dogs: 4.35  2.69 µmol/L94 AKI: Dogs95 Obesity and weight loss
product of methionine GFR marker CKD: Dogs94,95 in dogs96; icterus,
metabolism severe hemolysis and
lipemia95; cardiac
disease95
Big-Endothelin-1 Blood vessels, lung, Precursor to endothelin-1, a Inflammation Dogs94 Dogs: 6.51  1.86 CKD: Dogs94 Hypertension and
other tissues vasoconstrictor peptide pg/mL94 systemic inflammation94
including kidney
medulla

AKI indicates acute kidney injury; CKD, chronic kidney disease; FGF-23, fibroblast growth factor-23; GFR, glomerular filtration rate; LMW, low molecular weight; NGAL, neutrophil gelatinase-associated
lipocalin; SDMA, symmetric dimethylarginine.
Hokamp and Nabity

Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
Renal Biomarkers: Urine
Renal protein handling
Several publications are available that review the mech-
anisms of protein handling by the kidney in health and
disease.98–100 In brief, proteins with a molecular weight
< 40 kilodaltons (kDa) (low-molecular weight [LMW]
proteins) are able to freely pass through the glomerular
filtration barrier, while intermediate-molecular weight
(IMW) proteins, those approximately the size of albu-
min, face increased charge and size restrictions, and
high-molecular weight (HMW) proteins (> 100 kDa)
are generally completely restricted due to their large
size.98–100 Healthy tubules reabsorb proteins that are fil-
tered into the tubular space via receptor-mediated
endocytosis.98,100 Glomerular damage increases the per-
meability of the glomerular filtration barrier, typically
resulting in marked proteinuria, while tubular damage
results in mild proteinuria due to decreased reabsorp-
tion of proteins, leakage of proteins from the damaged
tubular epithelial cells, and upregulation of proteins
involved in injury and repair.98,99
When protein biomarkers are quantified in urine,
their concentration is often indexed to urine creatinine
(eg, urinary biomarker divided by urine creatinine) or
urine specific gravity. Indexing urinary biomarkers to
urine creatinine assumes that the excretion of urine
creatinine is constant between and within individuals,
and that both urinary biomarkers and creatinine are
inversely proportional to urinary flow rate. When
these assumptions are met, an increased or decreased
biomarker/creatinine ratio will reflect increased or
decreased biomarker excretion.101 However, when an
animal is not in steady state (ie, when renal function is
rapidly changing), the assumption of constant urine
creatinine excretion may not be correct, as demon-
strated in a study of human patients with AKI and post
kidney transplantation.101 Because of this, the practice
of indexing to urine creatinine in cases of AKI is ques-
tionable. Therefore, some authors have reported con-
centrations of biomarkers without indexing to
creatinine. For purposes of this review, biomarkers
that are indexed to urine creatinine are denoted as
uBiomarker/c, and those that are unindexed concen-
trations in the urine are denoted as uBiomarker.
Markers of glomerular damage/dysfunction
Immunoglobulins
Immunoglobulins are large glycoproteins made by
plasma cells in the spleen, lymph nodes, and bone mar-
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
row, and are involved in antibody-mediated
defense.98,102 The molecular weight of immunoglobu-
lins G (IgG) and M (IgM) are 150 kDa98,102,103 and
900 kDa98,102, respectively. Serum immunoglobulin A
(IgA) is present in monomeric, dimeric, and polymeric
forms, with the monomeric form having a molecular
weight of 160 kDa.104 Thus, IgG, IgM, and IgA are
HMW proteins that cannot pass through the glomeru-
lar filtration barrier in the healthy kidney. However,
with glomerular damage, they may pass into the uri-
nary filtrate; thus, they are considered markers of
glomerular damage.98
Measurement and stability. Species-specific ELISAs are
the most common and preferred method for detec-
tion of urinary immunoglobulins105,106; however,
thus far, detection of IgA in canine urine has only
been reported using Western blot.107–109 Canine-spe-
cific ELISA assays for IgG, IgM, and IgA are avail-
able (Bethyl Laboratories, Montgomery, TX, USA
and Immunology Consultants Laboratories [ICL],
Portland, OR, USA), and IgG and IgM ELISA assays
have been validated showing acceptable mean intra-
assay and inter-assay variabilities105,106,110,111, spik-
ing recovery106,110, and dilutional linearity.106,110
True stability testing of IgG in urine has not been
evaluated; however, uIgG/c in canine urine samples
stored for 8 years at 80°C were similar to those
stored for 2 years at 80°C.110
Values in healthy animals. Mean urinary IgG/
creatinine (uIgG/c) is generally < 3 mg/g, with
maximum values < 10 mg/g observed in all but one
study (Table 2).105,110,112–116 Published studies cur-
rently are not available describing the urine concen-
tration of IgM in healthy animals; however, in the
authors’ personal experience, urinary IgM concen-
tration is low in clinically healthy dogs. IgA was
undetectable in the urine of healthy dogs using
Western blot (Table 2).107–109
Nonrenal influences. A few studies found that urinary
IgG concentration is not significantly altered by
hematuria/hemoglobinuria105,115,116 or pyuria/uri-
nary tract infection.105 However, in the authors’
experience in dogs with primarily proteinuric CKD,
uIgG/c was significantly higher in dogs with hema-
turia, and fractional excretion of IgG (IgG_FE) was
higher in dogs with pyuria/bacteriuria compared
with dogs with inactive urine sediment (J.A.H.,
M.B.N., unpublished data). Similarly, urinary IgM/
35
Renal biomarkers review Hokamp and Nabity

Table 2. Summary of urinary biomarkers of glomerular damage/dysfunction in small animals.

Renal Location of Type of Protein/ Validation/ Values in Healthy Affected in AKI, Nonrenal
Biomarker Production Biomarker Species Animals CKD, or Both Influences

Albumin Hepatocytes Negative acute Dogs123 Dogs: uAlb/c: AKI: Treatment with
phase protein < 296.5 mg/g114–116,124,146; Dogs113–115,125,126 hydrocortisone
Alb_FE: 0%124 CKD: (dogs)111
Cats: uAlb: Dogs,116–119,123,124
11.2  8.4 mg/dL127 cats127,134
C-reactive Hepatocytes Positive acute Dogs105,132 Dogs: uCRP/c: AKI:
protein phase protein 1.06 µg/g;132 below Dogs105,112–115,132
detection limit of CKD:
immunoassay105,112–115,123 Dogs105,132
IgA Plasma cells in Antibody; Not detectable in AKI: Dogs107–109
spleen, lymph HMW protein healthy dog urine
nodes, bone (Western blot)107–109
marrow
IgG Plasma cells in Antibody; Dogs105,110,116 Dogs: uIgG/c: AKI: Hematuria*; Pyuria/
spleen, lymph HMW protein < 10 mg/g105,110,112–115 Dogs105,107–109,112–115 bacteriuria*;
nodes, bone CKD: Treatment with
marrow Dogs106,110,116–119 hydrocortisone111
IgM Plasma cells in Antibody; Dogs106 CKD: Dogs106 Hematuria*; pyuria/
spleen, lymph HMW protein bacteriuria*
nodes, bone
marrow
TXB2 Glomerular Cycloxygenase lipid Dogs105 Dogs: uTXB2/c: AKI: dogs114,115
mesangial cells metabolite; marker < 4.7 µg/g105,114,115
and podocytes of altered intra-renal
hemodynamics
Transferrin Primarily liver; Iron transport protein Cats: uTf: 0.09  CKD: Dogs,117,118
other 0.42 mg/dL127 Cats127,134
tissues as well

AKI indicates acute kidney injury; Alb_FE, fractional excretion of albumin; CKD, chronic kidney disease; HMW, high molecular weight; IgA, immunoglobu-
lin A; IgG, immunoglobulin G; IgM, immunoglobulin M; TXB2, thromboxane B2; uALB, urinary albumin concentration; uALB/c, urinary albumin/urinary
creatinine; uCRP/c, urinary C-reactive protein/urinary creatinine; uIgG/c, urinary immunoglobulin G/urinary creatinine; uTf, urinary transferrin concentra-
tion; uTXB2/c, urinary thromboxane B2/urinary creatinine.
*Personal observations.

creatinine (uIgM/c) and fractional excretion of IgM
(IgM_FE) were both significantly increased with
hematuria and pyuria/bacteriuria in these dogs
(J.A.H., M.B.N., unpublished data).
Renal disease in veterinary medicine. Acute kidney injury
(AKI): Urinary IgG is the main immunoglobulin evalu-
ated in diseases known to cause AKI, with fewer stud-
ies evaluating urinary IgA. Dogs with AKI due to a
variety of causes, including Babesia rossi, leishmaniasis,
and leptospirosis, have demonstrated increases in
uIgG/c105,112,113 or IgG and IgA on Western
blot105,107,108,112,113, supporting glomerular damage.
However, as expected, canine leptospirosis resulted
primarily in increased LMW proteins on sodium dode-
cyl sulfate polyacrylamide gel electrophoresis, consis-
tent with interstitial nephritis.108 Interestingly, in dogs
with snake envenomation, UPC was not increased
despite significantly increased uIgG/c vs control dogs
at baseline and 24 hours later.113
Pyometra can cause significant increases in
uIgG/c and UPC, with a positive correlation between
UPC and uIgG/c.109,114,115 This increase is typically
transient, decreasing significantly after ovariohys-
terectomy, and in some cases, uIgG/c returns to val-
ues that are not significantly different from healthy
dogs.114 A low proportion of bitches with pyometra
also had detectable urinary IgA.109 These studies
support that altered glomerular permselectivity can
be present in dogs with pyometra, and indeed,
histopathology demonstrated glomerulosclerosis as
the most common glomerular lesion in these dogs.
However, tubular atrophy, interstitial inflammation,
and fibrosis were often present as well, and the role
of pyometra vs previously underlying renal disease
in these older dogs is uncertain.115

36 Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
Currently there are no studies evaluating urinary
IgM in companion animals with AKI.
106,110,117,118
Chronic kidney disease (CKD): Urinary IgG
106
and IgM have been shown to increase in dogs
with CKD. In dogs with CKD due to X-linked hered-
itary nephropathy (XLHN), uIgG/c increased in early
stages of renal disease while uIgG/c remained low in
healthy age-matched littermates.110,118 Urinary IgG/c
often increased before UPC and continued to increase
in mid to late stages of disease progression.110 Further-
more, uIgG/c was moderately to highly positively cor-
related with most glomerular and tubulointerstitial
(TI) lesions based on histopathology.110 Urinary bio-
marker concentrations and their fractional excretions
were measured in dogs with naturally occurring CKD
to correlate biomarkers with types of renal damage
(glomerular vs TI) and their association with sur-
vival.106 Immunoglobulin G (uIgG/c and IgG_FE) and
IgM (uIgM/c and IgM_FE) demonstrated moderate,
positive correlations with glomerular damage based on
light and electron microscopy (r = .44–.58 and
r = .41–.58), respectively), which were similar to that
observed for UPC (r = .45–.57). Immunoglobulin
M_FE also correlated moderately well with TI damage
(r = .49). Markedly increased uIgM/c and uIgG/c were
associated with immune complex-mediated glomeru-
lonephritis (ICGN), while lower uIgM/c was observed
in juvenile nephropathies, nonimmune complex-
mediated glomerulonephropathies, and primary tubu-
lar disease. Both IgM_FE and IgG_FE were signifi-
cantly associated with faster time to death due to renal
disease in these dogs.106
Urinary IgG has been evaluated in several stud-
ies of dogs with increased cortisol due to either
exogenous or endogenous sources, since excess cor-
tisol causes proteinuria, likely by altering the
glomerular filtration barrier. In aged Beagles treated
over 24 weeks with hydrocortisone, uIgG/c and UPC
progressively increased, while tapering and cessation
of hydrocortisone treatment resulted in decreased
uIgG/c and UPC.111 In dogs with hyperadrenocorti-
cism, uIgG/c was significantly higher than in clini-
cally healthy controls, supporting glomerular
dysfunction.116 Finally, in dogs treated with trilos-
tane or hypophysectomy for ACTH-dependent
hyperadrenocorticism, uIgG/c decreased up to 15-
fold posttreatment. However, uIgG/c did not com-
pletely return to levels comparable to healthy dogs
in all cases, consistent with persistence of protein-
uria in 38% of dogs 12 months posttreatment.119
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
Additional urinary proteins indicating glomerular damage/
dysfunction
Albumin. The use of urinary albumin (Alb) in dogs as a
renal biomarker has recently been reviewed.2 Albumin
is a negative acute phase, IMW (approximately
65 kDa) serum protein synthesized primarily by hepa-
tocytes. It is considered primarily to be a marker of
glomerular damage, but uAlb can also be present with
tubular or vascular damage.98,120–122 Measurement of
uAlb has been validated in dogs123, and uAlb/c is ele-
vated in both AKI and CKD117,118,123,124, including
renal damage due to nephrotoxic drugs (methyl can-
tharadimide tablets and gentamicin)125,126, snake
envenomation113, pyometra114,115, and hypercorti-
solism.111,116,119 Pyometra caused transient albumin-
uria that significantly decreased or returned to values
not significantly different from healthy dogs after ovar-
iohysterectomy.114,115 Cats with stage I CKD had sig-
nificantly higher concentrations of uAlb than normal
cats, and uAlb concentration had higher sensitivity
and specificity for detection of CKD compared with
plasma creatinine.127
C-reactive protein. C-reactive protein (CRP) is a positive
acute phase protein in dogs, made primarily by hepato-
cytes.128,129 The MW of CRP ranges from 110 to
144 kDa130,131, therefore, its presence in the urine
supports glomerular damage. In dogs with various
causes of both AKI and CKD, including renal damage
due to leishmaniasis132, babesiosis112, snake enveno-
mation (24 hours post envenomation)113, and pyome-
tra114,115, uCRP/c increases.105 Dogs with pyometra
treated by ovariohysterectomy had uCRP/c values that
decreased to values not significantly different from
healthy dogs.114,115 In contrast, a significant difference
was not found in uCRP/c between healthy dogs and
those with CKD in one study, although uCRP was
undetectable in the healthy dogs while increased in 3
of 10 dogs with CKD.123 Age does not seem to have an
effect on uCRP/c in healthy dogs.123
Thus far, only one study evaluated the concentra-
tion of serum CRP in dogs with naturally occurring
renal disease. In this study, serum CRP was signifi-
cantly increased in dogs with reduced GFR, and the
authors suggested that stimulation of the inflamma-
tory acute phase response may be implicated in the
pathogenesis of renal disease in dogs.97
Other urinary protein markers of glomerular dam-
age not listed in Table 2 that have been shown to
increase in CKD include transthyretin117, adiponec-
37
Renal biomarkers review
tin133, and ferritin89 in dogs, and apolipoprotein-H in
cats.134
Markers of tubular damage/dysfunction
The proteins discussed in the next section are abnor-
mally present in the urine due to decreased tubular
reabsorption (retinol-binding protein (RBP), neu-
trophil gelatinase-associated lipocalin (NGAL), cys-
tatin C), upregulation of proteins involved in injury
and repair (NGAL), and decreased production by
damaged tubules (Tamm–Horsfall protein [THP]).
Proteins present due to release from damaged tubular
epithelial cells are discussed in the urinary enzyme
section. Additional examples of urinary biomarkers
present due to these 4 mechanisms are presented in
Table 3.
Retinol-binding protein (RBP)
Retinol-binding protein is a 21-kDa lipocalin that acts
as the transport protein for retinol in plasma.135 Reti-
nol-binding protein is primarily produced in the liver
but also in the kidney, lungs, spleen, brain, stomach,
heart, and skeletal muscle.136–138 Retinol-binding pro-
tein circulates in a complex with transthyretin (TTR),
which has a molecular weight of 54 kDa.135,139,140
Retinol-binding protein by itself is a LMW protein that
can freely pass through the glomerular filtration bar-
rier; however, the TTR-RBP complex is too large to pass
through the glomerular filtration barrier in the healthy
kidney.139 Retinol-binding protein in the renal filtrate
is reabsorbed by tubular epithelial cells.141 Tubular
damage and/or competition for reabsorption by the
presence of abnormally large amounts of protein (ie,
with glomerular damage) results in decreased reab-
sorption of RBP with subsequent loss of RBP into the
urine.142,143 Glomerular damage could also contribute
to urinary RBP due to loss of the TTR-RBP complex.
Measurement and stability. Human RBP immunoassays
have been validated for dogs and cats, with adequate
intra-assay and inter-assay variabilities (canine urine
and plasma105,110,144 and feline urine145), spiking
recovery (canine urine)110, and dilutional linearity
along a specific range of the standard curve (canine
urine).105,110 A canine-specific RBP ELISA was
recently marketed (ICL); however, validation and use
of this kit has not yet been published. Retinol-binding
protein concentration is similar in cystocentesis vs
voided urine samples from clinically healthy dogs.146
Retinol-binding protein appears to be relatively stable
in canine urine samples when frozen, ideally at
38 Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
80°C.110,146 All but one study146 normalized urinary
RBP concentration to urinary creatinine (uRBP/c
[mg/g]).105,106,110–116,119,123,124,145,147–149
Values in healthy animals. In healthy dogs and cats,
RBP is generally undetectable or minimally detect-
able in the urine by Western blot.145,150,151 Using
immunoassays to quantify urinary RBP in healthy
dogs, the highest reported uRBP/c was 0.9 mg/g116,
with most studies reporting means and medians
< 0.15 mg/g regardless of assay used
(Table 3).105,110–116,119,123,124,147 In healthy cats, uri-
nary RBP was below the limit of assay detec-
tion145,149, and it was not detectable in healthy
sheep by 2-dimensional gel electrophoresis and mass
spectrometry.152
Nonrenal influences. In dogs, age does not appear to
have a major influence on uRBP/c, as no significant
differences were found for uRBP/c between healthy
young and older dogs.110,123 However, a mild but sta-
tistically significant negative correlation with age was
found in young adolescent dogs, likely due to low crea-
tinine excretion in very young dogs.110 Pyuria, bacteri-
uria or positive urine culture, and at least mild to
moderate hematuria and hemoglobinuria do not seem
to significantly affect uRBP146 or uRBP/c105,112; how-
ever, in one study, a mild increase in uRBP was seen in
markedly hematuric samples.146 In the authors’ expe-
rience, fractional excretion of RBP (RBP_FE) was sig-
nificantly higher in pyuric/bacteriuric samples vs
inactive sediments from dogs with proteinuric CKD
(J.A.H., M.B.N., unpublished data). To the authors’
knowledge, nonrenal influences on urinary RBP have
not been published in cats.
Renal disease in veterinary medicine. AKI: Naturally
occurring AKI (eg, pyometra, babesiosis due to Babesia
rossi, and envenomation by cytotoxic and neurotoxic
snakes) transiently increases uRBP and uRBP/c in
dogs, presumptively indicating tubular dysfunc-
tion.105,113,115,151 Histologic confirmation of tubular
damage in dogs with pyometra found that dogs with
severe TI lesions on histopathology had higher uRBP/c
(in the 75th percentile) compared with dogs demon-
strating milder lesions.115 Typically, uRBP/c decreased
significantly after ovariohysterectomy in these dogs,
often to values comparable to healthy dogs.105,115
Urinary RBP has also been detected with 2-dimen-
sional gel electrophoresis in the urine of sheep with
AKI due to ketoprofen overdose.152
 Table 3. Summary of urinary protein and enzyme biomarkers of tubular damage/dysfunction in small and large animals.

Renal Location of Type of Mechanism Validation / Values in

Biomarker Production Protein/ for Altered species Healthy Animals Affected in AKI, CKD, or Both Nonrenal Influences
Hokamp and Nabity

Biomarker Excretion

Urinary proteins
Clusterin Renal tubules Glycoprotein Increased Dogs231 Dogs: uClu/c: 0.27 AKI: Dogs125,231
production (unitless) 231;
uClu: 38.5 ng/mL231
Cystatin C All nucleated cells LMW protein Decreased Dogs232 Cats: below limit AKI: Dogs126 Diabetes in cats233
and proteinase reabsorption Cats26 of quantification CKD: Dogs89,232, cats26,233
inhibitor of assay233
KIM-1 Renal tubules Glycoprotein Increased Undetectable Both, but mostly
production in healthy cats234 with acute processes
AKI: Dogs125, cats234
a lamb176
NGAL Neutrophils, LMW Decreased Dogs93,106,110,164 Dogs: uNGAL/c: AKI: Inflammation/urinary
kidney, bronchus, glycoprotein reabsorption < 6 µg/g;110,164,165 Dogs92,93,125,126,161,165–170 tract infection/pyuria
stomach, small and increased uNGAL: < 21.2 CKD: Dogs91–93,106,110,161,165 (dogs);161,164,165
intestine, pancreas, production ng/mL91–93,161,164 uNGAL/c decreased
prostate gland, thymus with body mass

Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
(dogs);164 Age
(dogs)110,164
RBP Primarily liver; Vitamin A Decreased Dogs105,110,144 Dogs: uRBP/c: AKI: Dogs105,113,115,151, Marked hematuria;146
also other organs carrier reabsorption Cats145 < 0.15 mg/ sheep152; Pyuria/bacteriuria
(kidney, lungs, spleen, protein g105,110–116,119,123,124,147; CKD: Dogs105,106,110,116–119,124,150,151, (RBP_FE)*; Negative
brain, stomach, Cats: Undetectable145 cats134,145,148,149 correlation with age in
heart, skeletal muscle) Sheep: Undetectable152 young adolescent
dogs110;Treatment with
hydrocortisone (dogs)111
THP Epithelial cells of Glycoprotein Decreased Cats235 Dogs: uTHP/c: CKD: Dogs117,144,151,174,175, Urolithiasis (cats)235
thick ascending production 10–65 mg/g174 cats134
limb of loop of Cats: uTHP: 49.2 
Henle and distal 35.5 µg/mL235
convoluted tubule
Urinary enzymes
AAP Renal tubular Enzyme Released Dogs191 Dogs: uAAP/c: AKI: Dogs125
brush border from brush 0.7–9.0 U/g191
enzyme border

(continued)
Renal biomarkers review

39
 Table 3 (continued)

40
ALP Renal tubular Enzyme Released Dogs: uALP/c: 0.25  AKI: Dogs147,213,215,
brush border from brush 1.17 U/g236;uALP: 5.8 sheep206
enzyme, highest border (0.4–12) U/L/mmol215
in renal proximal Horses: uALP/c:
convoluted tubule; 6.7  3.9 IU/g237;
Also in tubular
Renal biomarkers review

uALP: 10.2  4.0

lysosomes IU/L237; < 3.55
U/mmol225,238
Cauxin Proximal straight Carboxylesterase Uncertain Cats224 CKD: Cats134,223,224
tubular cells in cats protein whether
increased or
decreased with
tubular damage
GGT Renal tubular Enzyme Released from Horses193 Dogs: uGGT/c: < 42 U/ AKI: Dogs147,198,203,213,215,216,
brush border brush border g;192,195,208,210,216,236 horses205,207,
enzyme, highest 3.4 (0.6–6.0) U/L/mmol215 sheep206
in renal proximal uGGT: 6-112 U/L216
straight tubule Cats: uGGT/c: < 36.4 U/g199
Horses:uGGT/c: < 36.54 U/
g193,204,237,238; 0.33  0.8 U/
L/mmol200uGGT: 3.3  3.0 IU/
L;237 < 1.85 IU/mmol193,225,238
Calves: uGGT: 3.2 
2.6 U/µmol217
NAG Lysosomal enzyme Enzyme Cellular leakage Dogs110,123,146,191 Dogs and cats: AKI: Alkaline urine (reduced
in proximal renal (although and cats190 uNAG/c: Dogs114,115,125,126,167,168,194,197,198, activity);199 Hematuria and
120,191,195,199
tubules and associated with < 11 U/g cats185, sheep206 hemoglobinuria (inaccurate
other tissues; glomerular CKD: Dogs106,110,116,123, measurement due to similar
2 renal forms: damage, cats185 color of hemoglobin to m-
NAG-A and NAG-B; possibly due to crescol purple released by
circulates in lysosomal some substrates) 199;
the serum turnover Gender (higher in male
and/or leakage dogs)191,195
through
glomerular
filtration barrier)

AAP, alanine aminopeptidase; AKI, acute kidney injury; ALP, alkaline phosphatase; CKD, chronic kidney disease; GGT, gamma glutamyl-transpeptidase; KIM-1, kidney injury molecule-1; LMW, low molecular
weight; NAG, N-acetyl-b-D-glucosaminidase; NGAL, neutrophil gelatinase-associated lipocalin; RBP, retinol-binding protein; RBP_FE, fractional excretion of retinol-binding protein; THP, Tamm–Horsfall
protein; uAAP/c, urinary alanine aminopeptidase/urinary creatinine; uALP, urinary alkaline phosphatase concentration; uALP/c, urinary alkaline phosphatase/urinary creatinine; uClu, urinary clusterin
concentration; uClu/c, urinary clusterin/urinary creatinine; uGGT, urinary gamma glutamyl-transpeptidase; uGGT/c, urinary gamma glutamyl-transpeptidase/urinary creatinine; uNAG/c, urinary N-acetyl-b-
D-glucosaminidase/urinary creatinine; uNGAL, urinary neutrophil gelatinase-associated lipocalin concentration; uNGAL/c, urinary neutrophil gelatinase-associated lipocalin/urinary creatinine; uRBP/c,
urinary retinol-binding protein/urinary creatinine; uTHP, urinary Tamm–Horsfall protein concentration; uTHP/c, urinary Tamm–Horsfall protein/urinary creatinine
Hokamp and Nabity

Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
*Personal observations
Hokamp and Nabity
CKD: More studies have evaluated uRBP for detection
of tubular dysfunction in dogs and cats with CKD than
with AKI, and dogs with CKD have significantly
increased uRBP151, uRBP/c105,110,117,118,123,124,144,150,
and RBP_FE124,144 compared with healthy dogs. How-
ever, whether this increase is primarily present due to
tubular damage as opposed to presence of proteinuria
is controversial, as discussed below.
In dogs with CKD due to XLHN, uRBP/c was
increased prior to the onset of azotemia but after
onset of proteinuria, and urinary RBP increased with
disease progression throughout all disease stages
(based on sCr), with the most pronounced increase
in mid to late stages of renal disease.110,118,150 Fur-
thermore, uRBP/c had the strongest correlation with
both glomerular and TI lesions compared with other
biomarkers of renal function, and it correlated
most strongly with conventional measures of disease
severity (sCr, GFR, and interstitial fibrosis).110
Despite this, uRBP/c was not a significant indepen-
dent predictor of GFR based on multivariate analysis.
It was concluded that uRBP/c might be useful for
detecting early tubular damage before an obvious
increase in sCr.110
When biomarkers were correlated with histologi-
cally proven renal damage in dogs with naturally
occurring CKD due to a variety of causes, uRBP/c and
RBP_FE were moderately correlated with glomerular
and TI damage, with RBP_FE having the second stron-
gest correlation with TI damage following sCr.106
RBP_FE also increased significantly with each increase
in IRIS stage, while uRBP/c only increased signifi-
cantly in IRIS stages 3 and 4. Both uRBP/c and RBP_FE
were significantly associated with time to death due to
renal disease when evaluated individually; however,
in a multivariate analysis with other biomarkers, nei-
ther uRBP/c nor RBP_FE was significantly associated
with survival.106
Despite the promise of uRBP for early detection
of CKD and monitoring of progression, another study
concluded that proteinuria influenced uRBP/c more
than decreased renal function based on sCr and
plasma creatinine clearance. This conclusion was
based on finding uRBP/c to be significantly greater in
dogs with proteinuria and borderline proteinuria
compared with azotemic, nonproteinuric dogs, and
the inability of uRBP/c to detect reduced GFR.124
Dogs with hyperadrenocorticism had higher
uRBP/c compared with control dogs; however, UPC
was also significantly higher in these dogs compared to
controls.116 Additionally, in dogs with ACTH-depen-
dent hyperadrenocorticism, uRBP/c decreased signifi-
cantly after treatment with hypophysectomy119, such
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
that posttreatment median uRBP/c values were within
the range reported for healthy dogs. Urinary RBP/c
also decreased after treatment with trilostane; how-
ever, the decrease was not significant, and several dogs
had persistent proteinuria.119 These cumulative results
suggest that ACTH-dependent hyperadrenocorticism
results in decreased tubular protein reabsorption; how-
ever, the degree of reversibility and posttreatment val-
ues for uRBP/c depend on the type of treatment
(hypophysectomy vs trilostane) and persistence of pro-
teinuria.119 Finally, in aged dogs treated with hydro-
cortisone, uRBP/c increased with treatment and
decreased posttreatment.111
In cats, urinary RBP evaluation has focused on
those with CKD, hyperthyroidism, or both. These stud-
ies have shown that uRBP/c is significantly increased
in cats with either CKD134,145 or untreated hyperthy-
roidism145,149 compared with healthy cats. These find-
ings suggest that hyperthyroidism causes tubular
dysfunction in cats, and this tubular dysfunction may
be at least partly reversible, as uRBP/c often decreased
significantly (although was still detectable, unlike in
healthy cats) in cats treated with radioiodine.148,149
However, because hyperthyroidism can mask CKD in
cats, and CKD may be revealed after treatment for
hyperthyroidism, increased uRBP/c in hyperthyroid
cats could reflect CKD in some animals. Supporting
this theory, uRBP/c decreased significantly in cats that
did not develop azotemia post treatment for hyperthy-
roidism, but it remained elevated in cats that did
develop azotemia posttreatment. Thus, in hyperthy-
roid cats, it was suggested that uRBP/c might be a mar-
ker of reversible tubular dysfunction in healthy
kidneys, but also a marker of irreversible damage in
cats with preexisting CKD.148
Neutrophil gelatinase-associated lipocalin (NGAL)
Neutrophil gelatinase-associated lipocalin is a mem-
ber of the family of lipocalin-binding proteins origi-
nally isolated from the specific granules of human
neutrophils153,154, but it is also present in many nor-
mal tissues including the kidney.155 Neutrophil gela-
tinase-associated lipocalin is upregulated in epithelial
cells in neoplastic155,156 and inflammatory156 pro-
cesses. The original proposed function of NGAL was
as a bacteriostatic agent that binds bacterial sidero-
phores to prevent iron acquisition.157 Neutrophil
gelatinase-associated lipocalin has since been found
to be involved in many cellular mechanisms includ-
ing renoprotection158, and NGAL’s many functions
have been reviewed.159 Neutrophil gelatinase-asso-
ciated lipocalin is a LMW protein that freely passes
41
Renal biomarkers review
through the glomerular filtration barrier and is reab-
sorbed almost completely by the proximal tubules in
the healthy kidney.158 With renal damage and pro-
tein overload, reabsorption of NGAL in the proximal
tubules is impaired. In addition, there is increased
synthesis of NGAL by damaged tubular epithelial
cells.160 Three different molecular weight forms of
NGAL are present in canine urine161, including a
25 kDa monomeric protein that appears to originate
from renal tubular epithelial cells and is associated
with renal damage, a 45–50 kDa dimeric protein that
is the predominant form released by neutrophils and
appears most often with pyuria, and an NGAL/matrix
metalloproteinase (MMP) 9 heterodimer complex
that occurs with both renal injury and pyuria and
hematuria.153,161,162 Although ELISAs that distin-
guish between different molecular forms of human
NGAL are available, canine NGAL ELISAs are cur-
rently unable to make this discrimination.163
Measurement and stability. In domestic species, NGAL
has been evaluated in urine, serum, and plasma in
dogs, and it has been partially validated using canine-
specific ELISAs with acceptable intra-assay and
inter-assay variabilities, dilutional linearity, and spik-
ing recovery in canine urine and plasma.93,106,110,164
Neutrophil gelatinase-associated lipocalin has also
been validated in canine serum, but results were not
published.91 Neutrophil gelatinase-associated lipocalin
appears to be relatively stable in canine urine, as there
were minimal effects on uNGAL after 4 freeze–thaw
cycles, and no significant differences in uNGAL/c were
observed in samples collected up to 8 years apart,
stored at 80°C.110 No difference in uNGAL/c was
apparent between cystocentesis and voided samples165
or between 2-hour spot urine samples and 15-hour
collection samples.166 The 3 different molecular weight
forms of NGAL can be differentiated in canine urine
samples using Western blot.161 Values in healthy dogs
are reported in Table 3.
Nonrenal influences. In one study, healthy dogs
< 4 months of age often had much higher uNGAL/c
than dogs > 4 months of age, but it was suggested
that this was likely due to preputial neutrophil con-
tamination from voided urine samples from the
youngest dogs.110 In another study, there was no
correlation of uNGAL/c with age in adult dogs,
although uNGAL (not normalized) was weakly but
positively correlated with age. Furthermore, this
same study found that both uNGAL and uNGAL/c
decreased with body mass.164 Interestingly, periph-
42
Hokamp and Nabity
eral WBC count does not correlate with overall
serum NGAL (sNGAL)92; however, dogs with mono-
meric uNGAL had significantly higher peripheral
WBC and neutrophil counts than dogs without the
uNGAL monomer.161
Pyuria and urinary tract infections (UTI) can
markedly influence urinary NGAL concentrations.
Several studies showed that both uNGAL and uNGAL/
c were significantly higher in dogs with pyuria, UTI,
and other lower urinary tract diseases (such as transi-
tional cell carcinoma and calcium oxalate urolithiasis),
both with and without azotemia, compared with
healthy controls.161,164,165 In the authors’ experience
in dogs with proteinuric CKD, uNGAL/c was higher in
dogs with active vs inactive sediments (J.A.H., M.B.N.,
unpublished data). Although dogs with lower urinary
tract diseases had increased uNGAL/c compared with
control dogs, values were still lower than dogs with
renal disease.161,165 A uNGAL/c cutoff of > 2.57 lg/g
and a uNGAL cutoff of > 3.38 ng/ml had sensitivities
and specificities in the 70–80% range for dogs with vs
without a UTI.164 Furthermore, the 50 kDa dimer form
of NGAL was shown to be more common in urine from
dogs with pyuria, while the NGAL/MMP-9 complex
was found in dogs with pyuria and hematuria.161
Other nonrenal diseases (gastritis, protein losing
enteropathy, hepatic disease, enteritis, portal shunt,
bone fracture, intervertebral disk disease) do not
appear to affect uNGAL.161
Renal disease in veterinary medicine. AKI: While studies
of drug-induced AKI consistently demonstrate
increases in urinary NGAL, mixed results are reported
with regard to timing of this increase, which could at
least partly be due to differing protocols, particularly
with varying concentrations of gentamicin used. Two
separate studies in dogs given gentamicin found that
uNGAL/c increased early (as early as day 1 post admin-
istration) compared with other markers of nephrotoxi-
city (such as sCr and UN) and was correlated with the
severity of tubular damage, including tubular cell
necrosis, degeneration and regeneration, tubular cell
hyaline droplet formation, and hyaline casts.166,167 It
was concluded that uNGAL/c was a sensitive and pre-
dictive marker of gentamicin-induced nephrotoxic-
ity.166 However, a third study found that although
uNGAL/c was significantly correlated with GFR and
increased at the first time point evaluated (4 days after
gentamicin administration), the increase was not sta-
tistically significant until the second time point, at
8 days post administration. Thus, in this study,
uNGAL/c was not superior to more traditional markers
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
of renal function.126 In AKI induced by administration
of intravenous polymyxin B for 7 days, a dose-depen-
dent increase in uNGAL/c was observed, with signifi-
cantly increased uNGAL/c in the mid- and high-dose
groups on day 2.168 Finally, Beagle dogs administered
methyl cantharidimide tablets over 30 days demon-
strated significant increases in uNGAL in the high-dose
group, while middle- and low-dose groups did not
have significant changes in uNGAL.125
Repeatedly, studies have shown promise for NGAL
as a marker of naturally occurring AKI in dogs. Urinary
NGAL, uNGAL/c, and plasma NGAL (pNGAL) were all
significantly greater in dogs with azotemia from natu-
ral causes (whether due to AKI or CKD) vs healthy
control dogs92,93,161,165, and extremely high pNGAL
differentiated AKI from CKD in one study93 while
extremely elevated uNGAL/c was seen in dogs with
AKI compared to both CKD and lower urinary tract
diseases in another study.165 Furthermore, uNGAL/c
was increased in nonazotemic (IRIS Grade I) AKI, indi-
cating the presence of kidney injury before sCr
increased outside of the reference interval.165 Simi-
larly, in dogs that developed AKI post operatively,
median uNGAL was significantly greater 12 hours post
surgery and remained elevated for at least 3 days,
while sCr did not show a significant increase until
24 hours post surgery.169 Urinary NGAL and uNGAL/c
were also shown to be significantly increased (average
of 24-fold and 41-fold, respectively) from baseline
within 2 hours of reperfusion using a hemorrhage and
colloid fluid resuscitation model of renal injury in
Greyhounds.170 Thus far, uNGAL/c, uNGAL, and
sNGAL have not been shown to be predictors of sur-
vival in dogs with AKI.92,165
CKD: Dogs with CKD have demonstrated increased
uNGAL/c, uNGAL, sNGAL, and pNGAL compared with
healthy dogs and dogs with UTI or other lower urinary
tract diseases.91–93,110,161,165 Similar to findings in AKI
studies, increases in uNGAL/c occurred early in the
development of CKD in dogs with XLHN.110 Serum
NGAL and fractional excretion of NGAL (NGAL_FE)
also increased with increasing IRIS stages in dogs with
proteinuric CKD.106 Furthermore, uNGAL/c and
NGAL_FE correlated moderately to strongly with both
glomerular and TI lesions in dogs with CKD.106,110
Finally, higher sNGAL and NGAL_FE are associated
with shorter survival compared with lower values in
dogs with CKD.92,106 Serum NGAL concentration was
actually concluded in one study to be a better predictor
of clinical outcomes than sCr for dogs with CKD that
were already azotemic;92 however, this was not
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
repeatable in a second study of dogs with CKD that
were predominantly proteinuric but included both
azotemic and nonazotemic dogs.106
Additional urinary proteins indicating tubular damage/dys-
function
Although typically much more limited in their evalu-
ation, numerous other urinary proteins have been
studied as tubular biomarkers in domestic animals.
Several of these are presented briefly below, while
others with minimal references are listed in Table 3.
Tamm–Horsfall Protein. Tamm–Horsfall protein (THP,
otherwise called uromodulin) is a 100-kDa pro-
tein171 present in the thick ascending limb of the
loop of Henle and the distal convoluted
tubule.171,172 Tamm–Horsfall protein is one of the
major urinary proteins present in healthy dogs.171
The biologic function of the protein is still not fully
understood, but it is believed to have roles in water
and electrolyte balance in the thick ascending limb
of Henle’s loop, defense against UTI, prevention
against the formation of kidney stones, and in
innate immunity of the kidney.173 Normal urine
has high concentrations of THP, and significantly
reduced urinary THP concentrations and uTHP/c are
seen in dogs and cats with renal disease, including
CKD.117,134,144,151,174,175 Furthermore, uTHP/c corre-
lates negatively with plasma creatinine concentra-
tion and UPC.174 Therefore, reduced urinary THP
might be a marker of distal tubular damage in dogs
and cats.
Cystatin C. Cystatin C is a LMW protein (13 kDa), and
its presence in urine is a marker of proximal tubular
damage. A recent review includes studies of urinary
cystatin C26; therefore, only key information is pro-
vided in Table 3.
Other urinary protein markers of tubular dam-
age and dysfunction not listed in Table 3 that have
been shown to increase in AKI include calbindin-
D28K152, CD1d152, and heat shock protein 1B176 in
sheep, and interleukins 2, 7, and 8, monocyte
chemoattractant protein-1, granulocyte macrophage
colony-stimulating factor, and keratinocyte-derived
chemokine in dogs.177 Urinary proteins that were
increased in dogs with CKD include vitamin
D-binding protein117,118, a1-microglobulin118,
b2-microglobulin 110,118
, apolipoprotein A1118,
118 118
megalin , and cubilin. In cats with CKD, uri-
nary cystatin M134, transforming growth factor-
b178,179 and interleukin-8179 were increased while
43
Renal biomarkers review
vascular endothelial growth factor was
decreased.179
Urinary enzymes
Renal tubular epithelial cells contain enzymes which
have been explored as biomarkers of tubular damage
(Table 1). The most commonly studied enzymes in
domestic animals include N-acetyl-b-D-glucosamini-
dase (NAG), a lysosomal enzyme180, and gamma-glu-
tamyl transpeptidase (GGT) and alkaline phosphatase
(ALP), which are brush border enzymes.181 Cauxin
has also been studied in cats, and a brief discussion
of this marker will be included at the end of the
enzyme section. Two isoenzymes of NAG occur in
the kidney: NAG-A and NAG-B. In people, only
NAG-A can be detected in urine from patients with-
out renal disease, whereas renal damage and disease
results primarily in increased excretion of NAG-
B.182–184 Of note, both NAG-A and B are detectable
in healthy cats.185 Although present in the serum
and other tissues and cells, urinary NAG, GGT, and
ALP originate from the renal tubules in the absence
of glomerular damage.186–189
Measurement and stability. Activity of urinary enzymes
is expressed as units per liter, and an activity index is
typically calculated by normalizing to urinary crea-
tinine concentration. Validation of assays for urinary
NAG activity (uNAG) has been performed in dogs and
cats; however, to the authors’ knowledge, validation
of assays for urinary GGT (uGGT) and ALP (uALP)
activity has not been performed in domestic ani-
mals.110,190,191 In canine urine, overall intra-assay and
inter-assay variabilities, dilutional linearity, and spik-
ing recovery for NAG were acceptable.110,123,191 How-
ever, canine and feline urine samples with lower
concentrations of NAG tended to show higher coeffi-
cients of variation.110,190 NAG activity is relatively
stable in urine at 80°C for at least one year; however
enzyme degradation, which is not prevented by addi-
tion of a protease inhibitor, is still possible.110,146,190,191
Studies assessing stability at room temperature, 4°C,
and 20°C have shown contrasting findings, although
NAG appears to be stable for at least one month at
20°C in both feline and canine urine.110,146,190,191 Up
to 4–5 freeze–thaw cycles have been shown to signifi-
cantly affect urinary NAG activity in dogs and
cats.110,190 Thus, it is recommended to keep urine sam-
ples frozen at -80°C and to limit the number of freeze–
thaw cycles. No significant difference in uNAG activity
was seen between voided and cystocentesis samples
from dogs.146 While uGGT activity was relatively stable
44
Hokamp and Nabity
at 4°C for at least 4 days in dogs192, in equine urine,
uGGT was not stable after storage at 20°C, 4°C, and
25°C by 72 hours, with the greatest decrease in
enzyme activity occurring after freezing ( 20°C).193
Values in healthy animals. Urinary NAG, GGT, and ALP
activities are generally present at low levels in healthy
domestic animals (Table 3). In the urine of healthy
cats, the NAG-A isoenzyme activity was 2–3 times
higher than NAG-B.185
Nonrenal Influences. Age does not appear to affect
uNAG/c in dogs.146,194 However, 3 of 4 studies found
uNAG/c was significantly higher in males than
females.191,195–197 Additionally, uNAG/c decreased after
castration of male dogs; therefore, the increase in NAG
activity in males may be due to the enzyme content of
sperm.191,196 In cats, no significant difference in uNAG/
c or NAG isoenzymes was found between sexes.185,190
Spot measurements of uGGT/c and uNAG/c were
significantly correlated with 24-hours urine GGT and
uNAG excretion, respectively.192,198 However, large
intra- and inter-individual variability was noted for
uNAG/c.191 In cats, there was no apparent circadian
variation in NAG or GGT excretion, and while short
(4 hours) urine collection periods estimated 24-hour
uNAG/c and uGGT/c, there was greater variability in
enzyme indices over the shorter collection time per-
iod.199
In both dogs and cats, hematuria, pyuria, and
bacteriuria/UTI without concomitant pyelonephritis
does not appear to affect uNAG or uNAG/c.146,185,197
However, dogs with lower UTI accompanied by
pyelonephritis had markedly increased uNAG/c val-
ues, likely indicating the presence of tubular dam-
age.197 Further studies are needed to determine if
uNAG/c can accurately detect pyelonephritis. While
changes in urine pH did not seem to affect uNAG/c
in dogs195, in cats, NAG activity was decreased with
alkaline urine pH199 or demonstrated a weak nega-
tive association with urine pH.190 Furthermore,
induction of muscular inflammation with injection of
Freund’s complete adjuvant resulted in decreased
uGGT/c in horses, and it was suggested that the pres-
ence of inflammation may affect the reliability of
uGGT/c as an index of renal damage.200 One study
reported that uGGT/c was increased after the admin-
istration of a nonnephrotoxic agent in dogs and con-
cluded that this reflected false positive results.201
However, mild tubular damage might still have been
missed on ultrastructural examination given the ten-
dency for such lesions to be focally distributed.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
Renal disease in veterinary medicine. AKI: Urinary
enzymes, particularly NAG and GGT, have been most
extensively studied as early markers of AKI by chemi-
cal (drug) induction in domestic species. Gentamicin,
especially high doses, significantly increased uNAG/c
and uGGT/c in dogs, and uNAG/c increased as early as
24 hours post administration, and continued to
increase throughout the study period.126,167,198,202
Even therapeutic doses of gentamicin in dogs resulted
in a 2-fold increase in uGGT/c, although without statis-
tically significant changes in sCr, UPC, or USG.203 Sim-
ilarly, horses treated with a therapeutic dose of
gentamicin had significantly increased uGGT/c with-
out increased sCr during the treatment period.204
Another study found that uNAG/c correlated with the
severity of renal lesions and had high accuracy and
sensitivity for detection of renal injury compared with
UN.167 These and other studies support that urinary
enzymes are more sensitive and reliable for detecting
acute renal tubular damage induced by gentamicin
than markers of GFR.202
Other nephrotoxic drugs evaluated in the context
of tubular enzymes include polymyxin B (dogs)168,
methyl cantharidimide (dogs)125, sulfonamide (a
cat)185, neomycin (horses)205, ketoprofen (sheep)206,
and mercuric chloride and potassium dichromate
(ponies)207, all of which resulted in early increases in
uNAG/c, uGGT/c, or both. One study reported early
increases in uNAG/c and uGGT/c in dogs administered
a therapeutic dose of ketoprofen long-term, but noted
that these enzyme indices returned to clinically normal
values in both dogs despite continued drug administra-
tion.208 Overall, administration of nonsteroidal anti-
inflammatory drugs (NSAID) at a therapeutic dose did
not appear to significantly increase uGGT/c, uNAG/c,
or uALP/c in dogs.208–212 In horses treated with neo-
mycin, no histologic evidence of renal damage was
observed despite increases in uGGT/c.205 However, the
study does not indicate what types of histologic studies
were performed, and therefore, it is possible that renal
lesions may have been missed. Additionally, dogs
given intravenous polymyxin B for 7 days demon-
strated dose-dependent increases in uNAG/c, with sig-
nificantly increased uNAG/c occurring in the mid- and
high-dose groups on day 2.168 In one cat given sulfon-
amide to induce acute renal failure, uNAG/c increased
within 24 hours and continued to increase to very
high values several days after administration. N-
acetyl-b-D-glucosaminidase-A and NAG-B also both
increased, with a greater increase in NAG-B.185
Few studies are available evaluating urinary
enzyme activity in cases of naturally occurring AKI in
domestic animals. Dogs with pyometra have demon-
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
strated increased uNAG/c, uGGT, uGGT/c, uALP, and
uALP/c that, in several studies, decreased back into the
range of healthy dogs after ovariohysterectomy, sup-
porting transient AKI in these dogs.114,115,194,197,213,214
Furthermore, markedly increased uNAG/c was associ-
ated with severe TI lesions and reduced GFR in dogs
with pyometra.115,194 In client-owned dogs with renal
disease, uALP/c was a significant indicator of AKI com-
pared to dogs with CKD or healthy dogs (all confirmed
histologically), while uGGT/c was not shown to be as
useful for distinction.215 Significant correlations were
not detected between urinary enzyme levels and
extent of morphological kidney damage.215 Transient
increases in uGGT and/or uGGT/c were seen with
anesthesia and routine surgery in healthy dogs216 and
diarrheic calves217, and uGGT/c and uALP/c were
increased in dogs with European Adder envenoma-
tion.147
The studies in both drug-induced and naturally
occurring AKI support that tubular enzymes can be
sensitive markers of tubular damage. However, incon-
sistent results are present regarding the magnitude of
enzymuria, whether histologic changes are observed,
and whether or not azotemia develops following the
insult. Therefore, the usefulness of these markers in
predicting clinically significant tubular damage is
unknown.
CKD: Of the tubular enzymes, only NAG has been eval-
uated in dogs and cats with CKD. Urinary NAG/c
appears to be increased in most dogs and cats with
CKD as compared to healthy controls.110,123,197 In dogs
with XLHN, mild increases were observed as one of the
earliest findings, even before increased UPC; however,
it did not continue to increase with disease progression
beyond mid-stage disease.110 Furthermore, uNAG/c
was inconsistently associated with IRIS staging in dogs
with proteinuric CKD.106,123 Interestingly, in dogs
with XLHN, uNAG/c correlated moderately to strongly
with both glomerular and TI damage lesions.110 In con-
trast, uNAG/c at the time of biopsy in dogs with natu-
rally occurring CKD (mostly proteinuric and variably
azotemic) correlated moderately well with glomerular
damage alone and did not correlate with TI damage.106
Additionally, uNAG/c correlated moderately to
strongly with UPC and uIgG/c in both studies.106,110
These findings support that uNAG/c might be a better
indicator of glomerular rather than tubular damage in
canine proteinuric CKD.
Several studies in cats similarly suggest that
uNAG/c trends better with proteinuria than with tubu-
lar damage. One study found that when geriatric cats
45
Renal biomarkers review
were grouped according to plasma creatinine concen-
tration, there was no significant difference in uNAG/c
between groups, and uNAG/c was not correlated with
creatinine. However, when cats were grouped based
on proteinuria, cats with borderline proteinuria and
overt proteinuria had significantly higher uNAG/c
than nonproteinuric cats, and uNAG/c was moderately
correlated with UPC.190 uNAG/c was also unable to
distinguish azotemic from nonazotemic euthyroid
cats.218 Furthermore, uNAG/c was not significantly
associated with development of azotemia when evalu-
ated in a multivariate model, as uNAG/c did not pro-
vide any benefit over UPC for predicting development
of azotemia.219 In contrast, one study found that,
although uNAG/c increased in cats with CKD com-
pared to healthy cats, there was no correlation
between uNAG/c and severity of proteinuria, although
this was based on unindexed, semi-quantitative mea-
surement of proteinuria using a dipstick.185
Endocrine diseases may also influence urinary
NAG activity, presumably due to renal damage.
Dogs with hyperadrenocorticism had significantly
higher uNAG/c compared with control dogs.116 Fur-
thermore, while several other biomarkers (uALB/c,
uIgG/c, uRBP/c, and UPC) demonstrated significant
decreases after treatment for hyperadrenocorticism,
uNAG/c did not decrease significantly even after
treatment with trilostane and hypophysectomy.119
However, several dogs that were treated for hypera-
drenocorticism had persistent proteinuria.119 Despite
the increases in uNAG/c in dogs with naturally
increased cortisol due to hyperadrenocorticism, the
same effect was not seen in dogs treated with
hydrocortisone, both in comparison to the control
group and within the treatment group itself.111 In
dogs with diabetes mellitus, increased uNAG/c was
observed when the disease was not controlled (ie,
hyperglycemia, glucosuria, and ketonuria were pre-
sent), whereas uNAG/c values were comparable to
healthy dogs when blood glucose was controlled.197
Finally, azotemic and nonazotemic cats with hyper-
thyroidism had higher uNAG/c than healthy cats,
and uNAG/c decreased with treatment in both
groups.218 In this study, urine microalbumin con-
centration in hyperthyroid cats was statistically simi-
lar among healthy, azotemic, and nonazotemic
cats.218
The majority of studies show that urinary NAG lar-
gely trends with proteinuria. For both dogs and cats
with CKD, a possible reason behind the stronger corre-
lation of urinary NAG with glomerular damage/pro-
teinuria as compared with TI damage/azotemia could
be increased lysosomal activity as opposed to active
46 Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
proximal tubular cell damage. However, when
glomerular proteinuria is present, it is reasonable that
increased uNAG/c at least partially represents loss of
NAG from the blood due to altered glomerular perme-
ability.
Cauxin. Cauxin, a 70 kDa enzyme220, is constitutively
secreted from the proximal straight221 and distal220
tubular epithelial cells in the urine of domestic (partic-
ularly intact males)220,221 and big222 cats. Progressive
tubular damage due to CKD caused decreased tissue
expression223 and low urine excretion of cauxin134 in
cats, suggesting a decreased number of functional
tubular epithelial cells. However, when normalized to
urinary creatinine concentration, decreased cauxin
was not observed in cats with CKD, and in fact,
increased urinary cauxin/creatinine values were pre-
dictive of development of azotemia in geriatric cats.224
Other urinary enzymes noted to be increased
in AKI but not included in Table 3 include: glu-
tathione-S-transferase176, lactate dehydrogenase206,
acid phosphatase206, MMP/pro-MMP 2206 in sheep,
and MMP/pro-MMP 9 in horses.225
Conclusions
The number of widely available tests of kidney func-
tion and damage is currently limited, and our interpre-
tation of these tests, particularly creatinine, needs
improvement. However, there has recently been sig-
nificant progress in the evaluation of many new
biomarkers in dogs and cats with kidney disease. Most
of these biomarkers require further investigation as
well as test availability using a reliable, high-through-
put, and commercially available platform that has been
validated in the sample of interest before their wide-
spread use can be recommended and achieved. Still,
studies to date show promise that several of these
markers can and will aid in early detection, monitor-
ing, and assessment of prognosis in patients with kid-
ney disease. They can also help localize damage to the
kidney.
The evidence for the role of urinary biomarkers in
the early detection of tubular damage in AKI is particu-
larly compelling, whereas in animals with proteinuric
kidney disease, the influence of filtered proteins (origi-
nating from the blood) must be considered. There is
also the potential for nonrenal influences, such as
hematuria and pyuria, to alter biomarker concentra-
tions. For plasma-derived proteins serving as indicators
of tubular reabsorptive function (eg, RBP, cystatin C)
Hokamp and Nabity
these limitations are not likely to be overcome. How-
ever, for indicators of tubular damage, we should
strive to use biomarkers that are either exclusively
produced by the renal tubules or have renal tubular-
specific forms that can be distinguished from circulat-
ing forms of the protein. Without such specificity,
early, noninvasive detection of tubular damage will
remain challenging. Finally, no single biomarker is
likely to be sufficient for even one component of
altered kidney function or damage, and a panel of
tests will be needed in the future for comprehensive
evaluation to best determine renal status in an indi-
vidual animal.
Disclosure: Dr. Nabity serves on the Idexx Renal Advi-
sory Board.
References
1. Cobrin AR, Blois SL, Kruth SA, Abrams-Ogg AC,
Dewey C. Biomarkers in the assessment of acute and
chronic kidney diseases in the dog and cat. J Small
Anim Pract. 2013;54:647–655.
2. De Loor J, Daminet S, Smets P, Maddens B, Meyer E.
Urinary biomarkers for acute kidney injury in dogs. J
Vet Intern Med. 2013;27:998–1010.
3. Pressler BM. Clinical approach to advanced renal func-
tion testing in dogs and cats. Vet Clin North Am Small
Anim Pract. 2013;43:1193–1208, v.
4. Braun JP, Lefebvre HP, Watson AD. Creatinine in the
dog: a review. Vet Clin Pathol. 2003;32:162–179.
5. Brown SA, Finco DR, Crowell WA, Choat DC, Navar
LG. Single-nephron adaptations to partial renal abla-
tion in the dog. Am J Physiol. 1990;258:F495–F503.
6. Bov
ee KC, Kronfeld DS, Ramberg C, Goldschmidt M.
Long-term measurement of renal function in partially
nephrectomized dogs fed 56, 27, or 19% protein. Invest
Urol. 1979;16:378–384.
7. Bricker NS, Klahr S, Rieselbach RE. The functional
adaptation of the diseased kidney. I. Glomerular filtra-
tion rate. J Clin Invest. 1964;43:1915–1921.
8. Nabity MB, Lees GE, Boggess MM. SDMA assay valida-
tion, stability, and evaluation as a marker for early
detection of chronic kidney disease in dogs. J Vet Intern
Med. 2015;29:1036–1044.
9. Baral RM, Dhand NK, Freeman KP, Krockenberger
MB, Govendir M. Biological variation and reference
change values of feline plasma biochemistry analytes.
J Feline Med Surg. 2014;16:317–325.
10. Pagitz M, Frommlet F, Schwendenwein I. Evaluation
of biological variance of cystatin C in comparison with
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
other endogenous markers of glomerular filtration rate
in healthy dogs. J Vet Intern Med. 2007;21:936–942.
11. Ruaux CG, Carney PC, Suchodolski JS, Steiner JM.
Estimates of biological variation in routinely measured
biochemical analytes in clinically healthy dogs. Vet Clin
Pathol. 2012;41:541–547.
12. Rosset E, Rannou B, Casseleux G, Chalvet-Monfray K,
Buff S. Age-related changes in biochemical and hema-
tologic variables in Borzoi and Beagle puppies from
birth to 8 weeks. Vet Clin Pathol. 2012;41:272–282.
13. Rørtveit R, Saevik BK, Eggertsd

ottir AV, et al. Age-
related changes in hematologic and serum biochemical
variables in dogs aged 16-60 days. Vet Clin Pathol.
2015;44:47–57.
14. Misbach C, Chetboul V, Concordet D, et al. Basal
plasma concentrations of routine variables and packed
cell volume in clinically healthy adult small-sized dogs:
effect of breed, body weight, age, and gender, and
establishment of reference intervals. Vet Clin Pathol.
2014;43:371–380.
15. Zald
ıvar-L

opez S, Mar
ın LM, Iazbik MC, et al. Clinical
pathology of Greyhounds and other sighthounds. Vet
Clin Pathol. 2011;40:414–425.
16. M
edaille C, Trumel C, Concordet D, Vergez F, Braun
JP. Comparison of plasma/serum urea and creatinine
concentrations in the dog: a 5-year retrospective study
in a commercial veterinary clinical pathology labora-
tory. J Vet Med A Physiol Pathol Clin Med. 2004;51:119–
123.
17. Miyagawa Y, Takemura N, Hirose H. Assessments of
factors that affect glomerular filtration rate and indi-
rect markers of renal function in dogs and cats. J Vet
Med Sci. 2010;72:1129–1136.
18. Dunlop MM, Sanchez-Vazquez MJ, Freeman KP, et al.
Determination of serum biochemistry reference inter-
vals in a large sample of adult greyhounds. J Small
Anim Pract. 2011;52:4–10.
19. Feeman WE, Couto CG, Gray TL. Serum creatinine
concentrations in retired racing Greyhounds. Vet Clin
Pathol. 2003;32:40–42.
20. Reynolds BS, Concordet D, Germain CA, et al. Breed
dependency of reference intervals for plasma bio-
chemical values in cats. J Vet Intern Med. 2010;24:809–
818.
21. Concordet D, Vergez F, Trumel C, et al. A multicentric
retrospective study of serum/plasma urea and crea-
tinine concentrations in dogs using univariate and
multivariate decision rules to evaluate diagnostic effi-
ciency. Vet Clin Pathol. 2008;37:96–103.
22. Hall JA, Yerramilli M, Obare E, et al. Comparison of
serum concentrations of symmetric dimethylarginine
and creatinine as kidney function biomarkers in
47
Renal biomarkers review
healthy geriatric cats fed reduced protein foods
enriched with fish oil, L-carnitine, and medium-chain
triglycerides. Vet J. 2014;202:588–596.
23. Ulleberg T, Robben J, Nordahl KM, Ulleberg T, Heiene
R. Plasma creatinine in dogs: intra- and inter-labora-
tory variation in 10 European veterinary laboratories.
Acta Vet Scand. 2011;53:25.
24. Braun JP, Cab
e E, Geffr

e A, Lefebvre HP, Trumel C.
Comparison of plasma creatinine values measured by
different veterinary practices. Vet Rec. 2008;162:215–
216.
25. Harr KE, Flatland B, Nabity M, Freeman KP; ASVCP.
ASVCP guidelines: allowable total error guidelines for
biochemistry. Vet Clin Pathol. 2013;42:424–236.
26. Ghys L, Paepe D, Smets P, et al. Cystatin C: a new renal
marker and its potential use in small animal medicine.
J Vet Intern Med. 2014;28:1152–1164.
27. Wei H, Mundade R, Lange KC, Lu T. Protein arginine
methylation of non-histone proteins and its role in dis-
eases. Cell Cycle. 2014;13:32–41.
28. Kakimoto Y, Akazawa S. Isolation and identification of
N-G, N-G- and N-G, N’-G-dimethyl-arginine, N-epsi-
lon-mono-, di-, and trimethyllysine, and glucosyl-
galactosyl- and galactosyl-delta-hydroxylysine from
human urine. J Biol Chem. 1970;245:5751–5758.
29. Nakajima T, Matsuoka Y, Kakimoto Y. Isolation and
identification of N-G-monomethyl, N-G, N-G-
dimethyl- and N-G, N’ G-dimethylarginine from the
hydrolysate of proteins of bovine brain. Biochem Bio-
phys Acta. 1971;230:212–222.
30. Nijveldt RJ, Van-Leeuwen PA, Van-Guldener C,
et al. Net renal extraction of asymmetrical (ADMA)
and symmetrical (SDMA) dimethylarginine in fast-
ing humans. Nephrol Dial Transplant. 2002;17:1999–
2002.
31. Al-Banchaabouchi M, Marescau B, Possemiers I, et al.
NG, NG-dimethylarginine and NG, NG-dimethylargi-
nine in renal insufficiency. Pflugers Arch.
2000;439:524–531.
32. Nijveldt RJ, Teerlink T, van-Guldener C, et al. Han-
dling of asymmetrical dimethylarginine and symmetri-
cal dimethylarginine by the rat kidney under basal
conditions and during endotoxaemia. Nephrol Dial
Transplant. 2003;18:2542–2550.
33. Vallance P, Leone A, Calver A, Collier J, Moncada S.
Accumulation of an endogenous inhibitor of nitric
oxide synthesis in chronic renal failure. Lancet.
1992;339:572–575.
34. Fleck C, Janz A, Schweitzer F, et al. Serum concentra-
tions of asymmetric (ADMA) and symmetric (SDMA)
dimethylarginine in renal failure patients. Kidney Int.
2001;59:S14–S18.
48
Hokamp and Nabity
35. Bode-B€ oger SM, Scalera F, Kielstein JT, et al. Symmet-
rical dimethylarginine: a new combined parameter for
renal function and extent of coronary artery disease. J
Am Soc Nephrol. 2006;17:1128–1134.
36. Kielstein JT, Salpeter SR, Bode-Boeger SM, Cooke JP,
Fliser D. Symmetric dimethylarginine (SDMA) as
endogenous marker of renal function–a meta-analysis.
Nephrol Dial Transplant. 2006;21:2446–2451.
37. Ei Closs. Basha FZ, Habermeier A, F€
orstermann U.
Interference of L-arginine analogues with L-arginine
transport mediated by the y+ carrier hCAT-2B. Nitric
Oxide. 1997;1:65–73.
38. Feliers D, Lee DY, Gorin Y, Kasinath BS. Symmetric
dimethylarginine alters endothelial nitric oxide activ-
ity in glomerular endothelial cells. Cell Signal.
2015;27:1–5.
39. Schepers E, Speer T, Bode-B€ oger SM, Fliser D, Kiel-
stein JT. Dimethylarginines ADMA and SDMA: the
real water-soluble small toxins? Semin Nephrol.
2014;34:97–105.
40. Veldink H, Faulhaber-Walter R, Park JK, et al. Effects
of chronic SDMA infusion on glomerular filtration
rate, blood pressure, myocardial function and renal
histology in C57BL6/J mice. Nephrol Dial Transplant.
2013;28:1434–1439.
41. Schwedhelm E. Quantification of ADMA: analyti-
cal approaches. Vasc Med. 2005;10(Suppl. 1):S89–S95.
42. Tenderenda-Banasiuk E, Wasilewska A, Taranta-
Janusz K, Korzeniecka-Kozerska A. Asymmetric and
symmetric dimethylarginine in adolescents with hype-
ruricemia. Dis Markers. 2013;35:407–412.
43. Hall JA, Yerramilli M, Obare E, Yerramilli M, Jewell
DE. Comparison of serum concentrations of symmetric
dimethylarginine and creatinine as kidney function
biomarkers in cats with chronic kidney disease. J Vet
Intern Med. 2014;28:1676–1683.
44. Patch D, Obare E, Xie H. High throughput immunoas-
say that correlates to gold standard liquid chromatog-
raphy mass spectrometry (LC-MS) assay for the
chronic kidney disease (CKD) marker symmetric
dimethylarginine (SDMA) [abstract]. J Vet Intern Med.
2015;29:1216.
45. Yerramilli M, Obare E, Relford R. Stability of SDMA
(symmetric dimethylarginine) in canine and feline
serum and plasma [abstract]. J Vet Intern Med.
2013;27:737.
46. El-Khoury JM, Bunch DR, Reineks E, et al. A simple
and fast liquid chromatography-tandem mass spec-
trometry method for measurement of underivatized L-
arginine, symmetric dimethylarginine, and asymmet-
ric dimethylarginine and establishment of the refer-
ence ranges. Anal Bioanal Chem. 2012;402:771–779.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
47. Schwedhelm E, Xanthakis V, Maas R, et al. Plasma
symmetric dimethylarginine reference limits from the
Framingham offspring cohort. Clin Chem Lab Med.
2011;49:1907–1910.
48. Rentko V, Nabity M, Yerramilli M. Determination of
serum symmetric dimethylarginine reference limit in
clinically healthy dogs [abstract]. J Vet Intern Med.
2013;27:750.
49. Moesgaard SG, Holte AV, Mogensen T, et al. Effects of
breed, gender, exercise and white-coat effect on mark-
ers of endothelial function in dogs. Res Vet Sci.
2007;82:409–415.
50. Moesgaard SG, Pedersen LG, Teerlink T, Haggstrom J,
Pedersen HD. Neurohormonal and circulatory effects
of short-term treatment with enalapril and quinapril
in dogs with asymptomatic mitral regurgitation. J Vet
Intern Med. 2005;19:712–719.
51. Tatematsu S, Wakino S, Kanda T, et al. Role of nitric
oxide-producing and -degrading pathways in coronary
endothelial dysfunction in chronic kidney disease. J
Am Soc Nephrol. 2007;18:741–749.
52. Pedersen LG, Tarnow I, Olsen LH, Teerlink T, Pedersen
HD. Body size, but neither age nor asymptomatic
mitral regurgitation, influences plasma concentrations
of dimethylarginines in dogs. Res Vet Sci. 2006;80:336–
342.
53. Rifai K, Bode-Boeger SM, Martens-Lobenhoffer J,
et al. Removal of asymmetric dimethylarginine during
artificial liver support using fractionated plasma sepa-
ration and adsorption. Scand J Gastroenterol.
2010;45:1110–1115.
54. MacAllister RJ, Rambausek MH, Vallance P, et al.
Concentration of dimethyl-L-arginine in the plasma of
patients with end-stage renal failure. Nephrol Dial
Transplant. 1996;11:2449–2452.
55. Siroen MP, van-der-Sijp JR, Teerlink T, et al. The
human liver clears both asymmetric and symmetric
dimethylarginine. Hepatology. 2005;41:559–565.
56. Nijveldt RJ, Siroen MP, Teerlink T, et al. Gut and liver
handling of asymmetric and symmetric dimethy-
larginine in the rat under basal conditions and during
endotoxemia. Liver Int. 2004;24:510–518.
57. Ogawa T, Kimoto M, Sasaoka K. Purification and prop-
erties of a new enzyme, NG, NG-dimethylarginine
dimethylaminohydrolase, from rat kidney. J Biol Chem.
1989;264:10205–10209.
58. Schwedhelm E, B€ oger RH. The role of asymmetric and
symmetric dimethylarginines in renal disease. Nat Rev
Nephrol. 2011;7:275–285.
59. Kittel A, Maas R, K€
onig J, et al. In vivo evidence that
Agxt2 can regulate plasma levels of dimethylarginines
in mice. Biochem Biophys Res Commun. 2013;430:84–89.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
60. Krzyzanowska K, Mittermayer F, Kopp HP, Wolzt M,
Schernthaner G. Weight loss reduces circulating asym-
metrical dimethylarginine concentrations in morbidly
obese women. J Clin Endocrinol Metab. 2004;89:6277–
6281.
61. Blackwell S, O’Reilly DS, Reid D, Talwar D. Plasma
dimethylarginines during the acute inflammatory
response. Eur J Clin Invest. 2011;41:635–641.
62. Onozato ML, Tojo A, Leiper J, et al. Expression of NG,
NG-dimethylarginine dimethylaminohydrolase and
protein arginine N-methyltransferase isoforms in dia-
betic rat kidney: effects of angiotensin II receptor
blockers. Diabetes. 2008;57:172–180.
63. Teerlink T, Neele SJ, de-Jong S, Netelenbos JC, Ste-
houwer CD. Oestrogen replacement therapy lowers
plasma levels of asymmetrical dimethylarginine in
healthy postmenopausal women. Clin Sci (Lond).
2003;105:67–71.
64. Holden DP, Cartwright JE, Nussey SS, Whitley GS.
Estrogen stimulates dimethylarginine dimethylamino-
hydrolase activity and the metabolism of asymmetric
dimethylarginine. Circulation. 2003;108:1575–1580.
65. P€aiv€
a H, Lehtim€aki T, Laakso J, et al. Dietary composi-
tion as a determinant of plasma asymmetric dimethy-
larginine in subjects with mild hypercholesterolemia.
Metabolism. 2004;53:1072–1075.
66. Rytlewski K, Olszanecki R, Korbut R, Zdebski Z. Effects
of prolonged oral supplementation with l-arginine on
blood pressure and nitric oxide synthesis in preeclamp-
sia. Eur J Clin Invest. 2005;35:32–37.
67. Marliss EB, Chevalier S, Gougeon R, et al. Elevations
of plasma methylarginines in obesity and ageing are
related to insulin sensitivity and rates of protein turn-
over. Diabetologia. 2006;49:351–359.
68. Atzler D, Schwedhelm E, Nauck M, et al. Serum refer-
ence intervals of homoarginine, ADMA, and SDMA in
the Study of Health in Pomerania. Clin Chem Lab Med.
2014;52:1835–1842.
69. Lakhani K, Kay AR, Leiper J, Barry JA, Hardiman PJ.
Symmetric dimethylarginine (SDMA) is raised in
women with polycystic ovary syndrome: a pilot study.
J Obstet Gynaecol. 2011;31:417–419.
70. Hall J, Yerramilli M, Obare E, et al. Relationship
between lean body mass and serum renal biomarkers
in healthy dogs. J Vet Intern Med. 2015;29:808–814.
71. Braff J, Obare E, Yerramilli M, Elliott J, Yerramilli M.
Relationship between serum symmetric dimethy-
larginine concentration and glomerular filtration rate
in cats. J Vet Intern Med. 2014;28:1699–1701.
72. Jepson RE, Syme HM, Vallance C, Elliott J. Plasma
asymmetric dimethylarginine, symmetric dimethy-
larginine, l-arginine, and nitrite/nitrate concentra-
49
Renal biomarkers review
tions in cats with chronic kidney disease and hyperten-
sion. J Vet Intern Med. 2008;22:317–324.
73. de Brito Galvao JF, Nagode LA, Schenck PA, Chew DJ.
Calcitriol, calcidiol, parathyroid hormone, and fibrob-
last growth factor-23 interactions in chronic kidney
disease. J Vet Emerg Crit Care (San Antonio).
2013;23:134–162.
74. Seiler S, Heine GH, Fliser D. Clinical relevance of FGF-
23 in chronic kidney disease. Kidney Int Suppl. 2009;76:
S34–S42.
75. Liu S, Quarles LD. How fibroblast growth factor 23
works. J Am Soc Nephrol. 2007;18:1637–1647.
76. Shimada T, Kakitani M, Yamazaki Y, et al. Targeted
ablation of Fgf23 demonstrates an essential physiologi-
cal role of FGF23 in phosphate and vitamin D metabo-
lism. J Clin Invest. 2004;113:561–568.
77. Nakai K, Komaba H, Fukagawa M. New insights into
the role of fibroblast growth factor 23 in chronic kid-
ney disease. J Nephrol. 2010;23:619–625.
78. Finch NC, Geddes RF, Syme HM, Elliott J. Fibroblast
growth factor 23 (FGF-23) concentrations in cats with
early nonazotemic chronic kidney disease (CKD) and
in healthy geriatric cats. J Vet Intern Med. 2013;27:227–
233.
79. Geddes RF, Elliott J, Syme HM. The effect of feeding a
renal diet on plasma fibroblast growth factor 23 con-
centrations in cats with stable azotemic chronic kidney
disease. J Vet Intern Med. 2013;27:1354–1361.
80. Geddes RF, Finch NC, Elliott J, Syme HM. Fibroblast
growth factor 23 in feline chronic kidney disease. J Vet
Intern Med. 2013;27:234–241.
81. Williams TL, Elliott J, Syme HM. Calcium and phos-
phate homeostasis in hyperthyroid cats: associations
with development of azotaemia and survival time. J
Small Anim Pract. 2012;53:561–571.
82. Ghys LF, Meyer E, Paepe D, Delanghe J, Daminet S.
Analytical validation of a human particle-enhanced
nephelometric assay for cystatin C measurement in
feline serum and urine. Vet Clin Pathol. 2014;43:226–
234.
83. Gonul R, Kayar A, Or M. Assessment of renal function
in dogs with renal disease using serum cystatin C.
Indian Vet J. 2004;81:872–874.
84. Ghys LF, Paepe D, Duchateau L, et al. Biological vali-
dation of feline serum cystatin C: the effect of breed,
age and sex and establishment of a reference interval.
Vet J. 2015;204:168–173.
85. Martin C, Pechereau D, De la Farge F, Braun JP. Cys-
tatine C plasmatique chez le chat: Les technique
actuelles ne permettent pas de l’utiliser comme mar-
queur d’insufficance renale. Rev Med Vet.
2002;153:305–310.
50
Hokamp and Nabity
86. Pasa S, Bayramli G, Atasoy A, et al. Evaluation of
serum cystatin-C in dogs with visceral leishmaniasis.
Vet Res Commun. 2009;33:529–534.
87. Miyagawa Y, Takemura N, Hirose H. Evaluation of the
measurement of serum cystatin C by an enzyme-
linked immunosorbent assay for humans as a marker
of the glomerular filtration rate in dogs. J Vet Med Sci.
2009;71:1169–1176.
88. Braun JP, Perxachs A, Pechereau D, De la Farge F.
Plasma cystatin C in the dog: reference values and vari-
ations with renal failure. Comp Clin Pathol. 2002;11:44–
49.
89. Garcia-Martinez JD, Martinez-Subiela S, Tvarijonavi-
ciute A, Caldin M, Ceron JJ. Urinary ferritin and cys-
tatin C concentrations at different stages of kidney
disease in leishmaniotic dogs. Res Vet Sci. 2015;99:204–
207.
90. Poswiatowska-Kazczyszyn I. Usefulness of serum cys-
tatin C measurement for assessing renal function in
cats. Bull Vet Inst Pulawy. 2012;56:235–239.
91. Ahn HJ, Hyun C. Evaluation of serum neutrophil
gelatinase-associated lipocalin (NGAL) activity in dogs
with chronic kidney disease. Vet Rec. 2013;173:452.
92. Hsu WL, Lin YS, Hu YY, et al. Neutrophil gelatinase-
associated lipocalin in dogs with naturally occurring
renal diseases. J Vet Intern Med. 2014;28:437–442.
93. Steinbach S, Weis J, Schweighauser A, Francey T, Nei-
ger R. Plasma and urine neutrophil gelatinase-asso-
ciated lipocalin (NGAL) in dogs with acute kidney
injury or chronic kidney disease. J Vet Intern Med.
2014;28:264–269.
94. Rossi G, Giordano A, Breda S, et al. Big-endothelin
1 (big ET-1) and homocysteine in the serum of
dogs with chronic kidney disease. Vet J.
2013;198:109–115.
95. Rossi S, Rossi G, Giordano A, Paltrinieri S. Homocys-
teine measurement by an enzymatic method and
potential role of homocysteine as a biomarker in dogs.
J Vet Diagn Invest. 2008;20:644–649.
96. Tvarijonaviciute A, Ceron JJ, Holden SL, et al. Effect
of weight loss in obese dogs on indicators of renal func-
tion or disease. J Vet Intern Med. 2013;27:31–38.
97. Raila J, Schweigert FJ, Kohn B. C-reactive protein con-
centrations in serum of dogs with naturally occurring
renal disease. J Vet Diagn Invest. 2011;23:710–715.
98. D’Amico G, Bazzi C. Pathophysiology of proteinuria.
Kidney Int. 2003;63:809–825.
99. Maack T. Renal handling of low molecular weight pro-
teins. Am J Med. 1975;58:57–64.
100. Zandi-Nejad K, Eddy AA, Glassock RJ, Brenner BM.
Why is proteinuria an ominous biomarker of progres-
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
sive kidney disease? Kidney Int Suppl. 2004;66:S76–
S89.
101. Waikar SS, Sabbisetti VS, Bonventre JV. Normaliza-
tion of urinary biomarkers to creatinine during
changes in glomerular filtration rate. Kidney Int.
2010;78:486–494.
102. Tizard IR. Antibodies: Soluble Forms of BCR. 7th ed.
Philadelphia, PA: Saunders; 2004.
103. Edelman GM, Cunningham BA, Gall WE, et al. The
covalent structure of an entire gammaG immunoglob-
ulin molecule. Proc Natl Acad Sci USA. 1969;63:78–85.
104. Kerr MA. The structure and function of human IgA.
Biochem J. 1990;271:285–296.
105. Maddens BE, Daminet S, Demeyere K, et al. Valida-
tion of immunoassays for the candidate renal markers
C-reactive protein, immunoglobulin G, thromboxane
B2 and retinol binding protein in canine urine. Vet
Immunol Immunopathol. 2010;134:259–264.
106. Hokamp JA, Cianciolo RE, Boggess MM, et al. Corre-
lation of urine and serum biomarkers with renal dam-
age and survival in dogs with naturally occurring
chronic kidney disease. J Vet Intern Med. 2015; doi:
10.1111/jvim.13832. [Epub ahead of print]
107. Zaragoza C, Barrera R, Centeno F, et al. SDS-PAGE
and Western blot of urinary proteins in dogs with
leishmaniasis. Vet Res. 2003;34:137–151.
108. Zaragoza C, Barrera R, Centeno F, Tapia JA, Mane MC.
Characterization of renal damage in canine leptospiro-
sis by sodium dodecyl sulphate-polyacrylamide gel
electrophoresis (SDS-PAGE) and Western blotting of
the urinary proteins. J Comp Pathol. 2003;129:169–178.
109. Zaragoza C, Barrera R, Centeno F, Tapia JA, Mane
MC. Canine pyometra: a study of the urinary proteins
by SDS-PAGE and Western blot. Theriogenology.
2004;61:1259–1272.
110. Nabity MB, Lees GE, Cianciolo R, et al. Urinary
biomarkers of renal disease in dogs with X-linked
hereditary nephropathy. J Vet Intern Med.
2012;26:282–293.
111. Smets PM, Lefebvre HP, Aresu L, et al. Renal function
and morphology in aged Beagle dogs before and after
hydrocortisone administration. PLoS ONE. 2012;7:
e31702.
112. Defauw P, Schoeman JP, Smets P, et al. Assessment of
renal dysfunction using urinary markers in canine
babesiosis caused by Babesia rossi. Vet Parasitol.
2012;190:326–332.
113. Hrovat A, Schoeman JP, de Laat B, et al. Evaluation of
snake envenomation-induced renal dysfunction in
dogs using early urinary biomarkers of nephrotoxicity.
Vet J. 2013;198:239–244.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
114. Maddens B, Daminet S, Smets P, Meyer E. Escherichia
coli pyometra induces transient glomerular and tubu-
lar dysfunction in dogs. J Vet Intern Med.
2010;24:1263–1270.
115. Maddens B, Heiene R, Smets P, et al. Evaluation of
kidney injury in dogs with pyometra based on protein-
uria, renal histomorphology, and urinary biomarkers.
J Vet Intern Med. 2011;25:1075–1083.
116. Smets PM, Lefebvre HP, Kooistra HS, et al. Hypercorti-
solism affects glomerular and tubular function in dogs.
Vet J. 2012;192:532–534.
117. Raila J, Aupperle H, Raila G, Schoon HA, Schweigert
FJ. Renal pathology and urinary protein excretion in a
14-month-old Bernese mountain dog with chronic
renal failure. J Vet Med A Physiol Pathol Clin Med.
2007;54:131–135.
118. Vinge L, Lees GE, Nielsen R, et al. The effect of pro-
gressive glomerular disease on megalin-mediated
endocytosis in the kidney. Nephrol Dial Transplant.
2010;25:2458–2467.
119. Smets PM, Lefebvre HP, Meij BP, et al. Long-term fol-
low-up of renal function in dogs after treatment for
ACTH-dependent hyperadrenocorticism. J Vet Intern
Med. 2012;26:565–574.
120. Grauer GF. Measurement, interpretation, and impli-
cations of proteinuria and albuminuria. Vet Clin North
Am Small Anim Pract. 2007;37:283–295, vi-vii.
121. Yaqoob M, McClelland P, Patrick AW, et al. Tubulopa-
thy with macroalbuminuria due to diabetic nephropa-
thy and primary glomerulonephritis. Kidney Int Suppl.
1994;47:S101–S104.
122. Yaqoob M, McClelland P, Patrick AW, et al. Tubular
damage in microalbuminuric patients with primary
glomerulonephritis and diabetic nephropathy. Ren
Fail. 1995;17:43–49.
123. Smets PM, Meyer E, Maddens BE, Duchateau L,
Daminet S. Urinary markers in healthy young and
aged dogs and dogs with chronic kidney disease. J Vet
Intern Med. 2010;24:65–72.
124. Raila J, Brunnberg L, Schweigert FJ, Kohn B. Influ-
ence of kidney function on urinary excretion of albu-
min and retinol-binding protein in dogs with naturally
occurring renal disease. Am J Vet Res. 2010;71:1387–
1394.
125. Luo XQ, Yang X, Hu R, et al. [Effects of methyl can-
tharidimide tablets on urinary protein and enzymes in
Beagle dogs]. Zhongguo Zhong Yao Za Zhi.
2014;39:4426–4429.
126. Sasaki A, Sasaki Y, Iwama R, et al. Comparison of
renal biomarkers with glomerular filtration rate in
susceptibility to the detection of gentamicin-induced
51
Renal biomarkers review
acute kidney injury in dogs. J Comp Pathol.
2014;151:264–270.
127. Maeda H, Sogawa K, Sakaguchi K, et al. Urinary albu-
min and transferrin as early diagnostic markers of
chronic kidney disease. J Vet Med Sci. 2015;77:937–
943.
128. Ceron JJ, Eckersall PD, Martynez-Subiela S. Acute
phase proteins in dogs and cats: current knowledge
and future perspectives. Vet Clin Pathol. 2005;34:85–99.
129. Eckersall PD, Bell R. Acute phase proteins: biomarkers
of infection and inflammation in veterinary medicine.
Vet J. 2010;185:23–27.
130. Gotschlich EC, Edelman GM. C-reactive protein: a
molecule composed of subunits. Proc Natl Acad Sci
USA. 1965;54:558–566.
131. Kushner I, Somerville JA. Estimation of the molecular
size of C-reactive protein and CX-reactive protein in
serum. Biochim Biophys Acta. 1970;207:105–114.
132. Martinez-Subiela S, Garcia-Martinez JD, Tvarijonavi-
ciute A, et al. Urinary C reactive protein levels in dogs
with leishmaniasis at different stages of renal damage.
Res Vet Sci. 2013;95:924–929.
133. Tvarijonaviciute A, Ceron JJ, Martinez-Subiela S, Gar-
cia-Martinez JD. Serum and urinary adiponectin in
dogs with renal disease from leishmaniasis. Vet Rec.
2012;171:297.
134. Ferlizza E, Campos A, Neagu A, et al. The effect of
chronic kidney disease on the urine proteome in the
domestic cat (Felis catus). Vet J. 2015;204:73–81.
135. Kanai M, Raz A, Goodman DS. Retinol-binding pro-
tein: the transport protein for vitamin A in human
plasma. J Clin Invest. 1968;47:2025–2044.
136. Soprano DR, Soprano KJ, Goodman DS. Retinol-bind-
ing protein and transthyretin mRNA levels in visceral
yolk sac and liver during fetal development in the rat.
Proc Natl Acad Sci USA. 1986;83:7330–7334.
137. Soprano DR, Soprano KJ, Goodman DS. Retinol-bind-
ing protein messenger RNA levels in the liver and in
extrahepatic tissues of the rat. J Lipid Res.
1986;27:166–171.
138. Raila J, Buchholz I, Aupperle H, et al. The distribution
of vitamin A and retinol-binding protein in the blood
plasma, urine, liver and kidneys of carnivores. Vet Res.
2000;31:541–551.
139. Monaco HL. The transthyretin-retinol-binding protein
complex. Biochim Biophys Acta. 2000;1482:65–72.
140. Ingenbleek Y, Young V. Transthyretin (prealbumin) in
health and disease: nutritional implications. Annu Rev
Nutr. 1994;14:495–533.
141. Christensen EI, Willnow TE. Essential role of megalin
in renal proximal tubule for vitamin homeostasis. J
Am Soc Nephrol. 1999;10:2224–2236.
52
Hokamp and Nabity
142. Bernard AM, Vyskocil AA, Mahieu P, Lauwerys RR.
Assessment of urinary retinol-binding protein as an
index of proximal tubular injury. Clin Chem.
1987;33:775–779.
143. Christensen EI, Moskaug JO, Vorum H, et al. Evidence
for an essential role of megalin in transepithelial trans-
port of retinol. J Am Soc Nephrol. 1999;10:685–695.
144. Raila J, Forterre S, Kohn B, Brunnberg L, Schweigert
FJ. Effects of chronic renal disease on the transport of
vitamin A in plasma and urine of dogs. Am J Vet Res.
2003;64:874–879.
145. van Hoek I, Daminet S, Notebaert S, Janssens I, Meyer
E. Immunoassay of urinary retinol binding protein as
a putative renal marker in cats. J Immunol Methods.
2008;329:208–213.
146. Smets PM, Meyer E, Maddens B, Duchateau L, Dami-
net S. Effect of sampling method and storage condi-
tions on albumin, retinol-binding protein, and N-
acetyl-beta-D-glucosaminidase concentrations in
canine urine samples. J Vet Diagn Invest. 2010;22:896–
902.
147. Palviainen M, Raekallio M, Vainionpaa M, Lahtinen
H, Vainio O. Evaluation of renal impairment in dogs
after envenomation by the common European adder
(Vipera berus berus). Vet J. 2013;198:723–724.
148. van Hoek I, Lefebvre HP, Peremans K, et al. Short-
and long-term follow-up of glomerular and tubular
renal markers of kidney function in hyperthyroid cats
after treatment with radioiodine. Domest Anim Endocri-
nol. 2009;36:45–56.
149. van Hoek I, Meyer E, Duchateau L, et al. Retinol-
binding protein in serum and urine of hyperthyroid
cats before and after treatment with radioiodine. J Vet
Intern Med. 2009;23:1031–1037.
150. Nabity MB, Lees GE, Dangott LJ, et al. Proteomic anal-
ysis of urine from male dogs during early stages of
tubulointerstitial injury in a canine model of progres-
sive glomerular disease. Vet Clin Pathol. 2011;40:222–
236.
151. Forterre S, Raila J, Schweigert FJ. Protein profiling of
urine from dogs with renal disease using ProteinChip
analysis. J Vet Diagn Invest. 2004;16:271–277.
152. Palviainen M, Raekallio M, Rajamaki MM, Linden J,
Vainio O. Kidney-derived proteins in urine as
biomarkers of induced acute kidney injury in sheep.
Vet J. 2012;193:287–289.
153. Kjeldsen L, Johnsen AH, Sengelov H, Borregaard N.
Isolation and primary structure of NGAL, a novel pro-
tein associated with human neutrophil gelatinase. J
Biol Chem. 1993;268:10425–10432.
154. Bundgaard JR, Sengelov H, Borregaard N, Kjeldsen
L. Molecular cloning and expression of a cDNA
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
encoding NGAL: a lipocalin expressed in human
neutrophils. Biochem Biophys Res Commun.
1994;202:1468–1475.
155. Friedl A, Stoesz SP, Buckley P, Gould MN. Neutrophil
gelatinase-associated lipocalin in normal and neoplas-
tic human tissues. Cell type-specific pattern of expres-
sion. Histochem J. 1999;31:433–441.
156. Nielsen BS, Borregaard N, Bundgaard JR, et al. Induc-
tion of NGAL synthesis in epithelial cells of human
colorectal neoplasia and inflammatory bowel diseases.
Gut. 1996;38:414–420.
157. Goetz DH, Holmes MA, Borregaard N, et al. The neu-
trophil lipocalin NGAL is a bacteriostatic agent that
interferes with siderophore-mediated iron acquisition.
Mol Cell. 2002;10:1033–1043.
158. Mori K, Lee HT, Rapoport D, et al. Endocytic delivery
of lipocalin-siderophore-iron complex rescues the kid-
ney from ischemia-reperfusion injury. J Clin Invest.
2005;115:610–621.
159. Schmidt-Ott KM, Mori K, Li JY, et al. Dual action of
neutrophil gelatinase-associated lipocalin. J Am Soc
Nephrol. 2007;18:407–413.
160. Kuwabara T, Mori K, Mukoyama M, et al. Urinary
neutrophil gelatinase-associated lipocalin levels reflect
damage to glomeruli, proximal tubules, and distal
nephrons. Kidney Int. 2009;75:285–294.
161. Hsu WL, Chiou HC, Tung KC, et al. The different
molecular forms of urine neutrophil gelatinase-asso-
ciated lipocalin present in dogs with urinary diseases.
BMC Vet Res. 2014;10:202.
162. Cai L, Rubin J, Han W, Venge P, Xu S. The origin of
multiple molecular forms in urine of HNL/NGAL. Clin
J Am Soc Nephrol. 2010;5:2229–2235.
163. Bangert K, Rosenkilde N, Jorgensen JP, Baer A, Utten-
thal LO. Immunochemical Determination of Mono-
mer, Homodimer, and Total Neutrophil Gelatinase-
Associated Lipocalin [abstract]. American Society of
Nephrology, Kidney Week, 2012.
164. Daure E, Belanger MC, Beauchamp G, Lapointe C.
Elevation of neutrophil gelatinase-associated lipocalin
(NGAL) in non-azotemic dogs with urinary tract infec-
tion. Res Vet Sci. 2013;95:1181–1185.
165. Segev G, Palm C, LeRoy B, Cowgill LD, Westropp JL.
Evaluation of neutrophil gelatinase-associated lipoca-
lin as a marker of kidney injury in dogs. J Vet Intern
Med. 2013;27:1362–1367.
166. Kai K, Yamaguchi T, Yoshimatsu Y, et al. Neutrophil
gelatinase-associated lipocalin, a sensitive urinary bio-
marker of acute kidney injury in dogs receiving gen-
tamicin. J Toxicol Sci. 2013;38:269–277.
167. Zhou X, Ma B, Lin Z, et al. Evaluation of the useful-
ness of novel biomarkers for drug-induced acute kid-
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
ney injury in beagle dogs. Toxicol Appl Pharmacol.
2014;280:30–35.
168. Burt D, Crowell SJ, Ackley DC, Magee TV,
Aubrecht J. Application of emerging biomarkers of
acute kidney injury in development of kidney-
sparing polypeptide-based antibiotics. Drug Chem
Toxicol. 2014;37:204–212.
169. Lee YJ, Hu YY, Lin YS, et al. Urine neutrophil
gelatinase-associated lipocalin (NGAL) as a biomar-
ker for acute canine kidney injury. BMC Vet Res.
2012;8:248.
170. Davis J, Raisis AL, Cianciolo RE, et al. Urinary neu-
trophil gelatinase-associated lipocalin concentration
changes after acute haemorrhage and colloid-
mediated reperfusion in anaesthetized dogs. Vet
Anaesth Analg. 2015; doi: 10.1111/vaa.12311. [Epub
ahead of print]
171. Schweigert FJ, Raila J, Haebel S. Vitamin A excreted
in the urine of canines is associated with a Tamm-
Horsfall like protein. Vet Res. 2002;33:299–311.
172. Raila J, Neumann U, Schweigert FJ. Immunochemical
localization of megalin, retinol-binding protein and
Tamm-Horsfall glycoprotein in the kidneys of dogs. Vet
Res Commun. 2003;27:125–135.
173. Rampoldi L, Scolari F, Amoroso A, Ghiggeri G,
Devuyst O. The rediscovery of uromodulin (Tamm-
Horsfall protein): from tubulointerstitial nephropa-
thy to chronic kidney disease. Kidney Int.
2011;80:338–347.
174. Raila J, Schweigert FJ, Kohn B. Relationship between
urinary Tamm-Horsfall protein excretion and renal
function in dogs with naturally occurring renal dis-
ease. Vet Clin Pathol. 2014;43:261–265.
175. Mohamaden W, Wang H, Guan H, Meng X, Li J.
Immunohistochemical localization and mRNA quan-
tification of osteopontin and Tamm-Horsfall protein in
canine renal tissue after potassium oxalate injection.
BMC Vet Res. 2014;10:70.
176. Cooper TK, Zhong Q, Nabity M, Rosenberg G, Weiss
WJ. Use of urinary biomarkers of renal ischemia in a
lamb preclinical left ventricular assist device model.
Artif Organs. 2012;36:820–824.
177. McDuffie JE, Sablad M, Ma J, Snook S. Urinary
parameters predictive of cisplatin-induced acute renal
injury in dogs. Cytokine. 2010;52:156–162.
178. Arata S, Ohmi A, Mizukoshi F, et al. Urinary trans-
forming growth factor-beta1 in feline chronic renal
failure. J Vet Med Sci. 2005;67:1253–1255.
179. Habenicht LM, Webb TL, Clauss LA, Dow SW, Quimby
JM. Urinary cytokine levels in apparently healthy cats
and cats with chronic kidney disease. J Feline Med Surg.
2013;15:99–104.
53
Renal biomarkers review
180. Le Hir M, Dubach UC, Schmidt U. Quantitative distri-
bution of lysosomal hydrolases in the rat nephron. His-
tochemistry. 1979;63:245–251.
181. Guder WG, Ross BD. Enzyme distribution along the
nephron. Kidney Int. 1984;26:101–111.
182. Dance N, Price RG, Robinson D, Stirling JL. Beta-
galactosidase, beta-glucosidase and N-acetyl-beta-glu-
cosaminidase in human kidney. Clin Chim Acta.
1969;24:189–197.
183. Dance N, Price RG, Cattell WR, Lansdell J, Richards B.
The excretion of N-acetyl-beta-glucosaminidase and
beta-galactosidase by patients with renal disease. Clin
Chim Acta. 1970;27:87–92.
184. Price RG, Dance N, Richards B, Cattell WR. The excre-
tion of N-acetyl-beta-glucosaminidase and beta-galac-
tosidase following surgery to the kidney. Clin Chim
Acta. 1970;27:65–72.
185. Sato R, Soeta S, Syuto B, et al. Urinary excretion of N-
acetyl-beta-D-glucosaminidase and its isoenzymes in
cats with urinary disease. J Vet Med Sci. 2002;64:367–
371.
186. Kuska J, Kokot F. The electrophoretic spectrum of
gamma-glutamyl transpeptidase (GGTP) in the bile
and urine. Arch Immunol Ther Exp (Warsz).
1970;18:185–189.
187. Pillion DJ, Jeske AH, Leibach FH. Gamma-glutamyl
transpeptidase in the urine from an isolated rabbit kid-
ney perfused with and without DMSO. Biochem Phar-
macol. 1976;25:913–918.
188. Butterworth PJ. Human kidney and urinary alkaline
phosphatases. Biochem J. 1968;107:467–472.
189. Kuzniar J, Marchewka Z, Lembas-Bogaczyk J, Kuzniar
TJ, Klinger M. Etiology of increased enzymuria in dif-
ferent morphological forms of glomerulonephritis.
Nephron Physiol. 2004;98:p8–p14.
190. Jepson RE, Vallance C, Syme HM, Elliott J. Assess-
ment of urinary N-acetyl-beta-D-glucosaminidase
activity in geriatric cats with variable plasma crea-
tinine concentrations with and without azotemia. Am
J Vet Res. 2010;71:241–247.
191. Reusch C, Vochezer R, Weschta E. Enzyme activities
of urinary alanine aminopeptidase (AAP) and N-
acetyl-beta-D-glucosaminidase (NAG) in healthy
dogs. Zentralbl Veterinarmed A. 1991;38:90–98.
192. Gossett KA, Turnwald GH, Kearney MT, Greco DS,
Cleghorn B. Evaluation of gamma-glutamyl
transpeptidase-to-creatinine ratio from spot samples
of urine supernatant, as an indicator of urinary
enzyme excretion in dogs. Am J Vet Res. 1987;48:
455–457.
193. Adams R, McClure JJ, Gossett KA, Koonce KL, Ezigbo
C. Evaluation of a technique for measurement of
54
Hokamp and Nabity
gamma-glutamyltranspeptidase in equine urine. Am J
Vet Res. 1985;46:147–150.
194. Heiene R, Moe L, Molmen G. Calculation of uri-
nary enzyme excretion, with renal structure and
function in dogs with pyometra. Res Vet Sci. 2001;
70:129–137.
195. Brunker JD, Ponzio NM, Payton ME. Indices of urine
N-acetyl-beta-D-glucosaminidase and gamma-gluta-
myl transpeptidase activities in clinically normal adult
dogs. Am J Vet Res. 2009;70:297–301.
196. Higashiyama N, Nishiyama S, Itoh T, Nakamura M.
Effect of castration on urinary N-acetyl-beta-D-gluco-
saminidase levels in male beagles. Ren Physiol.
1983;6:226–231.
197. Sato R, Soeta S, Miyazaki M, et al. Clinical availability
of urinary N-acetyl-beta-D-glucosaminidase index in
dogs with urinary diseases. J Vet Med Sci. 2002;64:361–
365.
198. Grauer GF, Greco DS, Behrend EN, et al. Estimation of
quantitative enzymuria in dogs with gentamicin-
induced nephrotoxicosis using urine enzyme/crea-
tinine ratios from spot urine samples. J Vet Intern Med.
1995;9:324–327.
199. Uechi M, Uechi H, Nakayama T, et al. The circadian
variation of urinary N-acetyl-beta-D-glucosaminidase
and gamma-glutamyl transpeptidase in clinically
healthy cats. J Vet Med Sci. 1998;60:1033–1034.
200. Mills PC, Auer DE, Kramer H, Barry D, Ng JC. Effects
of inflammation-associated acute-phase response on
hepatic and renal indices in the horse. Aust Vet J.
1998;76:187–194.
201. Crivellenti LZ, Mesa JS, Meirelles AE, et al. False posi-
tivity of gamma-glutamyl transpeptidase measure-
ment in urine. Ren Fail. 2014;36:581–584.
202. Greco DS, Turnwald GH, Adams R, et al. Urinary
gamma-glutamyl transpeptidase activity in dogs with
gentamicin-induced nephrotoxicity. Am J Vet Res.
1985;46:2332–2335.
203. Rivers BJ, Walter PA, O’Brien TD, King VL, Polzin DJ.
Evaluation of urine gamma-glutamyl transpeptidase-
to-creatinine ratio as a diagnostic tool in an experi-
mental model of aminoglycoside-induced acute renal
failure in the dog. J Am Anim Hosp Assoc. 1996;32:323–
336.
204. Rossier Y, Divers TJ, Sweeney RW. Variations in uri-
nary gamma glutamyl transferase/urinary creatinine
ratio in horses with or without pleuropneumonia trea-
ted with gentamicin. Equine Vet J. 1995;27:217–220.
205. Fuentes VO, Gonzalez H, Sanchez V, Fuentes P,
Rosiles R. The effect of neomycin on the kidney func-
tion of the horse. Zentralbl Veterinarmed A.
1997;44:201–205.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Hokamp and Nabity
206. Raekallio MR, Saario-Paunio EM, Rajamaki MM,
et al. Early detection of ketoprofen-induced acute kid-
ney injury in sheep as determined by evaluation of
urinary enzyme activities. Am J Vet Res. 2010;71:1246–
1252.
207. Bayly WM, Brobst DF, Elfers RS, Reed SM. Serum
and urinary biochemistry and enzyme changes in
ponies with acute renal failure. Cornell Vet. 1986;
76:306–316.
208. Narita T, Tomizawa N, Sato R, Goryo M, Hara S. Effects
of long-term oral administration of ketoprofen in clini-
cally healthy beagle dogs. J Vet Med Sci. 2005;67:847–
853.
209. Borges M, Marini Filho R, Laposy CB, et al. Nons-
teroidal anti-inflammatory therapy: changes on renal
function of healthy dogs. Acta Cir Bras. 2013;28:842–
847.
210. Ko JC, Miyabiyashi T, Mandsager RE, Heaton-
Jones TG, Mauragis DF. Renal effects of carprofen
administered to healthy dogs anesthetized with
propofol and isoflurane. J Am Vet Med Assoc.
2000;217:346–349.
211. Lobetti RG, Joubert KE. Effect of administration of
nonsteroidal anti-inflammatory drugs before surgery
on renal function in clinically normal dogs. Am J Vet
Res. 2000;61:1501–1507.
212. Raekallio MR, Hielm-Bjorkman AK, Kejonen J, Salo-
nen HM, Sankari SM. Evaluation of adverse effects of
long-term orally administered carprofen in dogs. J Am
Vet Med Assoc. 2006;228:876–880.
213. de Schepper J, van der Stock J, Capiau E, de Cock I.
Renal injury in dogs with pyometra. Tijdschr Dierge-
neeskd. 1987;112(Suppl. 1):124S–126S.
214. de Schepper J, De Cock I, Capiau E. Urinary gamma-
glutamyl transferase and the degree of renal dysfunc-
tion in 75 bitches with pyometra. Res Vet Sci.
1989;46:396–400.
215. Heiene R, Biewenga WJ, Koeman JP. Urinary alkaline
phosphatase and y-glutamyl transferase as indicators
of acute renal damage in dogs. J Small Anim Pract.
1991;32:521–524.
216. Lobetti R, Lambrechts N. Effects of general anesthesia
and surgery on renal function in healthy dogs. Am J
Vet Res. 2000;61:121–124.
217. Ulutas B, Sahal M. Urinary GGT/creatinine ratio and
fractional excretion of electrolytes in diarrhoeic calves.
Acta Vet Hung. 2005;53:351–359.
218. Lapointe C, Belanger MC, Dunn M, Moreau M,
Bedard C. N-acetyl-beta-D-glucosaminidase index as
an early biomarker for chronic kidney disease in cats
with hyperthyroidism. J Vet Intern Med. 2008;22:1103–
1110.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology
Renal biomarkers review
219. Jepson RE, Brodbelt D, Vallance C, Syme HM, Elliott
J. Evaluation of predictors of the development of azo-
temia in cats. J Vet Intern Med. 2009;23:806–813.
220. Miyazaki M, Kamiie K, Soeta S, Taira H, Yamashita T.
Molecular cloning and characterization of a novel car-
boxylesterase-like protein that is physiologically pre-
sent at high concentrations in the urine of domestic
cats (Felis catus). Biochem J. 2003;370:101–110.
221. Miyazaki M, Yamashita T, Hosokawa M, Taira H,
Suzuki A. Species-, sex-, and age-dependent urinary
excretion of cauxin, a mammalian carboxylesterase.
Comp Biochem Physiol B Biochem Mol Biol.
2006;145:270–277.
222. McLean L, Hurst JL, Gaskell CJ, Lewis JC, Beynon RJ.
Characterization of cauxin in the urine of domestic
and big cats. J Chem Ecol. 2007;33:1997–2009.
223. Miyazaki M, Soeta S, Yamagishi N, et al. Tubulointer-
stitial nephritis causes decreased renal expression and
urinary excretion of cauxin, a major urinary protein of
the domestic cat. Res Vet Sci. 2007;82:76–79.
224. Jepson RE, Syme HM, Markwell P, et al. Measure-
ment of urinary cauxin in geriatric cats with variable
plasma creatinine concentrations and proteinuria and
evaluation of urine cauxin-to-creatinine concentra-
tion ratio as a predictor of developing azotemia. Am J
Vet Res. 2010;71:982–987.
225. Arosalo BM, Raekallio M, Rajamaki M, et al. Detect-
ing early kidney damage in horses with colic by mea-
suring matrix metalloproteinase -9 and -2, other
enzymes, urinary glucose and total proteins. Acta Vet
Scand. 2007;49:4.
226. Kaneko J, Harvey J, Bruss M. Clinical Biochemistry of
Domestic Animals. 6th ed. Burlington, MA: Academic
Press; 2008.
227. Almy FS, Christopher MM, King DP, Brown SA. Eval-
uation of cystatin C as an endogenous marker of
glomerular filtration rate in dogs. J Vet Intern Med.
2002;16:45–51.
228. Jensen AL, Bomholt M, Moe L. Preliminary evalua-
tion of a particle-enhanced turbidimetric immunoas-
say (PETIA) for the determination of serum cystatin C-
like immunoreactivity in dogs. Vet Clin Pathol.
2001;30:86–90.
229. Wehner A, Hartmann K, Hirschberger J. Utility of
serum cystatin C as a clinical measure of renal func-
tion in dogs. J Am Anim Hosp Assoc. 2008;44:131–138.
230. Oikonomou KA, Kapsoritakis AN, Theodoridou C,
et al. Neutrophil gelatinase-associated lipocalin
(NGAL) in inflammatory bowel disease: association
with pathophysiology of inflammation, established
markers, and disease activity. J Gastroenterol.
2012;47:519–530.
55
Renal biomarkers review
231. Garcia-Martinez JD, Tvarijonaviciute A, Ceron JJ, Cal-
din M, Martinez-Subiela S. Urinary clusterin as a renal
marker in dogs. J Vet Diagn Invest. 2012;24:301–306.
232. Monti P, Benchekroun G, Berlato D, Archer J. Initial
evaluation of canine urinary cystatin C as a marker of
renal tubular function. J Small Anim Pract.
2012;53:254–259.
233. Paepe D, Ghys LF, Smets P, et al. Routine kidney vari-
ables, glomerular filtration rate and urinary cystatin C
in cats with diabetes mellitus, cats with chronic kidney
disease and healthy cats. J Feline Med Surg.
2014;17:880–888.
234. Bland SK, Cote O, Clark ME, DeLay J, Bienzle D. Char-
acterization of kidney injury molecule-1 in cats. J Vet
Intern Med. 2014;28:1454–1464.
56
Hokamp and Nabity
235. Rhodes DC, Hinsman EJ, Rhodes JA, Hawkins EC. Uri-
nary Tamm-Horsfall glycoprotein concentrations in
normal and urolithiasis-affected male cats determined
by an ELISA. Zentralbl Veterinarmed A. 1992;39:621–
634.
236. Lobetti RG, Jacobson LS. Renal involvement in
dogs with babesiosis. J S Afr Vet Assoc. 2001;72:23–
28.
237. Brobst DF, Carroll RJ, Bayly WM. Urinary enzyme
concentrations in healthy horses. Cornell Vet.
1986;76:299–305.
238. Edwards DJ, Brownlow MA, Hutchins DR. Indices of
renal function: reference values in normal horses. Aust
Vet J. 1989;66:60–63.
Vet Clin Pathol 45/1 (2016) 28–56 ©2016 American Society for Veterinary Clinical Pathology