Gonçalo Serrano

The neutrophil-to-lymphocyte ratio (NLR) can help in assessing inflammatory diseases, sepsis, and chronic hepatic conditions in humans. Dogs with congenital portosystemic shunts (PSSs) have signs of generalized inflammation, and the clinical signs can overlap with other conditions, including hypoadrenocorticism (HOC). Thus, the potential diagnostic and prognostic value of leukocyte ratios as surrogate markers was assessed in a retrospective case–control study including 106 dogs diagnosed with PSSs. The disease control groups were dogs with parenchymal hepatopathy (PH; n = 22) or HOC (n = 31). In the PSS dogs, the blood NLRs were associated with the severity of systemic inflammation but not with the shunt type, hepatoencephalopathy, systemic infection, or hypoglycemia. The baseline NLRs did not differ between the three disease groups, between medically and surgically treated PSS dogs, or between those with successful PSS ligation and dogs experiencing peri-/post-surgical complications. However, dogs requiring two consecutive surgical interventions had significantly higher NLRs, and an NLR of <2.53 distinguished dogs with successful shunt ligation in one surgery from those requiring two consecutive surgeries for PSS closure. The blood NLR might be a useful clinicopathologic variable in PSS, but its value in helping differentiate PSS from HOC cases appears low. Integrating the NLR into a diagnostic algorithm may allow for a prediction of the number of surgical interventions required.

Background: In dogs with portal hypertension (PH), spec cPL is suggested to be increased despite normal pancreatic histology. After attenuation of congenital extrahepatic portosystemic shunts (cEHPSS), multiple acquired portosystemic shunt (MAPSS) can develop as consequence of sustained PH. Presence of MAPSS affects future therapeutic options and prognosis. Objective: Evaluate if spec cPL concentrations increase postoperatively in dogs that develop MAPSS and can thus serve as an indicator of PH. Animals: Twenty-four dogs with cEHPSS. Methods: Dogs classified according to surgical outcome after cEHPSS attenuation (8 with MAPSS [group M], 9 with closed cEHPSS [group C] and 7 with patent blood flow through the original cEHPSS, without evidence of MAPSS [group P]). Spec cPL was measured in preoperative samples (T0), 4 days (T1) and 1 (T2) and 3- to 6-months (T3) after surgery. Results: Spec cPL was within reference interval (2000 μg/L) and also 1 in group C (688 μg/L) and 1 in group P (839 μg/L) had increased spec cPL concentrations. No differences in spec cPL concentrations between groups or changes over time were identified. Conclusions and Clinical Importance: Spec cPL is not consistently increased in dogs that develop MAPSS after cEHPSS attenuation and has no potential as a biomarker for the identification of MAPSS after cEHPSS attenuation.

Background: Hepatic supportive diet (HSD), lactulose, and antimicrobials are medical treatments for dogs with congenital extrahepatic portosystemic shunts (cEHPSS). The relative contribution of these treatment components is currently unknown. Objectives: To determine which treatment combinations are most efficacious in pre-surgical control of clinical signs of cEHPSS in dogs. Animals: Thirty-six dogs with untreated cEHPSS. Methods: Three-arm randomized clinical trial. At inclusion (T0), dogs were divided into 3 groups: HSD (n = 12), HSD + lactulose (n = 12), or HSD + metronidazole (n = 12) and received the randomized treatment for 4 weeks (T1) followed by combined treatment of HSD + lactulose + metronidazole for 2 weeks or until cEHPSS attenuation (T2). Clinical score as well as fasting ammonia (FA) and C-reactive protein (CRP) concentrations were compared among groups and time points. Results: Thirty-four dogs were evaluated. Thirty-four dogs reached T1 and 29 dogs T2. At T1, clinical scores decreased in the HSD + lactulose (n = 11; P = .001), but not in the HSD (n = 8; P = .96) and HSD + metronidazole (n = 10; P = .06) groups. Adding metronidazole to HSD + lactulose (n = 11) did not result in further clinical score improvement (T2; P = 1.000). Moderate and weak correlation between clinical score and FA and clinical score and CRP was present (ρ = .35, P < .001; ρ = .27, P = .01, respectively) with FA decreasing over time on medical treatment (P = .001). Conclusions and Clinical Importance: Combined HSD + lactulose seems sufficient for pre-surgical cEHPSS stabilization unlike sole HSD or HSD + metronidazole. Medical treatment of cEHPSS clinical signs decreases FA.

Background: Diagnosing a congenital portosystemic shunt (cPSS) in dogs can be challenging. The current study aims to report diagnostic performance of fasting ammonia (FA), preprandial, postprandial and paired serum bile acids (SBA) and abdominal ultrasound (aUS) in dogs suspected of having a cPSS. Methods: Medical records of dogs suspected of having a cPSS at initial presentation were retrospectively reviewed. Results: In total, 192 dogs suspected of cPSS were included: a cPSS was confirmed in 147 dogs and excluded in 45 dogs. FA had the best combined sensitivity and specificity (77.4 and 93.3%, respectively) to diagnose cPSS. The sensitivity and negative predictive value were 100.0% for paired SBA, making paired SBA the best test to exclude cPSS in this population. Sensitivity and specificity of aUS were 80.8 and 90.0%, respectively. Conclusions: In dogs with clinical signs compatible with cPSS, elevated FA is suggestive of cPSS, whereas normal paired SBA makes the presence of a cPSS unlikely. Although aUS is a useful tool to diagnose cPSS, additional imaging is required to visualize cPSS in almost 20% of cases. Furthermore, the localisation of cPSS can be misdiagnosed, especially in case of extrahepatic cPSS that do not insert into the prehepatic vena cava.

Background Dogs with portosystemic shunts have an altered blood amino acid profile, with an abnormal branched‐chained amino acid (BCAA)‐to‐aromatic amino acid (AAA) ratio being the most common abnormality. Different liver diseases have distinctive amino acid profiles. Objectives Determine the changes in plasma amino acid profiles in dogs with extrahepatic portosystemic shunts (EHPSS) from diagnosis to complete closure. Animals Ten client‐owned dogs with EHPSS closed after surgical attenuation. Methods Prospective cohort study. Medical treatment was instituted in dogs diagnosed with EHPSS. At least 4 weeks later, gradual surgical attenuation was performed. Three months postoperatively, EHPSS closure was confirmed by transsplenic portal scintigraphy. Clinical signs were scored and blood was taken before institution of medical treatment, at time of surgery, and 3 months postoperatively. At the end of the study, the plasma amino acid profiles were analyzed in batch. Results The median BCAA‐to‐AAA ratio was extremely low (0.6) at time of diagnosis and remained low (0.5) at time of surgery, despite the fact that median neurological score significantly improved from 22 to 2 after starting medical treatment (P = .04). Three months after surgical attenuation, a significantly higher BCAA‐to‐AAA ratio (1.5) was observed (P < .001). Conclusions and Clinical Importance Medical treatment does not improve the BCAA‐to‐AAA ratio in dogs with EHPSS, despite substantial clinical improvement. Although the ratio significantly increased after EHPSS closure, it was still indicative of moderate to severe hepatic dysfunction in all dogs.

The clinical presentations of both liver disease and pancreatitis are nonspecific and overlapping, which may cause difficulty in diagnosis. In our retrospective pilot study, we assessed whether dogs with evidence of portal hypertension and absence of pancreatitis on pancreatic histology have increases in canine pancreatic lipase immunoreactivity (cPLI) and 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6′-methylresorufin) ester (DGGR) lipase. We included dogs that had been presented between 2008 and 2019 if they had normal pancreatic histology, histologically confirmed hepatopathy, and if canine pancreas-specific lipase (Spec cPL; Idexx) or DGGR lipase had been measured. Only dogs with portal hypertension were included. Six dogs fulfilled the inclusion criteria. Four of 6 and 2 of 6 dogs had Spec cPL and DGGR lipase exceeding the upper reference limit, respectively. From the 4 dogs with increased Spec cPL, 2 had concentrations of 200–400 µg/L and 2 had concentrations ≥ 400 µg/L. Our results suggest that canine portal hypertension might lead to increased Spec cPL and DGGR lipase values in the absence of pancreatitis on histology. Until more evidence in a larger number of dogs with portal hypertension is available, both tests should be interpreted cautiously in the presence of portal hypertension.

Background Liver function tests do not always normalize despite successful attenuation of extrahepatic portosystemic shunts (EHPSS). Objectives Assess the lidocaine/monoethylglycylxylidide (MEGX) test to determine liver perfusion after EHPSS closure. Animals Twenty dogs with EHPSS. Methods A prospective cohort study was performed and all dogs were tested at diagnosis, 1, 3, and 6 months postoperatively. After collecting a baseline blood sample (T0), 1 mg/kg body weight of lidocaine was injected intravenously. Fifteen (T15) and 30 minutes (T30) later, blood was collected. Plasma concentrations of lidocaine and its metabolites MEGX and glycylxylidide (GX) were determined, using a high‐performance liquid chromatography with electrospray ionization tandem mass spectrometry method. Three months postoperatively, transsplenic portal scintigraphy was performed to determine EHPSS closure. Results At T15, median MEGX concentrations were higher in dogs with closed EHPSS compared to diagnosis (33.73 ng/mL [21.11‐66.44 ng/mL] vs 13.74 ng/mL [7.25‐21.93 ng/mL]; P < .001), but were not different (12.28 ng/mL [10.62‐23.17 ng/mL] vs 13.74 ng/mL [7.25‐21.93 ng/mL]) in dogs with persistent shunting. Sensitivity to determine shunt closure for MEGX at T15 was 96.2% (95% confidence interval [CI]: 78.4‐99.8) and specificity 82.8% (95% CI: 63.5‐93.5). Conclusions and Clinical Importance The lidocaine/MEGX test is a promising, rapid, and noninvasive blood test that seems helpful to differentiate dogs with closed EHPSS and dogs with persistent shunting after gradual attenuation.

Background: Several options have been proposed for the treatment of congenital extrahepatic portosystemic shunts (cEHPSS) in dogs, but formal comparisons among different treatment options are currently unavailable. A previous evidence-based review (2012) found low quality of evidence for papers assessing the treatment of cEHPSS in dogs. Objectives: To assess the quality of evidence available in the treatment of cEHPSS, summarize the current state of knowledge with respect to outcome after cEHPSS management, and compare different treatment techniques. Animals: Not used. Methods: A bibliographic search was performed without date or language restrictions. Studies were assessed for quality of evidence (study design, study group sizes, subject enrollment quality, and overall risk of bias) and outcome measures reported (perioperative outcome, clinical outcome, and surgical or interventional outcome), all reported with 95% confidence intervals. A network meta-analysis was performed. Results: Forty-eight studies were included. Six retrospective studies (grade 4b) compared 2 techniques and 7 were abstracts (grade 5). The quality of evidence was low and risk of bias high. Regarding surgical outcome, statistically significant superiority of ameroid constrictor over thin film band was observed (P = .003). No other comparisons were statistically significant. Conclusions and Clinical Importance: The evidence base of choice of treatment of cEHPSS in dogs remains weak despite recent publications on the subject. Ameroid is superior to thin film band in causing EHPSS closure. Blinded randomized studies comparing different treatment modalities, which routinely include postoperative imaging to assess cEHPSS closure and acquired portosystemic shunt development are essential.