Received: 18 December 2020 Accepted: 1 October 2021

DOI: 10.1111/jvim.16279

STANDARD ARTICLE

Evaluation of and the prognostic factors for cats with

big kidney-little kidney syndrome

Yen-Tse Wu1,2 | Wan-Chu Hung3 | Po-Yao Huang1,2 | Han-Ju Tsai2 |

1,2 1,2
Ching-Ho Wu | Ya-Jane Lee

1
Institute of Veterinary Clinical Science, School
of Veterinary Medicine, College of Abstract
Bio-Resources and Agriculture, National Background: The term big kidney-little kidney syndrome in cats has been used for
Taiwan University, Taipei, Taiwan
2 many years, but the definitions are not consistent and relevant research is limited.
National Taiwan University Veterinary
Hospital, College of Bio-Resources and Objective: To determine the factors that differ between normal and BKLK cats, as
Agriculture, National Taiwan University, Taipei,
well as to develop models for predicting the 30-day survival of cats with ureteral
Taiwan
3
Department of Emergency and Critical Care, obstruction (UO).
Auburn University Veterinary Teaching Animals: Sixteen healthy cats and 64 cats with BKLK.
Hospital, Auburn, Alabama, USA
Methods: Retrospective study. To define BKLK by reference to data from clinically
Correspondence healthy cats. The demographic and clinicopathological data among groups were sta-
Ya-Jane Lee, Institute of Veterinary Clinical
Science, School of Veterinary Medicine, tistically analyzed.
No. 1, Sec. 4, Roosevelt Road, Taipei, Taiwan. Results: Big kidney-little kidney syndrome cats had higher blood urea nitrogen (BUN)
Email: [email protected]
(median [interquartile range] 69 [28-162] vs 21 [19–24] mg/dL, P < .001), creatinine
Funding information (5.6 [1.9-13.3] vs 1.3 [1.05-1.40] mg/dL, P < .001), and white blood cells (10 800
Ministry of Science and Technology, Taiwan,
Grant/Award Number: [7700-17 500] vs 6500 [4875-9350] /μL, P < .001) and lower hematocrit (32.8
MOST 109-2313-B-002-011 [27.1-38.4] vs 39.1 [38.1-40.4]%, P < .001), urine specific gravity (1.011
[1.009-1.016] vs 1.049 [1.044-1.057], P < .001) and pH (5.88 [5.49-6.44] vs 6.68
[6.00-7.18], P = .001) compared to the control cats. A lower body temperature (BT;
38.1 [37.9-38.2] vs 38.7 [38.3-39.2] C, P = .009), higher BUN (189 [150-252] vs 91
[36-170] mg/dL, P = .04), and creatinine (15.4 [13.3-17.4] vs 9.0 [3.1-14.2] mg/dL,
P = .03) were found among the UO cats that were not 30-day survivors. A combina-
tion of BUN, phosphorus, and BT can predict 30-day survival among UO cats with an
area under receiver operating characteristic curve of 0.863. (P = .01).
Conclusion: An increase in the length difference between kidneys can indicate UO,
but cannot predict outcome for BKLK cats.

KEYWORDS
AKI, CKD, feline, ureteral obstruction

Abbreviations: AUROC, area under receiver operating characteristic curve; BKLKS, big kidney-little kidney syndrome; BT, body temperature; BUN, blood urea nitrogen; CKD, chronic kidney
disease; IQR, interquartile range; L2, second lumbar vertebra; LK, left kidney; NLR, neutrophil-to-lymphocyte ratio; Non-UO, nonureteral obstruction; OR, odds ratio; RK, right kidney; ROC,
receiver operating characteristic; SI, surgical intervention; SUB, subcutaneous ureteral bypass system; UO, ureteral obstruction; UpH, urine pH; USG, urine specific gravity; WBCs, white blood
cells.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.

J Vet Intern Med. 2021;35:2787–2796. wileyonlinelibrary.com/journal/jvim 2787

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2788 WU ET AL.

1 | I N T RO DU CT I O N as well as normal urinalysis results; these control cats were enrolled

and used for the determination of the criteria of diagnosing BKLKS.
The term Big Kidney-Little Kidney Syndrome (BKLKS) was first All the cats had creatinine concentration lower than 1.6 mg/dL, and all
suggested in 2011 in Nephrology and Urology of Small Animals.1 The had plasma total thyroxine concentrations within normal limits. The
term describes an extreme asymmetry in size of the kidneys in a single length of both kidneys on an abdominal ventrodorsal radiograph was
cat. This has been often recognized to be the result of a unilateral ure- measured and the kidney length difference of each cat was recorded.
1
teral obstruction (UO), and be the cause of subsequent changes in The length of the right kidneys (RKs) ranged from 3.31 to 5.90 cm
renal structures including atrophy, fibrosis, or both, of the affected with a median of 4.37 cm. The length of the left kidney (LK) ranged
kidney as well as a compensatory hypertrophy of the contralateral from 3.48 to 5.87 cm with a median of 4.54 cm. The length differ-
kidney. These effects are the most frequent causes of the clinical pre- ences for the control group ranged from 0.01 to 0.69 cm with a
1
sentation of a large kidney and a little kidney in a cat. median of 0.23 cm. Based on these findings, we defined the upper
Cats are predisposed to UO as it could be due to their small ure- limit of this range as the cutoff value for determining BKLKS in this
teral lumen,2 and a high incidence of UO has been recorded in cats study. The largest value for length difference among the control cats
over recent decades.3 In cats, most UOs are secondary to calcium oxa- was 0.69 cm and, after taking observational error into account, we
4
late uroliths, but can also be caused by tumors, strictures, iatrogenic settled on 0.70 cm as the cutoff value. The criterion for BKLKS in this
ligation, surgical trauma, mucus, mucopurulent plugs, blood clots, and study was thus defined as a cat having a length difference between
dried solidified blood calculus.4-7 Ureteral obstruction in most cases is their 2 kidneys on abdominal ventrodorsal radiograph that exceeded
initially unilateral; however, animals often present for medical care 0.70 cm.
with bilateral UOs, or with a unilateral obstruction and concurrent
contralateral kidney dysfunction due to any cause of reduced renal
function including previous UO.4 2.2 | Cases selection and grouping
When UO occurs, it increases hydraulic pressure within the ureter
and renal pelvis, and if high enough, this is transmitted to the tubules For this retrospective study, radiograph records at the National
and Bowman's space, reducing glomerular filtration rate. If the contra- Taiwan University Veterinary Hospital were reviewed. The inclusion-
lateral renal function is preserved, the cat does not usually become ary criterion for BKLKS is a length difference between the kidneys
azotemic,5 and the episodes of the disease might easily be overlooked exceeding 0.7 cm when measured on abdominal ventrodorsal radio-
by the cats' owners. The UO can be dynamic and even resolve sponta- graph. Cases that fulfilled the inclusion criterion were identified. Cases
neously.8 When the obstruction is unresolved, however, whether it is were excluded if a renal mass, polycystic kidney disease, a perinephric
either complete or partial, this will affect the functioning of the kid- pseudocyst, feline infectious peritonitis, or any neoplastic disease
neys, as well as their structure and this then leads to the BKLKS. involving other body organs was highly suspected.
BKLKS is sometimes an incidental finding and such cats are typi- The selected cases were first separated into 2 groups based on
cally stable and often in clinical practice do not show signs of azote- whether an abdominal ultrasound examination had been performed.
mia.5 However, cats might be presented with uremia, either where Cats with an abdominal ultrasound examination were later divided
both kidneys appear to be chronically compromised, or where it into 2 groups based on whether or not an episode of UO was present
appears that 1 kidney has undergone compensatory hypertrophy and at presentation to the hospital. In this study, cats were grouped into
then becomes obstructed.5 The latter can result in severe azotemia the UO group mainly based on the presence of hydronephrosis (the
and be accompanied by life-threatening hyperkalemia.5 As there is no objective length of pelvis in transverse section exceeding 0.35 cm) or
consistent definition of BKLKS in veterinary medicine at present, the hydroureter (the diameter of the proximal ureter exceeding 0.2 cm on
primary objectives of this study are to describe the characteristics of ultrasound examination), with or without hyperechogenic materials
cats with BKLKS. Next, we aimed to define the correlation between detected in the ipsilateral ureteral outflow tract, with concomitant his-
the extent of BKLKS and various relevant clinical and clinicopathologi- tory. Relevant history included various acute clinical signs such as
cal values, as well as various radiographic and ultrasonographic fea- vomiting, anorexia, lethargy, dehydration, pain on abdominal palpa-
tures. Finally, we wanted to determine any potential prognostic tion, weight loss, oliguria/anuria or polydipsia with polyuria, and the
factors for cats with BKLKS. cat's clinicopathological results, such as an increased serum creatinine
value. Cats diagnosed with UO were further divided into 2 groups
based on whether the UO was treated by surgery including subcuta-
2 | MATERIALS AND METHODS neous ureteral bypass (SUB) or a ureteral stent (Figure 1).

2.1 | Criteria for diagnosing BKLKS

2.3 | Data collection
Sixteen clinically healthy cats underwent a complete physical exami-
nation and were found to have a normal abdominal radiographic The data for this study included a range of clinicopathological data as
examination, a normal blood count, and normal biochemistry values, well as medical images. These consisted of signalment, any previous
 19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WU ET AL. 2789

and/or if the obstructed cats survived as well as to establish cutoff

values for such predictions.
Kaplan-Meier curves were generated to assess survival; this was
done using the cutoff values established from the previous ROC curve
results, and then tested them using log-rank tests. Differences of
P < .05 were considered significant for the selected variables with a
95% confidence interval.

3 | RE SU LT S

F I G U R E 1 Summary of the diagnostic categories and In total, 64 cats that met the inclusion criteria were enrolled
management of 64 cats with big kidney-little kidney syndrome.
(Figure 1); these consisted of 38 (59%) domestic shorthairs, 6 (9%)
BKLKS, patients with big kidney-little kidney syndrome; SI, patient
with surgical intervention; SUB, patient with subcutaneous ureteral American Shorthair cats, 5 (7%) Chinchillas, 4 (6%) Scottish folds,
bypass surgery; Ultrasound, patients who underwent ultrasonographic 3 (4%) Persians, 2 (3%) Abyssinians, 2 (3%) British Shorthairs, 1 (1%)
examination; UO, patients with ureteral obstruction Ragdoll, and 3 (4%) cats with unrecorded breeds.
Based on the ventrodorsal abdominal radiographs, in addition to
having a greater difference in length (median, interquartile range
history of nephrological diseases, the physical examination findings, [IQR]; 1.38 [0.97-2.00] vs 0.23 [0.05-0.28] cm, P < .001), BKLKS cats
the radiographic examinations, ultrasound examinations, complete also had 1 kidney with increased absolute length (5.11 [2.51-5.52] vs
blood counts with a blood film evaluation and a manual (white blood 4.55 [4.11-4.79] cm, P = .002), and increased kidney-to-L2 ratio (2.59
cells [WBCs]) differential count, plasma biochemical profiles, urinalysis [2.40-2.84] vs 2.37 [2.21-2.63], P = .03) compared to the control cats.
(with the urine pH [UpH] measured by a pH meter), and outcome. However, the L2, LK, and RK length had no significant differences
The measurement of the difference in the size of each cat's kid- between the 2 groups (Table 1). There were 33 out of 64 cats (51%)
neys and an examination of their structures were all obtained from an in the BKLKS group whose LK was the larger 1, while 31 out of
abdominal ventrodorsal view radiography. These included length of 64 (48%) cats had their RK being the larger 1. Radiographically, there
the second lumbar vertebral body (L2), and the length of individual were 15 (23%) cats with nephrolith alone, 12 (18%) cats with nep-
kidneys. Kidney length differences, kidney-to-L2 ratio, and the differ- hrolith and ureterolith, 2 (3%) with nephrolith and cystolith, and
ences in ratio were calculated and then recorded. The ultrasound 1 (1%) cat with only cystolith.
results for the lengths of the individual kidneys were recorded in the When the BKLKS cats were compared to the control cats, there
sagittal or horizontal plane, which is where the longest kidney length were no significant difference in age (P = .7) and sex (P = .65) distri-
could be observed. Additionally, the degree of pelvic or ureteral dilata- bution between the 2 groups, but BKLKS cats had significantly higher
tion, if present, was also recorded. blood urea nitrogen (BUN) concentrations (P < .001), plasma creati-
The outcome for each cat was tracked and recorded for up to nine concentrations (P < .001), WBCs (P < .001), neutrophil counts
1825 days after initial presentation and the cats with UO were evalu- (P < .001), neutrophil-to-lymphocyte ratios (NLRs) (P < .001), and
ated as either survivors or nonsurvivors based on their survival for monocyte counts (P = .04). They also had lower alkaline phosphatase
30 days. activities (P = .006), hematocrits (P < .001), eosinophil counts
(P < .001), and lymphocyte counts (P = .03) (Table 1).
Urinalysis was performed on 34 (53%) of the BKLKS cats. The
2.4 | Statistical analysis BKLKS group were found to have significantly lower urine specific
gravity (USG; P < .001) as well as a lower UpH (P = .004) when com-
Statistical analysis was performed using a statistical software package pared to the control cats (Table 1).
(SPSS 25.0 for Mac). The Shapiro-Wilk test was used to determine the Overall, 50 out of the 64 BKLK cats (73%) underwent an ultrasono-
normal distribution condition for the continuous variables. The Mann- graphic examination. The median LK length was 3.67 cm (ranging from
Whitney test and Kruskal-Wallis test (post hoc with the Dunn test) 1.74 to 6.77 cm, n = 48), and median RK length was 3.62 cm (ranging
were used for comparisons between or among continuous variables, from 2.23 to 6.53 cm, n = 48). In total, 36 out of the 50 cats that
while Pearson chi-square was used for categorical variables. Linear underwent abdominal ultrasonography (72%) were diagnosed with UO
regression analysis was used to evaluate the relationship between by either hydronephrosis or hydroureter based on their ultrasono-
2 variables. Spearman correlation test was used to evaluate 2 nonpara- graphic findings, with 29 out of 36 (80%) having only hydronephrosis
metric variables. Logistic regression analysis was used for calculating noted, 2 out of 36 (5%) with only hydroureter, and 5 out of 36 (13%)
odds ratios (ORs) for univariate and multivariates. having both. The median pelvic dilatation in the obstructed cats was
Receiver operating characteristic (ROC) curve analyses were used 1.02 cm (range, 0.22-4.30 cm, n = 34), and the ureteral dilatation in the
to test the ability of variables to predict if a kidney was obstructed obstructed cats was 0.44 cm (range, 0.32-0.89 cm, n = 7).
 TABLE 1 Selected variables among the control cats, all BKLKS cats, the nonobstructed BKLKS cats, and the obstructed BKLKS cats
2790

Control (n = 16) All BKLKS (n = 64) Non-UO BKLKS (n = 14) UO BKLKS (n = 36)
*
Parameters Median (IQR) n Median (IQR) n P value Median (IQR) n Median (IQR) n P value†
Age (y) 8.00 (7.00-11.50) 16 9.00 (6.00-11.00) 64 .7 9.50 (7.75-12.00) 14 8.00 (6.00-11.00) 36 .69
BW (kg) 4.65 (3.50-6.07) 12 4.08 (3.34-5.26) 63 .26 4.22 (3.62-5.85) 13 3.91 (3.39-5.32) 36 .47
Sex (8M, 8F) 16 (36M, 28F) 64 .65 (8M, 6F) 14 (20M, 16F) 36 .92§
BT ( C) — — 38.4 (38.0-38.9) 41 — 38.7 (37.4-39.3) 5 38.5 (38.1-38.9) 27 .82‡
Length of L2 (cm) 1.89 (1.74-2.04) 16 1.96 (1.84-2.08) 64 .12 1.96 (1.88-2.18) 14 1.96 (1.84-2.05) 36 .56
Length diff. (cm) 0.23 (0.05-0.28)a 16 1.38 (0.97-2.00) 64 <.001 1.15 (0.95-1.37)b 14 1.72 (1.27-2.33)c 36 <.001
Ratio diff. 0.12 (0.02-0.16)a 16 0.75 (0.51-1.01) 64 <.001 0.59 (0.49-0.66)b 14 0.86 (0.62-1.21)c 36 <.001
a a,b
BK length (cm) 4.55 (4.11-4.79) 16 5.11 (2.51-5.52) 64 .002 5.03 (4.62-5.32) 14 5.23 (4.84-5.75)b 36 .001
a a,b b
BK-to-L2 ratio 2.37 (2.21-2.63) 16 2.59 (2.40-2.84) 64 .03 2.48 (2.34-2.65) 14 2.66 (2.48-2.89) 36 .005
Hematocrit (%) 39.1 (38.1-40.4)a 16 32.8 (27.1-38.4) 63 <.001 33.8 (30.4-41.0)a,b 14 30.4 (24.2-35.6)b 35 <.001
Platelets (103/μL) 223 (142-299) 16 273 (224-348) 63 .05 285 (165-389) 14 281 (237-348) 35 .09
WBCs (/μL) 6550 (4875-9350)a 16 10 800 (7700-17 500) 63 <.001 9950 (6550-15 550)a,b 14 10 600 (7700-17 500)b 35 .006
a b b
Neutrophils (/μL) 4419 (2421-6451) 16 9048 (5854-15 694) 61 <.001 7553 (4456-14 195) 13 8824 (6007-15 792) 34 .001
Lymphocytes (/μL) 1710 (954-2180) 16 990 (602-1623) 61 .03 990 (593-1331) 13 959 (471-1751) 34 .06
Eosinophils (/μL) 534 (300-890)a 16 180 (0-538) 60 <.001 500 (0-926)a,b 13 180 (0-326)b 33 .001
a b
NLR 2.67 (1.37-5.43) 16 7.91 (4.30-20.18) 61 <.001 6.70 (2.85-23.38) 13 10.32 (4.29-23.89)b 34 .001
a a b
BUN (mg/dL) 21.5 (19.0-24.5) 16 69 (28-162) 64 <.001 21.0 (18.3-53.8) 14 101.0 (49.3-198.0) 36 <.001
Creatinine (mg/dL) 1.30 (1.05-1.40)a 16 5.6 (1.9-13.3) 64 <.001 1.85 (1.58-4.18)b 14 10.35 (3.80-16.45)c 36 <.001
Albumin (g/dL) 3.10 (2.90-3.28) 16 3.2 (3.0-3.5) 61 .27 3.10 (3.05-3.45) 13 3.20 (2.80-3.40) 34 .56
Total protein (g/dL) 7.40 (7.10-7.98) 16 7.3 (6.9-8.0) 56 .54 7.30 (6.80-7.75) 13 7.25 (6.80-8.03) 30 .7
Glucose (g/dL) 134.5 (110-161) 16 138 (108-150) 13 .85 137 (108-146) 14 120 (108-160) 28 .8
K+ (mmol/L) — — 3.91 (3.54-4.65) 63 — 3.44 (3.05-3.75) 14 4.40 (3.77-5.20) 35 <.001‡
ALKP (U/L) 44.5 (38.5-48.0)a 16 34 (25-44) 57 .006 38.0 (30.5-81.0)a 14 30.0 (24.0-38.8)b 30 .001
a b
USG 1.049 (1.044-1.057) 16 1.011 (1.009-1.016) 34 <.001 1.010 (1.009-1.030) 7 1.010 (1.009-1.012)b 22 <.001
Urine pH 6.68 (6.00-7.18)a 16 5.88 (5.49-6.44) 34 .001 6.15 (5.76-6.40)a,b 7 5.82 (5.49-6.48)b 22 .01
Survival time (d) — — 255 (56-602) 64 — 204 (113-773) 14 272 (56-813) 36 1‡

Note: Superscript letters (a, b, c): Within a row, values with different superscripts differ significantly (P < .05).
Abbreviations: ALKP, alkaline phosphatase; BK, big kidney; BKLKS, big kidney-little kidney syndrome; BT, body temperature; BUN, blood urea nitrogen; BW, body weight; F, female; IQR, interquartile range; K+,
potassium; L2, second lumbar vertebra; M, male; NLR, neutrophil-to-lymphocyte ratio; Non-UO, nonureteral obstruction; ratio diff., the difference between the kidneys to second lumbar vertebra ratios; RBC,
red blood cells; UO, ureteral obstruction; USG, urine specific gravity; WBCs, white blood cells.
*
P value generated by Mann-Whitney test, between control cats and all BKLKS cats.
†
P value generated by Kruskal-Wallis test (post hoc with Dunn test), among control cats, nonobstructed BKLKS cats, and obstructed cats.
‡
P value generated by Mann-Whitney test, between nonobstructed BKLKS cats, and obstructed cats.
§
P value generated by chi-square test, between nonobstructed BKLKS cats, and obstructed cats.
WU ET AL.

19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
 19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WU ET AL. 2791

The obstructed BKLKS cats, when compared with nonobstructed ratios (no unit)], as this formula also had an AUROC of 0.908
BKLKS cats, had significantly larger length differences (median (P < .001), with the same sensitivity and specificity, and an optimal
1.72 cm vs 1.15 cm, P = .009), and ratio differences between their cutoff value at 41.3 (Figure 2).
kidneys, (median 0.86 vs 0.59, P = .008), higher plasma creatinine Overall, 16 out of 36 obstructed BKLKS cats (44%) received surgi-
concentrations (median 10.35 mg/dL vs 1.85 mg/dL, P < .001), higher cal intervention (SI), and this consisted of 13 (36%) cats that received
BUN concentrations (median 101.0 mg/dL vs 21.0 mg/dL, P < .001), SUB surgery, 1 (2%) cat that received SUB surgery and hemodialysis
and higher potassium concentrations (median 4.40 mmol/L vs treatment, 1 (2%) cat that received ureteral stent installation, and
3.34 mmol/L, P < .001), as well as lower alanine transaminase activi- 1 (2%) cat that received ureteral stent installation and peritoneal dialy-
ties (median 39 U/L vs 68 U/L, P = .03). The median survival time was sis treatment.
not significantly different between the obstructed BKLK cats The degree of pelvic dilatation (before operation; P = .01) was
(272 days, IQR 56-813 days) and the nonobstructed BKLK cats significantly higher in the obstructed cats that had received SI than
(204 days, IQR 113-773 days, P = 1) (Table 1). those that did not (median 1.17 [IQR 1.00-1.41], n = 14 vs median
The univariate analysis using logistic regression showed that 0.69 [IQR 0.51-1.21], n = 20).
increased creatinine (OR = 1.296), increased BUN (OR = 1.019), Among all the BKLKS cats, the difference in length between the
increased potassium (OR = 5.729), and a higher ratio difference kidneys was found to be linearly related to creatinine concentration
between the 2 kidneys (OR = 16.60) were significantly associated (R = 0.316, P = .01) and BUN concentration (R = 0.280, P = .03), but
with the presence of UO. When kidney length difference alone was was not linearly related to potassium concentration (P = .11), phos-
used as a variable to detect UO, it had an area under ROC (AUROC) phorus concentration (P = .19), degree of pelvic dilatation (P = .6), or
of 0.740 (P = .009). When multivariate analysis was performed using survival time (P = .74). Furthermore, in the UO cats, the degree of pel-
logistic regression, multiple variable combinations in different models vic dilatation was not significantly linearly correlated with any of the
were tested (Table S1), and a formula with the optimal AUROC was renal-related indices, including creatinine (P = .15), BUN (P = .14),
derived from the multivariate analysis with creatinine and potassium phosphorus (P = .22), and potassium (with P = .98).
concentrations, and the difference between the kidney-to-L2 ratios Using Spearman correlation, the length difference between the
being the variables: [Log (odds of obstruction) = 1.188 Creatinine kidneys in all of the BKLKS cats was found to be significantly corre-
(mg/dL) + 7.286 Potassium (mmol/L) + 18.76 Difference between lated with creatinine (P = .002) and BUN (P = .006), whereas in the
the kidney-to-L2 ratios (no unit)] (Table 2) served as a diagnostic test UO cats, the degree of pelvic dilatation was not significantly corre-
for determining whether UO was present; this had an AUROC of lated with any of the various renal-related indices (Table 3).
0.908 (P < .001), with a sensitivity of 94.3%, a specificity of 78.6% The median survival time of all BKLK cats was 254 days (range,
and an optimal cutoff value of 42.90. We later generated a second 0-1825 days).
formula with simplified coefficients adapted from the previous for- Setting the survival cutoff at 30 days for the obstructed BKLKS
mula: [Log (odds of obstruction) = 1.2 Creatinine (mg/dL) + 7.0 cats, body temperature (BT) (rectal temperature; P = .009) taken at
Potassium (mmol/L) + 18.0 Difference between the kidney-to-L2 presentation was found to be significantly lower in those cats that did

TABLE 2 Univariate and multivariate odds ratios for predicting ureteral obstruction in BKLKS cats

Univariate analysis Multivariate analysis

Variables OR 95% CI P value OR 95% CI P value

Serum creatinine (mg/dL) 1.296 1.08-1.56 .006 1.188 0.96-1.47 .11
Blood urea nitrogen (mg/dL) 1.019 1.00-1.03 .01
Phosphorus (mg/dL) 1.133 0.91-1.41 .27
Potassium (mmol/L) 5.729 1.70-19.37 .005 7.286 1.38-38.41 .02
Albumin (g/dL) 0.899 0.16-5.15 .91
Neutrophil-to-lymphocyte ratio 1.007 0.98-1.03 .6
Body temperature ( C) 1.418 0.36-5.55 .62
Body weight (kg) 0.791 0.49-1.28 .34
Length of big kidney (cm) 1.249 0.65-2.39 .5
Ratio of big kidney-to-L2 2.977 0.60-14.89 .18
Length difference (cm) 3.055 0.95-9.80 .06
Ratio difference 16.60 1.28-216.08 .03 18.76 0.883-398.73 .06

Note: The data were generated by binary logistic regression tests.

Abbreviations: BKLKS, big kidney-little kidney syndrome; CI, confidence interval; L2, second lumbar vertebra; OR, odds ratio; Ratio difference, difference
between the kidneys to second lumbar vertebra ratios.
 19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2792 WU ET AL.

group (median 478 days [IQR 129-1070 days]) did not have a signifi-
cantly longer survival than the latter group (median 229 days [IQR 25-
482 days], P = .19).
The univariate analysis results showed that BUN concentration
(OR = 1.010) was significantly associated with whether a UO-BKLK
cat was able to survive to 30 days (Table 5), and an equation was gen-
erated for this using multivariate analysis: [Log (odds of death) = 1.029
BUN (mg/dL) + 0.783 Phosphorus (mg/dL) + 0.918 BT ( C)]. The for-
mula served to establish a prognostic index as to whether a cat would
survive to 30 days; this had an AUROC of 0.863 (P = .01), a sensitivity
of 100%, a specificity of 78.9%, and an optimal cutoff value of 171.1.
Other multivariate analysis models are shown in Table S2. We later
generated a second formula with simplified coefficients adapted from
the previous formula: [Log (odds of death) = 1.0 BUN (mg/dL) + 0.8
Phosphorus (mg/dL) + 0.9 BT ( C)], as this formula also had an
AUROC of 0.863 (P < .01), with the same sensitivity and specificity,
and an optimal cutoff value at 166.9 (Figure 2). When the obstructed
BKLKS cats were divided into high-value and low-value groups based
on either 1 of the formulas, the survival time was significantly differ-
ent by log-rank test between the 2 groups (P = .01) (Figure 3).

4 | DI SCU SSION

In this study, we generated a cutoff value that will act as a reference

when diagnosing cats with BKLKS. This involves calculating the length
difference between 2 kidneys when observed on a ventrodorsal
abdominal radiograph in clinically healthy cats. Radiography and ultra-
sonography have both been applied as adequate tools for assessing
feline kidneys sizes. However, ultrasonography is also known for the
disadvantage to subjectively obtain the longest kidney axis for each
measurement as it relies heavily on user expertise, cat preparation,
and the ultrasound machine models.9,10 As a result, radiography was
chosen as our main imaging modality for it provides more objective
F I G U R E 2 Receiver-operating characteristic plots of diagnostic measurement of the kidneys and was not uncommon in our hospital.
tests for ureteral obstruction using the formula [1.2 Creatinine
Furthermore, in practices where only ultrasonography is available, it
(mg/dL) + 7.0 Potassium (mmol/L) + 18.0 Difference between the
kidney-to-L2 ratios] (A). The formula which was designed as a might be impossible to obtain the length of the second lumbar verte-
diagnostic test for 30-day survival in obstructed cats [1.0 BUN bra for the assessment of kidney size and the absolute values of renal
(mg/dL) + 0.8 Phosphorus (mg/dL) + 0.9 Body temperature ( C)] was length differences can be also applied for the cats with ultrasonogra-
presented with the ROC plot in (B). The area under the ROC (AUROC) phy examination. The data of the differences between the kidney-to-
for (A) is 0.908 (P < .001). Using a cutoff point of 41.3, for (A), the
second-lumbar-vertebra-ratios, measured on radiography, were also
sensitivity was 94.3% and the specificity was 78.6%. The AUROC for
provided to give the information regarding relative sizes of the kid-
(B) was 0.863 (P = .01). Using a cutoff point of 166.9, the sensitivity
was 100% and the specificity was 78.9%. BUN, blood urea nitrogen; neys in cats with different sizes.
ROC, receiver operating characteristic An equation was created for predicting the presence of UO
before an ultrasonographic examination is performed, allowing practi-
tioners to use other diagnostic modalities if ultrasonography is not

not survive (38.1 [37.9-38.2] C) than those that did survive (38.7 available. Although several studies in the past have recorded the sizes
[38.3-39.2] C). The BUN (P = .04) and creatinine (P = .03) concentra- of kidneys and the size differences between kidneys using abdominal
tions were also significantly higher in the nonsurvivor group than the radiographs,11,12 as well as renal pelvic sizes before SI,12,13 to our best
survivor group (Table 4). When we compared the survival rate for knowledge, no study until the present 1 has demonstrated a correla-
30 days after diagnosis, the UO cats that received SI (14/16 survived) tion between such length measurements, disease prognosis, and the
did not show a significantly better 30-day survival rate than that did severity of azotemia. In this study, the length difference between kid-
not undergo surgery (15/20 survived) (P = .35). In addition, the former neys was significantly larger in the UO group than that in the
 19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WU ET AL. 2793

T A B L E 3 Correlation between kidney length differences and various variables among all BKLKS cats, and between pelvic dilatation degree
and various variables among UO cats

Length differencea Spearman correlation P value Pelvic dilatation degreeb Spearman correlation P value
b a
Pelvic dilatation degree (cm) .149 .39 Length difference (cm) .196 .27
Hematocrit (%) .180 .16 Hematocrit (%) .055 .76
White blood cells (/μL) .112 .38 White blood cells (/μL) .199 .27
Blood urea nitrogen (mg/dL) .342 .006 Blood urea nitrogen (mg/dL) .145 .41
Creatinine (mg/dL) .387 .002 Creatinine (mg/dL) .198 .26
Potassium (mmol/L) .187 .14 Potassium (mmol/L) .080 .66
Phosphorus (mg/dL) .273 .07 Phosphorus (mg/dL) .117 .53
Survival time (d) .025 .85 Survival time (days) .097 .59

Abbreviations: BKLKS, big kidney-little kidney syndrome; UO, ureteral obstruction.

a
Measured using ventrodorsal abdominal radiography.
b
Measured using abdominal ultrasonography and the transverse plane of the obstructed kidney.

TABLE 4 A comparison of selected variables between survivors and nonsurvivors for 30 days among all obstructed BKLKS cats

Survival (n = 30) Nonsurvival (n = 7)

Variables Median IQR n Median IQR n P value


Body temperature ( C) 38.7 38.3-39.2 22 38.1 37.9-38.2 5 .009
White blood cells (/μL) 10 050 7625-13 775 28 11 600 9800-24 400 7 .11
Neutrophils (/μL) 8209 5392-12 049 28 12 943 8900-22 461 6 .06
Lymphocytes (/μL) 1100 496-1760 28 698 415-1532 6 .56
Neutrophil-to-lymphocyte ratio 7.87 4.29-15.13 28 24.15 8.35-48.13 6 .19
Blood urea nitrogen (mg/dL) 91 36-170 29 189 150-252 7 .04
Creatinine (mg/dL) 9.00 3.1-14.2 29 15.4 13.3-17.4 7 .03
Surgical intervention 14/29 (48.3%) 29 2/7 (28.6%) 7 .35a
Survival time (d) 392 156-1014 29 2 0-6 7 <.001

Abbreviations: BKLKS, big kidney-little kidney syndrome; IQR, interquartile range.

a
P value generated by chi-square test, between survivor and nonsurvivor cats.

TABLE 5 Univariate and multivariate odds ratios for predicting death within 30 days for obstructed BKLKS cats

Univariate analysis Multivariate analysis

Variables OR 95% CI P value OR 95% CI P value


Body temperature ( C) 0.177 0.02-1.33 .09 0.918 0.86-0.99 .02
BUN (mg/dL) 1.010 1.00-1.021 .05 1.029 1.00-1.06 .05
Creatinine (mg/dL) 1.072 0.97-1.18 .17
Phosphorus (mg/dL) 1.095 0.95-1.26 .21 0.783 0.51-1.21 .27
Potassium (mmol/L) 1.766 0.94-3.31 .08
Length difference (cm; Radiography) 1.098 0.42-2.87 .85
Size of renal pelvis (cm; Ultrasonography) 0.244 0.03-2.56 .21
Urine pH 0.114 0.01-9.24 .33

Note: The data were generated by binary logistic regression tests.

Abbreviations: BKLKS, big kidney-little kidney syndrome; BUN, blood urea nitrogen; CI, confidence interval; OR, odds ratio.

nonureteral obstruction (non-UO) group. However, the length differ- To date, no consistent criteria have been defined for diagnosing
ence between kidneys was found to be correlated only with creatinine hydronephrosis using abdominal ultrasonography. This is partly
and BUN concentrations but not with the days of survival in because that in healthy cats, cats with chronic kidney disease (CKD),
BKLKS cats. and cats with pyelonephritis, an increased renal pelvic diameter could
 19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2794 WU ET AL.

and a clinicopathological abnormality; there is a clear need for addi-

tional information to help with any such diagnosis.
In this study, it was first observed that, among cats with BKLKS,
when they are compared to control cats, there are significantly higher
concentrations of creatinine and BUN, lower USG values, and a trend
toward anemia being present. Furthermore, the UO cats, when com-
pared with the non-UO cats, have findings that are compatible with
the characteristics of postrenal azotemia. Specifically, hypercreatininemia
and hyperkalemia are common findings among cats with UO based on
various previous studies.12,13,15
When the non-UO group was compared with the control cats,
there is also a statistical significant difference in creatinine concentra-
tions. The lower USG in the non-UO group also pointed toward the
residual renal functioning of these cats being limited. Therefore, tak-
ing the clinicopathological abnormalities into account, non-UO BKLKS
F I G U R E 3 Receiver-operating characteristic plots of diagnostic
cats might be likely to have CKD.
tests for ureteral obstruction using the formula [1.2 Creatinine
The leukogram of BKLKS cats showed significantly higher seg-
(mg/dL) + 7.0 Potassium (mmol/L) + 18.0 Difference between the
kidney-to-L2 ratios] (A). The formula which was designed as a mented cell counts, lower lymphocyte counts, and a higher NLRs
diagnostic test for 30-day survival in obstructed cats [1.0 BUN when compared to control cats. Studies in human medicine have
(mg/dL) + 0.8 Phosphorus (mg/dL) + 0.9 Body temperature ( C)] was suggested that the NLR is possibly an early marker for detecting sep-
presented with the ROC plot in (B). The area under the ROC (AUROC) sis17 and community acquired pneumonia,18 as well as being an inde-
for (A) is 0.908 (P < .001). Using a cutoff point of 41.3, for (A), the
pendent prognostic factor for patients with various types of
sensitivity was 94.3% and the specificity was 78.6%. The AUROC for
(B) was 0.863 (P = .01). Using a cutoff point of 166.9, the sensitivity cancers.19 Furthermore, this ratio also seems to be associated with
was 100% and the specificity was 78.9%. BUN, blood urea nitrogen; renal and hepatic dysfunction in general.20 Although there has been
ROC, receiver operating characteristic no clear evidence of an association between NLR and veterinary med-
icine prognoses thus far, previous studies have pointed out that NLR
could be useful when predicting a prognosis for canine soft tissue
also be found, while not all cases of outflow obstruction are associ- sarcoma,21 as well as when identifying systemic inflammation in
14
ated with marked pelvic dilatation. In the past, 2 mm has been dogs.22 In this study, the increased NLR in all of the BKLKS cats, along
used as a cutoff value for the tentative diagnosis of UO.11 A report with increases in WBCs, possibly suggests the presence of
using pyelogram for definitive diagnosis of UO found the lower inflammation.
range for the affected pelvic diameter to be 3 mm by abdominal Urine pH in the UO group was significantly lower than in the con-
ultrasound.15 A more recent review article pointed out pelvic dia- trol cats. As stated, most UOs in cats are secondary to calcium oxalate
meter > 3.5 mm in the transverse plane of the kidneys needs to be uroliths.4 Furthermore, aciduria has been proposed as a risk factor for
14
interpreted as potentially abnormal, and more severe cases of pel- calcium oxalate formation.23 This result in our study supports the idea
14
vic dilatation occurred in cats with urinary outflow obstruction. that there is a higher possibility of calcium oxalate ureterolithiasis in
Although this value might still not be able to fully differentiate such cats, which is likely to contribute to UO, despite there being no
between UO and pyelonephritis, we decided to set the cutoff value direct evidence of this from stone analyses after surgery or at
for the presence of UO in this study at 3.5 mm, as it could have the necropsy.
potential to eliminate more cases in which CKD or mild pyelonephri- Subcutaneous ureteral bypass device is a viable treatment modal-
tis were the actual cause for the increased pelvic widths. However, ity for cats with benign UO.24 However, in this study, it should be
in cases with the absence of evident UO on imaging findings and noted that, among the UO group cats with a pelvic size exceeding
without the confirmation on antegrade pyelography or surgical 0.5 cm, which is a prerequisite for a nephrostomy tube to be placed
exploration, false positive and false negative diagnosis on UO could during SUB surgery,25 the 30-day survival time difference between
still occur in our study design. cats that have undergone SUB installation surgery, and those that
Similar to an earlier report stating that renal pelvic size is not have not had such an operation, was not significantly different. Spe-
16
associated with serum creatinine concentration, our results indi- cifically, there was no significant difference in overall survival
cated that the increase in renal pelvic size among UO cats is not corre- between the 2 groups (data not shown). However, with the relatively
lated with any renal-associated variable, including creatinine, small sample size and retrospective study design in the present study,
potassium, and phosphorus concentrations, although our study was as details specifying duration of previous azotemia, presence of other
underpowered in such calculations. Consequently, renal pelvis size concomitant diseases and other variables could not be standardized,
and the length difference between a cat's kidneys need to be inter- and that the surgical group had greater pyelectasia, implying a pre-
preted cautiously and should not be used alone to predict a prognosis existing disease severity difference; the results must be interpreted
 19391676, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jvim.16279 by Cochrane Colombia, Wiley Online Library on [07/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
WU ET AL. 2795

with extreme caution. More in-depth investigation and a stricter study function, and whether early or occult CKD existed in the control cats.
design into the use of SUB devices in cats with UO should still be The fact that not all of the BKLKS cats underwent urinalysis and
warranted. abdominal ultrasonographic examination could have affected our
Creatinine concentrations could correlate with true residual renal understanding and interpretation of their renal function and the dis-
function and that this can help to predict the prognosis of cats with ease processes. There was no recording of whether any fluid therapy
CKD.26,27 However, during acute kidney injury or UO, the reduction or diuretics were administered before the ultrasonographic examina-
in the renal function might be transient and is potentially reversible. tions, which could possibly have transiently affected the cats' measur-
Therefore, serum creatinine seems to be able to indicate only the able renal pelvic size. Furthermore, in this study, no antegrade
degree of the current reduction in glomerular filtration rate in the kid- pyelography or computed tomography was performed to confirm the
neys, but cannot be used as a reliable prognostic factor.28 In this diagnosis of UO, and this might have resulted in false-positive and
study, the results showed that, in UO cats, although there are signifi- false-negative diagnoses for UO. The various etiologies of the UO,
cant differences in plasma creatinine concentrations between 30-day when present, could not be confirmed in every case due to the lack of
survivors and nonsurvivors, creatinine values alone do not seem to be surgery or necropsy results. Finally, it was also not possible to
linked to the cats 30-day survival using logistic regression modeling. completely rule out cases with infiltrative renal diseases because sur-
On the other hand, BUN concentrations do not seem to be a gical biopsy or necropsy was not performed on the cats. A strict pro-
prognostic factor among cats with acute intrinsic renal failure,29 and spective study designed to answer the questions would be strongly
in cats receiving hemodialysis,30 plasma BUN values are able to serve warranted in the future.
as an adequate prognostic factor for UO cats in our present study.
The reason behind this difference is unclear; however, in recent ACKNOWLEDG MENT
human medical studies, a higher BUN has been associated with an Funding for this study was provided by Ministry of Science and Tech-
increased risk of cardiovascular death in patients hospitalized for nology, Taiwan, Grant number MOST 109-2313-B-002-011. Part of
heart failure,31,32 and in patients who suffer from death due to pneu- this study was presented at the 2018 ACVIM Forum, Seattle,
33
monia. Whether the prognostic value of BUN in this study was due Washington. The authors thank all the doctors at National Taiwan
to similar properties is still unknown. Further investigations targeting University Veterinary Hospital for providing the cases and collecting
this topic are necessary. the samples and images.
In the present study among UO cats, the BT of the nonsurvivor
group was significantly lower than that of the survivor group. CONFLICT OF INTEREST DECLARATION
Although the mechanism of a lower BT in these cats with renal dis- Authors declare no conflict of interest.
ease remains unclear, accumulating evidence based on human and
veterinary studies has pointed out there is an increasing prevalence of OF F-LABEL ANTIMI CROBIAL DECLARATION
34
hypothermia in uremic animals. This means that core BT might be Authors declare no off-label use of antimicrobials.
able to serve as a prognostic index,28,35 and this could lead to longer
veterinary hospital stays for hypothermic cats with urethral obstruc- INSTITU TIONAL ANIMAL C AR E AND USE COMMITTEE
tion.36 (IACUC) OR OTHER APPROVAL DECLARATION
The present study has multiple limitations due to its retrospective Approved by National Taiwan University, NTU106-EL-00008.
nature. The renal sizes measured in the radiographs might have errors
due to positioning differences between each cat. Furthermore, also in HUMAN E THICS APPROVAL DECLARATION
this context, interoperator variability might have affected the objec- Authors declare human ethics approval was not needed for this study.
tivity of the ultrasound measurements of the renal pelvis and ureters.
It is quite hard to estimate the duration of an obstruction or the level OR CID
of residual renal function before first presentation when acute azote- Ya-Jane Lee https://orcid.org/0000-0003-4884-7019
mia or possibly UO is present. The fact that the control group had not
been examined by abdominal ultrasonography could have resulted in RE FE RE NCE S
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