Staging is performed following canine patient diagnosis of L. infantum infection with clinical signs and/or clinicopathologic abnormalities to facilitate appropriate treatment and monitoring of the patient (Solano-Gallego et al., 2017). Infected but clinically healthy dogs are not included in this staging (see below).
Clinical staging in CanL
| CLINICAL STAGES | CLINICAL SIGNS | LABORATORY FINDINGS* | QUANTITATIVE SEROLOGY** | SPECIFIC THERAPY OR FOLLOW-UP | PROGNOSIS |
| STAGE I Mild disease |
Mild clinical signs such as example papular dermatitis or localized lymphadenomegaly | No clinicopathological abnormalities observed. Normal renal profile: creatinine < 1.4 mg/dL, non-proteinuric: UPC< 0.5 | Negative to low positive antibody levels | Scientific neglected*** | Good |
| STAGE II Moderate disease |
Diffuse or symmetrical cutaneous lesions such as example exfoliative dermatitisonychogryphosis, ulcerations (planum nasale, ears, footpads, bony prominences, mucocutaneous junctions), generalized lymphadenomegaly, loss of appetite and weight loss | Clinicopathological abnormalities compatible with L. infantum infection such as example mild non-regenerative anemia, hypergammaglobulinemia and hypoalbuminemia Substage a) Normal renal profile: creatinine < 1.4 mg/dl; non-proteinuric: UPC < 0.5 b) Proteinuric: creatinine < 1.4 mg/dL; UPC= 0.5-1 |
Low to high positive antibody levels | Meglumine antimoniate + allopurinol Miltefosine + allopurinol Substage b: Follow IRIS Guidelines for CKD |
Good to guarded |
| STAGE III Severe disease |
Dogs, which apart from the signs listed in stages I and II, may present signs originating due to immune-complex deposition (e.g. glomerulonephritis, uveitis) | Clinicopathological abnormalities listed in Stage II. CKD IRIS stage 1 with proteinuria UPC > 1 or CKD IRIS stage 2 (creatinine 1.4-2.8 mg/dl) | Medium to high positive antibody levels | Meglumine antimoniate + allopurinol Miltefosine + allopurinol Follow IRIS Guidelines for CKD |
Guarded to poor |
| STAGE IV Very severe disease |
Dogs with clinical signs listed in Stage III. Pulmonary thromboembolism, or nephrotic syndrome and end stage renal disease | Clinicopathological abnormalities listed in stages II and III. CKD IRIS stage 3 (creatinine 2.9-5 mg/dl) and CKD IRIS stage 4 (creatinine > 5 mg/dl) or Nephrotic syndrome or marked proteinuria UPC > 5 | Medium to high positive antibody levels | Specific treatment should be Poor instituted individually Follow IRIS Guidelines for CKD |
Poor |
* Full CBC, biochemistry profile and urinalysis
** Infection should be confirmed via other diagnostic techniques such as cytology, histology/immunohistochemistry and PCR in dogs with negative to medium positive antibody levels. High antibody levels, 3-4 fold higher than the well-established laboratory reference cut-off, are conclusive of CanL.
*** Dogs in stage I (mild disease) are likely to require short treatment with one or two conventional anti-Leishmania drugs (meglumine antimoniate, miltefosine, allopurinol). Adjunct immune-potentiating treatments or alone may be considered (domperidone, nucleotides plus AHCC – active hexose correlated compound). Alternatively, consider monitoring without treatment. There is limited evidence for treatment outcomes for dogs in this stage and, therefore, efficacy of these treatment options remain inconclusive.
IRIS recommendations must be strictly followed in stages III and IV (http://www.iris-kidney.com/ )
IRIS recommendations on proteinuria have changed since the publication of the last version of the LeishVet clinical staging.
UPC: urine protein:creatinine ratio; CKD: Chronic kidney disease; IRIS: International Renal Interest Society