CLINICAL STAGING, TREATMENT AND PROGNOSIS

A system that classifies the disease into four stages with the goal of assisting the clinician in determining the appropriate therapy, forecasting prognosis, and implementing follow-up steps required for the management of the leishmaniosis patient.

Clinical staging of CanL based on serological status, clinical signs, laboratory findings and type of therapy and prognosis for each clinical stage

CLINICAL STAGES SEROLOGY* CLINICAL SIGNS LABORATORY FINDINGS THERAPY PROGNOSIS
STAGE I
Mild disease
Negative to low positive antibody levels Dogs with mild clinical signs such as solitary lymphadenomegaly or papular dermatitis Usually no clinicopathological abnormalities observed.
Normal renal profile: creatinine < 1.4 mg/dl; non-proteinuric: UPC < 0.2
Scientific neglect **/
Monitoring of disease progression (see table 3)
Good
STAGE II
Moderate disease
Low to high positive antibody levels Dogs, which apart from the signs listed in Stage I, may present other clinical signs such as: diffuse or symmetrical cutaneous lesions such as exfoliative dermatitis/onychogryphosis, ulcerations (planum nasale, footpads, bony prominences, mucocutaneous junctions), generalized lymphadenomegaly, loss of appetite and weight loss Clinicopathological abnormalities such as mild non-regenerative anemia, hypergammaglobulinemia, hypoalbuminemia, serum hyperviscosity syndrome.
Substage
a) Normal renal profile: creatinine < 1.4 mg/dl; non-proteinuric: UPC < 0.5 b) Creatinine <1.4 mg/dl; UPC= 0.5-1
Allopurinol + meglumine antimoniate or miltefosine Good to guarded
STAGE III
Severe disease
Medium to high positive antibody levels Dogs, which apart from the signs listed in Stages I and II, may present signs originating from immune-complex lesions (e.g. uveitis and glomerulonephritis) Clinicopathological abnormalities listed in Stage II
Chronic kidney disease (CKD) IRIS stage I with UPC= 1-5 or stage II (creatinine 1.4-2 mg/dl) ***
Allopurinol + meglumine antimoniate or miltefosine

Follow IRIS guidelines for CKD****

Guarded to poor
STAGE IV
Very severe disease
Medium to high positive antibody levels Dogs with clinical signs listed in Stage III. Pulmonary thromboembolism, or nephrotic syndrome and end stage renal disease Clinicopathological abnormalities listed in Stage II
CKD IRIS stage III (creatinine 2.1-5 mg/dl) and stage IV (creatinine > 5mg/dl)*** or Nephrotic syndrome: marked proteinuria UPC> 5
Specific treatment should be instaured individually

Follow IRIS guidelines for CKD****

Poor
 

*Dogs with negative to medium positive antibody levels should be confirmed as infected with other diagnostic techniques such as cytology, histology/immunohistochemistry and PCR. High levels of antibodies are conclusive of a diagnosis of CanL and are defined as 3-4 fold increased of a well established laboratory reference cut-off.
**Dogs in Stage I (mild disease) are likely to require less prolonged treatment with one or two combined drugs (allopurinol, domperidone, meglumine antimoniate or miltefosine) or alternatively monitoring with no treatment. There is limited information on dogs in this stage and, therefore, treatment options remain to be defined.
***http://iris-kidney.com/guidelines/staging.html
****http://iris-kidney.com/guidelines/recommendations.html