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iagnostic biomarkers are measurable and quantifiable substances that can indicate the likely presence of a disease or a physiologic abnormality.1 The use
of molecular biomarkers is receiving increasing attention because of the advances in technology and the diculties encountered in diagnosing many conditions
using standard test methods. Better understanding of
disease pathogenesis has allowed the identification of
specific biomarkers that are being used to screen
patients at risk for a variety of diseases, as well as to
evaluate response to therapy and predict outcome.1
Among others, amino-terminal pro-C-type natriuretic
peptide (NT-proCNP), a stable product of cleavage of
C-type natriuretic peptide (CNP), is a novel biomarker
with potential diagnostic utility in sepsis.24
Amino-terminal pro-C-type natriuretic peptide
participates in vascular homeostasis and modulates
From the Departments of Clinical Studies and Pathobiology,
(Guieu, Bersenas, Holowaychuk, Brisson) and Centre for Public
Health and Zoonoses, Ontario Veterinary College, University of
Guelph, Guelph, ON, Canada (Weese).
All ELISAs were performed at the Ontario Veterinary College.
This manuscript represents a portion of a thesis to be submitted by
Dr Guieu to the Department of Clinical Studies, Ontario Veterinary
College, as partial fulfillment of the requirements for a Doctor of
Veterinary Science degree.
Corresponding author: Dr L.V. Guieu, Department of Clinical
Studies, Ontario Veterinary College, University of Guelph, Guelph,
ON N1G 2W1, Canada; e-mail: lvguieu@uoguelph.ca.
Abbreviations:
CNP
CSAD
CV
IL
IV
LPS
NSIRS
NT-proCNP
O/E
SIRS
SP
TNCC
TNF
TS
WBC
1301
Control Dogs
Five client-owned dogs undergoing abdominocentesis for diagnostic or therapeutic purposes unrelated to sepsis or SP were
included as controls. The following data were recorded for control
dogs: age, sex, breed, antibiotic therapy, and etiology of the
abdominal eusion. In these dogs, sepsis was excluded based on at
least 2 of the following criteria: SIRS criteria not fulfilled,12 recovery of eusate from patients with confirmed diagnosis consistent
with abdominal eusion of a nonseptic origin, absence of organisms or degenerate neutrophils on abdominal fluid cytologic examination, or patient follow up with no signs of sepsis or SP.
Abdominal fluid samples were centrifuged and stored as described
above.
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Guieu et al
Statistical Analysis
Data were analyzed for normality using the following tests:
ShapiroWilk, KolmogorovSmirnov, Cramervon Mises, and
AndersonDarling. Logarithmic transformations were performed
to meet assumptions of normality when necessary. A Fischers
exact test was used to compare NT-proCNP concentrations in
abdominal fluid from dogs with SP to control dogs, and a Wilcoxon sign rank test was used to compare NT-proCNP concentrations from serum and abdominal fluid from dogs with SP at
admission. ANOVA for repeated measures was used to test for
significant dierences between abdominal fluid and serum NTproCNP concentrations in dogs with SP from admission to CSAD
removal, as well as to test significant changes over time in abdominal fluid and serum NT-proCNP concentrations during the same
period. The assumptions of the ANOVA were assessed by comprehensive residual analysis. A Dunnetts adjustment or a multivariate t-test between treatments was applied when appropriate. When
sample mishandling occurred, the paired samples were removed
from statistical analysis. In samples with a reported NT-proCNP
concentration below the detection limit, half of the lower detection
limit was used for statistical analysis to allow for logarithmic
transformation.13 A mixed linear model that accounted for
repeated measures was used to determine if a significant association existed between abdominal fluid NT-proCNP concentrations
and concurrently measured TNCC, TS, and abdominal fluid production (24-hour volume).
Statistical significance was set at a P value <0.05 for all comparisons. Statistical analysis was performed using commercial software.g Graphs were generated using commercial software.h
Results
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Fig 1. Admission abdominal fluid and serum amino-terminal pro-C-type natriuretic peptide (NT-proCNP) concentrations in dogs with
septic peritonitis (SP) and abdominal fluid NT-proCNP concentrations in control dogs. The dotted line (. . .) represents the determined
abdominal fluid detection limit (0.40 pmol/L). All but 1 admission abdominal fluid NT-proCNP concentrations in dogs with SP were below
the detection limit. Significant dierences are indicated with * (P < 0.05).
NT-proCNP concentrations at admission were significantly lower than concentrations obtained each day
postoperatively (P < 0.0001). Neither abdominal fluid
nor serum NT-proCNP concentrations significantly
changed over time (all P > 0.050) during the postoperative period.
Amino-terminal pro-C-type natriuretic peptide concentrations measured at admission and until CSAD
removal were associated with lower TNCC (P < 0.001),
TS (P < 0.001), and abdominal drain fluid production
(P = 0.029) (Tables 2 and 3).
Discussion
Results of this study show that NT-proCNP can be
detected in canine abdominal fluid using a commercially
available ELISA previously validated on canine serum.4
Unexpectedly, dogs with SP had lower pre-operative
abdominal fluid NT-proCNP concentrations compared
to paired serum NT-proCNP concentrations. In addition, dogs with SP had lower admission abdominal fluid
NT-proCNP concentrations than control dogs. For
dogs with SP, abdominal fluid NT-proCNP concentrations increased during the recovery period compared to
admission, however, NT-proCNP concentrations
remained lower in the abdominal fluid compared to the
serum.
Table 1. Daily abdominal fluid and serum amino-terminal pro-C-type natriuretic peptide concentrations from dogs
with septic peritonitis.
Abdominal Fluid [NT-proCNP] (pmol/L)
Day
0
1
2
3
4
5
No. of Dogs
Median (Range)
No. of Dogs
6
12
12
12
9
2
ND (ND0.48)
3.19 (ND11.21)a
4.75 (0.9910.86)
4.02 (2.066.59)
2.91 (2.048.23)
2.61 (1.383.84)
6
11
10
12
9
2
Median (Range)
5.56
6.86
9.46
9.85
4.71
18.09
(1.9530.57)
(1.4142)
(2.6542)
(2.0431.09)
(2.5528.76)
(12.2423.93)
P Value
0.001
0.008
0.026
0.032
0.11
0.044
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Guieu et al
No. of Dogs
6
12
12
12
9
2
TNCC (9103/lL)
83.7
12.3
12.5
17.6
8.7
89.1
(15.9285)
(3.534.7)
(4141.6)
(2.5100.8)
(1109)
(2.1176)
TS (g/dL)
3.5
2.0
2.1
2.3
2.0
3.1
(2.84.8)
(2.04.3)
(2.04.8)
(2.04.4)
(2.02.6)
(2.73.4)
No. of Dogs
6
12
12
11
5
1
1.83 (0.93.16)
0.99 (0.352.39)
0.74 (0.1632.99)
0.44 (0.0862.26)
0.58 (0.222.1)
0.49
negative association between fluid production and NTproCNP concentration must be interpreted in light of a
lack of significant change post-admission in abdominal
fluid NT-proCNP concentration during the postoperative period. While cause and eect cannot be demonstrated, a dilutional eect cannot be excluded based on
these results.
Throughout the postoperative period, abdominal fluid
NT-proCNP concentrations were higher than at admission. The cause for the increase in abdominal fluid NTproCNP concentration from admission is unknown and
could be related to elapsed time from surgical manipulation, bacterial decontamination, the eects of an
indwelling abdominal drain, or return to normal steady
state. It should be emphasized that abdominal fluid was
collected from a CSAD during the postoperative period.
Previous veterinary studies have shown that abdominal
fluid characteristics including glucose and lactate concentration are altered when collected from a CSAD.19
Eects of the presence of an indwelling drain on NTproCNP concentration will require further investigation.
In this study, none of the dogs included developed
recurrence of SP. As such, no comment can be made
regarding potential changes associated with intestinal
surgical site failure on serum or abdominal fluid
NT-proCNP concentrations. Further investigation is
warranted to permit any conclusion regarding diagnostic utility of abdominal fluid NT-proCNP concentration
for intestinal dehiscence.
Unexpectedly, dogs with pre-operative SP had lower
abdominal fluid NT-proCNP concentrations than
abdominal fluid from control dogs. The control patients
were selected based on a lack of SP, however, underlying disease processes in the control dogs might have
contributed to the higher abdominal fluid NT-proCNP
concentrations observed. While it is known that serum
NT-proCNP concentrations are higher in human
patients with cardiac and liver diseases,20 it is currently
unknown whether these diseases aect the abdominal
fluid or serum NT-proCNP concentrations in dogs. The
eects of these nonseptic conditions on abdominal NTproCNP concentrations warrant further investigation.
This pilot study has several important limitations.
Validation of the ELISA kit for use on canine abdominal fluid was performed on a limited number of samples.
NT-proCNP concentration in abdominal fluid associated with diering etiologies has not been established,
and the ELISA requires further validation on abdominal
eusion of dierent causes before it could be considered
to provide any clinical utility. In this study, abdominal
fluid was centrifuged within an hour of collection and
stored at !80C, as recommended by the ELISA manufacturer for the measurement of NT-proCNP in serum.
Such abdominal fluid processing has also been reported
in previously published studies evaluating cytokine concentrations and acute phase protein concentrations in
the abdominal fluid of human patients for potential
diagnostic/screening purposes.8 Abdominal fluid sample
handling and the eects of freezing and storage on NTproCNP concentrations have not been studied. The
study population also included a small number of dogs
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with SP, with only 6 dogs enrolled at the time of admission, and had limited paired abdominal fluid and serum
samples, particularly by Day 5 as all dogs with SP
recovered uneventfully; this might limit the clinical and
statistical significance of our findings. Finally, because
all dogs recovered uneventfully, this precluded comparison of abdominal fluid and serum NT-proCNP concentration between the dogs that recovered uneventfully
and the dogs that developed surgical site failure.
In conclusion, NT-proCNP was successfully measured in abdominal fluid from control dogs and dogs
with SP during the postoperative period using an
ELISA kit previously validated for canine serum. Lack
of abdominal compartmentalization was identified
based on lower concentrations of NT-proCNP in the
abdominal fluid of dogs with SP compared to paired
serum samples. Further studies including larger populations of dogs are needed to determine the potential
diagnostic utility of abdominal fluid NT-proCNP concentrations for the diagnosis of SP at admission and
during the postoperative period.
Footnotes
a
Acknowledgments
The authors thank Dr. Darren Wood and Michelle
Beaudoin-Kimble for technical assistance as well as
Gabrielle Monteith, and William Sears for their assistance with statistical analyses. Funding for this project
was generously provided by the Ontario Veterinary College Pet Trust Fund.
Conflict of Interest Declaration: Authors disclose no
conflict of interest.
O-label Antimicrobial Declaration: Authors declare
no o-label use of antimicrobials.
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