Beyond Creatinine: Improving Detection and Outcomes of AKI in GDV

Acute kidney injury (AKI) in dogs with gastric dilatation and volvulus (GDV) presents a significant diagnostic challenge. While serum creatinine remains the most commonly used marker of kidney function, it has important limitations, particularly in the early stages of injury. In many cases, creatinine levels rise only after substantial renal damage has already occurred, delaying diagnosis and intervention¹. 

This limitation is especially relevant in GDV patients, where kidney injury often develops rapidly in response to systemic hypoperfusion and inflammatory stress. 

Biomarkers: A Window into Early Renal Injury 

Recent advances have highlighted the role of biomarkers in detecting early kidney injury. Among these, neutrophil gelatinase-associated lipocalin (NGAL) has shown particular promise. In the study, postoperative increases in plasma and urinary NGAL were observed even in the absence of increased serum creatinine². 

This finding suggests that structural kidney injury can occur independently of measurable functional decline. In other words, the kidneys may already be damaged even when traditional markers appear normal. 

NGAL is released from injured renal tubular cells but can also be produced by neutrophils during systemic inflammation. This dual origin means that elevated levels must be interpreted in a clinical context, particularly in conditions like GDV where inflammation is widespread^1,3. 

Timing Matters: Delayed Clinical Presentation 

One of the key challenges in managing AKI is its delayed clinical manifestation. In perioperative settings, signs of AKI may not appear until 2 to 4 days after surgery and, in some cases, up to 14 days later¹. 

This delay creates a critical gap in detection, as patients may appear stable immediately after surgery while underlying renal injury continues to progress. For clinicians, this emphasizes the importance of continued monitoring beyond the immediate postoperative period. 

AKI and Its Strong Link to Mortality 

The association between AKI and mortality is well established across both veterinary and human medicine. In GDV patients, this relationship is particularly pronounced. Dogs diagnosed with AKI were significantly less likely to survive to discharge, reinforcing its role as a major prognostic factor. 

Similar trends have been observed in other surgical populations, including dogs undergoing treatment for septic peritonitis and cardiac procedures¹. These findings suggest that AKI is a common and serious complication in critically ill surgical patients, regardless of the underlying condition. 

Gaps in Current Monitoring Practices 

The study also highlights several limitations in routine clinical monitoring. Not all dogs had postoperative creatinine measurements, and urinalysis was not consistently performed. Additionally, advanced biomarkers such as NGAL, cystatin, and GGT were not routinely available¹. 

These gaps likely resulted in underdiagnosis of early-stage AKI, particularly IRIS grade I cases. Without sensitive detection methods, subtle kidney injury may go unnoticed until it progresses to more severe stages. 

Moving Toward Better Clinical Practice 

Improving outcomes in GDV-associated AKI requires a shift in clinical approach. Rather than relying solely on creatinine, veterinarians should adopt a more comprehensive monitoring strategy that includes: 

• serial renal function assessment  

• close hemodynamic monitoring  

• awareness of delayed AKI onset  

• consideration of emerging biomarkers when available  

Early recognition allows for timely intervention, which may help prevent progression to severe renal failure. 

Conclusion 

AKI in GDV is a dynamic and evolving process that often begins before it becomes clinically apparent. The limitations of traditional diagnostic tools highlight the need for improved detection strategies, including the use of biomarkers and extended monitoring. By adopting a proactive approach, clinicians can better identify at-risk patients and improve survival outcomes in this challenging condition. 

References 

1. Suarez-Rodriguez JI, Lourenço BN, Huang JH, Brainard BM, Schmiedt CW. Acute kidney injury is associated with increased mortality in dogs with gastric dilatation and volvulus. Journal of the American Veterinary Medical Association. 2026 Feb 25;1(aop):1-9. https://avmajournals.avma.org/downloadpdf/view/journals/javma/aop/javma.25.11.0716/javma.25.11.0716.pdf 

2. Lehmann A, Brunner A, Marti E, Francey T, Steinbach S, Peters LM, Adamik KN. Concentrations and kinetics of renal biomarkers in dogs with gastric dilatation-volvulus with and without 24-h intravenous lidocaine. Frontiers in veterinary science. 2023 Feb 10;10:1115783. https://www.frontiersin.org/journals/veterinary-science/articles/10.3389/fvets.2023.1115783/pdf 

3. Monari E, Troìa R, Magna L, Gruarin M, Grisetti C, Fernandez M, Balboni A, Giunti M, Dondi F. Urine neutrophil gelatinase‐associated lipocalin to diagnose and characterize acute kidney injury in dogs. Journal of Veterinary Internal Medicine. 2020 Jan;34(1):176-85. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jvim.15645