Journal of Equine Veterinary Science 32 (2012) 268-273

Journal of Equine Veterinary Science

journal homepage: www.j-evs.com

Original Research

Evaluation of Urinary Variables as Diagnostic Indicators of Acute Kidney

Injury in Egyptian Draft Horses Treated With Phenylbutazone Therapy
Maged R. El-Ashker PhD a , Hussein S. Hussein PhD b, Mahmoud G. El-Sebaei PhD c
a
Department of Internal Medicine and Infectious Diseases, Faculty of Veterinary Medicine, Mansoura University, Mansoura 35516, Egypt
b
Department of Pathology, Faculty of Veterinary Medicine, Mansoura University, Mansoura 35516, Egypt
c
Department of Biochemistry, Faculty of Veterinary Medicine, Mansoura University, Mansoura 35516, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: The present study was undertaken to evaluate the diagnostic significance of various urinary
Received 4 June 2011 variables to detect acute kidney injury (AKI) in Egyptian draft horses treated with phenyl-
Received in revised form butazone (PBZ) therapy. Medical records of 52 draft horses, with a history of musculoskeletal
16 September 2011
painful conditions and treated frequently with various daily doses of injectable PBZ, were
Accepted 27 September 2011
Available online 15 December 2011
reviewed. Of those 52 horses, 38 were enrolled in this study. AKI was tentatively diagnosed
based on thorough history and clinical findings and in conjunction with multiple biochemical
screening tests. Accordingly, diseased horses were categorized into two main groups; the
Keywords:
Urinalysis
first group included 14 horses with prerenal azotemia, whereas the second group included
Horses 24 horses with renal azotemia. Biochemically, urinary malondialdehyde, urinary gamma-
Phenylbutazone glutamyl transferase/creatinine (Cr) ratio, urinary protein/Cr ratio, urinary glucose, urinary
Kidney Injury sodium, fractional excretion of sodium, and renal failure index were significantly higher
(P < .05) in horses of group 2 than those of group 1. However, values of urinary Cr, urine/
plasma Cr ratio, urinary urea, and urine/plasma urea ratio were significantly decreased
(P <.05) in horses of group 2. Analysis of receiver operating characteristic curve showed high
sensitivity and specificity of most tested urinary variables as well as their derived indices for
detection of AKI in diseased horses. Our findings suggest that the examined urinary variables
as well as their ratios are helpful in documenting AKI associated with PBZ nephrotoxicity in
Egyptian draft horses; however, their interpretation should be done in the light of the specific
clinical setting and in conjunction with a thorough clinical and physical examination.
Ó 2012 Elsevier Inc. All rights reserved.

1. Introduction use arachidonic acid to generate the same product, prosta-

Most nonsteroidal anti-inflammatory drugs (NSAIDs)
are inhibitors of one or more of the cyclooxygenase enzymes
(COX). In general, there are two major COX isoenzymes:
COX-1 is expressed constitutively in most tissues, whereas
COX-2 is induced in inflammation. Both COX-1 and COX-2
The authors of this author have no financial or personal relationship
with other people or organizations that could appropriately influence or
bias the content of the article.
Corresponding author at: Maged Rezk El-Ashker, PhD, Faculty of
Veterinary Medicine, Mansoura University Internal Medicine and Infec-
tious and Fish Diseases, 60 El-Gomhoria, Mansoura University, Mansoura,
Dakahlia 35516, Egypt.
E-mail address: maged_elashker@yahoo.com (M.R. El-Ashker).
glandin H2. Several enzymes further modify this product to
generate bioactive lipids (prostanoids) such as prostacyclin,
thromboxane A2, and prostaglandins (PGs) D2, E2, and F2.
These prostanoids influence immune system, cardiovas-
cular system, gastrointestinal system, renovascular system,
pulmonary system, central nervous system, and reproduc-
tive function [1]. Of note, it is now recognized that COX-2 is
expressed in normal endothelial cells in response to share
stress and that inhibition of COX-2 is associated with
suppression of prostacyclin synthesis [2]. Phenylbutazone
(PBZ) is a nonselective COX inhibitor, meaning that it inhi-
bits both COX-1 and COX-2 at therapeutic concentrations
achieved in patients [3]. Although PBZ is one of the most
popular and economical agents used in horses and its

0737-0806/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jevs.2011.09.072
 M.R. El-Ashker et al. / Journal of Equine Veterinary Science 32 (2012) 268-273
clinical efficacy appears to compare favorably with other
NSAIDs [4], its clearance from acidic (inflamed) tissues is
slower than plasma elimination, indicating that its thera-
peutic effects may persist in tissues after plasma levels have
decreased to negligible levels [5]. Despite its beneficial
effects for many disease conditions, its overuse and misuse
can result in deleterious findings and a high incidence of
side effects [6]. In horses, gastrointestinal ulcerations, acute
renal failure (ARF), and renal papillary necrosis are the most
common clinical syndromes associated with PBZ toxicity.
Renal papillary necrosis is generally irreversible, but enough
renal function may be preserved to allow compensation
once the COX inhibitor is discontinued [3]. Although several
urinary biochemical tests have been reported as useful in
detecting early kidney injury in horses [7,8], they have not
been studied in horses treated frequently with PBZ therapy.
Therefore, the present study was carried out to evaluate the
diagnostic value of various urinary analytes as well as their
derived ratios to detect acute kidney injury (AKI) associated
with PBZ toxicity in Egyptian draft horses.
2. Materials and Methods
2.1. Study Design and Data Collection
The clinical study was performed at The Veterinary
Teaching Hospital, Faculty of Veterinary Medicine,
Mansoura University, Mansoura, Egypt, and also included
cases admitted to our private clinic between October 2006
and March 2009. Medical records of 52 Egyptian horses
(36 females; 16 males), with orthopedic diseases, were
reviewed, of which, 38 adult horses (26 females; 12 males)
were enrolled in this study. The inclusion criteria included
horses (aged 3-4 years) with a history of painful musculo-
skeletal conditions and were treated solely with various
daily doses of injectable PBZ as well as those who did not
receive fluid therapy before sampling. However, foals aged
<2 years and adult horses that received anti-inflammatory
medications other than PBZ were excluded from the study
(n ¼ 14). Complete medical record evaluation for each
horse was performed based on thorough historical findings
and clinical signs. On admission, poor appetite, ventral
edema, lethargy and reluctance to walk, hair-loss and dry
skin, intermittent colic, and occasionally, diarrhea with
occult blood were considered as the chief complaints. AKI
was tentatively diagnosed in horses based on thorough
history and clinical setting and in conjunction with
multiple biochemical screening tests, including plasma and
urine creatinine (Cr) and urea levels as well as urine specific
gravity (U- specific gravity). Accordingly, diseased horses
were categorized into two main groups; the first group
included 14 horses with prerenal azotemia, whereas the
second group included 24 horses with renal azotemia. For
comparison, 15 apparently healthy Egyptian draft horses of
both sexes (10 females and five males) were randomly
selected and considered as a control group.
2.2. Clinical Examinations
Thorough physical examinations of diseased as well as
clinically healthy horses were carried out according to
Radostits et al. [9].
269
2.3. Sampling and Measurements
2.3.1. Urine Samples
Urine samples were collected from clinically healthy
as well as diseased horses by urethral catheterization
without sedation. Each urine sample was divided into two
aliquots; one aliquot was used for physical and microscopic
examination as well as determination of U-specific gravity,
whereas the other aliquot was centrifuged at 1,500  g
for 10 minutes at 4 C, and then the supernatant was stored
at 20 C for later biochemical analyses, which was per-
formed within a 1-week period. U-specific gravity was
determined using calibrated refractometer (Atago Hand
Refractometer; Atago, Japan), whereas the biochemical
analyses of urine samples included estimation of urinary
malondialdehyde (U-MDA), urinary gamma-glutamyl
transferase/creatinine ratio (U-GGT/Cr), urinary protein
(U-protein), urinary glucose (U-glucose), U-Cr, urinary urea
(U-urea), and urinary sodium (U-sodium) by using stan-
dard laboratory techniques. U-MDA, U-GGT, U-glucose,
U-Cr, U-urea, U-sodium, and U-protein concentrations
were spectrophotometrically measured by enzymatic assay
using commercial test kits supplied by Bio Diagnostic (Bio
Diagnostic, Cairo, Egypt). Urinary MDA was determined by
measurement of thiobarbituric acid reactive substances
(TBARS). We selected the thiobarbituric acid test in this
study because this method is popular and clinically used to
measure MDA [10]. Briefly, aliquot of 500 mL of urine or
MDA standards was mixed with 500 mL of thiobarbituric
acid (1%, pH 1.5) and boiled for 30 minutes. After cooling at
room temperature, its absorbance was measured at 540 nm
with a microplate reader. We also measured the absor-
bance of reactive solution of every urine sample and vehicle
of thiobarbituric acid as the blank of TBARS. The final
concentration of MDA was expressed as the difference
between TBARS and blank to diminish the interference of
urine chromogens. Urinary enzyme activities as well as
U-protein concentrations were given in relation to U-Cr
concentrations, that is, U-GGT/Cr (International Unit
[IU]/mmol), whereas urinary protein/creatinine ratio
(U-Prot/Cr) was calculated by multiplying it by 8.84 to
convert Cr from mmol/L to mg/L. U/P Cr ratio, U/P urea
ratio, fractional excretion of sodium (FENa), and renal
failure index (RFI) were also calculated. RFI was calculated
as U-sodium concentration divided by the U/P Cr
ratio, whereas FENa(%) was calculated according to the
equation (plasma Cr  urine sodium) / (plasma sodium 
urine Cr) [11].
2.3.2. Blood Samples
Ten milliliters of blood sample was collected from all
examined horses via jugular vein puncture into a tube
containing 5-mg ethylenediaminetetraacetic acid. After
collection, the blood sample was divided into two aliquots;
one was used for hematologic evaluation, whereas the
other was immediately centrifuged at 2,500  g for
5 minutes for separation of blood plasma, which was kept
frozen at 20 C for further biochemical analyses of Cr and
urea. The selected biochemical variables were spectro-
photometrically measured by enzymatic assay using
commercial test kits supplied by Bio Diagnostic (Bio Diag-
nostic, Cairo, Egypt).
270 M.R. El-Ashker et al. / Journal of Equine Veterinary Science 32 (2012) 268-273

Table 1
Clinical findings of acute kidney injury associated with phenylbutazone toxicity in Egyptian draft horses (n ¼ 38)

Variables Group 1 Group 2

(n ¼ 14) (n ¼ 24)

Appetite Inappetance (n ¼ 9), anorexia (n ¼ 5) Inappetance (n ¼ 2), anorexia (n ¼ 22)

Visible mucous membrane color Rosy red (n ¼ 5), pale (n ¼ 5), icteric (n ¼ 4) Pale (n ¼ 21), icteric (n ¼ 3)
Severity of Abdominal pain Mild intermittent (n ¼ 14) Mild intermittent (n ¼ 17), moderate (n ¼ 7)
Hair loss and dry skin (n ¼ 1) (n ¼ 16)
Abdominal auscultation Hypomotility (n ¼ 13), stasis (n ¼ 1) Stasis (n ¼ 24)
Lethargy and reluctance to walk (n ¼ 14) (n ¼ 24)
Occult blood in feces Present (n ¼ 1) Present (n ¼ 17)
Ventral edema (abdomen and hind limbs) (n ¼ 12) (n ¼ 24)
Weight loss (n ¼ 11) (n ¼ 24)
Depression (n ¼ 14) (n ¼ 24)
Gingivitis Absent (n ¼ 13)
Oral ulcerative lesions (n ¼ 2) (n ¼ 16)
Heart rate (Beat/min) 58.6  7.26 86.6  3.84
Respiratory rate (Cycle/min) 15.6  2.07 23.0  1.00
Rectal temperature 38.4  0.54 39.6  0.54
% of mortality 0.0 70.8

2.4. Postmortem and Histopathologic Examinations 3. Results

Necropsy was performed on expired horses, and speci-
mens from kidney were fixed in 10% neutral buffered
formalin. Sections of 5 mm in thickness were prepared and
stained with hematoxylin and eosin and were examined
microscopically according to the method described by
Bancroff et al. [12].
2.5. Medical Management
On admission, all diseased horses were initially managed
by discontinuation of PBZ administration and dietary
modification to laxative food (bran mashes). For each
case, the following medications were administered: sucral-
fate (Gastrofait; Egyptian International Pharmaceutical
Company, Egypt) at 20 mg/kg orally, ranitidine (Ranitidine;
Medical Union Pharmaceutical Company, Egypt) at 1.5 mg/kg
intravenous (IV) twice daily and also orally at 6.6 mg/kg
every 8 hours, metronidazole (Flagyl; Alexandria Company
for Chemical and Pharmaceutical, Egypt) at 15 mg/kg orally
twice daily, Al/Mg hydroxide (Mucogel; Egyptian Pharma-
ceutical International Company, Egypt) at 0.5 mg/kg orally
every 6 hours, and xylazine (Xylaject; Egyptian company for
chemical and pharmaceutical) at 1.0 mg/kg IV when needed
to control abdominal pain. IV fluid therapy was also
administered according to the degree of dehydration.
2.6. Statistical Analysis
Results of clinical and laboratory variables in diseased
horses are summarized in Tables 1e3. Clinically, heart rate,
respiratory rate, and rectal temperature were significantly
higher (P < .05) in horses of group 2 than in those of group
1 and control group (32.2  1.42 beats/min, 12.2 
0.8 cycles/min, 37.40  0.17 C, respectively). Biochemically,
U-MDA, U-GGT/Cr ratio, U-Prot/Cr ratio, U-glucose,
U-sodium, FENa, and RFI were significantly higher (P < .05)
in horses of group 2 than in those of group 1; however,
values of U-Cr, U/P Cr ratio, U-urea, and U/P urea ratio were
significantly decreased in horses of group 2 (P < 0.05).
U-specific gravity was significantly higher (P < .05) in
horses of group 1, whereas its values were significantly
decreased (P < .05) in horses of group 2 (P < .05). Micro-
scopic examination of urine sediments of horses in group 1
revealed normal findings (12 of 14) and occasional hyaline
casts (two of 14), whereas transitional epithelial cells and
granular and muddy brown casts were evident in all cases
of group 2. Red blood cells (>100 cells high power field)
were also observed in horses of group 2 (n ¼ 14). packed
cell volume (PCV)% was higher in horses of group 1 than in
those of group 2 compared with the control group (P < .05).
Total erythrocytic counts were significantly lower in horses
Table 2
Mean values  SD of various hematologic changes in clinically healthy
horses and those with acute kidney injury associated with phenylbuta-
zone toxicity in Egyptian draft horses (n ¼ 38)

Data were statistically analyzed using statistical soft- Variables Control Group (1) Group (2)
ware program (GraphPad prism version 5.0, Graph Pad (n ¼ 15) (n ¼ 14) (n ¼ 24)
software Inc., San Diego). Mean and standard deviation for
Hematocrit (PCV%) 33.0  3.60a 46.8  6.70b 38.40  4.50a
each variable were estimated. Differences between groups Total erythrocytic 9.80  1.73a 5.71  0.70b 4.53  0.78b
were compared by 1-way analysis of variance using Duncan count  106/mL
test. Receiver operating characteristic curve (ROC) was used Total leucocytic 8.82  1.57a 10.36  1.63a 5.90  1.12b
to assess the sensitivity and specificity of selected urinary count  103/mL
Neutrophils  103/mL 4.59  1.07a 5.55  0.53a 2.86  0.59b
variables as well as their derived indices to detect AKI
Band cells/ mL 0.0a 0.0a 265.0  72.0b
in diseased horses as a result of PBZ nephrotoxicity. Lymphocytes  103/mL 3.97  1.62a 4.82  1.26a, b
2.70  0.48b
Results were considered statistically significant at P < .05. Eosinophils/mL 41.0  37.8a 83.0  49a 40.0  32.0a
Spearman correlation coefficient was also applied to Monocytes/mL 77.0  37.0a 125  97a 51.00  27.0a
examine the correlation between U-Prot/Cr ratio and other a,b
Variables with different superscript in the same raw are signifi-
urinary biochemical variables. cantly different at P < .05.
 M.R. El-Ashker et al. / Journal of Equine Veterinary Science 32 (2012) 268-273 271

Table 3
Mean values  SD of urinary variables and their ratios in clinically healthy
A Area under the curve: 1.0
Confidence Interval: 1.0-1.0
horses (n ¼ 15) and those with acute kidney injury associated with P < 0.01
phenylbutazone toxicity in Egyptian draft horses (n ¼ 38)
150 Cuttoff: > 2.35
Variables Control Group 1 Group 2 Likelihood ratio: 3.0
Sensitivity: 100 %
(n ¼ 15) (n ¼ 14) (n ¼ 24)
specificity: 66.70 %

S e n s i t i vi t y %
U-MDA (mmol/L) 2.0  0.3a 2.2  0.3a 9.45  5.34b 100
U-GGT/Cr (IU/mmol) 1.5  0.3a 1.46  0.41a 6.94  4.72b
U-specific gravity 1.027  0.002a 1.036  0.001b 1.011  0.002c
U-Prot/Cr 0.33  0.2a 0.41  0.13a 8.64  3.5b
U-Glucose (mmol/L) ND 0.07  0.1a 10.0  9.6b
U-Cr (mmol/L)  103 11.845a 11.315a 6.85b 50
U/P Cr ratio 129  31a 114  38a 17.9  4.0b
U-Urea (mmol/L) 132  5.0a 118  8.0a 54  30b
U/P urea ratio 33.8  5.1a 15.3  4.25b 6.38  7.31b
U-sodium (mmol/L) 9.4  1.1a 12.3  1.5a 47.2  19b 0
FENa (%) 0.03  0.008a 0.08  0.01a 1.7  1.1b 0 20 40 60 80
RFI 0.07  0.008a 0.10  0.0a 2.63  1.34b
Specificity%
U-MDA, urinary malondialdehyde; U-GGT/Cr, urinary gamma glutamyl
transferase/creatinine ratio; U-specific gravity, urine specific gravity;
U-Prot/Cr, urinary protein/creatinine ratio; ND, not detectable; U-Cr,
B Area under the curve: 0.952
Confidence Interval: 0.817-1.08
urinary creatinine; U/P Cr ratio, urine/plasma creatinine ratio; U/P urea
P < 0.03
ratio, urina/plasma urea ratio; FENa fractional excretion of sodium; RFI,
150 Cuttoff: > 1.75
renal failure index.
a,b
Variables with different superscript in the same raw are signifi-
Likelihood ratio: 2.50
cantly different at P < .05. Sensitivity: 85.7 %
specificity: 66.70 %
S e ns i ti vi ty %

of groups 1 and 2 than in those of control group (P < .05).
Leucopenia, neutropenia, and lymphopenia were also
observed in horses of group 2 compared with those of
group 1 (Table 2). Plasma Cr (mmol/L) and urea (mmol/L)
levels were significantly higher (P < 0.05) in horses of
group 2 (403.9  73.3; 2.68  1.73) than in those of group 1
(111.3  55.6; 1.34  0.4) and the control group (95.47 
20.3; 0.66  0.09). Analysis of ROC curve showed high
sensitivity and specificity of most tested urinary variables
as well as their derived indices for detection of AKI in
diseased horses (Table 4, Fig. 1A and B). Of the tested
variables, U-Prot/Cr ratio, U-Cr, U/P Cr, U-urea, U/P urea
ratio, U-sodium, FENa, and RFI had the highest sensitivity
(100%) and specificity (100%); however, U-specific gravity,
U-MDA, U-GGT/Cr ratio, and U-glucose showed high
sensitivity and much less specificity. A positive correlation
was found between U-Prot/Cr ratio and U-GGT activities
(r ¼ 0.778; P < .01), U-MDA (r ¼ 0.643, P < .01), U-sodium
(r ¼ 0.780, P < .01), FENa (r ¼ 0.781, P < .01), U-glucose (r ¼
0.793, P < .01), and RFI (r ¼ 0.799, P < .01); however,
100
50
0
0 20 40 60 80
Specificity%
Fig. 1. (A) Analysis of receiver operating characteristic curve of urinary
malondialdehyde in horses with acute kidney injury associated with
phenylbutazone nephrotoxicity in Egyptian draft horses. (B) Analysis of
receiver operating characteristic curve of urinary gamma-glutamyl trans-
ferase/creatinine ratio in horses with acute kidney injury associated with
phenylbutazone nephrotoxicity in Egyptian draft horses.
negative correlation was found between this ratio and
U-specific gravity (r ¼ 0.764, P < .001), U-Cr (r ¼ 0.774,
P < .01), U-urea (r ¼ 0.820, P < .01), U/P urea (r ¼ 0.856,
P < .01), and U/P Cr ratios (r ¼ 0.817, P < .01). Of the 38

Table 4
Analysis of receiver operating characteristic curve of various urinary analytes and their derived indices for detection of acute kidney injury associated with
phenylbutazone toxicity in Egyptian draft horses (n ¼ 38).

Variables AUC Cutoff point P value 95% CI Sensitivity % Specificity % Likelihood ratio

U-MDA (mmol/L) 1.0 >2.35 <0.01 1.0e1.0 100 66.7 3.0

U-GGT/Cr (IU/mmol) 0.95 >1.75 <0.03 0.82e1.1 85.7 66.7 2.5
U-Specific gravity 1.0 <1.033 <0.001 1.0e1.0 100 85.7 7.0
U-Prot/Cr 1.0 >1.90 <0.016 1.0e1.0 100 100 3.0
U-Glucose (mmol/L) 0.93 >0.015 <0.04 0.76e1.1 85.7 66.7 2.5
U-Cr (mmol/L) x103 1.0 <9.60 <0.02 1.0e1.0 100 100 3.0
U/P creatinine 1.0 <46.8 <0.016 1.0e1.0 100 100 3.0
U-Urea (mmol/L) 1.0 <101 <0.016 1.0e1.0 100 100 3.0
U/P urea 1.0 <18.8 <0.016 1.0e1.0 100 100 3.0
U-Sodium (mmol/L) 1.0 >17.0 <0.016 1.0e1.0 100 100 3.0
FENa (%) 1.0 >0.13 <0.016 1.0e1.0 100 100 5.0
RFI 1.0 >0.15 <0.016 1.0e1.0 100 100 2.5

AUC, area under the curve; 95% CI, 95% confidence interval; U-MDA, urinary malondialdehyde; U-GGT/Cr, urinary gamma-glutamyl transferase/creatinine
ratio; U-prot/Cr, urinary protein/creatinine ratio; U-Cr urinary creatinine; U/P Cr ratio, urine/plasma creatinine ratio; U/P urea ratio, urinary/plasma urea
ratio; FENa, fractional excretion of sodium; RFI, renal failure index.
272 M.R. El-Ashker et al. / Journal of Equine Veterinary Science 32 (2012) 268-273
Fig. 2. The renal cortex showed congested glomerular tufts (arrowhead) and
intertubular capillaries (arrow).
diseased horses, 21 survived, whereas the remaining 17
horses did not respond to the medical therapy and died
after exhibiting severe unrelenting abdominal pain. Post-
mortem examination of the 17 expired horses showed
hemorrhagic and ulcerative inflammation of the entire
colon and cecum with varying degrees in all cases.
Congestion with presence of ulcerative lesions in the
glandular portion of the stomach was also recorded. The
renal cortex showed congested glomerular tufts (arrow-
head) and intertubular capillaries (arrow) (Fig. 2). Hemor-
rhage adjacent to renal medulla was seen (Fig. 3).
Degenerated renal papillary epithelium with small and
dark nuclei was seen (Fig. 4).
4. Discussion
Our interest in diagnosis of AKI in Egyptian horses
treated with various daily doses of PBZ was stimulated
through observations on a number of clinical cases that
indicated that it might be a more common disease than it
was generally realized. In the present study, diagnosis of
AKI was established on the basis of thorough case history,
clinical findings, and results of multiple plasma and urinary
laboratory analyses. Based on the data retrieved from the
medical records, it has been found that the only therapeutic
medication given to all horses was PBZ (1-2 g for 8-12 days
in horses of group 1, and 4-6 g for 4-7 days in horses of
group 2). The extreme range of dosages as well as the
extreme variation in duration of maintenance dosages used
Fig. 3. Hemorrhage adjacent to renal medulla is seen (arrow).
Fig. 4. Degenerated renal papillary epithelium with small and dark nuclei is
seen (arrow).
suggests that the dosage of PBZ was not itself sufficient to
produce AKI in diseased horses. Dehydration or hemo-
concentration with inadequate renal perfusion, endotox-
emia, and physiological stress associated with draft
working apparently played a significant role. Our finding
was in accordance with another previous study [13].
Interestingly, it was found that horses of group 2 had
normal PCV% compared with that of group 1 despite
exhibiting clinical manifestations of dehydration (dry
mucous membranes, prolonged skin tent test, and capillary
refill time); this might be in part due to presence of anemia
that was masked by dehydration. It has been hypothesized
that PBZ inhibition of PG E2 production decreases gastro-
intestinal mucosal blood flow, resulting in hypoxic or
ischemic mucosal damage with subsequent blood loss from
ulcerated mucosa [14]. The development of nephropathy in
horses of group 2 is thought to be the result of reduction of
blood supply in the vasa recta, leading to ischemia of the
renal papilla because of decrease in production of vaso-
dilatory prostaglandins PGs (E2 and I2). Reduced water
intake and hypovolemia lead to reduced urine output and
probably reduced urine flow in the loops of Henle such that
appropriate conditions can no longer be maintained in the
papillary interstitium. These two events act synergistically,
resulting in necrosis of the papillary interstitium and loss of
the overlying epithelium [13,15]. Experimental NSAID
administration to anesthetized animals has revealed
medullary ischemia as a result of shunting of blood flow
from the renal medulla to the cortex [16].
Although the clinical findings of AKI in diseased horses
were nonspecific (Table 1), results of plasma and urinary
biochemical variables as well as histopathologic findings
confirmed our suspicion of renal failure. The classic urinary
and plasma biochemical findings in horses of group 1 might
suggest prerenal azotemia, which reflect the influence of
noradrenalin, angiotensin II, vasopressin, and low urinary
flow rate on salt and water reabsorption from urine [17].
Definitive diagnosis of prerenal azotemia rests on rapid
recovery after restoration of renal perfusion. On the
contrary, the urinary and plasma biochemical findings of
horses in group 2 might suggest renal azotemia (Table 3).
These biochemical features reflect the impaired ability of
injured tubule epithelium to respond to noradrenalin,
angiotensin II, aldosterone, and vasopressin. As previously
 M.R. El-Ashker et al. / Journal of Equine Veterinary Science 32 (2012) 268-273
mentioned, renal azotemia differs from prerenal azotemia
in that a significant number of renal parenchymal cells have
been injured, and ARF does not resolve immediately after
restoration of renal blood flow [17].
Analysis of the ROC curve showed high sensitivity and
specificity of the selected urine variables and their derived
indices to detect AKI in Egyptian draft horses as a result of
PBZ nephrotoxicity. The cutoff point of these variables
might suggest their diagnostic usefulness for detection of
PBZ nephrotoxicity in diseased horses. These diagnostic
methods might help in the early identification of renal
disease in horses. In addition, practitioners might be able to
offer more informed prognoses after a more complete
evaluation of renal function. The increased U-MDA levels in
diseased horses might indicate renal oxidative injury. This
finding was in agreement with another report that stated
that U-MDA is a useful marker for detection of cisplatin-
induced renal damage in rats [18]. Another report also
confirmed that U-GGT is a sensitive indicator of impaired
renal function in dogs clinically infected with leishmaniasis
[19]. However, views on what constitutes a clinically
significant increase of U-GGT/Cr ratio are varying. Our
result was in harmony with that reported by Arosalo et al.
[7] who mentioned that values of U-GGT/Cr in horses with
colic was 5.87  10.61 (IU/mmol) compared with control
stallions (1.14  0.53 IU/mmol), suggesting an early kidney
injury. Similarly, in a previous study, values >2.83 IU/mmol
were significant [20]; however, another researcher
considered a U-GGT/Cr ratio more significant when it
exceeds 11.3 IU/mmol for an adult horse [21]. In the present
study, the activity of this enzyme was clearly less than that.
Thus, due to lack of studies, it is difficult to determine the
threshold values for urine enzymes, which, in turn, makes
it difficult to differentiate between renal insufficiency that
needs to be addressed or transient kidney damage that
does not affect the prognosis of the horse.
U-Prot/Cr ratio has been discussed in horses with colic
[7] and has been extensively evaluated in dogs with many
disease processes [19] and shown to be helpful in deter-
mining prognosis of chronic kidney diseases in several
recent studies. However, it has not been evaluated in horses
with PBZ nephropathy. The correlation between U-Prot/Cr
ratio and other urinary analytes might suggest its impor-
tance for detection of AKI associated with PBZ toxicity in
Egyptian draft horses. As previously mentioned, in horses
with colic [7] and in ponies with gentamicin nephrotoxicity
[22], the increased levels of U-glucose observed in horses of
group 2 might be attributed to damage of the proximal
tubulur cells and reduction in their ability to absorb glucose
with subsequent leakage into urine.
5. Conclusion
Our findings suggest that the examined urinary variables
as well as their derived ratios are helpful in documenting
AKI associated with PBZ nephrotoxicity in Egyptian draft
horses; however, their interpretation should be done in the
light of the specific clinical setting and in conjunction with
a thorough history and physical examination.
273
Acknowledgment
The authors thank Prof. Dr. Mohamed Ahmed Youssef,
Professor of Internal Medicine, Faculty of Veterinary
Medicine, Mansoura University, for his great assistance in
revising the manuscript.
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