Accuracy of GFR Estimating Equations in Patients with Discordances between Creatinine and Cystatin C-Based Estimations

SIGNIFICANCE STATEMENT

Large discordances between eGFR on the basis of creatinine (eGFR cr ) or cystatin C (eGFR cys ) are common in clinical practice. However, which GFR estimating equation (eGFR cr , eGFR cys , or eGFR cr-cys ) is most accurate in these settings is not known. In this real-world study of 9404 concurrent measurements of creatinine, cystatin C, and iohexol clearance, all three equations performed similarly when eGFR cr and eGFR cys were similar (45% of cases). However, with large discordances (55% of cases), eGFR cr-cys was much more accurate than either alone. These findings were consistent among individuals with cardiovascular disease, heart failure, diabetes mellitus, liver disease, and cancer who have been underrepresented in research cohorts. Thus, when eGFR cr and eGFR cys are largely discordant in clinical practice, eGFR cr-cys is more accurate than eGFR cr or eGFR cys .

BACKGROUND

Cystatin C is recommended as a confirmatory test to eGFR when more precise estimates are needed for clinical decision making. Although eGFR on the basis of both creatinine and cystatin (eGFR cr-cys ) is the most accurate estimate in research studies, it is uncertain whether this is true in real-world settings, particularly when there are large discordances between eGFR based on creatinine (eGFR cr ) and that based on cystatin C (eGFR cys ).

METHODS

We included 6185 adults referred for measured GFR (mGFR) using plasma clearance of iohexol in Stockholm, Sweden, who had 9404 concurrent measurements of creatinine, cystatin C, and iohexol clearance. The performance of eGFR cr , eGFR cys , and eGFR cr-cys was assessed against mGFR with median bias, P30 , and correct classification of GFR categories. We stratified analyses within three categories: eGFR cys at least 20% lower than eGFR cr (eGFR cys eGFR cr ).

RESULTS

eGFR cr and eGFR cys were similar in 4226 (45%) samples, and among these samples all three estimating equations performed similarly. By contrast, eGFR cr-cys was much more accurate in cases of discordance. For example, when eGFR cys eGFR cr (8% of samples), the median biases were -4.5, 8.4, and 1.4 ml/min per 1.73m 2 . The findings were consistent among individuals with cardiovascular disease, heart failure, diabetes mellitus, liver disease, and cancer.

CONCLUSIONS

When eGFR cr and eGFR cys are highly discordant in clinical practice, eGFR cr-cys is more accurate than either eGFR cr or eGFR cys .

Investigating the biodegradability of iodinated X-ray contrast media in simultaneous nitrification and denitrification system

The present study investigated the biodegradation of three iodinated X-ray contrast media (ICM), namely, iopamidol, iohexol, and iopromide, in simultaneous nitrification-denitrification (SND) system maintained in a sequencing batch reactor (SBR). The results showed that variable aeration patterns (anoxic-aerobic-anoxic) and micro-aerobic condition were most effective in the biotransformation of ICM while achieving organic carbon and nitrogen removal. The highest removal efficiencies of iopamidol, iohexol, and iopromide were 48.24%, 47.75%, and 57.46%, respectively, in micro-aerobic condition. Iopamidol was highly resistant to biodegradation and possessed the lowest K_bio value, followed by iohexol and iopromide, regardless of operating conditions. The removal of iopamidol and iopromide was affected by the inhibition of nitrifiers. The transformation products after hydroxylation, dehydrogenation, and deiodination of ICM were detected in the treated effluent. Due to the addition of ICM, the abundance of denitrifier genera Rhodobacter and Unclassified Comamonadaceae increased, and the abundance of class TM7-3 decreased. The presence of ICM affected the microbial dynamics, and the diversity of microbes in SND resulted in improving the biodegradability of the compounds.

Fate and removal of iodinated X-ray contrast media in membrane bioreactor: Microbial dynamics and effects of different operational parameters

Iodinated X-ray contrast media (ICM) are mainly used in medical sector, and their presence in environmental waters is a cause of concern as they are capable of forming highly toxic iodinated disinfection byproducts. In the present study, the removal mechanisms of the three ICM- iohexol, iopromide, and iopamidol were elucidated in a lab-scale aerobic membrane bioreactor (MBR). At steady-state operation (solids retention time (SRT)- 70 days, organic loading rate (OLR)- 0.80 KgCOD/m³-day, nitrogen loading rate (NLR)- 0.08 KgNH₄-N/m³-day, hydraulic retention time (HRT)- 12 h), the average removal of iohexol and iopromide was found to be 34.9 and 45.2 %, respectively, whereas iopamidol proved to be highly recalcitrant in aerobic conditions of the MBR (removal <10 % in all phases of the MBR operation). Further, through batch kinetic studies and mass balance analysis, it was observed that ICM were primarily biotransformed in the MBR system and biosorption (K_d < 10 L/Kg) was negligible. The biodegradation rate coefficient values (K_biol) of the ICM were found to be <0.65 L/g-d which indicate that biotransformation rate of ICM was slow. Increased OLR (1.60 KgCOD/m³-day) and reduced SRT (20 days) were found to negatively affect the removal of the ICM. Further, the removal of ICM was found to depend on its initial concentration, and the increment in the ammonium loading (0.16 KgNH₄-N/m³-day) did not favor its removal. The dosing of ICM altered the microbial dynamics of the mixed liquor and reduced the microbial diversity and richness. Bdellovibrio, Zoogloea, and bacteria belonging to TM7-3 class, Cryomorphaceae and Hyphomonadaceae families may contribute in ICM biotransformation.

Novel Metabolites to Improve Glomerular Filtration Rate Estimation

INTRODUCTION

The glomerular filtration rate (GFR) is crucial for chronic kidney disease (CKD) diagnosis and therapy. Various studies have sought to recognize ideal endogenous markers to improve the estimated GFR for clinical practice. To screen out potential novel metabolites related to GFR (mGFR) measurement in CKD patients from the Chinese population, we identified more biomarkers for improving GFR estimation.

METHODS

Fifty-three CKD participants were recruited from the Third Affiliated Hospital of Sun Yat-sen University in 2020. For each participant, mGFR was evaluated by utilizing the plasma clearance of iohexol and collecting serum samples for untargeted metabolomics analyses by ultrahigh-performance liquid chromatography-tandem mass spectroscopy. All participants were divided into four groups according to mGFR. The metabolite peak area data were uploaded to MetaboAnalyst 5.0 for one-way analysis of variance, principal component analysis, and partial least squares-discriminant analysis and confirmed the metabolites whose levels increased or decreased with mGFR and variable importance in projection (VIP) values >1. Metabolites were ranked by correlation with the original values of mGFR, and metabolites with a correlation coefficient >0.8 and VIP >2 were identified.

RESULTS

We screened out 198 metabolites that increased or decreased with mGFR decline. After ranking by correlation with mGFR, the top 50 metabolites were confirmed. Further studies confirmed the 10 most highly correlated metabolites.

CONCLUSION

We screened out the metabolites that increased or decreased with mGFR decline in CKD patients from the Chinese population, and 10 of them were highly correlated. They are potential novel metabolites to improve GFR estimation.

Deep learning reconstruction allows for usage of contrast agent of lower concentration for coronary CTA than filtered back projection and hybrid iterative reconstruction

BACKGROUND

The demand for homogeneous and higher vascular contrast enhancement is critical to provide an appropriate interpretation of abnormal vascular findings in coronary computed tomography angiography (CTA).

PURPOSE

To evaluate the effect of various contrast media concentrations (Iohexol-370, Iohexol-300, Iohexol-240) and image reconstructions (filtered back projection [FBP], hybrid iterative reconstruction [IR], and deep learning reconstruction [DLR]) on coronary CTA.

MATERIAL AND METHODS

A total of 63 patients referred for coronary CTA between July and October 2021 were enrolled in this prospective study, and they randomly received one of three contrast media. CTA images were reconstructed with FBP, hybrid IR, and DLR. The CT attenuation, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated for all three images. The images were subjectively evaluated by two radiologists in terms of overall image quality, artifacts, image noise, and vessel wall delineation on a 5-point Likert scale.

RESULTS

The application of DLR resulted in significantly lower image noise; higher CT attenuation, SNR, and CNR; and better subjective analysis among the three different concentrations of contrast media groups (P < 0.001). There was no significant difference in the CT attenuation of the left ventricle (P = 0.089) and coronary arteries (P = 0.072) between hybrid IR at Iohexol-300 and DLR at Iohexol-240. Furthermore, application of DLR to the Iohexol-240 significantly improved SNR and CNR; it achieved higher subjective scores compared with hybrid IR at Iohexol-300 (P < 0.001).

CONCLUSION

We suggest that using DLR with Iohexol-240 contrast media is preferable to hybrid IR with Iohexol-300 contrast media in coronary CTA.

Occurrence and risk of iodinated X-ray contrast media in source and tap water from Jiangsu province, China

Microcontaminants in the water environment have received increasing attention due to their adverse effects on human health and wildlife. However, iodinated X-ray contrast media (ICM), a type of microcontaminants, have not yet been systematically documented in source and tap water. This study investigated ICM in water samples via a sampling activity from 25 drinking water sources and their corresponding 30 household taps in south-central Jiangsu Province, China. The total concentrations of ICM ranged from 14.2 to 138.5 ng/L in source water and 3.7 to 101.3 ng/L in tap water, respectively. The calculated average water treatment efficiency to remove ICM is 38.3% with large variation under different processes (ranging from 7.3% to 75.7%), which implied that ICM could not be effectively removed using current treatment technologies. By integrating other ICM into the predominant compound iohexol with relative potency factors, the health risks of total ICM through water consumption were assessed using the Monte Carlo simulation. The results concluded that the risk of ingesting ICM through tap water was not a major health concern for adults, teens, or children in the study area. Nevertheless, due to the lack of long-term toxicity data relevant for humans for ICM, this risk may be underestimated, which requires further research.

Long-term Transplant Function After Thrombolytic Treatment Ex Vivo of Donated Kidneys Retrieved 4 to 5 H After Circulatory Death

BACKGROUND

Using a novel thrombolytic technique, we present long-term transplant function, measured by creatinine and iohexol clearance, after utilizing kidneys from porcine donors with uncontrolled donation after circulatory deaths, with 4.5-5 h of warm ischemia.

METHODS

Pigs in the study group were subjected to simulated circulatory death. After 2 h, ice slush was inserted into the abdomen and 4.5 h after death, the kidneys were retrieved. Lys-plasminogen, antithrombin-III, and alteplase were injected through the renal arteries on the back table. Subsequent ex vivo perfusion was continued for 3 h at 15°C, followed by 3 h with red blood cells at 32°C, and then transplanted into pigs as an autologous graft as only renal support. Living-donor recipient pigs that did not receive ex vivo perfusion, and unilateral nephrectomized pigs served as the controls.

RESULTS

Pigs in the study group (n = 13), surviving 10 d or more were included, of which 7 survived for 3 mo. Four animals in the living-donor group (n = 6) and all 5 nephrectomized animals survived for 3 mo. Creatinine levels in the plasma and urine, neutrophil gelatinase-associated lipocalin levels, Kidney Injury Marker-1 expression, and iohexol clearance at 3 mo did not differ significantly between the study and living-donor groups. Histology and transmission electron microscopy after 3 mo showed negligible fibrosis and no other damage.

CONCLUSIONS

The present method salvages kidneys from extended unontrolled donation after circulatory death using thrombolytic treatment while preserving histology and enabling transplantation after ex vivo reconditioning, with clinically acceptable late function after 3 mo, as measured by creatinine and iohexol clearance.

Removal of carbamazepine, venlafaxine and iohexol from wastewater effluent using coupled microalgal-bacterial biofilm

We evaluated the removal capacity of a coupled microalgal-bacterial biofilm (CMBB) to eliminate three recalcitrant pharmaceuticals. The CMBB's efficiency, operating at different biofilm concentrations, with or without light, was compared and analyzed to correlate these parameters to pharmaceutical removal and their effect on the microorganism community. Removal rates changed with changing pharmaceutical and biofilm concentrations: higher biofilm concentrations presented higher removal. Removal of 82-94% venlafaxine and 18-51% carbamazepine was obtained with 5 days of CMBB treatment. No iohexol removal was observed. Light, microorganism composition, and dissolved oxygen concentration are essential parameters governing the removal of pharmaceuticals and ammonia. Chlorophyll concentration increased with time, even in the dark. Three bacterial phyla were dominant: Proteobacteria, Bacteroidetes and Firmicutes. The dominant eukaryotic supergroups were Archaeplastida, Excavata and SAR. A study of the microorganisms' community indicated that not only do the species in the biofilm play an important role; environment, concentration and interactions among them are also important. CMBB has the potential to provide low-cost and sustainable treatment for wastewater and recalcitrant pharmaceutical removal. The microenvironments on the biofilm created by the microalgae and bacteria improved treatment efficiency.

Reliability of glomerular filtration rate estimating formulas compared to iohexol plasma clearance in critically ill children

Accurate renal function assessment is crucial to guide intensive care decision-making and drug dosing. Estimates of glomerular filtration rate (eGFR) are routinely used in critically ill children; however, these formulas were never evaluated against measured GFR (mGFR) in this population. We aimed to assess the reliability of common eGFR formulas compared to iohexol plasma clearance (CL_iohexol) in a pediatric intensive care (PICU) population. Secondary outcomes were the prevalence of acute kidney injury (AKI) (by pRIFLE criteria) and augmented renal clearance (ARC) (defined as standard GFR for age + 2 standard deviations (SD)) within 48 h after admission based on mGFR and eGFR by the revised Schwartz formula and the difference between these two methods to diagnose AKI and ARC. In children, between 0 and 15 years of age, without chronic renal disease, GFR was measured by CL_iohexol and estimated using 26 formulas based on creatinine (Scr), cystatine C (CysC), and betatrace protein (BTP), early after PICU admission. eGFR and mGFR results were compared for the entire study population and in subgroups according to age, using Bland-Altman analysis with calculation of bias, precision, and accuracy expressed as percentage of eGFR results within 30% (P30) and 10% (P10) of mGFR. CL_iohexol was measured in 98 patients. Mean CL_iohexol (± SD) was 115 ± 54 ml/min/1.73m². Most eGFR formulas showed overestimation of mGFR with large bias and poor precision reflected by wide limits of agreement (LoA). Bias was larger with CysC- and BTP-based formulas compared to Scr-based formulas. In the entire study population, none of the eGFR formulas showed the minimal desired P30 > 75%. The widely used revised Schwartz formula overestimated mGFR with a high percentage bias of - 18 ± 51% (95% confidence interval (CI) - 29; - 9), poor precision with 95% LoA from - 120 to 84% and insufficient accuracy reflected by P30 of only 51% (95% CI 41; 61), and P10 of 21% (95% CI 13; 66) in the overall population. Although performance of Scr-based formulas was worst in children below 1 month of age, exclusion of neonates and younger children did not result in improved agreement and accuracy. Based on mGFR, prevalence of AKI and ARC within 48 h was 17% and 45% of patients, respectively. There was poor agreement between revised Schwartz formula and mGFR to diagnose AKI (kappa value of 0.342, p < 0.001; sensitivity of 30%, 95% CI 5; 20%) and ARC (kappa value of 0.342, p < 0.001; sensitivity of 70%, 95% CI 33; 58).

CONCLUSION

In this proof-of-concept study, eGFR formulas were found to be largely inaccurate in the PICU population. Clinicians should therefore use these formulas with caution to guide drug dosing and therapeutic interventions in critically ill children. More research in subgroup populations is warranted to conclude on generalizability of these study findings.

CLINICALTRIALS

gov NCT05179564, registered retrospectively on January 5, 2022.

WHAT IS KNOWN

• Both acute kidney injury and augmented renal clearance may be present in PICU patients and warrant adaptation of therapy, including drug dosing. • Biomarker-based eGFR formulas are widely used for GFR assessment in critically ill children, although endogenous filtration biomarkers have important limitations in PICU patients and eGFR formulas have never been validated against measured GFR in this population.

WHAT IS NEW

• eGFR formulas were found to be largely inaccurate in the PICU population when compared to measured GFR by iohexol clearance. Clinicians should therefore use these formulas with caution to guide drug dosing and therapeutic interventions in critically ill children. • Iohexol plasma clearance could be considered an alternative for accurate GFR assessment in PICU patients.

A proof of principle study investigating the effects of supplemental concentrated brewer's yeast on markers of gut permeability, inflammation, and fecal metabolites in healthy non-challenged adult sled dogs

Yeast-derived β-glucans impact immunity, though their effects on gut permeability and inflammation are less understood. Most research has investigated other components of the yeast cell wall, such as the prebiotic mannan- and fructo-oligosaccharides. The objective of this study was to assess the effects of feeding a concentrated yeast product on markers of inflammation (serum amyloid A [SAA] and haptoglobin [Hp]) and oxidative status (malondialdehyde [MDA]), fecal products of fermentation, and gut permeability. Nineteen privately owned domestic Siberian huskies, and one Alaskan husky (9 females: 5 intact, 4 spayed; 11 males: 3 intact, 8 neutered), with an average age of 4.8 ± 2.6 yr and body weight (BW) of 25.6 ± 4.1 kg, were used in this study. Dogs were blocked and randomly allocated to one of two diet groups. Ten dogs received a dry extruded diet. The other 10 received the same diet top dressed with yeast for a daily β-glucan dose of 7 mg/kg BW for 10 wk. Fecal collection, for evaluation of fecal metabolites, and scoring occurred weekly. Gut permeability was assessed using the chromium-labeled ethylenediamine tetra-acetic acid (Cr-EDTA) and iohexol markers prior to the initiation of dietary treatment and after 10 wk of treatment. Blood samples were collected premarker administration and 0.5, 1, 2, 3, 4, 5, and 6 h postadministration. Fasting concentrations of SAA, Hp, and MDA were measured on weeks -1, 2, 4, and 8. Incremental area under the curve (I-AUC) was calculated for serum iohexol and Cr-EDTA concentrations. All data were analyzed using PROC GLIMMIX of SAS with dog as random effect, and week as fixed effect and repeated measure. Dogs receiving treatment tended to have decreased I-AUC of Iohexol (P = 0.10) and Cr-EDTA (P = 0.06) between baseline and cessation of treatment compared to the change over time in I-AUC for control (Ctl) dogs. Treatment dogs had lower Hp concentrations (P ≤ 0.05) than Ctl. There were no differences between treatments for SAA and MDA concentrations (P > 0.05). Fecal arabinose concentrations were greater in treatment (Trt) dogs (P ≤ 0.05) compared to Ctl, though no other fecal metabolites were affected by treatment. There was no difference in the relative frequency of defecations scored at any fecal score between Trt and Ctl dogs, and mean score did not differ between groups (P > 0.10). These data suggest that concentrated brewer's yeast may have the potential to reduce gut permeability without impacting inflammatory status and markers of health in adult dogs.

Sex Differences in Age-Related Loss of Kidney Function

BACKGROUND

CKD is more prevalent in women, but more men receive kidney replacement therapy for kidney failure. This apparent contradiction is not well understood.

METHODS

We investigated sex differences in the loss of kidney function and whether any sex disparities could be explained by comorbidity or CKD risk factors. In the Renal Iohexol Clearance Survey (RENIS) in northern Europe, we recruited 1837 persons (53% women, aged 50-62 years) representative of the general population and without self-reported diabetes, CKD, or cardiovascular disease. Participants' GFR was measured by plasma iohexol clearance in 2007-2009 (n=1627), 2013-2015 (n=1324), and 2018-2020 (n=1384). At each study visit, healthy persons were defined as having no major chronic diseases or risk factors for CKD. We used generalized additive mixed models to assess age- and sex-specific GFR decline rates.

RESULTS

Women had a lower GFR than men at baseline (mean [SD], 90.0 [14.0] versus 98.0 [13.7] ml/min per 1.73 m2; P<0.001). The mean GFR change rate was -0.96 (95% confidence interval [CI], -0.88 to -1.04) ml/min per 1.73 m2 per year in women and -1.20 (95% confidence interval [CI], -1.12 to -1.28) in men. Although the relationship between age and GFR was very close to linear in women, it was curvilinear in men, with steeper GFR slopes at older ages (nonlinear effect; P<0.001). Healthy persons had a slower GFR decline, but health status did not explain the sex difference in the GFR decline.

CONCLUSION

Among middle-aged and elderly individuals in the general population, decline in the mean GFR in women was slower than in men, independent of health status.

Risk factors of anaphylaxis in Korea: Identifying drug-induced anaphylaxis culprits using big data

Drug-induced anaphylaxis is a fatal medical condition whose incidence has been increasing continuously. Due to differences between genetic backgrounds and health care systems, different populations may be prone to various causative drugs. Using the Health Insurance Service and Assessment Service database, we investigated culprit drugs for drug-induced anaphylaxis and common medication risk factors in the Korean general population. We collected medical prescription histories within 3 days prior to anaphylaxis between January 2011 and December 2019 from the HIRA database. Designed as a case-crossover study, the attributable visits (case visits) were matched to medical visits (control visits) with the drug sets for each visit. We collected a list of medication risk factors for anaphylaxis and calculated the risk ratio of each agent using the chi-square test and conditional logistic regression analysis. A total of 159,473 individuals were listed in the database with a diagnosis of anaphylaxis in the HIRA from 2011 to 2019. After evaluating the suitability of control visits for matching with a case visit, 8168 subjects and 767 drugs were analyzed. The chi-square analysis identified 31 drugs as potential risk factors for drug-induced anaphylaxis in Korea. After applying a conditional logistic regression analysis for each agent, 5 drugs were found to be the common medication risk factors for drug-induced anaphylaxis: cefaclor, iopromide, iohexol, iomeprol, and tolperisone. We found 5 medication risk factors that showed the highest risk of drug-induced anaphylaxis and their degree of risk using an objective methodology in the Korean general population.

Toward efficient electrocatalytic degradation of iohexol using active anodes: A laser-made versus commercial anodes

The X-ray iodinated contrast medium iohexol is frequently detected in aquatic environments due to its high persistence and the inefficiency of its degradation by conventional wastewater treatments. Hence, the challenge faced in this study is the development of an alternative electrochemical treatment using active anodes. We investigate the oxidation of iohexol (16.42 mg L^-1) using different operating conditions, focusing on the role of different mixed metal oxide anodes in the treatment efficiency. The electrocatalytic efficiency of the Ti/RuO₂-TiO₂ anode prepared using a CO₂ laser heating and an ionic liquid is compared with Ti/RuO₂-TiO₂-IrO₂ and Ti/IrO₂-Ta₂O₅ commercial anodes. The hypochlorite ions generated by the anodes are also analyzed. The effect of the electrolyte composition (NaCl, Na₂SO₄, and NaClO₄) and current density (15, 30, and 50 mA cm^-2) on the iohexol degradation is also studied. The Ti/RuO₂-TiO₂ laser-made anode is more efficient than the commercial anodes. After optimizing experimental parameters, this anode removes 95.5% of iohexol in 60 min and displays the highest kinetic rate (0.059 min^-1) with the lowest energy consumption per order (0.21 kWh m^-3order^-1), using NaCl solution as the electrolyte and applying 15 mA cm^-2. Additionally, iohexol-intensified groundwater was used to compare the efficiency of anodes. The Ti/RuO₂-TiO₂ is also more efficient in removing the organic charge from the real water matrix (21.7% TOC) than the commercial anodes. Notably, the iohexol removal achieved is higher than all electrochemical treatments already reported using state-of-the-art non-active anodes in lower electrolysis time. Therefore, data from this study indicate that the electrochemical degradation of iohexol using the Ti/RuO₂-TiO₂ anode is efficient and has excellent cost-effectiveness; thus, it is a promising approach in the degradation of iohexol from wastewater. Furthermore, the Ti/RuO₂-TiO₂ active anode is competitive and can be an excellent option for treating effluents contaminated with recalcitrant organic compounds such as iohexol.

"De-Shrinking" EBEs: The Solution for Bayesian Therapeutic Drug Monitoring

BACKGROUND

Therapeutic drug monitoring (TDM) aims at individualising a dosage regimen and is increasingly being performed by estimating individual pharmacokinetic parameters via empirical Bayes estimates (EBEs). However, EBEs suffer from shrinkage that makes them biased. This bias is a weakness for TDM and probably a barrier to the acceptance of drug dosage adjustments by prescribers.

OBJECTIVE

The aim of this article is to propose a methodology that allows a correction of EBE shrinkage and an improvement in their precision.

METHODS

As EBEs are defined, they can be seen as a special case of ridge estimators depending on a parameter usually denoted λ. After a bias correction depending on λ, we chose λ so that the individual pharmacokinetic estimations have minimal imprecision. Our estimate is by construction always better than EBE with respect to bias (i.e. shrinkage) and precision.

RESULTS

We illustrate the performance of this approach with two different drugs: iohexol and isavuconazole. Depending on the patient's actual pharmacokinetic parameter values, the improvement given by our approach ranged from 0 to 100%.

CONCLUSION

This innovative methodology is promising since, to the best of our knowledge, no other individual shrinkage correction has been proposed.

Enhanced degradation of iohexol in water by CuFe2O4 activated peroxymonosulfate: Efficiency, mechanism and degradation pathway

Iohexol as an iodinated X-ray contrast agent is widely used, and it is the potential precursor for toxic iodinated disinfection by-products in the disinfection process. In this study, a series of CuFe₂O₄ catalysts were prepared by sol-gel method with different molar ratios of total metal cations to citric acid ([Meⁿ⁺]_T/CA) and employed as heterogeneous catalysts to activate peroxymonosulfate (PMS) for the removal of iohexol. The catalysts were characterized by various technologies, and the effect of [Meⁿ⁺]_T/CA molar ratio on the catalysts' properties was explored. The CuFe₂O₄ synthesized with [Meⁿ⁺]_T/CA molar ratio of 1:1 showed the best catalytic activity to PMS, and 95.0% of 1.0 mg/L iohexol was removed within 15 min by using 50 mg/L CuFe₂O₄ and 20 mg/L PMS. The quenching experiment and electron spin resonance (ESR) spectra indicated the generation of SO₄^- and OH in the CuFe₂O₄/PMS system, and the quantity experiments revealed that the generation concentration of SO₄^- was ten times higher than that of OH. The generation mechanism of SO₄^- and ·OH were investigated by ATR-FTIR and X-ray photoelectron spectroscopy (XPS) spectra. The effects of catalyst dosage, PMS and iohexol concentration on the removal of iohexol were studied, and various water matrix factors including solution pH, natural organic matter (NOM) concentration and inorganic ions were also considered. Based on the twelve intermediate products of iohexol detected by UPLC-QTOF/MS, the degradation pathway was proposed. The high catalytic activity and reusability of CuFe₂O₄ indicated that CuFe₂O₄ activating PMS is an effective and sustainable way for the treatment of iohexol.

3-Aminophenylboronic acid-mediated aggregation of gold nanoparticles for colorimetric sensing of iohexol in environmental and biological samples

Iohexol (IHO), as one of iodinated X-ray contrast, is often used as not only a chemical marker for tracking wastewater contamination in aquatic environment, but also an ideal glomerular filtration rate marker for explorating kidney disease. To these aims, it is important to establish reliable, fast, and cheap methods to detect IHO in environmental and biological samples. This work describes for the first time the development of a selective, sensitive and reliable colorimetric sensing assay for the fast determination of IHO in environmental and biological samples based on 3-aminophenylboronic acid (3-APBA) mediated aggregation of gold nanoparticles (AuNPs). In this approach, 3-APBA can assemble on the AuNPs surface through electrostatic interaction between its amino groups with the negatively charged citrate stabilizer of AuNPs to form AuNP@3-APBA. Subsequently, the aggregation and visual color change of the assembled AuNP@3-APBA are induced by the covalent reaction between boronic acid ligands of 3-APBA and cis-diols of IHO. The developed assay presented a very simple operating procedure and a rapid analysis time of around 10 min. The developed assay also exhibited good selectivity and a low limit of detection (LOD) of 0.005 mM for detecting IHO. Moreover, the developed assay showed comparable accuracy and precision to the high-performance liquid chromatography-diode array detector (HPLC-DAD) method when used for the rapid determination of IHO in river water and human urine samples. The recoveries of IHO at three spiking levels were in the range of 91.5-106.3% with relative standard deviation (RSD) values below 6.39%.

Contrast media injection protocol for portovenous phase abdominal CT: does a fixed injection duration improve hepatic enhancement over a fixed injection rate?

PURPOSE

To assess whether a fixed contrast media (CM) injection duration improves the magnitude and inter-patient variability in hepatic enhancement over a fixed injection rate.

METHODS

Outpatients who underwent portovenous phase abdominal CT (fixed duration, February-November 2018; fixed rate, January-July 2020) with 1.22 mL/kg iohexol 350 were included. Subjects with liver, kidney or heart disease were excluded. The number of subjects and injection protocols were as follows: fixed duration arm, 56 women, 60 men, 35 s injection duration; fixed rate arm, 66 women, 62 men, 3 mL/s injection rate. Liver attenuation measurements were obtained from regions of interest on pre- and post-contrast images. Mean hepatic enhancement (MHE) and MHE normalized to iodine dose (MHE/I) were compared (unpaired t-tests and F-tests).

RESULTS

There was no statistically significant difference in age, weight, body mass index or CM dosing (p > 0.05). Enhancement indices were significantly lower in the fixed rate group as compared to the fixed duration group, as follows: MHE, 50.0 ± 12 vs. 54.8 ± 11 HU (p = 0.001); and MHE/I, 1.53 ± 0.43 vs. 1.66 ± 0.51 HU/g, (p = 0.04). However, there was no significant difference in the variances of MHE (p = 0.51) and MHE/I (p = 0.08).

CONCLUSION

A fixed CM injection duration yields a greater magnitude in hepatic enhancement indices than a fixed injection rate. Inter-patient variability in hepatic enhancement indices do not significantly differ between the two injection protocols.

A New Panel-Estimated GFR, Including β2-Microglobulin and β-Trace Protein and Not Including Race, Developed in a Diverse Population

RATIONALE AND OBJECTIVE

Glomerular filtration rate (GFR) estimation based on creatinine and cystatin C (eGFRcr-cys) is more accurate than estimated GFR (eGFR) based on creatinine or cystatin C alone (eGFRcr or eGFRcys, respectively), but the inclusion of creatinine in eGFRcr-cys requires specification of a person's race. β2-Microglobulin (B2M) and β-trace protein (BTP) are alternative filtration markers that appear to be less influenced by race than creatinine is.

STUDY DESIGN

Study of diagnostic test accuracy.

SETTING AND PARTICIPANTS

Development in a pooled population of 7 studies with 5,017 participants with and without chronic kidney disease. External validation in a pooled population of 7 other studies with 2,245 participants.

TESTS COMPARED

Panel eGFR using B2M and BTP in addition to cystatin C (3-marker panel) or creatinine and cystatin C (4-marker panel) with and without age and sex or race.

OUTCOMES

GFR measured as the urinary clearance of iothalamate, plasma clearance of iohexol, or plasma clearance of [51Cr]EDTA.

RESULTS

Mean measured GFRs were 58.1 and 83.2 mL/min/1.73 m2, and the proportions of Black participants were 38.6% and 24.0%, in the development and validation populations, respectively. In development, addition of age and sex improved the performance of all equations compared with equations without age and sex, but addition of race did not further improve the performance. In validation, the 4-marker panels were more accurate than the 3-marker panels (P < 0.001). The 3-marker panel without race was more accurate than eGFRcys (percentage of estimates greater than 30% different from measured GFR [1 - P30] of 15.6% vs 17.4%; P = 0.01), and the 4-marker panel without race was as accurate as eGFRcr-cys (1 - P30 of 8.6% vs 9.4%; P = 0.2). Results were generally consistent across subgroups.

LIMITATIONS

No representation of participants with severe comorbid illness and from geographic areas outside of North America and Europe.

CONCLUSIONS

The 4-marker panel eGFR is as accurate as eGFRcr-cys without requiring specification of race. A more accurate race-free eGFR could be an important advance.

Age- and sex-dependent clinical equations to estimate glomerular filtration rates in children and young adults with chronic kidney disease

Using data (2655 observations from 928 participants) from the Chronic Kidney Disease in Children Study, we developed and internally validated new glomerular filtration rate estimating equations for clinical use in children and young adults: two forms of K × [heigh(ht) / serum creatinine(sCr)] and two forms of K × [1 / cystatin C(cysC)]. For each marker, one equation used a sex-dependent K; in the other, K is sex-and age-dependent. Glomerular filtration rate (GFR) was measured directly by plasma iohexol disappearance. The equations using ht⁄sCr had sex-specific constants of 41.8 for males and 37.6 for females. In the age- dependent models, K increased monotonically for children 1-18 years old and was constant for young adults 18-25 years. For males, K ranged from 35.7 for one-year-olds to 50.8 for those 18 and older. For females, the values of K ranged from 33.1 to 41.4. Constant K values for cystatin-C equations were 81.9 for males and 74.9 for females. With age-dependency, K varied non-monotonically with the highest values at age 15 for males (K of 87.2) and 12 years for females (K of 79.9). Use of an age-dependent K with ht/sCr models reduced average bias, notably in young children and young adults; age-dependent cystatin-C models produced similar agreement to using a constant K in children under 18 years, but reduced bias in young adults. These age-dependent proposed equations were evaluated alongside estimated GFRs from 11 other published equations for pediatrics and young adults. Only our proposed equations yielded non- significant bias and within 30% accuracy values greater than 85% in both the pediatric and young adult subpopulations.

Evaluating chronic kidney disease in rural South Africa: comparing estimated glomerular filtration rate using point-of-care creatinine to iohexol measured GFR

OBJECTIVES

The prevalence of chronic kidney disease is rising rapidly in low- and middle-income countries. Serum creatinine and estimation of glomerular filtration rate (GFR) are critical diagnostic tools, yet access to centralised laboratory services remains limited in primary care resource-limited settings. The aim of this study was to evaluate point-of-care (POC) technologies for serum creatinine measurement and to compare their performance to a gold standard measurement using iohexol measured GFR (mGFR).

METHODS

POC creatinine was measured using iSTAT^® and StatSensor^® devices in capillary and venous whole blood, and laboratory creatinine was measured using the compensated kinetic Jaffe method in 670 participants from a rural area in South Africa. GFR estimating equations Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease (CKD-EPI and MDRD) for POC and laboratory creatinine were compared to iohexol mGFR.

RESULTS

Calculated GFR for laboratory and POC creatinine measurements overestimated GFR (positive bias of 1.9-34.1 mL/min/1.73 m²). However, all POC devices had less positive bias than the laboratory Jaffe method (1.9-14.7 vs. 34.1 for MDRD, and 8.4-19.9 vs. 28.6 for CKD-EPI). Accuracy within 30% of mGFR ranged from 0.56 to 0.72 for POC devices and from 0.36 to 0.43 for the laboratory Jaffe method. POC devices showed wider imprecision with coefficients of variation ranging from 4.6 to 10.2% compared to 3.5% for the laboratory Jaffe method.

CONCLUSIONS

POC estimated GFR (eGFR) showed improved performance over laboratory Jaffe eGFR, however POC devices suffered from imprecision and large bias. The laboratory Jaffe method performed poorly, highlighting the need for laboratories to move to enzymatic methods to measure creatinine.

Catalytic ozonation of iohexol with α-Fe0.9Mn0.1OOH in water: Efficiency, degradation mechanism and toxicity evaluation

Iohexol, a widely used iodinated X-ray contrast media, is difficult to completely degrade with the traditional water treatment process. Catalytic ozonation with synthesized α-Fe_0.9Mn_0.1OOH as the catalyst can significantly promote the degradation of iohexol relative to that with ozonation alone. Hydroxyl radicals play a predominant role during the degradation of iohexol. The effect of various factors, including catalyst dose, ozone dose, iohexol concentration and water matrix factors, on the catalytic performance were investigated. The presence of α-Fe_0.9Mn_0.1OOH in the catalytic system can significantly promote the removal of iohexol and mineralization of the dissolved organic carbon in real water samples. The intermediate products were determined by high-resolution liquid chromatography, and the reaction site was predicted by frontier electron density (FED) calculations. The degradation mechanism of iohexol followed the processes of H-abstraction, amide hydrolysis, amide oxidation, and ·OH substitution. Higher exposure concentrations of iohexol had a negative effect on the survival and hatching rates in the development of zebrafish embryos. The autonomic movement process and heartbeat rate of the zebrafish larvae showed significant differences as the exposure concentration of iohexol increased. The catalytic ozonation process with α-Fe_0.9Mn_0.1OOH can decrease the toxicity of iohexol containing water.

[Spinal motor segment labeling with a mixture of n-butyl-2-cyanoacrylate and iohexol in determining the level of thoracic spine surgery]

Erroneous determining the level of spine surgery is an urgent problem in modern vertebrology. Incidence of this complication is up to 1 per 3110 patients, among patients undergoing thoracic spine surgery - 1 per 25 patients. Despite widespread use of spine surgery, there is still no standard rational method for prevention of erroneous determining the level of intervention.

OBJECTIVE

To develop a safe minimally invasive low-traumatic and cost-effective method for preoperative marking the level of thoracic spine surgery.

MATERIAL AND METHODS

A mixture of biodegradable adhesive based on cyanoacrylate and water-soluble iodine-containing X-ray contrast agent was used for preoperative marking in 8 patients scheduled for thoracic spine and spinal cord surgery. This mixture was injected into paravertebral tissues at the level of further intervention.

RESULTS

Preoperative marking ensured a fixed and clearly visible landmark during intraoperative fluoroscopy in 7 patients. In 1 patient, mixture spread in paravertebral soft tissues that did not allow us to obtain appropriate landmark during intraoperative radiography.

CONCLUSION

The described method makes it possible to create an immobile X-ray-positive «mark» in paravertebral soft tissues, which can be used to control the level of intervention at all surgical stages.

Evaluation of a dual-purpose contrast medium for radiography and ultrasonography of the small intestine in dogs

OBJECTIVE

To evaluate a contrast medium that could be used for radiographic and ultrasonographic assessment of the small intestine in dogs.

ANIMALS

8 healthy adult Beagles.

PROCEDURES

Carboxymethylcellulose (CMC; 0.5% solution) was combined with iohexol (300 mg of iodine/mL) to yield modified contrast medium (MCM). Dogs were orally administered the first of 3 MCMs (10 mL/kg [9.5 mL of CMC/kg plus 0.5 mL of iohexol/kg]). Radiographic and ultrasonographic assessment of the small intestine followed 10 minutes after administration and every 10 minutes thereafter, until MCM was seen within the ascending colon. Minimally, 1 week elapsed between dosing of subsequent MCMs (10 mL/kg [9 mL of CMC/kg plus 1 mL of iohexol/kg and 8.5 mL of CMC/kg plus 1.5 mL of iohexol/kg]) and repeated radiography and ultrasonography.

RESULTS

Radiographic contrast enhancement of the small intestine was best with MCM that combined 8.5 mL of CMC/kg and 1.5 mL of iohexol/kg. Mean small intestinal transit time for all MCMs was 86 minutes. All MCMs did not interfere with ultrasonographic assessment of the small intestine and may have improved visualization of the far-field small intestinal walls.

CONCLUSIONS AND CLINICAL RELEVANCE

An MCM that combined 8.5 mL of 0.5% CMC/kg and 1.5 mL of iohexol/kg could be an alternative to barium or iohexol alone for contrast small intestinal radiography in dogs, especially when abdominal ultrasonography is to follow contrast radiography.

Effect of slice thickness on computed tomographic perfusion analysis of the pancreas in healthy dogs

OBJECTIVE

To evaluate the effect of slice thickness on CT perfusion analysis of the pancreas in healthy dogs.

ANIMALS

12 healthy Beagles.

PROCEDURES

After precontrast CT scans, CT perfusion scans of the pancreatic body were performed every second for 30 seconds by sequential CT scanning after injection of contrast medium (iohexol; 300 mg of 1/kg) at a rate of 3 mL/s. Each dog underwent CT perfusion scans twice in a crossover-design study with 2 different slice thicknesses (2.4 and 4.8 mm). Computed tomographic pancreatic perfusion variables, including blood flow, blood volume determined with the maximum slope model, times to the start of enhancement and peak enhancement, permeability, and blood volume determined by Patlak plot analysis, were measured independently by 2 reviewers. The CT perfusion variables were compared between slice thicknesses. Interoperator reproducibility was determined by ICC calculation.

RESULTS

Interoperator reproducibility of CT perfusion variable measurements was excellent on 2.4-mm (mean ± SD ICC, 0.81 ± 0.17) and 4.8-mm (0.90 ± 0.07) slice thicknesses, except for time to peak pancreatic enhancement on 2.4-mm-thick slices, which had moderate reproducibility (intraclass correlation coefficient, 0.473). There was no significant difference in measurements of blood flow, blood volume by either method, times to the start and peak of pancreatic enhancement, or permeability between slice thicknesses.

CONCLUSIONS AND CLINICAL RELEVANCE

Results supported that a thin slice thickness of 2.4 mm can be used for assessment of pancreatic perfusion variables in healthy dogs.

Thermosensitive Liposomes Encapsulating Anti-Cancer Agent Lomustine, and Contrast Medium Iohexol, for Thermochemotherapy: Preparation, Characterization, and In Vivo Evaluation

Thermosensitive liposome-based drug delivery systems (DDS) are powerful tools for site-specific delivery of chemotherapeutics, especially when combined with regional hyperthermia. The objective of this work was to develop a novel thermosensitive liposomal DDS loaded with lomustine, a chemotherapeutic compound, and iohexol, a contrast medium for visualization by CT. Thermosensitive compound liposomes (TSCLs) composed of DPPC were prepared by reverse-phase evaporation and investigated for encapsulation efficiency, temperature-sensitivity, release kinetics, and In Vivo pharmacokinetics. The size and zeta-potential of TSCLs ranged from 250 to 300 nm and -15 to -30 mV, respectively. At 41 °C, TSCLs were shown to release over 90% of iohexol and lomustine within 4 h. The in vitro release profiles of iohexol and lomustine at 41 °C conformed to first-order kinetics and Weibullmodel, respectively. Phase-transition did not occur after incorporation of cholesterol and soybean phospholipids. In Vivo evaluation performed with C6 glioma model rats proved the prolonged half-lives and improved bioavailability by liposomal encapsulation for both compounds under mild local hyperthermia. The TSCLs used in this study may offer a clinically promising mean of increasing efficacy and controlling toxicity.