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Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) occurrence in critically ill patients is common and is associated with a substantial increase in morbidity and mortality. The scope of this review is to summarize the most recent evidence-based knowledge for prevention of AKI. RECENT FINDINGS Recent recommendations for prevention of AKI in ICU patients are all 'negative' and, similarly, the most recent and updated guidelines about major topic areas of interest for AKI, including definition and classification, prevention, and pharmacologic treatment, have failed to identify single evidence-based recommendations for prevention and treatment of AKI. Therefore, the evaluation and management of AKI should be guided by clinical algorithms aiming to protocolized hemodynamic optimization, metabolic control, monitoring of intra-abdominal hypertension, use of diuretics to control fluid overload, and careful management of nephrotoxic factors. SUMMARY Key components of optimal AKI prevention include maintenance of renal perfusion and avoidance of precipitating factors. Adequate renal blood flow maintenance is the first strategy to employ not only to assure renal oxygenation, but also to prevent nephrotoxic drugs-associated AKI. Many potential therapies and interventions are on the horizon, but most of the future research will need to focus more on a step-wise, protocoled, kidney-oriented approach, than on single treatments.
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Hjortrup PB, Haase N, Wetterslev M, Perner A. Clinical review: Predictive value of neutrophil gelatinase-associated lipocalin for acute kidney injury in intensive care patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:211. [PMID: 23680259 PMCID: PMC3672520 DOI: 10.1186/cc11855] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neutrophil gelatinase-associated lipocalin (NGAL) may be an early marker of acute kidney injury (AKI), but elevated NGAL occurs in a wide range of systemic diseases. Because intensive care patients have high levels of comorbidity, our objective was to conduct a systematic review of the literature to evaluate the value of plasma and urinary NGAL to predict AKI in these patients. We conducted a systematic electronic literature search of MEDLINE through PubMed, EMBASE, and Cochrane Library for all English language research publications evaluating the predictive value of plasma or urinary NGAL (or both) for AKI in adult intensive care patients. Two authors independently extracted data by using a standardized extraction sheet including study characteristics, type of NGAL measurements, and type of outcome measures. The primary summary measure was area under receiver operating characteristic curve (AuROC) for NGAL to predict study outcomes. Eleven studies with a total of 2,875 (range of 20 to 632) participants were included: seven studies assessed urinary NGAL and six assessed plasma NGAL. The included studies varied in design, including observation period from NGAL sampling to AKI follow-up (range of 12 hours to 7 days), definition of baseline creatinine value, and urinary NGAL quantification method (normalizing to urinary creatinine or absolute concentration). AuROC values for the prediction of AKI ranged from 0.54 to 0.98. Five studies reported AuROC for use of renal replacement therapy ranging from 0.73 to 0.89, and four studies reported AuROC for mortality ranging from 0.58 to 0.83. There were no differences in the predictive values of urinary and plasma NGAL. The heterogeneity in study design and results made it difficult to evaluate the value of NGAL to predict AKI in intensive care patients. NGAL seems to have reasonable value in predicting use of renal replacement therapy but not mortality.
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Pons B, Lautrette A, Oziel J, Dellamonica J, Vermesch R, Ezingeard E, Mariat C, Bernardin G, Zeni F, Cohen Y, Tardy B, Souweine B, Vincent F, Darmon M. Diagnostic accuracy of early urinary index changes in differentiating transient from persistent acute kidney injury in critically ill patients: multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R56. [PMID: 23531299 PMCID: PMC3733426 DOI: 10.1186/cc12582] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 03/21/2013] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Urinary indices have limited effectiveness in separating transient acute kidney injury (AKI) from persistent AKI in ICU patients. Their time-course may vary with the mechanism of AKI. The primary objective of this study was to evaluate the diagnostic value of changes over time of the usual urinary indices in separating transient AKI from persistent AKI. METHODS An observational prospective multicenter study was performed in six ICUs involving 244 consecutive patients, including 97 without AKI, 54 with transient AKI, and 93 with persistent AKI. Urinary sodium, urea and creatinine were measured at ICU admission (H0) and on 6-hour urine samples during the first 24 ICU hours (H6, H12, H18, and H24). Transient AKI was defined as AKI with a cause for renal hypoperfusion and reversal within 3 days. RESULTS Significant increases from H0 to H24 were noted in fractional excretion of urea (median, 31% (22 to 41%) and 39% (29 to 48%) at H24, P<0.0001), urinary urea/plasma urea ratio (15 (7 to 28) and 20 (9 to 40), P<0.0001), and urinary creatinine/plasma creatinine ratio (50 (24 to 101) and 57 (29 to 104), P=0.01). Fractional excretion of sodium did not change significantly during the first 24 hours in the ICU (P=0.13). Neither urinary index values at ICU admission nor changes in urinary indices between H0 and H24 performed sufficiently well to recommend their use in clinical setting (area under the receiver-operating characteristic curve≤0.65). CONCLUSION Although urinary indices at H24 performed slightly better than those at H0 in differentiating transient AKI from persistent AKI, they remain insufficiently reliable to be clinically relevant.
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Katagiri D, Doi K, Matsubara T, Negishi K, Hamasaki Y, Nakamura K, Ishii T, Yahagi N, Noiri E. New biomarker panel of plasma neutrophil gelatinase-associated lipocalin and endotoxin activity assay for detecting sepsis in acute kidney injury. J Crit Care 2013; 28:564-70. [PMID: 23499422 DOI: 10.1016/j.jcrc.2013.01.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 01/11/2013] [Accepted: 01/12/2013] [Indexed: 12/21/2022]
Abstract
PURPOSE Septic acute kidney injury (AKI) shows an unacceptably high mortality rate. Detection of sepsis is important for the clinical management of AKI patients. This study was undertaken to evaluate 2 biomarkers of neutrophil gelatinase-associated lipocalin (NGAL) and endotoxin activity (EA) assay and their combination for detecting sepsis in AKI. MATERIALS AND METHODS Adult intensive care unit patients consisting of 40 non-AKI, 65 AKI without sepsis, 10 non-AKI with sepsis, and 24 septic AKI were examined in a cross-sectional manner. Plasma NGAL and EA values in whole blood were measured at recruitment. We evaluated whether combining 2 different biomarkers would improve the performance of each biomarker using receiver operating characteristic analysis. RESULTS Plasma NGAL was significantly higher in septic AKI patients than in the other AKI patients and non-AKI patients, whereas EA values were higher in septic patients than nonseptic patients irrespective of AKI complication. Combination of plasma NGAL and EA value increased the area under the curve of the receiver operating characteristic curve and showed better performance compared with a clinical model consisting of clinically available variables. CONCLUSION Combinations of plasma NGAL and EA, which are operating via different pathological pathways, significantly improved their detection performance in complicated conditions of septic AKI.
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Affiliation(s)
- Daisuke Katagiri
- Department of Nephrology and Endocrinology, University Hospital, The University of Tokyo, Tokyo, Japan
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Kokkoris S, Pipili C, Grapsa E, Kyprianou T, Nanas S. Novel biomarkers of acute kidney injury in the general adult ICU: a review. Ren Fail 2013; 35:579-91. [PMID: 23472851 DOI: 10.3109/0886022x.2013.773835] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury is one of the most frequent problems occurring in the critically ill patients of the intensive care units and it is well established that it increases both morbidity and mortality in these patients. Moreover, despite technological and pharmaceutical advances during the last decades, the incidence as well as the mortality associated with acute kidney injury in these patients remains unchanged. Creatinine, the most common renal dysfunction biomarker in use, has many disadvantages, such as time delay in its increase and the influence by other factors on its serum concentration, such as age, gender, muscle mass, etc. Hence, the need for better renal biomarkers in order to timely intervene for acute kidney injury prevention is imperative. The lack of an early biomarker is an obstacle for the development of new acute kidney injury prevention strategies. With the incidence of acute kidney injury reaching epidemic dimensions, the need for novel markers is urgent. During the last years, the research for finding such biomarkers has been intense. The purpose of the present article is to review the studies which have tested the predictive ability of those markers (in urine and/or plasma) for early detection of acute kidney injury in the mixed adult intensive care unit population and underline the potential limitations encountered in the various studies.
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Affiliation(s)
- Stelios Kokkoris
- First Critical Care Department, Medical School, National and Kapodistrian University of Athens, "Evangelismos" General Hospital, Athens, Greece
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Jayakumar C, Ranganathan P, Devarajan P, Krawczeski CD, Looney S, Ramesh G. Semaphorin 3A is a new early diagnostic biomarker of experimental and pediatric acute kidney injury. PLoS One 2013; 8:e58446. [PMID: 23469280 PMCID: PMC3587608 DOI: 10.1371/journal.pone.0058446] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/04/2013] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Semaphorin 3A is a secreted protein that regulates cell motility and attachment in axon guidance, vascular growth, immune cell regulation and tumor progression. However, nothing is known about its role in kidney pathophysiology. Here, we determined whether semaphorin3A is induced after acute kidney injury (AKI) and whether urinary semaphorin 3A can predict AKI in humans undergoing cardiopulmonary bypass (CPB). METHODS AND PRINCIPAL FINDINGS In animals, semaphorin 3A is localized in distal tubules of the kidney and excretion increased within 3 hr after reperfusion of the kidney whereas serum creatinine was significantly raised at 24 hr. In humans, using serum creatinine, AKI was detected on average only 48 hours after CPB. In contrast, urine semaphorin increased at 2 hours after CPB, peaked at 6 hours (2596±591 pg/mg creatinine), and was no longer significantly elevated 12 hours after CPB. The predictive power of semaphorin 3A as demonstrated by area under the receiver-operating characteristic curve for diagnosis of AKI at 2, 6, and 12 hours after CPB was 0.88, 0.81, and 0.74, respectively. The 2-hour urine semaphorin measurement strongly correlated with duration and severity of AKI, as well as length of hospital stay. Adjusting for CPB time and gender, the 2-hour semaphorin remained an independent predictor of AKI, with an odds ratio of 2.19. CONCLUSION Our results suggest that semaphorin 3A is an early, predictive biomarker in experimental and pediatric AKI, and may allow for the reliable early diagnosis and prognosis of AKI after CPB, much before the rise in serum creatinine.
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Affiliation(s)
- Calpurnia Jayakumar
- Department of Medicine and Vascular Biology Center, Georgia Health Sciences University, Augusta, Georgia, United States of America
| | - Punithavathi Ranganathan
- Department of Medicine and Vascular Biology Center, Georgia Health Sciences University, Augusta, Georgia, United States of America
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States of America
| | - Catherine D. Krawczeski
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States of America
| | - Stephen Looney
- Department of Biostatistics, Georgia Health Sciences University, Augusta, Georgia, United States of America
| | - Ganesan Ramesh
- Department of Medicine and Vascular Biology Center, Georgia Health Sciences University, Augusta, Georgia, United States of America
- * E-mail:
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Di Somma S, Magrini L, De Berardinis B, Marino R, Ferri E, Moscatelli P, Ballarino P, Carpinteri G, Noto P, Gliozzo B, Paladino L, Di Stasio E. Additive value of blood neutrophil gelatinase-associated lipocalin to clinical judgement in acute kidney injury diagnosis and mortality prediction in patients hospitalized from the emergency department. Crit Care 2013; 17:R29. [PMID: 23402494 PMCID: PMC4056001 DOI: 10.1186/cc12510] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 02/07/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is a common complication among hospitalized patients. The aim of this study was to evaluate the utility of blood neutrophil gelatinase-associated lipocalin (NGAL) assessment as an aid in the early risk evaluation for AKI development in admitted patients. METHODS This is a multicenter Italian prospective emergency department (ED) cohort study in which we enrolled 665 patients admitted to hospital from the ED. RESULTS Blood NGAL and serum creatinine (sCr) were determined at ED presentation (T0), and at: 6 (T6), 12 (T12), 24 (T24) and 72 (T72) hours after hospitalization. A preliminary assessment of AKI by the treating ED physician occurred in 218 out of 665 patients (33%), while RIFLE AKI by expert nephrologists was confirmed in 49 out of 665 patients (7%). The ED physician's initial judgement lacked sensitivity and specificity, overpredicting the diagnosis of AKI in 27% of the cohort, while missing 20% of those with AKI as a final diagnosis. CONCLUSIONS Our study demonstrated that assessment of a patient's initial blood NGAL when admitted to hospital from the ED improved the initial clinical diagnosis of AKI and predicted in-hospital mortality. Blood NGAL assessment coupled with the ED physician's clinical judgment may prove useful in deciding the appropriate strategies for patients at risk for the development of AKI.See related commentary by Legrand et al., http://ccforum.com/content/17/2/132.
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Cho E, Yang HN, Jo SK, Cho WY, Kim HK. The role of urinary liver-type fatty acid-binding protein in critically ill patients. J Korean Med Sci 2013; 28:100-5. [PMID: 23341719 PMCID: PMC3546087 DOI: 10.3346/jkms.2013.28.1.100] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 10/24/2012] [Indexed: 12/19/2022] Open
Abstract
Although several urinary biomarkers have been validated as early diagnostic markers of acute kidney injury (AKI), their usefulness as outcome predictors is not well established. This study aimed to determine the diagnostic and prognostic abilities of urinary liver-type fatty acid-binding protein (L-FABP) in heterogeneous critically ill patients. We prospectively collected data on patients admitted to medical and surgical intensive care units (ICUs) from July 2010 to June 2011. Urine neutrophil gelatinase-associated lipocalin (NGAL) and L-FABP at the time of ICU admission were quantitated. Of the 145 patients, 54 (37.2%) had AKI defined by the Acute Kidney Injury Network (AKIN) criteria. AKI patients showed significantly higher level of urinary NGAL and L-FABP and also higher mortality than non-AKI patients. The diagnostic performances, assessed by the area under the ROC curve, were 0.773 for NGAL and 0.780 for L-FABP, demonstrating their usefulness in diagnosing AKI. In multivariate Cox analysis, urinary L-FABP was an independent predictor for 90-day mortality. Urinary L-FABP seems to be promising both for the diagnosis of AKI and for the prediction of prognosis in heterogeneous ICU patients. It needs to be further validated for clinical utility.
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Affiliation(s)
- Eunjung Cho
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, The Institute of Renal Disease, Seoul, Korea
| | - Ha Na Yang
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, The Institute of Renal Disease, Seoul, Korea
| | - Sang-Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, The Institute of Renal Disease, Seoul, Korea
| | - Won-Yong Cho
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, The Institute of Renal Disease, Seoul, Korea
| | - Hyoung-Kyu Kim
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, The Institute of Renal Disease, Seoul, Korea
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Susantitaphong P, Siribamrungwong M, Doi K, Noiri E, Terrin N, Jaber BL. Performance of urinary liver-type fatty acid-binding protein in acute kidney injury: a meta-analysis. Am J Kidney Dis 2012; 61:430-9. [PMID: 23228945 DOI: 10.1053/j.ajkd.2012.10.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/10/2012] [Indexed: 01/08/2023]
Abstract
BACKGROUND Urinary liver-type fatty acid-binding protein (L-FABP) is a proximal tubular injury candidate biomarker for early detection of acute kidney injury (AKI), with variable performance characteristics depending on clinical settings. STUDY DESIGN Meta-analysis of diagnostic test studies assessing the performance of urinary L-FABP in AKI. SETTING & POPULATION Literature search in MEDLINE, EMBASE, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov using search terms "liver-type fatty acid-binding protein" and "L-FABP." SELECTION CRITERIA FOR STUDIES Studies of humans investigating the performance characteristics of urinary L-FABP for the early diagnosis of AKI and AKI-related outcomes, including dialysis requirement and mortality. PREDICTOR Urinary L-FABP. OUTCOMES Diagnosis of AKI, dialysis requirement, and in-hospital death. RESULTS 15 prospective cohort and 2 case-control studies were identified. Only 7 cohort studies could be meta-analyzed. The estimated sensitivity of urinary L-FABP level for the diagnosis of AKI was 74.5% (95% CI, 60.4%-84.8%), and specificity was 77.6% (95% CI, 61.5%-88.2%). The estimated sensitivity of urinary L-FABP level for predicting dialysis requirement was 69.1% (95% CI, 34.6%-90.5%), and specificity was 42.7% (95% CI, 3.1%-94.5%); for in-hospital mortality, sensitivity and specificity were 93.2% (95% CI, 66.2%-99.0%) and 78.8% (95% CI, 27.0%-97.4%), respectively. LIMITATIONS Paucity and low quality of studies, different clinical settings, and variable definitions of AKI. CONCLUSIONS Although urinary L-FABP may be a promising biomarker for early detection of AKI and prediction of dialysis requirement and in-hospital mortality, its potential value needs to be validated in large studies and across a broader spectrum of clinical settings.
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Affiliation(s)
- Paweena Susantitaphong
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St. Elizabeth's Medical Center, Boston, MA 02135, USA
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Mårtensson J, Martling CR, Bell M. Novel biomarkers of acute kidney injury and failure: clinical applicability. Br J Anaesth 2012; 109:843-50. [DOI: 10.1093/bja/aes357] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Zhang X, Gibson B, Mori R, Snow-Lisy D, Yamaguchi Y, Campbell SC, Simmons MN, Daly TM. Analytical and biological validation of a multiplex immunoassay for acute kidney injury biomarkers. Clin Chim Acta 2012; 415:88-93. [PMID: 23041213 DOI: 10.1016/j.cca.2012.09.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 09/19/2012] [Accepted: 09/21/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a dynamic process that can involve inflammatory, hypoxic, and structural changes to the kidney. We evaluated a multiplex panel of markers representing different AKI mechanisms as a tool to provide integrated assessment of AKI status in a single assay. METHODS Urinary cystatin C (CysC), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1) and interleukin-18 (IL-18) were measured by multiplex electrochemiluminescence immunoassay. Analytical performance was compared to the biological and pathological variation of these markers in human samples. RESULTS Linearity was established over a 3- to 4-log range for all markers, which spanned the reference ranges established from healthy donors. Imprecision was below 15%, comparing favorably with the observed biological variation of these markers. Control patients fell within donor-derived reference ranges for most markers, but a subset of patients showed CysC and KIM-1 elevations in the absence of documented AKI. CONCLUSION The multiplex assay is reliable for simultaneous quantitation of CysC, IL-18, KIM-1 and NGAL in human urine, and performs at levels sufficient for clinical application. The observed differences in biological variability and baseline levels suggest that clinical strategies to detect AKI will need to vary depending upon the specific markers used.
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Affiliation(s)
- Xiaochun Zhang
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States
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Ostermann M, Philips BJ, Forni LG. Clinical review: Biomarkers of acute kidney injury: where are we now? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:233. [PMID: 23014769 PMCID: PMC3682238 DOI: 10.1186/cc11380] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The recognition that acute kidney injury (AKI) is a significant independent risk factor for morbidity and mortality has resulted in a substantial number of publications over the past 5 years or more. In no small part these have, to a degree, highlighted the inadequacy of conventional markers of renal insufficiency in the acute setting. Much effort has been invested in the identification of early, specific AKI markers in order to aid early diagnosis of AKI and hopefully improve outcome. The search for a 'biomarker' of AKI has seen early promise replaced by a degree of pessimism due to the lack of a clear candidate molecule and variability of results. We outline the major studies described to date as well as discuss potential reasons for the discrepancies observed and suggest that evolution of the field may result in success with ultimately an improvement in patient outcomes.
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Kokkoris S, Parisi M, Ioannidou S, Douka E, Pipili C, Kyprianou T, Kotanidou A, Nanas S. Combination of renal biomarkers predicts acute kidney injury in critically ill adults. Ren Fail 2012; 34:1100-8. [PMID: 22889061 DOI: 10.3109/0886022x.2012.713279] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Most studies so far have focused on the performance of individual biomarkers to detect early acute kidney injury (AKI) in the adult intensive care unit (ICU) patients; however, they have not determined the predictive ability of their combinations. The aim of this study was to compare the predictive abilities of plasma neutrophil gelatinase-associated lipocalin (pNGAL), urine neutrophil gelatinase-associated lipocalin (uNGAL), plasma cystatin C (pCysC), serum creatinine (sCr), and their combinations in detecting AKI in an adult general ICU population. METHODS A total of 100 consecutive ICU patients were included in the analysis. AKI was defined according to RIFLE criteria. Biomarker predictive abilities were evaluated by area under the curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS AKI occurred in 36% of patients 7 days post-admission. All three novel biomarkers as well as sCr had moderate predictive abilities for AKI occurrence. The most efficient combinations (pNGAL + sCr and pNGAL + uNGAL + sCr) were selected to participate in the subsequent analyses. Both combinations, when added to a reference clinical model, increased its AUC significantly (0.858, p = 0.04). Their NRI (0.78, p = 0.0002) was equal to that of pNGAL, but higher than that of the other three biomarkers, whereas their IDI was higher than that of any individual biomarker (0.23, p = 0.0001). Both combinations had better specificities, positive likelihood ratios, and positive predictive values than those of any individual biomarker. CONCLUSION The biomarker combinations had better predictive characteristics compared with those of each biomarker alone.
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Affiliation(s)
- Stelios Kokkoris
- First Critical Care Department, Medical School, National and Kapodistrian University of Athens, Evangelismos General Hospital, Athens, Greece
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Abstract
PURPOSE OF REVIEW Expanding rates of acute kidney injury (AKI) coupled with increasing awareness of its short-term and long-term sequelae have focused efforts to identify patients at risk for this disease and its complications. This review details the recent attempts to identify novel risk factors for AKI, describes further refinements in the diagnostic and prognostic approach using biological markers of injury, and highlights the features of AKI that independently predict poor long-term outcomes. RECENT FINDINGS The presence of proteinuria predicts the development of AKI independently of estimated glomerular filtration rate. Initial results from a large prospective study of AKI biomarkers in cardiac surgery indicate lower agreement with serum creatinine as an AKI standard than observed in early studies. AKI severity and duration are important predictors of chronic kidney disease and long-term mortality. A minority of patients surviving AKI with decreased kidney function is seen by a nephrologist. SUMMARY Although the pathophysiologic link is unclear, proteinuria is an easily measurable risk factor for AKI worth considering before anticipated procedures or medication exposures carrying nephrologic risk. Investigation extending beyond agreement with serum creatinine is needed to fully understand the diagnostic and prognostic value of AKI biomarkers. Severity and duration are components of AKI that can help risk-stratify survivors in need of monitoring or nephrology referral.
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Affiliation(s)
- Edward D Siew
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2372, USA.
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Abstract
Despite our increasing ability to support vital organs and resuscitate patients, the morbidity and mortality of acute kidney injury (AKI) remain high in the intensive care unit (ICU). The ability to predict the occurrence of AKI is crucial for the development of preventive strategies. Early diagnosis of AKI requires markers that are sensitive and easily applicable in clinical practice. The use of Doppler ultrasonography to assess renal perfusion is increasing in many kidney diseases and in the ICU. The Doppler-based renal resistive index, which is a simple, rapid, noninvasive, and repeatable marker, could be a promising tool to prematurely detect the patients most at risk of developing AKI in the ICU and to distinguish transient from persistent AKI. Moreover, the resistive index could also be useful to adjust preventive or therapeutic modalities for the kidney perfusion at the bedside. The recent progress in ultrasound with contrast-enhanced ultrasound gives the opportunity to assess not only the kidney macrocirculation but also the kidney microcirculation in the ICU.
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Insuffisance rénale aiguë : intérêt des nouveaux biomarqueurs. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0487-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bivet FG. Nonuse of RIFLE classification urine output criteria: biases for acute kidney injury biomarkers performance assessment? Crit Care Med 2012; 40:1692; author reply 1692-3. [PMID: 22511170 DOI: 10.1097/ccm.0b013e318246b72a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Li Y, Fu C, Zhou X, Xiao Z, Zhu X, Jin M, Li X, Feng X. Urine interleukin-18 and cystatin-C as biomarkers of acute kidney injury in critically ill neonates. Pediatr Nephrol 2012; 27:851-60. [PMID: 22228436 PMCID: PMC3315640 DOI: 10.1007/s00467-011-2072-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 11/03/2011] [Accepted: 11/04/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Urinary interleukin-18 and cystatin-C are suggested to be biomarkers for predicting acute kidney injury (AKI). The aims of this study are to examine whether the urinary concentrations of interleukin-18 and cystatin-C vary with gestational age and other factors in non-AKI control neonates, and to determine whether urinary interleukin-18 and cystatin-C can predict AKI development in non-septic critically ill neonates, independently of potential confounders. METHODS We enrolled 62 non-septic critically ill neonates. Urine was collected every 48-72 h during the first 10 days of life. RESULTS Urinary concentration of cystatin-C, but not interleukin-18, decreased with increasing gestational age and body weight, but not with increasing postnatal age in non-AKI control neonates. Both urinary interleukin-18 and cystatin-C were associated with AKI, even after controlling for gestational and postnatal age, birth weight, gender, Apgar score and the score for neonatal acute physiology in non-septic critically ill neonates. Urinary interleukin-18 and cystatin-C had odds ratios of 2.27 and 2.07, and achieved the area under-the-receiver-operating-characteristic curve of 0.72 and 0.92, respectively, for predicting AKI. CONCLUSIONS The urinary concentration of cystatin-C, but not interleukin-18, may decrease with increasing renal maturity. Both urinary interleukin-18 and cystatin-C are independently predictive of AKI in non-septic critically ill neonates.
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Affiliation(s)
- Yanhong Li
- Department of Nephrology, Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China.
| | - Chenlu Fu
- Department of Nephrology, Children’s Hospital of Soochow University, Suzhou, China
| | - Xiaofei Zhou
- Department of Neonatology, Children’s Hospital of Soochow University, Suzhou, China
| | - Zhihui Xiao
- Department of Neonatology, Children’s Hospital of Soochow University, Suzhou, China
| | - Xueming Zhu
- Institute of Pediatric Research, Children’s Hospital of Soochow University, Suzhou, China
| | - Meifang Jin
- Institute of Pediatric Research, Children’s Hospital of Soochow University, Suzhou, China
| | - Xiaozhong Li
- Department of Nephrology, Children’s Hospital of Soochow University, Suzhou, China
| | - Xing Feng
- Department of Neonatology, Children’s Hospital of Soochow University, Suzhou, China
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Nonuse of RIFLE classification urine output criteria. Crit Care Med 2012. [DOI: 10.1097/ccm.0b013e31824c8fd3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Renal function at hospital admission and mortality due to acute kidney injury after myocardial infarction. PLoS One 2012; 7:e35496. [PMID: 22539974 PMCID: PMC3335121 DOI: 10.1371/journal.pone.0035496] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Accepted: 03/20/2012] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The role of an impaired estimated glomerular filtration rate (eGFR) at hospital admission in the outcome of acute kidney injury (AKI) after acute myocardial infarction (AMI) has been underreported. The aim of this study was to assess the influence of an admission eGFR<60 mL/min/1.73 m(2) on the incidence and early and late mortality of AMI-associated AKI. METHODS A prospective study of 828 AMI patients was performed. AKI was defined as a serum creatinine increase of ≥ 50% from the time of admission (RIFLE criteria) in the first 7 days of hospitalization. Patients were divided into subgroups according to their eGFR upon hospital admission (MDRD formula, mL/min/1.73 m(2)) and the development of AKI: eGFR ≥ 60 without AKI, eGFR<60 without AKI, eGFR ≥ 60 with AKI and eGFR<60 with AKI. RESULTS Overall, 14.6% of the patients in this study developed AKI. The admission eGFR had no impact on the incidence of AKI. However, the admission eGFR was associated with the outcome of AMI-associated AKI. The adjusted hazard ratios (AHR, Cox multivariate analysis) for 30-day mortality were 2.00 (95% CI 1.11-3.61) for eGFR<60 without AKI, 4.76 (95% CI 2.45-9.26) for eGFR ≥ 60 with AKI and 6.27 (95% CI 3.20-12.29) for eGFR<60 with AKI. Only an admission eGFR of <60 with AKI was significantly associated with a 30-day to 1-year mortality hazard (AHR 3.05, 95% CI 1.50-6.19). CONCLUSIONS AKI development was associated with an increased early mortality hazard in AMI patients with either preserved or impaired admission eGFR. Only the association of impaired admission eGFR and AKI was associated with an increased hazard for late mortality among these patients.
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Lv XB, Lian GY, Wang HR, Song E, Yao H, Wang MH. Renal function at hospital admission and mortality due to acute kidney injury after myocardial infarction. PLoS One 2012. [PMID: 23717443 DOI: 10.1371/journal.pone] [Citation(s) in RCA: 476] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The role of an impaired estimated glomerular filtration rate (eGFR) at hospital admission in the outcome of acute kidney injury (AKI) after acute myocardial infarction (AMI) has been underreported. The aim of this study was to assess the influence of an admission eGFR<60 mL/min/1.73 m(2) on the incidence and early and late mortality of AMI-associated AKI. METHODS A prospective study of 828 AMI patients was performed. AKI was defined as a serum creatinine increase of ≥ 50% from the time of admission (RIFLE criteria) in the first 7 days of hospitalization. Patients were divided into subgroups according to their eGFR upon hospital admission (MDRD formula, mL/min/1.73 m(2)) and the development of AKI: eGFR ≥ 60 without AKI, eGFR<60 without AKI, eGFR ≥ 60 with AKI and eGFR<60 with AKI. RESULTS Overall, 14.6% of the patients in this study developed AKI. The admission eGFR had no impact on the incidence of AKI. However, the admission eGFR was associated with the outcome of AMI-associated AKI. The adjusted hazard ratios (AHR, Cox multivariate analysis) for 30-day mortality were 2.00 (95% CI 1.11-3.61) for eGFR<60 without AKI, 4.76 (95% CI 2.45-9.26) for eGFR ≥ 60 with AKI and 6.27 (95% CI 3.20-12.29) for eGFR<60 with AKI. Only an admission eGFR of <60 with AKI was significantly associated with a 30-day to 1-year mortality hazard (AHR 3.05, 95% CI 1.50-6.19). CONCLUSIONS AKI development was associated with an increased early mortality hazard in AMI patients with either preserved or impaired admission eGFR. Only the association of impaired admission eGFR and AKI was associated with an increased hazard for late mortality among these patients.
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Affiliation(s)
- Xiao-Bin Lv
- Medical Research Center Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
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Katagiri D, Doi K, Honda K, Negishi K, Fujita T, Hisagi M, Ono M, Matsubara T, Yahagi N, Iwagami M, Ohtake T, Kobayashi S, Sugaya T, Noiri E. Combination of two urinary biomarkers predicts acute kidney injury after adult cardiac surgery. Ann Thorac Surg 2012; 93:577-83. [PMID: 22269724 DOI: 10.1016/j.athoracsur.2011.10.048] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/14/2011] [Accepted: 10/20/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Urinary L-type fatty acid-binding protein (L-FABP) has not been evaluated for adult post-cardiac surgery acute kidney injury (AKI) to date. This study was undertaken to evaluate a biomarker panel consisting of urinary L-FABP and N-acetyl-β-D-glucosaminidase (NAG), a more established urinary marker of kidney injury, for AKI diagnosis in adult post-cardiac surgery patients. METHODS This study prospectively evaluated 77 adult patients who underwent cardiac surgery at 2 general hospitals. Urinary L-FABP and NAG were measured before surgery, at intensive care unit arrival after surgery (0 hours), 4, and 12 hours after arrival. The AKI was diagnosed by the Acute Kidney Injury Network criteria. RESULTS Of 77 patients, 28 patients (36.4%) developed AKI after surgery. Urinary L-FABP and NAG were significantly increased. However, receiver operating characteristic (ROC) analysis revealed that the biomarkers' performance was statistically significant but limited for clinical translation (area under the curve of ROC [AUC-ROC] for L-FABP at 4 hours 0.72 and NAG 0.75). Urinary L-FABP showed high sensitivity and NAG detected AKI with high specificity. Therefore, we combined these 2 biomarkers, which revealed that this combination panel can detect AKI with higher accuracy than either biomarker measurement alone (AUC-ROC 0.81). Moreover, this biomarker panel improved AKI risk prediction significantly compared with predictions made using the clinical model alone. CONCLUSIONS When urinary L-FABP and NAG are combined, they can detect AKI adequately, even in a heterogeneous population of adult post-cardiac surgery AKI. Combining 2 markers with different sensitivity and specificity presents a reasonable strategy to improve the diagnostic performance of biomarkers.
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Affiliation(s)
- Daisuke Katagiri
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
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