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Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative. Nat Rev Nephrol 2021; 17:605-618. [PMID: 33976395 PMCID: PMC8367817 DOI: 10.1038/s41581-021-00418-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 02/03/2023]
Abstract
Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.
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Wang Z, Wang L, Cao C, Jin H, Zhang Y, Liu Y, Gao Y, Liang X, Li G, Shou S. Heparin Attenuates Histone-Mediated Cytotoxicity in Septic Acute Kidney Injury. Front Med (Lausanne) 2020; 7:586652. [PMID: 33344474 PMCID: PMC7738632 DOI: 10.3389/fmed.2020.586652] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Histones are considered potential risk factors that contribute to the development of septic acute kidney injury (SAKI) by inducing apoptosis and inflammation. This study aimed to explore the protective effects of heparin on septic acute kidney injury through the neutralization of extracellular histones (EH) and to uncover the underlying mechanism. C57BL mice (16 each) were randomly divided into the sham group, the sepsis group (established by cecal ligation and puncture operation, CLP), and the heparin intervention group. Mice in the heparin intervention group received a subcutaneous injection of unfractionated heparin (0.03 IU/g) 4 h after CLP. At 6 h after the operation, nine mice from each group were sacrificed by the removal of the eyeballs to harvest blood samples; the upper half of the right kidney was used as the study sample. Mice renal tubular epithelial cells cultivated in six-well plates were equally divided into five groups. We cultured cells treated with either histone (40 U), histone (40 U) + heparin (25 IU/ml), histone(40U) + lipopolysaccharides (LPS; 10 μg/ml), or histone (40 U) + LPS (10 μg/ml) + heparin (25 IU/ml) for 6 h. For the histone + heparin group and the histone + LPS + heparin group, histone (and LPS) were treated with heparin simultaneously. Mice in the heparin intervention group showed decreased levels of EH4, neutrophil gelatinase-associated lipocalin (NAGL), kidney injury molecule-1 (KIM-1), tumor necrosis factor-α (TNF-α), and interleukin (IL)-6 in the blood serum, longer average 72-h survival rate, significantly decreased kidney tissue edema, and a clearer glomerular structure coupled with decreased protein and mRNA expression levels of kidney apoptosis-related proteins (cleaved Caspase-3/Caspase-3 and Bax/Bcl-2) compared with those in the sepsis group at 6 h after CLP (P < 0.05). Meanwhile, cells in the heparin intervention group exhibited lower expression levels of serum EH4 and inflammatory cytokines, a lower apoptosis rate, and decreased expression of apoptosis-related proteins, both at protein and mRNA levels, than those in the histone-stimulated group at 6 h after stimulation (P < 0.05). Heparin may alleviate apoptosis and inflammation through the neutralization of histones, thus playing a protective role against septic acute kidney injury.
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Affiliation(s)
- Ziyi Wang
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Lijun Wang
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Cao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Heng Jin
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan Zhang
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yancun Liu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yulei Gao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Xue Liang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Songtao Shou
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
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103
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Albert C, Zapf A, Haase M, Röver C, Pickering JW, Albert A, Bellomo R, Breidthardt T, Camou F, Chen Z, Chocron S, Cruz D, de Geus HRH, Devarajan P, Di Somma S, Doi K, Endre ZH, Garcia-Alvarez M, Hjortrup PB, Hur M, Karaolanis G, Kavalci C, Kim H, Lentini P, Liebetrau C, Lipcsey M, Mårtensson J, Müller C, Nanas S, Nickolas TL, Pipili C, Ronco C, Rosa-Diez GJ, Ralib A, Soto K, Braun-Dullaeus RC, Heinz J, Haase-Fielitz A. Neutrophil Gelatinase-Associated Lipocalin Measured on Clinical Laboratory Platforms for the Prediction of Acute Kidney Injury and the Associated Need for Dialysis Therapy: A Systematic Review and Meta-analysis. Am J Kidney Dis 2020; 76:826-841.e1. [PMID: 32679151 PMCID: PMC8283708 DOI: 10.1053/j.ajkd.2020.05.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 05/24/2020] [Indexed: 01/02/2023]
Abstract
RATIONALE & OBJECTIVE The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction. STUDY DESIGN Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines. SETTING & STUDY POPULATIONS Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms. SELECTION CRITERIA FOR STUDIES PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI. DATA EXTRACTION Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis. ANALYTICAL APPROACH Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses. RESULTS We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively. LIMITATIONS Practice variability in initiation of dialysis. Imperfect harmonization of data across studies. CONCLUSIONS Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.
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Affiliation(s)
- Christian Albert
- University Clinic for Cardiology and Angiology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany; Diaverum Renal Services Germany, Potsdam, Germany.
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Michael Haase
- Faculty of Medicine, Otto-von-Guericke University, Magdeburg, Germany; Diaverum Renal Services Germany, Potsdam, Germany
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - John W Pickering
- Department of Medicine, University of Otago Christchurch; Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Annemarie Albert
- Diaverum Renal Services Germany, Potsdam, Germany; Department for Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, The Austin Hospital, Melbourne, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Tobias Breidthardt
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Nephrology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Fabrice Camou
- Service de réanimation médicale, hôpital Saint-André, CHU de Bordeaux, France
| | - Zhongquing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangdong, China
| | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Dinna Cruz
- Division of Nephrology-Hypertension, University of California, San Diego, CA
| | - Hilde R H de Geus
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH
| | - Salvatore Di Somma
- Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sapienza' University of Rome S. Andrea Hospital, Rome, Italy
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | | | - Peter B Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Cemil Kavalci
- Emergency Department, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Hanah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Paolo Lentini
- Department of Nephrology and Dialysis, San Bassiano Hospital, Bassano del Grappa, Italy
| | | | - Miklós Lipcsey
- CIRRUS, Hedenstierna laboratory, Anaesthesiology and Intensive care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Mårtensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Christian Müller
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Nephrology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Serafim Nanas
- First Critical Care Department, 'Evangelismos' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas L Nickolas
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Chrysoula Pipili
- First Critical Care Department, 'Evangelismos' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Claudio Ronco
- Department of Nephrology, Dialysis & Transplantation, University of Padova, Vicenza, Italy; International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Guillermo J Rosa-Diez
- Department of Nephrology, Dialysis and Transplantation, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Azrina Ralib
- Department of Anaesthesiology and Intensive Care, International Islamic University Malaysia, Pahang, Malaysia
| | - Karina Soto
- Department of Nephrology, Hospital Fernando Fonseca, Lisbon, Portugal; CEAUL, Centro de Estatística e Aplicações da Universidade de Lisboa, Lisbon, Portugal
| | - Rüdiger C Braun-Dullaeus
- University Clinic for Cardiology and Angiology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| | - Judith Heinz
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane, Faculty of Health Sciences, University of Potsdam, Potsdam, Germany
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104
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Koeze J, van der Horst ICC, Keus F, Wiersema R, Dieperink W, Kootstra-Ros JE, Zijlstra JG, van Meurs M. Plasma neutrophil gelatinase-associated lipocalin at intensive care unit admission as a predictor of acute kidney injury progression. Clin Kidney J 2020; 13:994-1002. [PMID: 33391742 PMCID: PMC7769547 DOI: 10.1093/ckj/sfaa002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication in patients during intensive care unit (ICU) admission. AKI is defined as an increase in serum creatinine (SCr) and/or a reduction in urine output. SCr is a marker of renal function with several limitations, which led to the search for biomarkers for earlier AKI detection. Our aim was to study the predictive value of plasma neutrophil gelatinase-associated lipocalin (NGAL) at admission as a biomarker for AKI progression during the first 48 h of ICU admission in an unselected, heterogeneous ICU patient population. METHODS We conducted a prospective observational study in an academic tertiary referral ICU population. We recorded AKI progression in all ICU patients during the first 48 h of ICU admission in a 6-week period. Plasma NGAL was measured at admission but levels were not reported to the attending clinicians. As possible predictors of AKI progression, pre-existing AKI risk factors were recorded. We examined the association of clinical parameters and plasma NGAL levels at ICU admission with the incidence and progression of AKI within the first 48 h of the ICU stay. RESULTS A total of 361 patients were included. Patients without AKI progression during the first 48 h of ICU admission had median NGAL levels at admission of 115 ng/mL [interquartile range (IQR) 81-201]. Patients with AKI progression during the first 48 h of ICU admission had median NGAL levels at admission of 156 ng/mL (IQR 97-267). To predict AKI progression, a multivariant model with age, sex, diabetes mellitus, body mass index, admission type, Acute Physiology and Chronic Health Evaluation score and SCr at admission had an area under the receiver operating characteristics (ROC) curve of 0.765. Adding NGAL to this model showed a small increase in the area under the ROC curve to 0.783 (95% confidence interval 0.714-0.853). CONCLUSIONS NGAL levels at admission were higher in patients with progression of AKI during the first 48 h of ICU admission, but adding NGAL levels at admission to a model predicting this AKI progression showed no significant additive value.
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Affiliation(s)
- Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wim Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jenny E Kootstra-Ros
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Medical Biology Section, Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Medical Biology Section, Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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105
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Ilaria G, Kianoush K, Ruxandra B, Francesca M, Mariarosa C, Davide G, Claudio R. Clinical adoption of Nephrocheck® in the early detection of acute kidney injury. Ann Clin Biochem 2020; 58:6-15. [PMID: 33081495 DOI: 10.1177/0004563220970032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury is a common complication of acute illnesses and is associated with increased morbidity and mortality. Over the past years several acute kidney injury biomarkers for diagnostication, decision-making processes, and prognosis of acute kidney injury and its outcomes have been developed and validated. Among these biomarkers, tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7), the so-called cell cycle arrest biomarkers, showed a superior profile of accuracy and stability even in patients with substantial comorbidities. Therefore, in 2014, the US Food and Drug Administration approved the use of the product of TIMP-2 and IGFBP7 ([TIMP-2] × [IGFBP7]), known as cell cycle arrest biomarkers, to aid critical care physicians and nephrologists in the early prediction of acute kidney injury in the critical care setting. To date, Nephrocheck® is the only commercially available test for [TIMP-2] × [IGFBP7]. In this narrative review, we describe the growing clinical and investigational momentum of biomarkers, focusing on [TIMP-2] × [IGFBP7], as one of the most promising candidate biomarkers. Additionally, we review the current state of clinical implementation of Nephrocheck®.
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Affiliation(s)
- Godi Ilaria
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy.,Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care Medicine, University of Padova, Padova, Italy
| | - Kashani Kianoush
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Boteanu Ruxandra
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy
| | - Martino Francesca
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Carta Mariarosa
- Clinical Chemistry and Laboratory medicine, San Bortolo Hospital, Vicenza, Italy
| | - Giavarina Davide
- Clinical Chemistry and Laboratory medicine, San Bortolo Hospital, Vicenza, Italy
| | - Ronco Claudio
- International Renal Research Institute of Vicenza (IRRIV) San Bortolo Hospital, Vicenza, Italy.,Department of Medicine, University of Padova, Padova, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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106
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Kurth MJ, McBride WT, McLean G, Watt J, Domanska A, Lamont JV, Maguire D, Fitzgerald P, Ruddock MW. Acute kidney injury risk in orthopaedic trauma patients pre and post surgery using a biomarker algorithm and clinical risk score. Sci Rep 2020; 10:20005. [PMID: 33203963 PMCID: PMC7673130 DOI: 10.1038/s41598-020-76929-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 10/23/2020] [Indexed: 12/22/2022] Open
Abstract
Acute kidney injury (AKI) after major trauma is associated with increased mortality. The aim of this study was to assess if measurement of blood biomarkers in combination with clinical characteristics could be used to develop a tool to assist clinicians in identifying which orthopaedic trauma patients are at risk of AKI. This is a prospective study of 237 orthopaedic trauma patients who were consecutively scheduled for open reduction and internal fixation of their fracture between May 2012 and August 2013. Clinical characteristics were recorded, and 28 biomarkers were analysed in patient blood samples. Post operatively a combination of H-FABP, sTNFR1 and MK had the highest predictive ability to identify patients at risk of developing AKI (AUROC 0.885). Three clinical characteristics; age, dementia and hypertension were identified in the orthopaedic trauma patients as potential risks for the development of AKI. Combining biomarker data with clinical characteristics allowed us to develop a proactive AKI clinical tool, which grouped patients into four risk categories that were associated with a clinical management regime that impacted patient care, management, length of hospital stay, and efficient use of hospital resources.
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Affiliation(s)
- Mary Jo Kurth
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - William T McBride
- Department of Cardiac Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Gavin McLean
- Trauma and Orthopaedics, Craigavon Area Hospital, 68 Lurgan Road, Portadown, Craigavon, BT63 5QQ, Northern Ireland, UK
| | - Joanne Watt
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Anna Domanska
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - John V Lamont
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Daniel Maguire
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Peter Fitzgerald
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Mark W Ruddock
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK.
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107
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Allegretti AS, Solà E, Ginès P. Clinical Application of Kidney Biomarkers in Cirrhosis. Am J Kidney Dis 2020; 76:710-719. [DOI: 10.1053/j.ajkd.2020.03.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/09/2020] [Indexed: 12/14/2022]
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108
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Abstract
Acute kidney injury (AKI) is a threatening medical condition associated with poor outcomes at different settings. The development of standardized diagnostic criteria and new biomarkers addressed significant clinical impacts of AKI and the need for an early AKI detection, respectively. There have been some breakthroughs in understanding the pathogenesis of AKI through basic research; however, treatments against AKI aside from renal replacement therapy (RRT) have not shown adequate successful results. Biomarkers that could identify good responders to certain treatment are expected to facilitate translation of basic research findings. Most patients with severe AKI treated with RRT died due to multiple-organ failure, not renal dysfunction. Hence, it is essential to identify other organ dysfunctions induced by AKI as organ crosstalk. Also, a multidisciplinary approach of critical care nephrology is needed to evaluate a complex organ crosstalk in AKI. For disruptive innovation for AKI, we further explore these new aspects of AKI, which previously were considered outside the scope of nephrology.
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Affiliation(s)
- Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, 113-8655, Japan.
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109
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Meisner A, Parikh CR, Kerr KF. Developing biomarker combinations in multicenter studies via direct maximization and penalization. Stat Med 2020; 39:3412-3426. [PMID: 32794249 PMCID: PMC10556091 DOI: 10.1002/sim.8673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 04/30/2020] [Accepted: 06/05/2020] [Indexed: 01/14/2023]
Abstract
Motivated by a study of acute kidney injury, we consider the setting of biomarker studies involving patients at multiple centers where the goal is to develop a biomarker combination for diagnosis, prognosis, or screening. As biomarker studies become larger, this type of data structure will be encountered more frequently. In the presence of multiple centers, one way to assess the predictive capacity of a given combination is to consider the center-adjusted area under the receiver operating characteristic curve (aAUC), a summary of the ability of the combination to discriminate between cases and controls in each center. Rather than using a general method, such as logistic regression, to construct the biomarker combination, we propose directly maximizing the aAUC. Furthermore, it may be desirable to have a biomarker combination with similar performance across centers. To that end, we allow for penalization of the variability in the center-specific AUCs. We demonstrate desirable asymptotic properties of the resulting combinations. Simulations provide small-sample evidence that maximizing the aAUC can lead to combinations with improved performance. We also use simulated data to illustrate the utility of constructing combinations by maximizing the aAUC while penalizing variability. Finally, we apply these methods to data from the study of acute kidney injury.
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Affiliation(s)
- Allison Meisner
- Department of Biostatistics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
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110
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Zong Q, Ge M, Chen T, Chen C, Wang Z, Wang D. Risk factors and long-term outcomes of acute kidney injury complication after type A acute aortic dissection surgery in young patients. J Cardiothorac Surg 2020; 15:315. [PMID: 33059693 PMCID: PMC7560008 DOI: 10.1186/s13019-020-01365-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/05/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify risk factors and long-term outcomes of acute kidney injury (AKI) in young patients who underwent type A acute aortic dissection (TA-AAD) emergency surgeries. METHODS This retrospective study enrolled 121 consecutive patients less than 40 years old who received TA-AAD emergency surgeries between January 2014 to December 2018 in Nanjing Drum Tower hospital. The diagnosis of AKI was made based on the KDIGO criteria. Multivariable regression analysis was performed to identify risk factors for postoperative AKI. Kaplan-Meier curves were generated to compare long-term outcomes between patients with and without AKI complication after TA-AAD surgeries. RESULTS Among all enrolled patients, AKI occurred in 51 patients (42.1%) and renal replacement therapy (RRT) was required in 15 patients (12.4%). The development of postoperative AKI was associated with increased 30-day mortality (P = 0.041), longer ICU stay time (P < 0.001) and hospital stay time (P = 0.006). Multivariable analysis indicated that elevated preoperative serum cystatin C (sCyC) (OR = 6.506, 95% CI: 1.852-22.855, P = 0.003) was the only independent risk factor for developing AKI. The areas under the receiver-operating characteristic curve (AUC) of preoperative sCyC was 0.800 (95% CI: 0.719, 0.882). Preoperative sCyC had a sensitivity of 64.7% and a specificity of 83.8% in diagnosing postoperative AKI with a cut-off value of 0.895 mg/L. In addition, our data suggested there was no difference discovered regarding long-term cumulative survival rate between patients with and without AKI during a median 29 months follow-up period. CONCLUSIONS Postoperative AKI after TA-AAD surgeries was relatively common in young patients and associated with increased short-term mortality. Elevated preoperative sCyC was identified as an independent risk factor for AKI with potential diagnostic merit.
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Affiliation(s)
- Qiuyan Zong
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Min Ge
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Tao Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Cheng Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Zhigang Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Dongjin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China.
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Chapman CL, Johnson BD, Parker MD, Hostler D, Pryor RR, Schlader Z. Kidney physiology and pathophysiology during heat stress and the modification by exercise, dehydration, heat acclimation and aging. Temperature (Austin) 2020; 8:108-159. [PMID: 33997113 PMCID: PMC8098077 DOI: 10.1080/23328940.2020.1826841] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
The kidneys' integrative responses to heat stress aid thermoregulation, cardiovascular control, and water and electrolyte regulation. Recent evidence suggests the kidneys are at increased risk of pathological events during heat stress, namely acute kidney injury (AKI), and that this risk is compounded by dehydration and exercise. This heat stress related AKI is believed to contribute to the epidemic of chronic kidney disease (CKD) occurring in occupational settings. It is estimated that AKI and CKD affect upwards of 45 million individuals in the global workforce. Water and electrolyte disturbances and AKI, both of which are representative of kidney-related pathology, are the two leading causes of hospitalizations during heat waves in older adults. Structural and physiological alterations in aging kidneys likely contribute to this increased risk. With this background, this comprehensive narrative review will provide the first aggregation of research into the integrative physiological response of the kidneys to heat stress. While the focus of this review is on the human kidneys, we will utilize both human and animal data to describe these responses to passive and exercise heat stress, and how they are altered with heat acclimation. Additionally, we will discuss recent studies that indicate an increased risk of AKI due to exercise in the heat. Lastly, we will introduce the emerging public health crisis of older adults during extreme heat events and how the aging kidneys may be more susceptible to injury during heat stress.
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Affiliation(s)
- Christopher L. Chapman
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
| | - Blair D. Johnson
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Mark D. Parker
- Department of Physiology and Biophysics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - David Hostler
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Riana R. Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, USA
| | - Zachary Schlader
- Department of Kinesiology, School of Public Health, Indiana University, Bloomington, IN, USA
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Liu C, Mor MK, Palevsky PM, Kaufman JS, Thiessen Philbrook H, Weisbord SD, Parikh CR. Postangiography Increases in Serum Creatinine and Biomarkers of Injury and Repair. Clin J Am Soc Nephrol 2020; 15:1240-1250. [PMID: 32839195 PMCID: PMC7480551 DOI: 10.2215/cjn.15931219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES It is unknown whether iodinated contrast causes kidney parenchymal damage. Biomarkers that are more specific to nephron injury than serum creatinine may provide insight into whether contrast-associated AKI reflects tubular damage. We assessed the association between biomarker changes after contrast angiography with contrast-associated AKI and 90-day major adverse kidney events and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal analysis of participants from the biomarker substudy of the Prevention of Serious Adverse Events following Angiography trial. We measured injury (kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, IL-18) and repair (monocyte chemoattractant protein-1, uromodulin, YKL-40) proteins from plasma and urine samples at baseline and 2-4 hours postangiography. We assessed the associations between absolute changes and relative ratios of biomarkers with contrast-associated AKI and 90-day major adverse kidney events and death. RESULTS Participants (n=922) were predominately men (97%) with diabetes (82%). Mean age was 70±8 years, and eGFR was 48±13 ml/min per 1.73 m2; 73 (8%) and 60 (7%) participants experienced contrast-associated AKI and 90-day major adverse kidney events and death, respectively. No postangiography urine biomarkers were associated with contrast-associated AKI. Postangiography plasma kidney injury molecule-1 and IL-18 were significantly higher in participants with contrast-associated AKI compared with those who did not develop contrast-associated AKI: 428 (248, 745) versus 306 (179, 567) mg/dl; P=0.04 and 325 (247, 422) versus 280 (212, 366) mg/dl; P=0.009, respectively. The majority of patients did not experience an increase in urine or plasma biomarkers. Absolute changes in plasma IL-18 were comparable in participants with contrast-associated AKI (-30 [-71, -9] mg/dl) and those without contrast-associated AKI (-27 [-53, -10] mg/dl; P=0.62). Relative ratios of plasma IL-18 were also comparable in participants with contrast-associated AKI (0.91; 0.86, 0.97) and those without contrast-associated AKI (0.91; 0.85, 0.96; P=0.54). CONCLUSIONS The lack of significant differences in the absolute changes and relative ratios of injury and repair biomarkers by contrast-associated AKI status suggests that the majority of mild contrast-associated AKI cases may be driven by hemodynamic changes at the kidney.
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Affiliation(s)
- Caroline Liu
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania .,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Paul M Palevsky
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - James S Kaufman
- Division of Nephrology, Veterans Affairs New York Harbor Healthcare System and New York University School of Medicine, New York, New York
| | | | - Steven D Weisbord
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal Section, Medical Service and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bjornstad EC, Muronya W, Kamija M, Smith Z, Munthali CK, Gibson K, Mottl AK, Charles A, Marshall SW, Golightly YM, Gower EW. Validity of Urine NGALds Dipstick for Acute Kidney Injury in a Malawian Trauma Cohort. Kidney Int Rep 2020; 5:1791-1798. [PMID: 33102973 PMCID: PMC7569698 DOI: 10.1016/j.ekir.2020.07.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/24/2020] [Accepted: 07/17/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Acute kidney injury (AKI) is a major cause of mortality worldwide, particularly in low-resource settings with limited diagnostic testing. Neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in predicting AKI. Nested within a larger, prospective cohort study evaluating AKI incidence in admitted trauma patients, our objective was to evaluate a novel dipstick, NGALds, for the prediction of AKI in Malawi, Africa. Methods Participants were >6 months of age. Spearman rank correlation coefficients (R) assessed NGAL categories (negative [≤50 ng/ml], low risk [51−149 ng/ml], moderate risk [150−299 ng/ml], and high risk [≥300 ng/ml]) for the urine NGALds dipstick and laboratory-based NGAL Test. Results We enrolled 285 participants (one-third children). Thirteen percent developed AKI. The dipstick captured 45 of 52 participants (86.5%) with moderate- or high-risk NGAL values on laboratory-based testing (R = 0.74). The dipstick had sensitivity of 44.4%, specificity of 73.5%, positive predictive value of 19.5%, and negative predictive value of 90.2% for predicting AKI. Acute kidney injury was associated with an increased risk of mortality (relative risk [RR] = 3.9, 95% confidence interval [CI] = 1.9−8.2), but mortality risk greatly increased among children who first had a positive (≥150 ng/ml) NGALds result (RR = 12.0, 95% CI = 1.8−78.4). Conclusions The NGALds dipstick performed similarly to the NGAL Test in this low-resource setting and may be a useful tool to rule out AKI. It may be even more important in predicting high mortality risk among children.
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Affiliation(s)
- Erica C Bjornstad
- Department of Pediatrics, Division of Nephrology, University of Alabama Birmingham, Alabama, USA.,Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, North Carolina, USA
| | - William Muronya
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Manly Kamija
- Univeristy of North Carolina Project Malawi, Lilongwe, Malawi
| | - Zachary Smith
- Univeristy of North Carolina Project Malawi, Lilongwe, Malawi.,Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Charles K Munthali
- Department of Medicine, Renal Unit, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Keisha Gibson
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amy K Mottl
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Malawi Surgical Initiative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen W Marshall
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, North Carolina, USA.,University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Yvonne M Golightly
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, North Carolina, USA.,University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Emily W Gower
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, North Carolina, USA
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Elevated Urinary Neutrophil Gelatinase-Associated Lipocalin Is a Biomarker for Lupus Nephritis: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2768326. [PMID: 32685458 PMCID: PMC7346103 DOI: 10.1155/2020/2768326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/30/2020] [Indexed: 01/20/2023]
Abstract
Objective Lupus nephritis (LN) is a major and severe complication of systemic lupus erythematosus (SLE). Neutrophil gelatinase-associated lipocalin (NGAL), as a promising next-generation biomarker in clinical nephrology, has received extensive attention. However, its diagnostic performance in LN has high variability. Therefore, we performed an updated meta-analysis to further evaluate the diagnostic accuracy of urinary NGAL (uNGAL). Materials and Methods PubMed, Embase, and Cochrane Library were searched from inception to October 27, 2019. Meta-analysis was performed with a bivariate random effects model. Additionally, the summary receiver operating characteristic (SROC) curves were established. The sources of heterogeneity were explored by meta-regression, subgroup analysis, and sensitivity analysis. Publication bias was assessed using the Deeks test. Results 19 articles consisting of 21 eligible studies were included. In diagnosing LN, the estimates (95% confidence interval (CI)) were as follows: sensitivity, 0.84 (0.71-0.91); specificity, 0.91 (0.70-0.98); and the SROC-AUC value, 0.92 (0.90-0.94). In identifying active LN, the estimates were as follows: sensitivity, 0.72 (0.56-0.84); specificity, 0.71 (0.51-0.84); and the AUC value, 0.77 (0.74-0.81). With respect to predicting renal flare, the estimates were as follows: sensitivity, 0.80 (0.57-0.92); specificity, 0.67 (0.58-0.75); and the AUC value, 0.74 (0.70-0.78). For the studies to distinguish proliferative LN, the estimates were as follows: sensitivity, 0.87 (0.66-0.97), and specificity, 0.69 (0.39-0.91). Deeks' funnel plot suggested that there was no significant publication bias. Conclusions Our meta-analysis indicates that uNGAL was a useful biomarker for diagnosis, estimation of activity, and prediction of renal flare of LN. In addition, the usefulness of uNGAL to distinguish pathological types of LN needs to be further investigated.
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Kamenshchikov NO, Anfinogenova YJ, Kozlov BN, Svirko YS, Pekarskiy SE, Evtushenko VV, Lugovsky VA, Shipulin VM, Lomivorotov VV, Podoksenov YK. Nitric oxide delivery during cardiopulmonary bypass reduces acute kidney injury: A randomized trial. J Thorac Cardiovasc Surg 2020; 163:1393-1403.e9. [PMID: 32718702 DOI: 10.1016/j.jtcvs.2020.03.182] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of nitric oxide (NO) supplementation to the CPB circuit on the development of cardiac surgery-associated AKI. METHODS This prospective randomized controlled study included 96 patients with moderate risk of renal complications who underwent elective cardiac surgery with CPB. The study protocol was registered at ClinicalTrials.gov (identifier NCT03527381). Patients were randomly allocated to either NO supplementation to the CPB bypass circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, 40-ppm NO was administered during the entire CPB period. The primary outcome was the incidence of AKI. RESULTS NO treatment was associated with a significant decrease in AKI incidence (10 cases [20.8%] vs 20 cases [41.6%] in the control group; relative risk, 0.5; 95% confidence interval, 0.26-0.95; P = .023) and a higher median urine output during CPB (2.6 mL/kg/h [interquartile range (IQR), 2.1-5.08 mL/kg/h] vs 1.7 mL/kg/h [IQR, 0.80-2.50 mL/kg/h]; P = .0002). The median urinary neutrophil gelatinase-associated lipocalin level at 4 hours after surgery was significantly lower in the NO treatment group (1.12 ng/mL [IQR, 0.75-5.8 ng/mL] vs 4.62 ng/mL [IQR, 2.02-34.55 ng/mL]; P = .005). In the NO treatment group, concentrations of NO metabolites were significantly increased at 5 minutes postclamping, at 5 minutes after declamping, and at the end of the operation. Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups. CONCLUSIONS NO administration in patients at moderate risk of renal complications undergoing elective cardiac surgery with CPB was associated with a lower incidence of AKI.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia.
| | - Yana J Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Boris N Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
| | - Yulia S Svirko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
| | - Stanislav E Pekarskiy
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Vladimir V Evtushenko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Vladimir A Lugovsky
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Vladimir M Shipulin
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Critical Care, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Yuriy K Podoksenov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia; Department of Cardiovascular Surgery, Siberian State Medical University, Tomsk, Russia
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Li C, Yang J, Xu F, Han D, Zheng S, Kaaya RE, Wang S, Lyu J. A prognostic nomogram for the cancer-specific survival of patients with upper-tract urothelial carcinoma based on the Surveillance, Epidemiology, and End Results Database. BMC Cancer 2020; 20:534. [PMID: 32513124 PMCID: PMC7282122 DOI: 10.1186/s12885-020-07019-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/28/2020] [Indexed: 12/29/2022] Open
Abstract
Background The aim of this study was to establish a comprehensive nomogram for the cancer-specific survival (CSS) of patients with upper-tract urothelial carcinoma (UTUC) and compare it with the traditional American Joint Committee on Cancer (AJCC) staging system in order to determine its reliability. Methods This study analyzed 9505 patients with UTUC in the Surveillance, Epidemiology, and End Results (SEER) database. R software was used to randomly divided the patients in a 7-to-3 ratio to form a training cohort (n = 6653) and a validation cohort (n = 2852). Multivariable Cox regression was used to identify predictive variables. The new survival model was compared with the AJCC prognosis model using the concordance index (C-index), the area under the time-dependent receiver operating characteristics curve (AUC), the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), calibration plotting, and decision-curve analysis (DCA). Results We have established a nomogram for determining the 3-, 5-, and 8-year CSS probabilities of UTUC patients. The nomogram indicates that the AJCC stage has the greatest influence on CSS in UTUC, followed by the age at diagnosis, surgery status, tumor size, radiotherapy status, histological grade, marital status, chemotherapy status, race, and finally sex. The C-index was higher for the nomogram than the AJCC staging system in both the training cohort (0.785 versus 0.747) and the validation cohort (0.779 versus 0.739). Calibration plotting demonstrated that the model has good calibration ability. The AUC, NRI, IDI, and DCA of the nomogram showed that it performs better than the AJCC staging system alone. Conclusions This study is the first to establish a comprehensive UTUC nomogram based on the SEER database and evaluate it using a series of indicators. Our novel nomogram can help clinical staff to predict the 3-, 5-, and 8-year CSS probabilities of UTUC patients more accurately than using the AJCC staging system.
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Affiliation(s)
- Chengzhuo Li
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Jin Yang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Didi Han
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Shuai Zheng
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,School of Public Health, Shaanxi University of Chinese Medicine, Xi'an, Shaanxi, China
| | - Rahel Elishilia Kaaya
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Shengpeng Wang
- Cardiovascular Research Center, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, People's Republic of China. .,Key Laboratory of Environment and Genes Related to Diseases of Ministry of Education, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China.
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China. .,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China.
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Thongprayoon C, Hansrivijit P, Bathini T, Vallabhajosyula S, Mekraksakit P, Kaewput W, Cheungpasitporn W. Predicting Acute Kidney Injury after Cardiac Surgery by Machine Learning Approaches. J Clin Med 2020; 9:jcm9061767. [PMID: 32517295 PMCID: PMC7355827 DOI: 10.3390/jcm9061767] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023] Open
Abstract
Cardiac surgery-associated AKI (CSA-AKI) is common after cardiac surgery and has an adverse impact on short- and long-term mortality. Early identification of patients at high risk of CSA-AKI by applying risk prediction models allows clinicians to closely monitor these patients and initiate effective preventive and therapeutic approaches to lessen the incidence of AKI. Several risk prediction models and risk assessment scores have been developed for CSA-AKI. However, the definition of AKI and the variables utilized in these risk scores differ, making general utility complex. Recently, the utility of artificial intelligence coupled with machine learning, has generated much interest and many studies in clinical medicine, including CSA-AKI. In this article, we discussed the evolution of models established by machine learning approaches to predict CSA-AKI.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | | | - Poemlarp Mekraksakit
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79424, USA;
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
- Correspondence: ; Tel.: +1-601-984-5670; Fax: +1-601-984-5765
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Ugwuowo U, Yamamoto Y, Arora T, Saran I, Partridge C, Biswas A, Martin M, Moledina DG, Greenberg JH, Simonov M, Mansour SG, Vela R, Testani JM, Rao V, Rentfro K, Obeid W, Parikh CR, Wilson FP. Real-Time Prediction of Acute Kidney Injury in Hospitalized Adults: Implementation and Proof of Concept. Am J Kidney Dis 2020; 76:806-814.e1. [PMID: 32505812 DOI: 10.1053/j.ajkd.2020.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/05/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Acute kidney injury (AKI) is diagnosed based on changes in serum creatinine concentration, a late marker of this syndrome. Algorithms that predict elevated risk for AKI are of great interest, but no studies have incorporated such an algorithm into the electronic health record to assist with clinical care. We describe the experience of implementing such an algorithm. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS 2,856 hospitalized adults in a single urban tertiary-care hospital with an algorithm-predicted risk for AKI in the next 24 hours>15%. Alerts were also used to target a convenience sample of 100 patients for measurement of 16 urine and 6 blood biomarkers. EXPOSURE Clinical characteristics at the time of pre-AKI alert. OUTCOME AKI within 24 hours of pre-AKI alert (AKI24). ANALYTICAL APPROACH Descriptive statistics and univariable associations. RESULTS At enrollment, mean predicted probability of AKI24 was 19.1%; 18.9% of patients went on to develop AKI24. Outcomes were generally poor among this population, with 29% inpatient mortality among those who developed AKI24 and 14% among those who did not (P<0.001). Systolic blood pressure<100mm Hg (28% of patients with AKI24 vs 18% without), heart rate>100 beats/min (32% of patients with AKI24 vs 24% without), and oxygen saturation<92% (15% of patients with AKI24 vs 6% without) were all more common among those who developed AKI24. Of all biomarkers measured, only hyaline casts on urine microscopy (72% of patients with AKI24 vs 25% without) and fractional excretion of urea nitrogen (20% [IQR, 12%-36%] among patients with AKI24 vs 34% [IQR, 25%-44%] without) differed between those who did and did not develop AKI24. LIMITATIONS Single-center study, reliance on serum creatinine level for AKI diagnosis, small number of patients undergoing biomarker evaluation. CONCLUSIONS A real-time AKI risk model was successfully integrated into the EHR.
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Affiliation(s)
- Ugochukwu Ugwuowo
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yu Yamamoto
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Tanima Arora
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Ishan Saran
- Department of Physics, Emory University, Atlanta, GA
| | - Caitlin Partridge
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, CT
| | - Aditya Biswas
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Melissa Martin
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Dennis G Moledina
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Jason H Greenberg
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT; Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Michael Simonov
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Sherry G Mansour
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Ricardo Vela
- Department of Mechanical Engineering, University of Texas at El Paso. El Paso, TX
| | - Jeffrey M Testani
- Section of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Veena Rao
- Section of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Keith Rentfro
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Wassim Obeid
- Johns Hopkins University School of Medicine, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chirag R Parikh
- Johns Hopkins University School of Medicine, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - F Perry Wilson
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT.
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119
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Hussain ML, Hamid PF, Chakane N. Will urinary biomarkers provide a breakthrough in diagnosing cardiac surgery-associated AKI? - A systematic review. Biomarkers 2020; 25:375-383. [PMID: 32479185 DOI: 10.1080/1354750x.2020.1777199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Acute kidney injury following cardiac surgery is a dreaded complication contributing to early mortality. Diagnosing AKI using serum creatinine usually results in a delay. To combat this, certain kidney damage specific biomarkers were investigated to identify if they can serve as early predictors of cardiac surgery-associated AKI (CSA-AKI). This study systematically reviews three such biomarkers; NGAL, tissue inhibitor of matrix metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP7) to identify if they can serve as early predictors of CSA-AKI.Methods: Systematic search was carried out on literature reporting the diagnostic ability of the three biomarkers from databases in accordance with PRISMA guidelines.Results: We found 43 articles reporting urinary-NGAL levels (n = 34 in adults, n = 9 in children) and 10 studies reporting TIMP-2 and IGFBP7 levels among adults. Interestingly, NGAL showed high diagnostic value in predicting AKI in children (seven among nine studies with AUROC > 0.8). The cell cycle arrest biomarkers, namely TIMP-2 and IGFBP7, showed high diagnostic value in predicting AKI in adults (five among ten studies with AUROC > 0.8).Conclusion: In predicting CSA-AKI; the diagnostic value of NGAL is high in the paediatric population while the diagnostic value of TIMP-2 and IGFBP7 is high in adults.
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Affiliation(s)
- Mohmmed Laique Hussain
- Medical Research, California Institute of Behavioural Neurosciences and Psychology, Fairfield, CA, USA
| | - Pousette Farouk Hamid
- Medical Research, California Institute of Behavioural Neurosciences and Psychology, Fairfield, CA, USA
| | - Ntema Chakane
- Medical Research, California Institute of Behavioural Neurosciences and Psychology, Fairfield, CA, USA
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120
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Lumlertgul N, Amprai M, Tachaboon S, Dinhuzen J, Peerapornratana S, Kerr SJ, Srisawat N. Urine Neutrophil Gelatinase-associated Lipocalin (NGAL) for Prediction of Persistent AKI and Major Adverse Kidney Events. Sci Rep 2020; 10:8718. [PMID: 32457335 PMCID: PMC7250906 DOI: 10.1038/s41598-020-65764-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/30/2020] [Indexed: 12/29/2022] Open
Abstract
We aimed to determine whether urinary neutrophil gelatinase-associated lipocalin (uNGAL) can accurately predict persistent AKI, major adverse kidney events at 30 days (MAKE30) and 365 days (MAKE365) in hospitalized AKI patients. This is a retrospective study of adult patients who were admitted at King Chulalongkorn Memorial Hospital. We performed multivariable logistic regression for persistent AKI, MAKE30, and MAKE365. We developed equations for predicting MAKE30 and MAKE365 and divided the dataset into derivation and validation cohorts. uNGAL performance and predictive models were assessed using the area under the receiver operating characteristic curve (AROC). Among 1,322 patients with AKI, 76.9%, 45.1%, and 61.7% had persistent AKI, MAKE30, and MAKE365. The AROC were 0.75 (95% confidence interval[CI] 0.70–0.80), 0.66 (95%CI 0.61–0.71), and 0.64 (95%CI 0.59–0.70) for prediction of persistent AKI, MAKE30, and MAKE365 by uNGAL. The AROC in the validation dataset combining uNGAL with clinical covariates were 0.74 (95%CI 0.69–0.79) and 0.72 (95%CI 0.67–0.77) for MAKE30 and MAKE365. We demonstrated an association between uNGAL and persistent AKI, MAKE30, and MAKE365. Prediction models combining uNGAL can modestly predict MAKE30 and MAKE365. Therefore, uNGAL is a useful tool for improving AKI risk stratification.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Monpraween Amprai
- Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sasipha Tachaboon
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Janejira Dinhuzen
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sadudee Peerapornratana
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephen J Kerr
- Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,The Kirby Institute, The University of New South Wales, Sydney, Australia
| | - Nattachai Srisawat
- Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. .,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. .,Academic of Science, Royal Society of Thailand, Bangkok, Thailand. .,Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand. .,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
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121
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Li Y, Xu J, Wang Y, Zhang Y, Jiang W, Shen B, Ding X. A novel machine learning algorithm, Bayesian networks model, to predict the high-risk patients with cardiac surgery-associated acute kidney injury. Clin Cardiol 2020; 43:752-761. [PMID: 32400109 PMCID: PMC7368305 DOI: 10.1002/clc.23377] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CSA-AKI) is a well-recognized complication with an ominous outcome. HYPOTHESIS Bayesian networks (BNs) not only can reveal the complex interrelationships between predictors and CSA-AKI, but predict the individual risk of CSA-AKI occurrence. METHODS During 2013 and 2015, we recruited 5533 eligible participants who underwent cardiac surgery from a tertiary hospital in eastern China. Data on demographics, clinical and laboratory information were prospectively recorded in the electronic medical system and analyzed by gLASSO-logistic regression and BNs. RESULTS The incidences of CSA-AKI and severe CSA-AKI were 37.5% and 11.1%. BNs model revealed that gender, left ventricular ejection fractions (LVEF), serum creatinine (SCr), serum uric acid (SUA), platelet, and aortic cross-clamp time (ACCT) were found as the parent nodes of CSA-AKI, while ultrafiltration volume and postoperative central venous pressure (CVP) were connected with CSA-AKI as children nodes. In the severe CSA-AKI model, age, proteinuria, and SUA were directly linked to severe AKI; the new nodes of NYHA grade and direct bilirubin created relationships with severe AKI through was related to LVEF, surgery types, and SCr level. The internal AUCs for predicting CSA-AKI and severe AKI were 0.755 and 0.845, which remained 0.736 and 0.816 in the external validation. Given the known variables, the risk for CSA-AKI can be inferred at individual levels based on the established BNs model and prior information. CONCLUSION BNs model has a high accuracy, good interpretability, and strong generalizability in predicting CSA-AKI. It facilitates physicians to identify high-risk patients and implement protective strategies to improve the prognosis.
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Affiliation(s)
- Yang Li
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Jiarui Xu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Yimei Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Yunlu Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Wuhua Jiang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Bo Shen
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Medical Center of Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China.,Hemodialysis Quality Control Center of Shanghai, Shanghai, China
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Abstract
The current unidimensional paradigm of kidney disease detection is incompatible with the complexity and heterogeneity of renal pathology. The diagnosis of kidney disease has largely focused on glomerular filtration, while assessment of kidney tubular health has notably been absent. Following insult, the kidney tubular cells undergo a cascade of cellular responses that result in the production and accumulation of low-molecular-weight proteins in the urine and systemic circulation. Modern advancements in molecular analysis and proteomics have allowed the identification and quantification of these proteins as biomarkers for assessing and characterizing kidney diseases. In this review, we highlight promising biomarkers of kidney tubular health that have strong underpinnings in the pathophysiology of kidney disease. These biomarkers have been applied to various specific clinical settings from the spectrum of acute to chronic kidney diseases, demonstrating the potential to improve patient care.
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Affiliation(s)
- William R Zhang
- Kidney Health Research Collaborative, University of California San Francisco School of Medicine, San Francisco, California 94121, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA;
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123
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Griffin BR, Gist KM, Faubel S. Current Status of Novel Biomarkers for the Diagnosis of Acute Kidney Injury: A Historical Perspective. J Intensive Care Med 2020; 35:415-424. [PMID: 30654681 PMCID: PMC7333543 DOI: 10.1177/0885066618824531] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is a common and serious medical condition associated with significant increases in morbidity, mortality, and cost of care. Because of the high incidence and poor outcomes associated with AKI, there has been significant interest in the development of new therapies for the prevention and treatment of the disease. A lack of efficacy in drug trials led to the concern that AKI was not being diagnosed early enough for an effective intervention and that a rise in serum creatinine itself is not a sensitive-enough marker. Researchers have been searching for novel biomarkers that can not only assess a decline in kidney function but also demonstrate structural damage to the kidney and at time points earlier than increases in serum creatinine measurements allow. Over the past 10 years, there have been 3300 new publications and hundreds of new biomarkers investigated, yet concern still remains regarding AKI biomarker performance. The AKI biomarkers are yet to be widely utilized in clinical practice, leading some to question whether AKI biomarkers will ever reach their initial promise. However, we believe that biomarkers are an important part of current and future AKI research and clinical management. In this review, we compare the historical contexts of acute myocardial ischemia and AKI biomarker development to illustrate the progress that has been made within AKI biomarker research in a relatively short period of time and also to point out key differences between the disease processes that have been barriers to widespread AKI biomarker adoption. Finally, we discuss potential paths by which biomarkers can lead to appropriate AKI treatment responses that lower morbidity and mortality.
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Affiliation(s)
- Benjamin R. Griffin
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M. Gist
- Department of Pediatrics, The Heart Institute, University of Colorado, Aurora, CO, USA
| | - Sarah Faubel
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Renal Section, Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA
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124
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Thongprayoon C, Hansrivijit P, Kovvuru K, Kanduri SR, Torres-Ortiz A, Acharya P, Gonzalez-Suarez ML, Kaewput W, Bathini T, Cheungpasitporn W. Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm. J Clin Med 2020; 9:E1104. [PMID: 32294894 PMCID: PMC7230860 DOI: 10.3390/jcm9041104] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Karthik Kovvuru
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Swetha R. Kanduri
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Aldo Torres-Ortiz
- Department of Medicine, Ochsner Medical Center, New Orleans, LA 70121, USA;
| | - Prakrati Acharya
- Division of Nephrology, Department of Medicine, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA;
| | - Maria L. Gonzalez-Suarez
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
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Küllmar M, Massoth C, Ostermann M, Campos S, Grau Novellas N, Thomson G, Haffner M, Arndt C, Wulf H, Irqsusi M, Monaco F, Di Prima A, Garcia Alvarez M, Italiano S, Cegarra SanMartin V, Kunst G, Nair S, L'Acqua C, Hoste EAJ, Vandenberghe W, Honore PM, Kellum J, Forni L, Grieshaber P, Weiss R, Gerss J, Wempe C, Meersch M, Zarbock A. Biomarker-guided implementation of the KDIGO guidelines to reduce the occurrence of acute kidney injury in patients after cardiac surgery (PrevAKI-multicentre): protocol for a multicentre, observational study followed by randomised controlled feasibility trial. BMJ Open 2020; 10:e034201. [PMID: 32265240 PMCID: PMC7245412 DOI: 10.1136/bmjopen-2019-034201] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/09/2020] [Accepted: 03/04/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is a frequent complication after cardiac surgery with adverse short-term and long-term outcomes. Although prevention of AKI (PrevAKI) is strongly recommended, the optimal strategy is uncertain. The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommended a bundle of supportive measures in high-risk patients. In a single-centre trial, we recently demonstrated that the strict implementation of the KDIGO bundle significantly reduced the occurrence of AKI after cardiac surgery. In this feasibility study, we aim to evaluate whether the study protocol can be implemented in a multicentre setting in preparation for a large multicentre trial. METHODS AND ANALYSIS We plan to conduct a prospective, observational survey followed by a randomised controlled, multicentre, multinational clinical trial including 280 patients undergoing cardiac surgery with cardiopulmonary bypass. The purpose of the observational survey is to explore the adherence to the KDIGO recommendations in routine clinical practice. The second phase is a randomised controlled trial. The objective is to investigate whether the trial protocol is implementable in a large multicentre, multinational setting. The primary endpoint of the interventional part is the compliance rate with the protocol. Secondary endpoints include the occurrence of any AKI and moderate/severe AKI as defined by the KDIGO criteria within 72 hours after surgery, renal recovery at day 90, use of renal replacement therapy (RRT) and mortality at days 30, 60 and 90, the combined endpoint major adverse kidney events consisting of persistent renal dysfunction, RRT and mortality at day 90 and safety outcomes. ETHICS AND DISSEMINATION The PrevAKI multicentre study has been approved by the leading Research Ethics Committee of the University of Münster and the respective Research Ethics Committee at each participating site. The results will be used to design a large, definitive trial. TRIAL REGISTRATION NUMBER NCT03244514.
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Affiliation(s)
- Mira Küllmar
- Anesthesiology, Intensive Care and Pain Medicine, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
| | - Christina Massoth
- Anesthesiology, Intensive Care and Pain Medicine, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Sara Campos
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Neus Grau Novellas
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Gary Thomson
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael Haffner
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Christian Arndt
- Department of Anesthesiology and Operative Intensive Care, University Hospital Marburg, Marburg, UK
| | - Hinnerk Wulf
- Anesthesiology & Intensive Care Medicine, Philipps-Universitat Marburg Fachbereich Medizin, Marburg, Germany
| | - Marc Irqsusi
- Department of Cardiothoracic Surgery, Philipps-Universitat Marburg Fachbereich Medizin, Marburg, Germany
| | - Fabrizio Monaco
- Intensive Care and Anesthesia Unit, Scientific Institute San Raffaele, Milano, Italy
| | - Ambra Di Prima
- Intensive Care and Anesthesia Unit, Scientific Institute San Raffaele, Milano, Italy
| | - Mercedes Garcia Alvarez
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
| | - Stefano Italiano
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
| | | | - Gudrun Kunst
- Department of Anesthesia, Critical Care and Pain, King's College London, London, UK
| | - Shrijit Nair
- Department of Anesthesia, Critical Care and Pain, King's College London, London, UK
| | - Camilla L'Acqua
- Department of Anesthesia and Critical Care, Centro Cardiologico Monzino IRCCS, Milano, Lombardia, Italy
| | | | | | | | - John Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lui Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital NHS Trust, Guildford, Surrey, UK
| | - Philippe Grieshaber
- Department of Cardiac Surgery, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Raphael Weiss
- Department of Anaesthesiology, University Hospital Münster, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Carola Wempe
- Anesthesiology, Intensive Care and Pain Medicine, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
| | - Melanie Meersch
- Anesthesiology, Intensive Care and Pain Medicine, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
| | - Alexander Zarbock
- Anesthesiology, Intensive Care and Pain Medicine, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
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Abstract
Several biomarkers have been developed to detect acute kidney injury (AKI) and predict outcomes. Most AKI biomarkers have been shown to be expressed before serum creatinine and to be more sensitive and specific than urine output. Only a few studies have examined how implementation can change clinical outcomes. A second generation of AKI biomarkers have been developed. These markers, including tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulinlike growth factor-binding protein 7 (IGFBP7), have obtained regulatory approval in many countries based on large, rigorous clinical studies and small, single-centered trials and have begun to establish clinical utility.
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127
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Baek HS, Lee Y, Jang HM, Cho J, Hyun MC, Kim YH, Hwang SK, Cho MH. Variation in clinical usefulness of biomarkers of acute kidney injury in young children undergoing cardiac surgery. Clin Exp Pediatr 2020; 63:151-156. [PMID: 32023398 PMCID: PMC7170782 DOI: 10.3345/cep.2019.00913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/11/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is one of the most significant postoperative complications of pediatric cardiac surgery. Because serum creatinine has limitations as a diagnostic marker of AKI, new biomarkers including neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) are being evaluated to overcome these limitations and detect AKI at an early stage after cardiac surgery. PURPOSE This study aimed to investigate the clinical usefulness of these biomarkers in young children. METHODS Thirty patients with congenital heart diseases who underwent cardiac surgery using cardiopulmonary bypass (CPB) were selected, and their urine and blood samples were collected at baseline and 6, 24, and 48 hours after surgery. Serum creatinine and blood urea nitrogen levels as well as NGAL, KIM-1, and IL-18 levels in urine samples were measured, and clinical parameters were evaluated. RESULTS Of the 30 patients, 12 developed AKI within 48 hours after cardiac surgery. In the AKI group, 8 of 12 (66.6%) met AKI criteria after 24 hours, and urine KIM-1/creatinine (Cr) level (with adjustment of urine creatinine) peaked at 24 hours with significant difference from baseline level. Additionally, urine KIM-1/Cr level in the AKI group was significantly higher than in the non-AKI group at 6 hours. However, urine NGAL/Cr and IL-18/Cr levels showed no specific trend with time for 48 hours after cardiac surgery. CONCLUSION It is suggested that urine KIM-1/Cr concentration could be considered a good biomarker for early AKI prediction after open cardiac surgery using CPB in young children with congenital heart diseases.
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Affiliation(s)
- Hee Sun Baek
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Youngok Lee
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Hea Min Jang
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Joonyong Cho
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Myung Chul Hyun
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Yeo Hyang Kim
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Su-Kyeong Hwang
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu, Korea
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128
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Peters H, Macke C, Mommsen P, Zeckey C, Clausen JD, Krettek C, Neunaber C, Winkelmann M. Predictive Value of Osteoprotegerin and Neutrophil Gelatinase-associated Lipocalin on Multiple Organ Failure in Multiple Trauma. In Vivo 2020; 33:1573-1580. [PMID: 31471407 DOI: 10.21873/invivo.11639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM Multiple organ dysfunction syndrome (MODS) is the leading cause of late posttraumatic mortality. This study analyzed the prognostic values of osteoprotegerin (OPG) and neutrophil gelatinase-associated lipocalin (NGAL/lipocalin 2) compared to interleukin-6 (IL-6) in multiply injured patients. PATIENTS AND METHODS A retrospective observational cohort study on multiply injured patients with an injury severity score (ISS) of ≥16 was performed. OPG, NGAL and IL-6 blood concentrations were measured. Statistical analysis comprised receiver-operating-characteristic (ROC) analysis with the corresponding area under the curve (AUC). RESULTS Thirty-nine patients with a mean ISS of 34±11 were included. Fourteen patients (36%) developed MODS and 8 patients (21%) died. Plasma levels of NGAL, OPG, and IL-6 were significantly elevated in the MODS+ group. Each biomarker positively correlated with MODS score and diagnosis of MODS. CONCLUSION NGAL and OPG might be indicative of MODS and could have the potential to be biomarkers in the early detection of patients at risk of posttraumatic MODS.
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Affiliation(s)
- Henning Peters
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Christian Macke
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Philipp Mommsen
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Christian Zeckey
- Trauma Department, Hannover Medical School, Hannover, Germany.,Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Munich, Germany
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Patel DM, Thiessen-Philbrook H, Brown JR, McArthur E, Moledina DG, Mansour SG, Shlipak MG, Koyner JL, Kavsak P, Whitlock RP, Everett AD, Malenka DJ, Garg AX, Coca SG, Parikh CR. Association of plasma-soluble ST2 and galectin-3 with cardiovascular events and mortality following cardiac surgery. Am Heart J 2020; 220:253-263. [PMID: 31911262 PMCID: PMC7008086 DOI: 10.1016/j.ahj.2019.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 11/24/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cardiac surgery induces hemodynamic stress on the myocardium, and this process can be associated with significant post-operative morbidity and mortality. Soluble suppression of tumorigenicity 2 (sST2) and galectin-3 (gal-3) are biomarkers of myocardial remodeling and fibrosis; however, their potential association with post-operative changes is unknown. METHODS We measured peri-operative plasma sST2 and gal-3 levels in two prospective cohorts (TRIBE-AKI and NNE) of over 1800 patients who underwent cardiac surgery. sST2 and gal-3 levels were evaluated for association with a composite primary outcome of cardiovascular event or mortality over median follow-up periods of 3.4 and 6.0 years, respectively, for the two cohorts. Meta-analysis of hazard ratio estimates from the cohorts was performed using random effects models. RESULTS Cohorts demonstrated event rates of 70.2 and 66.8 per 1000 person-years for the primary composite outcome. After adjustment for clinical covariates, higher post-operative sST2 and gal-3 levels were significantly associated with cardiovascular event or mortality [pooled estimate HRs: sST2 1.29 (95% CI 1.16, 1.44); gal-3 1.26 (95% CI 1.09, 1.46)]. These associations were not significantly modified by pre-operative congestive heart failure or AKI. CONCLUSIONS Higher post-operative sST2 and gal-3 values were associated with increased incidence of cardiovascular event or mortality. These two biomarkers should be further studied for potential clinical utility for patients undergoing cardiac surgery.
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Affiliation(s)
- Dipal M Patel
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | | | - Jeremiah R Brown
- Dartmouth Institute for Health Policy and Clinical Practice, and the Departments of Biomedical Data Science and Epidemiology, Geisel School of Medicine, Lebanon, NH
| | | | - Dennis G Moledina
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT; Section of Nephrology, Yale University School of Medicine, New Haven, CT
| | - Sherry G Mansour
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT; Section of Nephrology, Yale University School of Medicine, New Haven, CT
| | - Michael G Shlipak
- Kidney Health Research Collaborative, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco VA Medical Center and University of California, San Francisco, CA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Peter Kavsak
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute and Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - David J Malenka
- Dartmouth Institute for Health Policy and Clinical Practice, and the Departments of Biomedical Data Science and Epidemiology, Geisel School of Medicine, Lebanon, NH
| | - Amit X Garg
- ICES, Toronto, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chirag R Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, MD.
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130
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Fuhrman DY, Kellum JA, Joyce EL, Miyashita Y, Mazariegos GV, Ganoza A, Squires JE. The use of urinary biomarkers to predict acute kidney injury in children after liver transplant. Pediatr Transplant 2020; 24:e13608. [PMID: 31652022 PMCID: PMC7216780 DOI: 10.1111/petr.13608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AKI after pediatric liver transplantation is associated with increased morbidity and mortality. The role of urinary biomarkers for the prediction of AKI in pediatric patients after liver transplantation has not been previously reported. The primary objective of this prospective pilot study was to determine the predictive capabilities of urinary KIM-1, NGAL, TIMP-2, and IGFBP7 for diagnosing AKI. METHODS Sixteen children undergoing liver transplantation were enrolled in the study over a 19-month time period. The Kidney Disease Improving Outcomes criteria for urine output and serum creatinine were used to define AKI. Predictive ability was evaluated using the area under the curve obtained by ROC analysis. RESULTS AKI occurred in 6 (37.5%) of the patients between 2 and 4 days after transplant. There were no differences in any of the biomarkers prior to transplant. When obtained within 6 hours after transplant, the area under the ROC curve for predicting AKI was 0.758 (95% CI: 0.458-1.00) for KIM-1, 0.900 (95% CI: 0.724-1.00) for NGAL, and 0.933 (95% CI: 0.812-1.00) for the product of TIMP-2 and IGFBP7 ([TIMP-2]·[IGFBP7]). CONCLUSIONS Our results show that both NGAL and [TIMP-2]·[IGFBP7] provide significant discrimination for AKI risk following liver transplant in children. Larger studies are needed to determine the optimal time point for measuring these biomarkers and to validate our findings.
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Affiliation(s)
- Dana Y. Fuhrman
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, Pittsburgh, PA, USA
- Division of Pediatric Nephrology, Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - John A. Kellum
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, Pittsburgh, PA, USA
| | - Emily L. Joyce
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, Pittsburgh, PA, USA
- Division of Pediatric Nephrology, Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Yosuke Miyashita
- Division of Pediatric Nephrology, Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - George V. Mazariegos
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Armando Ganoza
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James E. Squires
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
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131
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Allen JC, Gardner DS, Skinner H, Harvey D, Sharman A, Devonald MAJ. Definition of hourly urine output influences reported incidence and staging of acute kidney injury. BMC Nephrol 2020; 21:19. [PMID: 31941447 PMCID: PMC6964092 DOI: 10.1186/s12882-019-1678-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 12/30/2019] [Indexed: 12/22/2022] Open
Abstract
Background Acute kidney injury (AKI) is commonly defined using the KDIGO system, which includes criteria based on reduced urine output (UO). There is no consensus on whether UO should be measured using consecutive hourly readings or mean output. This makes KDIGO UO definition and staging of AKI vulnerable to inconsistency which has implications both for research and clinical practice. The objective of this study was to investigate whether the way in which UO is defined affects incidence and staging of AKI. Methods We conducted a retrospective analysis of two single centre observational studies investigating (i) patients undergoing cardiac surgery and (ii) patients admitted to general intensive care units (ICU). AKI was identified using KDIGO serum creatinine (SCr) criteria and two methods of UO (UOcons: UO meeting KDIGO criteria in each consecutive hour; UOmean: mean hourly UO meeting KDIGO criteria). Results Data from 151 CICU and 150 ICU admissions were analysed. Incidence of AKI using SCr alone was 23.8% in CICU and 32% in ICU. Incidence increased in both groups when UO was considered, with inclusion of UOmean more than doubling reported incidence of AKI (CICU: UOcons 39.7%, UOmean 72.8%; ICU: UOcons 51.3%, UOmean 69.3%). In both groups UOcons led to a larger increase in KDIGO stage 1 but UOmean increased the incidence of KDIGO stage 2. Conclusions We demonstrate a serious lack of clarity in the internationally accepted AKI definition leading to significant variability in reporting of AKI incidence.
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Affiliation(s)
- Jennifer C Allen
- Nottingham Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK. .,Faculty of Medicine and Health Sciences, School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Leicestershire, LE12 5RD, UK.
| | - David S Gardner
- Faculty of Medicine and Health Sciences, School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Leicestershire, LE12 5RD, UK
| | - Henry Skinner
- Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK
| | - Daniel Harvey
- Department of Critical Care, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK
| | - Andrew Sharman
- Department of Critical Care, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK
| | - Mark A J Devonald
- Nottingham Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK. .,Faculty of Medicine and Health Sciences, School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Leicestershire, LE12 5RD, UK.
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132
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Lee CC, Chang CH, Cheng YL, Kuo G, Chen SW, Li YJ, Chen YT, Tian YC. Diagnostic Performance of Cyclophilin A in Cardiac Surgery-Associated Acute Kidney Injury. J Clin Med 2019; 9:jcm9010108. [PMID: 31906134 PMCID: PMC7019745 DOI: 10.3390/jcm9010108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 01/04/2023] Open
Abstract
Acute kidney injury (AKI) is associated with increased morbidity and mortality and is frequently encountered in cardiovascular surgical intensive care units (CVS-ICU). In this study, we aimed at investigating the utility of cyclophilin A (CypA) for the early detection of postoperative AKI in patients undergoing cardiac surgery. This was a prospective observational study conducted in a CVS-ICU of a tertiary care university hospital. All prospective clinical and laboratory data were evaluated as predictors of AKI. Serum and urine CypA, as well as urine neutrophil gelatinase-associated lipocalin (uNGAL), were examined within 6 h after cardiac surgery. The discriminative power for the prediction of AKI was evaluated using the area under the receiver operator characteristic curve (AUROC). We found that both serum CypA and urine CypA were significantly higher in the AKI group than in the non-AKI group. For discriminating AKI and dialysis-requiring AKI, serum CypA demonstrated acceptable AUROC values (0.689 and 0.738, respectively). The discrimination ability of urine CypA for predicting AKI was modest, but it was acceptable for predicting dialysis-requiring AKI (AUROC = 0.762). uNGAL best predicted the development of AKI, but its sensitivity was not good. A combination of serum CypA and uNGAL enhanced the overall performance for predicting the future development of AKI and dialysis-requiring AKI. Our results suggest that CypA is suitable as a biomarker for the early detection of postoperative AKI in CVS-ICU. However, it has better discriminating ability when combined with uNGAL for predicting AKI in CVS-ICU patients.
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Affiliation(s)
- Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.-C.L.); (C.-H.C.); (Y.-L.C.); (G.K.); (Y.-J.L.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.-C.L.); (C.-H.C.); (Y.-L.C.); (G.K.); (Y.-J.L.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Ya-Lien Cheng
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.-C.L.); (C.-H.C.); (Y.-L.C.); (G.K.); (Y.-J.L.)
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.-C.L.); (C.-H.C.); (Y.-L.C.); (G.K.); (Y.-J.L.)
| | - Shao-Wei Chen
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yi-Jung Li
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.-C.L.); (C.-H.C.); (Y.-L.C.); (G.K.); (Y.-J.L.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Yi-Ting Chen
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (C.-C.L.); (C.-H.C.); (Y.-L.C.); (G.K.); (Y.-J.L.)
- Correspondence: ; Tel.: +886-3-3281200-8181
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Kerr KF, Morenz ER, Roth J, Thiessen-Philbrook H, Coca SG, Parikh CR. Developing Biomarker Panels to Predict Progression of Acute Kidney Injury After Cardiac Surgery. Kidney Int Rep 2019; 4:1677-1688. [PMID: 31844804 PMCID: PMC6895663 DOI: 10.1016/j.ekir.2019.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction Acute kidney injury (AKI) is a frequent complication of cardiac surgery, but only a fraction of cardiac surgery patients that experience postoperative AKI have progression to more severe stages. Biomarkers that can distinguish patients that will experience progression of AKI are potentially useful for clinical care and/or the development of therapies. Methods Data come from a prospective cohort study of cardiac surgery patients; the analytic dataset contained data from 354 cardiac surgery patients meeting criteria for AKI following surgery. Candidate predictors were 38 biomarkers of kidney function, insult, or injury measured at the time of AKI diagnosis. The outcome was AKI progression, defined as worsening of AKI Network stage. We investigated combining biomarkers with Bayesian model averaging (BMA) and random forests of classification trees, with and without center transformation. For both approaches, we used resampling-based methods to avoid optimistic bias in our assessment of model performance. Results BMA yielded a combination of 3 biomarkers and an optimism-corrected estimated area under the receiver operating characteristic curve (AUC) of 0.75 (95% confidence interval [CI]: 0.68, 0.82). The random forests approach, which nominally uses all biomarkers, had an estimated AUC of 0.74 (95% CI: 0.66, 0.82). A second application of random forests applied to biomarker values after a center-specific transformation had an estimated AUC of 0.80 (95% CI: 0.72, 0.88). Conclusion These findings suggest that the application of advanced statistical techniques to combine biomarkers offers only modest improvements over use of single biomarkers alone. This exemplifies a common experience in biomarker research: combinations of modestly performing biomarkers often also have modest performance.
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Affiliation(s)
- Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Eric R Morenz
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Jeremy Roth
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | - Steven G Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Skrypnyk NI, Gist KM, Okamura K, Montford JR, You Z, Yang H, Moldovan R, Bodoni E, Blaine JT, Edelstein CL, Soranno DE, Kirkbride-Romeo LA, Griffin BR, Altmann C, Faubel S. IL-6-mediated hepatocyte production is the primary source of plasma and urine neutrophil gelatinase-associated lipocalin during acute kidney injury. Kidney Int 2019; 97:966-979. [PMID: 32081304 DOI: 10.1016/j.kint.2019.11.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 10/09/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Abstract
Neutrophil gelatinase associated lipocalin (NGAL, Lcn2) is the most widely studied biomarker of acute kidney injury (AKI). Previous studies have demonstrated that NGAL is produced by the kidney and released into the urine and plasma. Consequently, NGAL is currently considered a tubule specific injury marker of AKI. However, the utility of NGAL to predict AKI has been variable suggesting that other mechanisms of production are present. IL-6 is a proinflammatory cytokine increased in plasma by two hours of AKI and mediates distant organ effects. Herein, we investigated the role of IL-6 in renal and extra-renal NGAL production. Wild type mice with ischemic AKI had increased plasma IL-6, increased hepatic NGAL mRNA, increased plasma NGAL, and increased urine NGAL; all reduced in IL-6 knockout mice. Intravenous IL-6 in normal mice increased hepatic NGAL mRNA, plasma NGAL and urine NGAL. In mice with hepatocyte specific NGAL deletion (Lcn2hep-/-) and ischemic AKI, hepatic NGAL mRNA was absent, and plasma and urine NGAL were reduced. Since urine NGAL levels appear to be dependent on plasma levels, the renal handling of circulating NGAL was examined using recombinant human NGAL. After intravenous recombinant human NGAL administration to mice, human NGAL in mouse urine was detected by ELISA during proximal tubular dysfunction, but not in pre-renal azotemia. Thus, during AKI, IL-6 mediates hepatic NGAL production, hepatocytes are the primary source of plasma and urine NGAL, and plasma NGAL appears in the urine during proximal tubule dysfunction. Hence, our data change the paradigm by which NGAL should be interpreted as a biomarker of AKI.
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Affiliation(s)
- Nataliya I Skrypnyk
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Katja M Gist
- Department of Cardiology, The Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kayo Okamura
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - John R Montford
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA; Renal Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Zhiying You
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Haichun Yang
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Radu Moldovan
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA; Advanced Light Microscopy Core Facility, Aurora, Colorado, USA
| | - Evelyn Bodoni
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA; Advanced Light Microscopy Core Facility, Aurora, Colorado, USA
| | - Judith T Blaine
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Charles L Edelstein
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Danielle E Soranno
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA; Department of Pediatrics and Bioengineering, University of Colorado, Aurora, Colorado, USA
| | - Lara A Kirkbride-Romeo
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Benjamin R Griffin
- Department of Medicine, Division of Nephrology, University of Iowa, Iowa City, Iowa, USA
| | - Chris Altmann
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA
| | - Sarah Faubel
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado, USA; Renal Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
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135
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Urinary Matrix Metalloproteinase-7 and Prediction of AKI Progression Post Cardiac Surgery. DISEASE MARKERS 2019; 2019:9217571. [PMID: 31827648 PMCID: PMC6885836 DOI: 10.1155/2019/9217571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/28/2019] [Accepted: 10/01/2019] [Indexed: 11/18/2022]
Abstract
Aims Early detection of patients at high risk for progressive acute kidney injury (AKI) after cardiac surgery remains a major challenge. We aim to evaluate the utility of urinary matrix metalloproteinase-7 (uMMP-7) and other reported biomarkers for predicting AKI progression during postoperative hospital stay. Methods We conducted a prospective, multicenter cohort study in 121 adult patients with stage 1 or 2 AKI after cardiac surgery. uMMP-7 and other well-reported biomarkers (uIL-18, uNGAL, and UACR) were measured at time of AKI clinical diagnosis. The primary outcome is the progression of AKI after cardiac surgery, defined as worsening of AKI stage (stage 1 to either stage 2 or stage 3 or from stage 2 to stage 3). Results A level of uMMP-7 > 7.8 μg/g Cr at time of AKI diagnosis conveyed an 8-fold risk of AKI progression as compared to those with uMMP-7 < 2.7 μg/g after adjusting for clinical risk factors. The performance of uMMP-7 for predicting progressive AKI was good with an AUC of 0.80. The combination of uMMP-7 and IL-18 produces the greatest AUC for predicting progressive AKI. Addition of uMMP-7 to the clinical risk factor model significantly improved risk reclassification for AKI progression. Conclusions uMMP-7, measured at time of AKI clinical diagnosis, is a novel biomarker for predicting the progression of AKI after cardiac surgery. Adding uMMP-7 to the clinical risk factor model may be used as a noninvasive approach to identify a subpopulation that is at high risk for progressive AKI after cardiac surgery.
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McBride WT, Kurth MJ, McLean G, Domanska A, Lamont JV, Maguire D, Watt J, Fitzgerald P, Young I, Joseph J, Ruddock MW. Stratifying risk of acute kidney injury in pre and post cardiac surgery patients using a novel biomarker-based algorithm and clinical risk score. Sci Rep 2019; 9:16963. [PMID: 31740699 PMCID: PMC6861253 DOI: 10.1038/s41598-019-53349-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/31/2019] [Indexed: 12/22/2022] Open
Abstract
Acute kidney injury (AKI) following cardiac surgery significantly increases morbidity and mortality risks. Improving existing clinical methods of identifying patients at risk of perioperative AKI may advance management and treatment options. This study investigated whether a combination of biomarkers and clinical factors pre and post cardiac surgery could stratify patients at risk of developing AKI. Patients (n = 401) consecutively scheduled for elective cardiac surgery were prospectively studied. Clinical data was recorded and blood samples were tested for 31 biomarkers. Areas under receiver operating characteristic (AUROCs) were generated for biomarkers pre and postoperatively to stratify patients at risk of AKI. Preoperatively sTNFR1 had the highest predictive ability to identify risk of developing AKI postoperatively (AUROC 0.748). Postoperatively a combination of H-FABP, midkine and sTNFR2 had the highest predictive ability to identify AKI risk (AUROC 0.836). Preoperative clinical risk factors included patient age, body mass index and diabetes. Perioperative factors included cardio pulmonary bypass, cross-clamp and operation times, intra-aortic balloon pump, blood products and resternotomy. Combining biomarker risk score (BRS) with clinical risk score (CRS) enabled pre and postoperative assignment of patients to AKI risk categories. Combining BRS with CRS will allow better management of cardiac patients at risk of developing AKI.
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Affiliation(s)
- William T McBride
- Department of Cardiac Anaesthesia, Belfast Health & Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Mary Jo Kurth
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Gavin McLean
- Department of Cardiac Anaesthesia, Belfast Health & Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Anna Domanska
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - John V Lamont
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Daniel Maguire
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Joanne Watt
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Peter Fitzgerald
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Ian Young
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, 97 Lisburn Road, Health Sciences Building, Belfast, BT9 7BL, Northern Ireland, UK
| | - Jijin Joseph
- Department of Cardiac Anaesthesia, Belfast Health & Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Mark W Ruddock
- Randox Laboratories Ltd, Clinical Studies Group, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK.
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137
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Wang X, Lin X, Xie B, Huang R, Yan Y, Liu S, Zhu M, Lu R, Qian J, Ni Z, Xue S, Che M. Early serum cystatin C-enhanced risk prediction for acute kidney injury post cardiac surgery: a prospective, observational, cohort study. Biomarkers 2019; 25:20-26. [PMID: 31686541 DOI: 10.1080/1354750x.2019.1688865] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Xudong Wang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinghui Lin
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Xie
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ritai Huang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yucheng Yan
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shang Liu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mingli Zhu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Renhua Lu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaqi Qian
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Song Xue
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Miaolin Che
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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138
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Cherry AD, Hauck JN, Andrew BY, Li YJ, Privratsky JR, Kartha LD, Nicoara A, Thompson A, Mathew JP, Stafford-Smith M. Intraoperative renal resistive index threshold as an acute kidney injury biomarker. J Clin Anesth 2019; 61:109626. [PMID: 31699495 DOI: 10.1016/j.jclinane.2019.109626] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/13/2019] [Accepted: 09/20/2019] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVE The lag in creatinine-mediated diagnosis of cardiac surgery-associated acute kidney injury (AKI) may be impeding the development of renoprotection therapies. Postoperative renal resistive index (RRI) measured by transabdominal Doppler ultrasound is a promising early AKI biomarker. RRI measured intraoperatively by transesophageal echocardiography (TEE) is available even earlier but is less evaluated. Therefore, we conducted an assessment of intraoperative RRI as an AKI biomarker using previously reported post-renal insult thresholds. DESIGN Retrospective convenience sample. SETTING Intraoperative. PATIENTS 180 adult cardiac surgical patients between July 2013 and July 2014. INTERVENTION None. MEASUREMENTS Pre- and post-cardiopulmonary bypass (CPB) RRI thresholds, measured using intraoperative TEE, exceeding 0.74 or 0.79 were used to evaluate for an association with KDIGO AKI risk using the Chi-square test. Other consensus AKI criteria (AKIN, RIFLE) were similarly evaluated. Additional t-test analyses examined the relationship of pre- and pre-to-post (delta) CPB RRI with AKI. MAIN RESULTS Post-CPB RRI for 99 patients included 36 and 23 with values exceeding 0.74 and 0.79, respectively. Analyses confirmed associations of both RRI thresholds with all consensus AKI definitions (0.74; KDIGO: p = 0.05, AKIN: p = 0.03, RIFLE: p = 0.03, 0.79; KDIGO: p = 0.002, AKIN: p = 0.001, RIFLE: p = 0.004). In contrast, pre-CPB and pre-to post-CPB RRI were not associated with AKI. CONCLUSIONS RRI obtained intraoperatively in cardiac surgery patients, assessed using previously reported thresholds, is highly associated with AKI and warrants further evaluation as a promising "earliest" AKI biomarker. These significant findings suggest that RRI assessment should be included in the standard intraoperative TEE exam.
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Affiliation(s)
- Anne D Cherry
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Jennifer N Hauck
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Benjamin Y Andrew
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Yi-Ju Li
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Jamie R Privratsky
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Lakshmi D Kartha
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA; MetroHealth Hospital, Dept. of Internal Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Alina Nicoara
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Annemarie Thompson
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Joseph P Mathew
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Mark Stafford-Smith
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
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139
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Li H, Xu Q, Wang Y, Chen K, Li J. Serum neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for predicting high dose methotrexate associated acute kidney injury in children with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2019; 85:95-103. [PMID: 31676986 DOI: 10.1007/s00280-019-03980-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/17/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The present study was aimed at assessing the value of serum NGAL in identifying early acute kidney injury induced by HDMTX. METHODS Children aged 1-14 years with newly diagnosed ALL receiving MTX over 3 g/m2 were enrolled. Serum NGAL concentrations, serum creatinine (Scr) and MTX concentrations were measured. The area under the receiver-operating characteristic curve (ROC) was used for evaluating variables' ability of early diagnosis of AKI. RESULTS A total of 196 courses of 62 patients were assessed, and 22 courses (11.2%) developed AKI. Twenty-four hours serum NGAL concentrations, 24 h Scr ratio, 48 h Scr ratio, CMTX24 h, CMTX48 h, CMTX72 h were significantly higher in patients with AKI. The combination of 24 h Scr ratio and 24 h serum NGAL had higher value for detecting HDMTX induced AKI compared with the 24 h Scr ratio. And the combination had similar value for detecting HDMTX induced AKI compared with the 48 h Scr ratio. After 48 h, CMTX48 h had a satisfying accuracy in predicting AKI. The proportion of post-HDMTX sepsis in patients with AKI was significantly higher than that in patients without AKI. CONCLUSIONS Serum NGAL levels could be used as a marker in identifying the direct kidney tubular damage induced by HDMTX. The combination of 24 h Scr ratio and 24 h serum NGAL had higher value for early diagnosis of HDMTX associated AKI compared with the 24 h Scr ratio.
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Affiliation(s)
- Hui Li
- Department of Hematology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Qiong Xu
- Department of Clinical Pharmacology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiangan District, Wuhan, 430016, Hubei, China.
| | - Yang Wang
- Department of Clinical Pharmacology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiangan District, Wuhan, 430016, Hubei, China
| | - Kailan Chen
- Department of Hematology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Jianxin Li
- Department of Hematology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
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140
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Li D, Yan Sun W, Fu B, Xu A, Wang Y. Lipocalin-2-The myth of its expression and function. Basic Clin Pharmacol Toxicol 2019; 127:142-151. [PMID: 31597008 DOI: 10.1111/bcpt.13332] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/19/2019] [Indexed: 01/01/2023]
Abstract
Lipocalin-2 is a functional biomarker for acute and chronic kidney diseases, heart failure and obesity-related medical complications. It is rapidly induced in epithelial cells under stress conditions, but constitutively produced from pre-adipocytes and mature adipocytes. Measuring the lipocalin-2 levels represents an effective approach for risk prediction, patient stratification and disease management. Nevertheless, due to ligand-binding, post-translational modification and protein-protein interaction, lipocalin-2 exists as multiple variants that elicit different pathophysiological functions. To characterize the specific structure-functional relationships of lipocalin-2 variants is critical for the development of biomarker assays with sufficient precision and reliability. Moreover, identifying the pathological forms of lipocalin-2 will provide new therapeutic targets and treatment approaches for obesity-related complications.
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Affiliation(s)
- Dahui Li
- The State Key Laboratory of Pharmaceutical Biotechnology and Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Wai Yan Sun
- The State Key Laboratory of Pharmaceutical Biotechnology and Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Bowen Fu
- The State Key Laboratory of Pharmaceutical Biotechnology and Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Aimin Xu
- The State Key Laboratory of Pharmaceutical Biotechnology and Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Yu Wang
- The State Key Laboratory of Pharmaceutical Biotechnology and Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
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141
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Alkaline Phosphatase Treatment of Acute Kidney Injury in an Infant Piglet Model of Cardiopulmonary Bypass with Deep Hypothermic Circulatory Arrest. Sci Rep 2019; 9:14175. [PMID: 31578351 PMCID: PMC6775126 DOI: 10.1038/s41598-019-50481-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 09/13/2019] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) is associated with prolonged hospitalization and mortality following infant cardiac surgery, but therapeutic options are limited. Alkaline phosphatase (AP) infusion reduced AKI in phase 2 sepsis trials but has not been evaluated for cardiac surgery-induced AKI. We developed a porcine model of infant cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) to investigate post-CPB/DHCA AKI, measure serum/renal tissue AP activity with escalating doses of AP infusion, and provide preliminary assessment of AP infusion for prevention of AKI. Infant pigs underwent CPB with DHCA followed by survival for 4 h. Groups were treated with escalating doses of bovine intestinal AP (1, 5, or 25U/kg/hr). Anesthesia controls were mechanically ventilated for 7 h without CPB. CPB/DHCA animals demonstrated histologic and biomarker evidence of AKI as well as decreased serum and renal tissue AP compared to anesthesia controls. Only high dose AP infusion significantly increased serum or renal tissue AP activity. Preliminary efficacy evaluation demonstrated a trend towards decreased AKI in the high dose AP group. The results of this dose-finding study indicate that AP infusion at the dose of 25U/kg/hr corrects serum and tissue AP deficiency and may prevent AKI in this piglet model of infant CPB/DHCA.
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142
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Jacob KA, Leaf DE. Prevention of Cardiac Surgery-Associated Acute Kidney Injury: A Review of Current Strategies. Anesthesiol Clin 2019; 37:729-749. [PMID: 31677688 PMCID: PMC7644277 DOI: 10.1016/j.anclin.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute kidney injury is a common and often severe postoperative complication after cardiac surgery, and is associated with poor short-term and long-term outcomes. Numerous randomized controlled trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated acute kidney injury. Unfortunately, most trials that have been conducted to date have been negative. However, encouraging results have been demonstrated with preoperative administration of corticosteroids, leukocyte filtration, and administration of inhaled nitric oxide intraoperatively, and implementation of a Kidney Disease: Improving Global Outcomes bundle of care approach postoperatively. These findings require validation in large, multicenter trials.
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Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Mail Stop E03.511, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Medial Research Building Room MR416B, Boston, MA 02115, USA
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143
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Slaughter JL, Cua CL, Notestine JL, Rivera BK, Marzec L, Hade EM, Maitre NL, Klebanoff MA, Ilgenfritz M, Le VT, Lewandowski DJ, Backes CH. Early prediction of spontaneous Patent Ductus Arteriosus (PDA) closure and PDA-associated outcomes: a prospective cohort investigation. BMC Pediatr 2019; 19:333. [PMID: 31519154 PMCID: PMC6743099 DOI: 10.1186/s12887-019-1708-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term outcomes (chronic lung disease, neurodevelopmental delay). Although pharmacologic and/or interventional treatments to close PDA likely benefit some infants, widespread routine treatment of all preterm infants with PDA may not improve outcomes. Most PDAs close spontaneously by 44-weeks postmenstrual age; treatment is increasingly controversial, varying markedly between institutions and providers. Because treatment detriments may outweigh benefits, especially in infants destined for early, spontaneous PDA closure, the relevant unanswered clinical question is not whether to treat all preterm infants with PDA, but whom to treat (and when). Clinicians cannot currently predict in the first month which infants are at highest risk for persistent PDA, nor which combination of clinical risk factors, echocardiographic measurements, and biomarkers best predict PDA-associated harm. METHODS Prospective cohort of untreated infants with PDA (n=450) will be used to predict spontaneous ductal closure timing. Clinical measures, serum (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide) and urine (neutrophil gelatinase-associated lipocalin, heart-type fatty acid-binding protein) biomarkers, and echocardiographic variables collected during each of first 4 postnatal weeks will be analyzed to identify those associated with long-term impairment. Myocardial deformation imaging and tissue Doppler imaging, innovative echocardiographic techniques, will facilitate quantitative evaluation of myocardial performance. Aim1 will estimate probability of spontaneous PDA closure and predict timing of ductal closure using echocardiographic, biomarker, and clinical predictors. Aim2 will specify which echocardiographic predictors and biomarkers are associated with mortality and respiratory illness severity at 36-weeks postmenstrual age. Aim3 will identify which echocardiographic predictors and biomarkers are associated with 22 to 26-month neurodevelopmental delay. Models will be validated in a separate cohort of infants (n=225) enrolled subsequent to primary study cohort. DISCUSSION The current study will make significant contributions to scientific knowledge and effective PDA management. Study results will reduce unnecessary and harmful overtreatment of infants with a high probability of early spontaneous PDA closure and facilitate development of outcomes-focused trials to examine effectiveness of PDA closure in "high-risk" infants most likely to receive benefit. TRIAL REGISTRATION ClinicalTrials.gov NCT03782610. Registered 20 December 2018.
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Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Clifford L Cua
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer L Notestine
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brian K Rivera
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Laura Marzec
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Erinn M Hade
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Nathalie L Maitre
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA.,Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Megan Ilgenfritz
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA
| | - Vi T Le
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dennis J Lewandowski
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carl H Backes
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA. .,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA. .,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA. .,Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio, USA.
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Moledina DG, Mansour SG, Jia Y, Obeid W, Thiessen-Philbrook H, Koyner JL, McArthur E, Garg AX, Wilson FP, Shlipak MG, Coca SG, Parikh CR. Association of T Cell-Derived Inflammatory Cytokines With Acute Kidney Injury and Mortality After Cardiac Surgery. Kidney Int Rep 2019; 4:1689-1697. [PMID: 31844805 PMCID: PMC6895592 DOI: 10.1016/j.ekir.2019.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/06/2019] [Accepted: 09/02/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Animal models of renal ischemia-reperfusion injury (IRI) demonstrate that interferon (IFN)-γ producing T-helper (Th)-1 cells worsen acute kidney injury (AKI), whereas interleukin (IL)-4– and IL-13–producing Th2 cells lead to repair. We tested the association of these cytokines with AKI and mortality in patients who underwent cardiac surgery. Methods In 1444 participants of a multicenter, prospective, observational cohort, we measured 10 plasma biomarkers before and after cardiac surgery (IFN-γ, IL-4, IL-13, tumor necrosis factor [TNF]-α, IL-1β, IL-2, IL-6, IL-8, IL-10, and IL-12p70) and combined these biomarkers using principal component analysis (PCA). We also tested independent associations of Th1 (IFN-γ) and Th2 (IL-4 and IL-13) biomarkers with clinical outcomes of postoperative AKI and 1-year mortality. Results AKI occurred in 492 participants (34%), and 1-year mortality occurred in 81 participants (6%). Within 6 hours after surgery, IFN-γ, IL-4, and IL-13 increased 2.1-, 6.0-, and 4.6-fold, respectively, from their preoperative levels. Patients with higher levels of IFN-γ had higher odds of AKI (adjusted odds ratio per log change, 1.35 [1.13, 1.6]) and mortality (1.51 [1.17, 1.94]). Patients with higher levels of IL-4 and IL-13 also had higher odds of AKI (1.26 [1.09, 1.46] and 1.4 [1.16, 1.69], respectively) and mortality (1.46 [1.18, 1.82] and 1.71 [1.27, 2.31], respectively). Adding biomarkers to the clinical variables through use of PCA improved the area under the curve by 0.01 for AKI and 0.04 for mortality, resulting in final areas under the curve of 0.85 (0.83–0.87) and 0.76 (0.70–0.81), respectively. Conclusion Both Th1 and Th2 cytokines increased immediately after cardiac surgery and were associated with AKI and 1-year mortality. Our findings indicate activation of both Th1 and Th2 pathways after cardiac surgery rather than predominance of either pathway.
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Affiliation(s)
- Dennis G Moledina
- Program of Applied Translational Research, Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sherry G Mansour
- Program of Applied Translational Research, Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yaqi Jia
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wassim Obeid
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Canada
| | - F Perry Wilson
- Program of Applied Translational Research, Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco VA Medical Center, University of California, San Francisco, California, USA
| | - Steven G Coca
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chirag R Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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145
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Hoste EAJ, Kellum JA, Selby NM, Zarbock A, Palevsky PM, Bagshaw SM, Goldstein SL, Cerdá J, Chawla LS. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol 2019; 14:607-625. [PMID: 30135570 DOI: 10.1038/s41581-018-0052-0] [Citation(s) in RCA: 671] [Impact Index Per Article: 134.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute kidney injury (AKI) is a commonly encountered syndrome associated with various aetiologies and pathophysiological processes leading to decreased kidney function. In addition to retention of waste products, impaired electrolyte homeostasis and altered drug concentrations, AKI induces a generalized inflammatory response that affects distant organs. Full recovery of kidney function is uncommon, which leaves these patients at risk of long-term morbidity and death. Estimates of AKI prevalence range from <1% to 66%. These variations can be explained by not only population differences but also inconsistent use of standardized AKI classification criteria. The aetiology and incidence of AKI also differ between high-income and low-to-middle-income countries. High-income countries show a lower incidence of AKI than do low-to-middle-income countries, where contaminated water and endemic diseases such as malaria contribute to a high burden of AKI. Outcomes of AKI are similar to or more severe than those of patients in high-income countries. In all resource settings, suboptimal early recognition and care of patients with AKI impede their recovery and lead to high mortality, which highlights unmet needs for improved detection and diagnosis of AKI and for efforts to improve care for these patients.
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Affiliation(s)
- Eric A J Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium.
| | - John A Kellum
- Center for Critical Care Nephrology, Pittsburgh, PA, USA
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Campus, Nottingham, UK
| | - Alexander Zarbock
- University of Münster, Department of Anesthesiology, Intensive Care and Pain Medicine, Münster, Germany
| | - Paul M Palevsky
- VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jorge Cerdá
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY, USA
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Silver SA, Gerarduzzi C. Found in Translation: Reasons for Optimism in the Pursuit to Prevent Chronic Kidney Disease After Acute Kidney Injury. Can J Kidney Health Dis 2019; 6:2054358119868740. [PMID: 31452903 PMCID: PMC6698989 DOI: 10.1177/2054358119868740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/21/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose of review: The current review will discuss on the progress of studying the transition
phase between acute kidney injury (AKI) and chronic kidney disease (CKD)
through improved animal models, common AKI and CKD pathways, and how human
studies may inform different translational approaches. Sources of information: PubMed and Google Scholar. Methods: A narrative review was performed using the main terms “acute kidney injury,”
“chronic kidney disease,” “end-stage renal disease,” “animal models,”
“review,” “decision-making,” and “translational research.” Key findings: The last decade has shown much progress in the study of AKI, including
evidence of a pathophysiological link between AKI and CKD. We are now in a
phase of redesigning animal models and discovering mechanisms that can
replicate the pathological conditions of the AKI-to-CKD continuum.
Translating these findings into the clinic is a barrier that must be
overcome. To this end, current efforts include prediction of AKI onset and
maladaptive repair, detecting patients susceptible to the progression of
chronic maladaptive repair, and understanding shared signaling mechanisms
between AKI and CKD. Limitations: This is a narrative review of the literature that is partially influenced by
the knowledge, perspectives, and experiences of the authors and their
research background. Implications: Overall, this new knowledge from the AKI-to-CKD continuum will help bridge
the discontinuity that exists between animal models and patients, resulting
in more effective translational biomarkers and therapeutics to test in known
AKI pathologies thereby preventing the chronicity of kidney injury
progression.
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Affiliation(s)
- Samuel A. Silver
- Division of Nephrology, Kingston Health
Sciences Center, Queen’s University, Kingston, ON, Canada
| | - Casimiro Gerarduzzi
- Division de Néphrologie, Centre de
recherche de l’Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
- Département de Médecine, Faculté de
Médecine, Université de Montréal, Montréal, Québec, Canada
- Casimiro Gerarduzzi, Division de
Néphrologie, Centre de recherche de l’Hôpital Maisonneuve-Rosemont, 5345,
boulevard de l’Assomption, Montreal, QC H1T 2M4, Canada.
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Shashaty MGS, Forker CM, Miano TA, Wu Q, Yang W, Oyster ML, Porteous MK, Cantu EE, Diamond JM, Christie JD. The association of post-lung transplant acute kidney injury with mortality is independent of primary graft dysfunction: A cohort study. Clin Transplant 2019; 33:e13678. [PMID: 31355953 DOI: 10.1111/ctr.13678] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prior studies of post-lung transplant acute kidney injury (AKI) have not accounted for confounding effects of primary graft dysfunction (PGD). We sought to test the impact of PGD on AKI risk factors and on the association of AKI with mortality. METHODS We included patients transplanted at the University of Pennsylvania from 2005-12, defined AKI using consensus criteria during transplant hospitalization, and defined PGD as grade 3 at 48-72 hours. We used multivariable logistic regression to test the impact of PGD on AKI risk factors and Cox models to test association of AKI with one-year mortality adjusting for PGD and other confounders. RESULTS Of 299 patients, 188 (62.9%) developed AKI with 142 (75%) cases occurring by postoperative day 4. In multivariable models, PGD was strongly associated with AKI (OR 3.76, 95% CI 1.72-8.19, P = .001) but minimally changed associations of other risk factors with AKI. Both AKI (HR 3.64, 95% CI 1.68-7.88, P = .001) and PGD (HR 2.55, 95% CI 1.40-4.64, P = .002) were independently associated with one-year mortality. CONCLUSIONS Post-lung transplant AKI risk factors and association of AKI with mortality were independent of PGD. AKI may therefore be a target for improving lung transplant mortality rather than simply an epiphenomenon of PGD.
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Affiliation(s)
- Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caitlin M Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle L Oyster
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary K Porteous
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward E Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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148
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Forker CM, Miano TA, Reilly JP, Oyster ML, Porteous MK, Cantu EE, Ware LB, Diamond JM, Christie JD, Shashaty MGS. Postreperfusion plasma endothelial activation markers are associated with acute kidney injury after lung transplantation. Am J Transplant 2019; 19:2366-2373. [PMID: 31017370 PMCID: PMC6658345 DOI: 10.1111/ajt.15402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 03/31/2019] [Accepted: 04/03/2019] [Indexed: 01/25/2023]
Abstract
Acute kidney injury (AKI) is common after lung transplantation, but molecular markers remain poorly studied. The endothelial activation markers soluble thrombomodulin (sTM), protein C, and plasminogen activator inhibitor-1 (PAI-1) are implicated in kidney microcirculatory injury in animal models of AKI. We tested the association of 6-hour postreperfusion plasma levels of these markers with posttransplant AKI severity in patients enrolled in the Lung Transplant Outcomes Group prospective cohort study at the University of Pennsylvania during two eras: 2004-06 (n = 61) and 2013-15 (n = 67). We defined AKI stage through postoperative day 5 using Kidney Disease Improving Global Outcomes creatinine criteria. We used multivariable ordinal logistic regression to determine the association of each biomarker with AKI, adjusted for primary graft dysfunction and extracorporeal life support. AKI occurred in 57 (45%) patients across both eras: 28 (22%) stage 1, 29 (23%) stage 2-3. Higher sTM and lower protein C plasma levels were associated with AKI stage in each era and remained so in multivariable models utilizing both eras (sTM: OR 1.76 [95% CI 1.19-2.60] per standard deviation, P = .005; protein C: OR 0.54 [1.19-2.60], P = .003). We conclude that 6-hour postreperfusion plasma sTM and protein C levels are associated with early postlung transplant AKI severity.
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Affiliation(s)
- Caitlin M. Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Todd A. Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P. Reilly
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle L. Oyster
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary K. Porteous
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward E. Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joshua M. Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G. S. Shashaty
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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149
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Menez S, Hanouneh M, Shafi T, Jaar BG. Indoxyl sulfate is associated with mortality after AKI - more evidence needed! BMC Nephrol 2019; 20:280. [PMID: 31345164 PMCID: PMC6659241 DOI: 10.1186/s12882-019-1465-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022] Open
Abstract
Patients who develop acute kidney injury (AKI) have significantly higher short-term outcomes including in-hospital mortality. The development of AKI has been associated with long-term consequences including progression to chronic kidney disease (CKD) and higher rates of cardiovascular disease (CVD) and mortality. In recent years there has been a growing push for the discovery of novel methods to diagnose AKI at earlier stages, and for an improvement in risk stratification and prognosis following AKI.Wang and colleagues assessed the association of total serum indoxyl sulfate (IS) levels, a protein bound uremic toxin, with 90-day mortality after hospital-acquired AKI (HA-AKI). These authors found that serum IS levels were significantly elevated in patients with HA-AKI (2.74 ± 0.75 μg/mL) compared to healthy subjects (1.73 ± 0.11 μg/ml, P < 0.001) and critically ill patients (2.46 ± 0.35 μg/ml, P = 0.016).The mechanisms of this relationship remain unclear, with a limited understanding of cause-specific mortality associated with either the high or low-IS group. One limitation of this current study is an understanding of the acceptable or expected higher level in IS during episodes of AKI. IS levels remained persistently elevated at day 7 compared to β2-microglobulin and serum creatinine which were both lower at 7 days. It is unclear, however, if levels of β2-microglobulin and serum creatinine were lower for other reasons, such as if any patients with AKI required dialysis.This work provides an important addition to the field of AKI research, specifically in the evaluation of readily measurable biomarkers and outcomes after AKI. Moving forward, further validation in studies of acute kidney injury are needed to develop a better understanding of IS levels at the time of AKI diagnosis and trends during the course of AKI.
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Affiliation(s)
- Steven Menez
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD, 21287, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, 2024 E. Monument Street, Baltimore, MD, 21205, USA
| | - Mohamad Hanouneh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD, 21287, USA.,Nephrology Center of Maryland, 5601 Loch Raven Boulevard, Suite 3 North, Baltimore, MD, 21239, USA
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD, 21287, USA.,Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Bernard G Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD, 21287, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. .,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, 2024 E. Monument Street, Baltimore, MD, 21205, USA. .,Nephrology Center of Maryland, 5601 Loch Raven Boulevard, Suite 3 North, Baltimore, MD, 21239, USA.
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150
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Qian Y, Che L, Yan Y, Lu R, Zhu M, Xue S, Ni Z, Gu L. Urine klotho is a potential early biomarker for acute kidney injury and associated with poor renal outcome after cardiac surgery. BMC Nephrol 2019; 20:268. [PMID: 31315593 PMCID: PMC6637468 DOI: 10.1186/s12882-019-1460-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 07/09/2019] [Indexed: 12/11/2022] Open
Abstract
Background Current paradigms of detecting acute kidney injury (AKI) are insensitive and non-specific. Klotho is a pleiotropic protein that is predominantly expressed in renal tubules. In this study, we evaluated the diagnostic and prognostic roles of urine Klotho for AKI following cardiac surgery. Methods We conducted a prospective study involving 91 patients undergoing cardiac surgery. AKI was defined according to the AKIN definition. The renal outcomes within 7 days after operation were evaluated. Perioperative levels of urine Klotho and urine neutrophil gelatinase-associated lipocalin (NGAL) were measured by using ELISA. Results Of 91 participants, 33 patients (36.26%) developed AKI. Of these AKI patients, 21 (63.64%), 8 (24.24%), and 4 (12.12%) were staged 1, 2, and 3, respectively. Serum creatinine in AKI patients began to slightly increase at first postoperative time and reached the AKI diagnostic value 1 day after operation. Postoperative urine Klotho peaked at the first postoperative time (0 h after admission to the intensive care unit (ICU)) in patients with AKI, and was higher than that in non-AKI patients up to day 3. The AUC of detecting AKI for urine Klotho was higher than urine NGAL at the first postoperative time and 4 h after admission to the ICU. In a multivariate model, increased first postoperative urine Klotho may be an independent predictor for AKI occurrence following cardiac surgery. The concentrations of first postoperative urine Klotho were higher in AKI stage 2 and 3 than those in stage 1 (p < 0.05), and were higher in patients with incomplete recovery of renal function than those with complete recovery (p < 0.05). Conclusions Urine Klotho may serve as an early biomarker for AKI and subsequent poor short-term renal outcome in patients undergoing cardiac surgery.
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Affiliation(s)
- Yingying Qian
- Department of Nephrology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lin Che
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yucheng Yan
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Renhua Lu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Mingli Zhu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Song Xue
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Leyi Gu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
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