Determination of creatinine-related molecules in saliva by reversed-phase liquid chromatography with tandem mass spectrometry and the evaluation of hemodialysis in chronic kidney disease patients

Development of a novel method for the simultaneous detection of trimethylamine N-oxide and creatinine in the saliva of patients with chronic kidney disease - Its utility in saliva as an alternative to blood

Chronic kidney disease (CKD) is associated with increased levels of creatinine and other uremic toxins (UTs), which impaired kidneys cannot filtrate. Typically, CKD is diagnosed by calculating the estimated glomerular filtration rate using serum creatinine or cystatin C levels. In pursuit of more sensitive and reliable biomarkers of kidney dysfunction, scientific attention has turned towards other UTs, such as trimethylamine N-oxide (TMAO), successfully quantified in standard matrices, blood and urine. However, less invasive monitoring of kidney function can be performed using an alternative diagnostic biofluid, saliva, which has been shown to contain clinically relevant concentrations of renal function markers. Accurate quantitative estimation of serum biomarkers using saliva measurements can only be achieved provided that there is a tight saliva-serum correlation for the analyte of interest. Therefore, we aimed to verify the correlation between saliva and serum levels of TMAO in CKD patients using newly developed and validated quantitative liquid chromatography coupled to mass spectrometry (LC-MS) method for simultaneous detection of TMAO, and creatinine - the conventional marker of renal impairment. Secondly, we applied this method to quantify TMAO and creatinine levels in the resting saliva of CKD patients collected with a standardised method involving swab-based collectors. A good linear correlation was obtained between the concentration of creatinine in serum and resting saliva of CKD patients (r = 0.72, p = 0.029) and even better in the case of TMAO (r = 0.81, p = 0.008). The analysed validation criteria were fulfilled. No significant influence of the type of swab in the Salivette® device on creatinine and TMAO concentrations in saliva was detected. Our study indicates that saliva can be successfully used in the non-invasive monitoring of renal failure in CKD by measuring salivary TMAO concentrations.

Saliva as Biomarker for Oral and Chronic Degenerative Non-Communicable Diseases

Saliva is a very complex fluid and it is essential to maintain several physiological processes and functions, including oral health, taste, digestion and immunological defenses. Saliva composition and the oral microbiome can be influenced by several factors, like diet and smoking habits, and their alteration can represent an important access point for pathogens and, thus, for systemic illness onset. In this review, we explore the potentiality of saliva as a new tool for the early detection of some pathological conditions, such as oral diseases, chronic degenerative non-communicable diseases, among these chronic kidney disease (CKD). We also examined the possible correlation between oral and systemic diseases and oral and gut microbiota dysbiosis. In particular, we deeply analyzed the relationship between oral diseases and CKD. In this context, some salivary parameters can represent a new device to detect either oral or systemic pathologies. Moreover, the positive modulation of oral and gut microbiota induced by prebiotics, postbiotics, or symbiotics could represent a new possible adjuvant therapy in the clinical management of oral diseases and CKD.

A smartphone-integrated portable rotating platform for estimation of concentration level of plasma-creatinine using whole human blood

The measurement of creatinine concentration is performed to monitor the renal health. The devices available in modern clinical laboratories for measuring creatinine concentration are accurate and provide results rapidly but may be prohibitively expensive for resource-poor settings. Therefore, developing an inexpensive yet accurate device for measuring creatinine concentration is needed. Consequently, we developed a simple, affordable, and portable spinning disc for measuring plasma-creatinine concentration with 10 μL of whole human blood. 5 μL of the alkaline picrate solution is loaded into the device and rotated at 1000 rpm to transport this solution to the periphery of the microchannel. Further, 10 μL whole blood is loaded in the same channel and spun at 1300 rpm for 10 min. The creatinine in plasma reacts with alkaline picrate (Jaffe reaction), and the color of the mixture changes to yellow-orange color. The resulting color is captured with a smartphone, and creatinine concentration is estimated using an in-house developed app (CREA-SESE). The value of creatinine measured with the present device and the gold standard device are highly correlated (R² = 0.998). The bias and standard deviation of the difference between the two measurements are 0.134 mg/dL and 0.143 mg/dL. This study demonstrates the feasibility of a simple, inexpensive, and portable rotating device for measuring creatinine concentration using 10 μL of whole human blood, which can easily be deployed to the underserved population in resource-constrained settings to monitor renal diseases.

Ultra-rapid capillary zone electrophoresis method for simultaneous determination of arginine and ibuprofen

The combination of arginine and ibuprofen is widely used for pain relief with a faster onset of action than conventional ibuprofen. Therefore, the determination of both compounds in a single run is highly desirable for rapid quality control applications. This paper reports an ultra-fast method (100 injections/h) for simultaneous determination of arginine and ibuprofen using capillary electrophoresis with capacitively coupled contactless conductivity detection. The separation of arginine as cation and ibuprofen as anion was achieved using a background electrolyte composed by an equimolar mixture of 10 mmol/L of 2-(cyclohexylamino) ethanesulfonic acid and boric acid with pH adjusted to 8.4 using potassium hydroxide. The limits of detections were 5.3 and 10.0 μmol/L for arginine and ibuprofen, respectively. The proposed method is simple, fast (one analysis every 35 s), environmentally friendly (minimal waste generation) and accurate (recovery values between 95 and 98%).

Saliva as a tool for monitoring hemodialysis: a systematic review and meta-analysis

This study aimed to assess whether the reductions in serum urea and creatinine levels are different from the reductions in salivary urea and creatinine levels that occur after hemodialysis in chronic renal patients. The systematic review protocol was registered in the PROSPERO database. Eight databases were searched to identify pretest-posttest studies of chronic kidney disease patients undergoing hemodialysis, with no language or year restrictions. The JBI Critical Appraisal Tool was used to assess the risk of bias. Meta-analyses using random-effect models were conducted to compare salivary and serum correlations and to pooled mean and proportion differences from pre- to posthemodialysis urea and creatinine levels by subgroup analysis. The I2 test was used to assess heterogeneity, and a meta-regression was performed to statistically assess correlations and differences in the pooled effects pre- and postdialysis. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to assess the certainty of evidence. The search resulted in 1404 records, and only six studies (n = 252 participants) fulfilled the eligibility criteria and were included. The studies were published between 2013 and 2018. All studies showed a significant reduction in both salivary and serum urea/creatinine levels. All eligible studies presented a low risk of bias. The meta-analysis shows a moderate to high correlation between salivary and blood levels of urea (r: 0.79; 95% CI: 0.56-1.00) and creatinine (r: 0.64; 95%CI: 0.16-1.00), with a very low level of certainty. The reductions in salivary urea and creatinine levels are similar to and correlated with the reductions in blood urea and creatine levels after hemodialysis among chronic kidney disease patients.

Determination of leucine and isoleucine/allo-isoleucine by electrospray ionization-tandem mass spectrometry and partial least square regression: Application to saliva samples

Herein we propose, for the first time, a rapid method based on flow injection analysis, electrospray ionization-tandem mass spectrometry (FIA-ESI-MS/MS) and multivariate calibration for the determination of l-leucine, l-isoleucine and L-allo-isoleucine in saliva. As far as we know, multivariate calibration has never been applied to the data from this non-separative approach. The possibilities of its use were explored and the results obtained were compared with the corresponding ones when using univariate calibration. Partial least square regression (PLS1) multivariate calibration models were built for each analyte by analyzing different saliva samples, and were subsequently applied to the analysis of another set of samples which had not been used in any calibration step. For Leu, the model worked satisfactorily with root mean square errors in the prediction step of 17%. This error can be considered acceptable and is common in methodologies that do not include a separation step. Results were compared with those obtained when univariate calibration was used, using the m/z transition 132.1 → 43.0 as the quantitation variable. In this case, the obtained results were not acceptable, with RMSEP of 236%, due to the fact that saliva samples contained another compound, different to the target analytes, which also shared the same transition. Ile and aIle have the same fragmentation patterns, so quantification of the sum of both compounds was performed, with RMSEP of 14% using a PLS1 model. Similar results were obtained when a univariate calibration model using the m/z transition 132.1 → 69.0 was employed. However, the use of this transition should be carefully examined when other compounds present in the matrix contribute to the analytical signal. The method increases sample throughput more than one order of magnitude compared to the corresponding LC-ESI-MS/MS method and is especially suitable as screening. When abnormally high or low concentrations of the analytes studied are obtained, the use of the method that includes separation is recommended to confirm the results.

Saliva as an alternative to blood in the determination of uremic state in adult patients with chronic kidney disease: a systematic review and meta-analysis

OBJECTIVES

To assess whether salivary urea and creatinine levels accurately reflect their serum levels in blood samples of adults to detect chronic kidney disease.

MATERIALS AND METHODS

A systematic review was conducted in eight electronic databases. The protocol was registered in PROSPERO. Only diagnostic test studies were included. The JBI critical appraisal tools assessed the risk of bias. A meta-analysis of proportions was performed. The GRADE tool assessed the quality of evidence and strength of recommendation across the studies included.

RESULTS

Eight studies met the eligibility criteria and were included. Six studies assessed salivary urea, and six studies assessed salivary creatinine. All studies presented moderate risk of bias. The meta-analysis depicted an overall sensitivity of 93.3% (95% CI = 88.6; 97.9) for salivary creatinine levels and 87.5% (95% CI = 83.2; 91.8) for salivary urea levels, while the overall specificity was 87.1% (95% CI = 82.8; 91.3) and 83.2% (95% CI = 65.0; 101.4) for salivary creatinine and urea levels, respectively. The overall accuracy of salivary creatinine was 5.2 percentage points higher compared with salivary urea levels (90.8% vs. 85.6%). According to the GRADE tool, the analysed outcomes were classified as having low to moderate level of certainty.

CONCLUSION

Compared with blood samples, salivary urea and creatinine levels presented high diagnostic values for chronic kidney disease screening, but should not be considered equivalent to levels obtained from blood at stages three, four, or five of the disease.

CLINICAL SIGNIFICANCE

Chronic kidney disease patients could receive a clinically significant benefit from replacing blood with saliva for potentially monitoring renal function. Saliva collection presents greater simplicity, comfort, safety, and lower collection cost.

Preparation of Isotopically Labelled Standards of Creatinine Via H/D Exchange and Their Application in Quantitative Analysis by LC-MS

Kidneys play a crucial role in maintaining metabolic homeostasis in a body. Serum creatinine concentration is a simple test used as an indicator of renal function. One of the known ways of quantifying creatinine concentration is the liquid chromatography-mass spectrometry (LC-MS) method, using an isotopically labeled analog of creatinine as an internal standard. Unfortunately, such isotope-labeled analogs are expensive and their synthesis is complex. Here we demonstrate a facile preparation of deuterated analogues of creatinine, via the H/D exchange of hydrogens located at the α-carbon (α-C) of the N-methylated amino acid part, under basic conditions. The stability of retrieved isotopologues was analyzed under both neutral or acidic conditions, and the results revealed that the introduced deuterons do not undergo back-exchange. In addition, the coelution of deuterated and non-deuterated forms under acidic and neutral conditions was observed. The prepared isotopologues were successfully applied in the quantitative LC-MS analysis of urine samples, and the results demonstrated that the presented strategy is novel and inexpensive, and that the quantification correlates with the commonly used Jaffe test method.

Fabrication of an improved amperometric creatinine biosensor based on enzymes nanoparticles bound to Au electrode

An improved amperometric creatinine biosensor was fabricated that dependent on covalent immobilisation of nanoparticles of creatininase (CANPs), creatinase (CINPs) and sarcosine oxidase (SOxNPs) onto gold electrode (AuE). The CANPs/CINPs/SOxNPs/AuE was characterised by scanning electron microscopy and cyclic voltammetry at various stages. The working electrode exhibited optimal response within 2 s at a potential of 0.6 V, against Ag/AgCl, pH 6.5 and 30 °C. A linear relationship was observed between creatinine concentration range, 0.1-200μM and biosensor response i.e. current in mA, under optimum conditions. Biosensor offered a low detection limit of 0.1 μM with long storage stability. Analytical recoveries of added creatinine in blood sera at 0.5 mM and at 1.0 mM concentrations, were 92.0% and 79.20% respectively. The precision i.e. within and between-batch coefficients of variation were 2.04% and 3.06% respectively. There was a good correlation (R² = 0.99) between level of creatinine in sera, as calculated by the colorimetric method and present electrode. The CANPs/CINPs/SOxNPs/Au electrode was reused 200 times during the period of 180 days, with just 10% loss in its initial activity, while being stored at 4 °C, when not in use.HighlightsPrepared and characterised creatininase (CA), creatinase (CI) sarcosine oxidase (SOx) nanoparticles and immobilised them onto gold electrode (AuE) for fabrication of an improved amperometric creatinine biosensor.The biosensor displayed a limit of detection (LOD) of 0.1 μM with a linear working range of 0.1 μM-200 μM.The biosensor was evaluated and applied to measure elevated creatinine levels in sera from whom suffering from kidney and muscular disorders.The working electrode retained 90% of its initial activity, while being stored dry at 4 ˚C for 180 days.

Saliva for assessing creatinine, uric acid, and potassium in nephropathic patients

Background

Lab tests on saliva could be useful because of low invasivity. Previous reports indicated that creatinine, uric acid, and potassium are measurable in saliva. For these analytes the study investigated methodology of saliva tests and correlations between plasma and saliva levels.

Methods

The study enrolled 15 healthy volunteers for methodological analyses and 42 nephropathic patients for plasma-saliva correlations (35 non-dialysis and 7 dialysis). Saliva was collected by synthetic swap right after venipuncture for blood withdrawal. Blood and saliva, unless otherwise indicated, were collected early in the morning after overnight fast and lab tests were performed in fresh samples by automated biochemistry (standard). Methodological analyses included blind duplicates, different collection mouth sites, day-to-day variability, different collection times, and freezing-thawing effects. Analyses on plasma-saliva correlations included post-dialysis changes.

Results

For saliva lab tests of all analytes, blind duplicates, samples from different mouth sites or of different days were not significantly different but were significantly correlated (differences ≤14.4%; R ≥ 0.620, P ≤ 0.01). For all analytes, mid-morning saliva had lower levels than but correlated with standard saliva (differences ≥15.8%; R ≥ 0.728, P ≤ 0.01). Frozen-thawed saliva had lower levels than fresh saliva for uric acid only (− 17.2%, P < 0.001). Frozen-thawed saliva correlated with fresh saliva for all analytes (R ≥ 0.818, P ≤ 0.001). Saliva and plasma levels differed but correlated with plasma for creatinine (R = 0.874, P < 0.001), uric acid (R = 0.821, P < 0.001) and potassium (R = 0.767, P < 0.001). Post-dialysis changes in saliva paralleled post-dialysis changes in plasma.

Conclusion

Saliva levels of creatinine, uric acid, and potassium are measurable and correlated with their plasma levels. Early morning fasting fresh saliva samples are advisable because later collection times or freezing lower the saliva levels of these analytes.

Salivary levels of phosphorus and urea as indices of their plasma levels in nephropathic patients

BACKGROUND

Phosphorus and urea are measurable in saliva. Measurements of saliva phosphorus (S-Pho) and saliva urea (S-Urea) could be useful because of low invasivity. Data are limited to saliva tests methodology and to correlations between plasma and saliva compositions. S-Pho and S-Urea were investigated focusing on blind duplicates, differences between collection sites, differences between collection times, freezing-thawing effects, and plasma-saliva correlations.

METHODS

Tests were performed using fresh saliva collected by synthetic swap early morning after overnight fast (standard). Methodology was investigated in fifteen healthy volunteers. Plasma-saliva correlations were investigated in thirty nephropathic outpatients.

RESULTS

S-Pho and S-Urea in all measurements ranged above detection limits (0.3 mmol/L). In healthy volunteers, S-Pho and S-Urea were similar in duplicates (results for S-Pho and S-Urea: % difference between samples ≤ 4.85%; R between samples ≥ .976, P < .001), in samples from different mouth sites (≤4.24%; R ≥ .887, P < .001), and in samples of different days (≤5.61%; R ≥ .606, P < .01) but, compared to standard, were substantially lower in after-breakfast samples (-28.0% and -21.3%; R ≥ .786, P < .001) and slightly lower in frozen-thawed samples (-12.4% and -5.92%; R ≥ .742, P < .001). In nephropathic patients, S-Pho was higher than but correlated with plasma phosphorus (saliva/plasma ratio 4.80; R = .686, P < .001), whereas S-Urea and plasma urea were similar and correlated with each other (saliva/plasma ratio 0.96; R = .944, P < .001). Post-dialysis changes in S-Pho and S-Urea paralleled post-dialysis changes in plasma phosphorus and urea.

CONCLUSION

S-Pho and S-Urea reflect plasma phosphorus and plasma urea. Early morning fasting fresh samples are advisable because collection time and freezing-thawing affect saliva tests.