Predictive Value of Gamma-Glutamyl Transferase Levels for Contrast-Induced Nephropathy in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention

Unveiling the Mysteries of Contrast-Induced Acute Kidney Injury: New Horizons in Pathogenesis and Prevention

The utilization of contrast media (CM) in clinical diagnostic imaging and interventional procedures has escalated, leading to a gradual increase in the incidence of contrast-induced acute kidney injury (CI-AKI). Presently, the scarcity of effective pharmacological treatments for CI-AKI poses significant challenges to clinical management. Firstly, we explore the pathogenesis of CI-AKI in this review. Beyond renal medullary ischemia and hypoxia, oxidative stress, cellular apoptosis, and inflammation, emerging mechanisms such as ferroptosis, release of neutrophil extracellular traps (NETs), and nitrosative stress, which offer promising avenues for the management of CI-AKI, are identified. Secondly, a comprehensive strategy for the early prevention of CI-AKI is introduced. Investigating the risk factors associated with CI-AKI is essential for the timely identification of high-risk groups. Additionally, exploring early sensitive biomarkers is crucial for early diagnosis. A synergistic approach that combines these sensitive biomarkers, CI-AKI risk factors, and disease risk prediction models enhances both the accuracy and efficiency of early diagnostic processes. Finally, we explore recent pharmacological and non-pharmacological interventions for the management of Cl-AKI. Beyond the traditional focus on the antioxidant N-acetylcysteine (NAC), we look at active compounds from traditional Chinese medicine, including tetramethylpyrazine (TMP), salvianolic acid B (Sal B), as well as emerging preventive medications like N-acetylcysteine amide (NACA), alprostadil, and others, which all showed potential benefits in animal and clinical studies for CI-AKI prevention. Furthermore, innovative strategies such as calorie restriction (CR), enhanced external counterpulsation (EECP), and mesenchymal stem cell therapy are highlighted as providing fresh insights into Cl-AKI prevention and management.

Definition, Staging, and Role of Biomarkers in Acute Kidney Injury in the Context of Cardiovascular Interventions

Acute kidney injury (AKI) is a frequently occurring complication of cardiovascular interventions, and associated with adverse outcomes. Therefore, a clear definition of AKI is of paramount importance to enable timely recognition and treatment. Historically, changes in the serum creatinine and urine output have been used to define AKI, and the criteria have evolved over time with better understanding of the impact of AKI on the outcomes. However, the reliance on serum creatinine for these AKI definitions carries numerous limitations including delayed rise, inability to differentiate between hemodynamics versus structural injury and assay variability to name a few.

Gamma glutamyl transferase as a biomarker to predict contrast-induced nephropathy among patients with acute coronary syndrome undergoing coronary interventions: a meta-analysis

The third most frequent reason for hospitalized acute kidney injury is contrast-induced nephropathy (CIN). Percutaneous coronary intervention (PCI) and coronary angiography (CAG) are two interventions that can result in CIN. In this study, we sought to determine how well gamma-glutamyl transferase (GGT) can predict CIN following CAG and PCI.

Method

Two researchers searched through PubMed, Scopus, and Web of Science in November 2022 to find articles that examined GGT levels in CIN patients following PCI or CAG. To rate the quality of the studies, the Joanna Briggs Institute Critical Appraisal Checklist was employed. The Cochran test and I2 statistics were utilized to assess study heterogeneity. To calculate the number of participants required to reject the null hypothesis, power analysis was used. We evaluated the epidemiologic strength of the results using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The authors used Comprehensive Meta-analysis Version 3 to summarize the results.

Results

GGT was shown to be considerably greater in patients with CIN according to the meta-analysis's findings (odds ratio: 3.21, 95% CI: 1.26-8.15, P=0.014); nevertheless, the findings were accompanied by significant heterogeneity (I2=91.93%, P<0.001). Although the relationship between CIN and GGT was power full regarding power analysis (1- β =1, number of effect sizes=4, the average number per group=336), very low quality of evidence was observed regarding GRADE criteria.

Conclusions

These results suggest the GGT level may be a predictor of contrast-induced nephropathy in patients having cardiac catheterization; however, more research is required to prove the epidemiological validity.

CHA2DS2-VASc, a Simple Clinical Score Expanding Its Boundaries to Predict Contrast-Induced Acute Kidney Injury After Primary Percutaneous Coronary Interventions

Objective

Promising results of CHA₂DS₂-VASc score have been reported for the prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, data of its predictive strength in the context of primary PCI are not available. Therefore, in this study, we have assessed predictive value of CHA₂DS₂-VASc score for CI-AKI after primary PCI.

Methods

This analytical cross-sectional study was conducted between January 2021 and June 2021 at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Inclusion criteria of the study was consecutive adult patients who had undergone primary PCI. Baseline CHA₂DS₂-VASc score was calculated, and either a 25% or 0.5 mg/dL increase in post-procedure serum creatinine level as compared to baseline level was categorized as CI-AKI.

Results

A total of 691 patients were included, of which 82.1% (567) were male. CI-AKI after primary PCI was observed in 63 (9.1%) patients, out of which 66.7% (42) of patients had CHA₂DS₂-VASc score of ≥2. The area under the curve (AUC) for the score was 0.725 [0.662 to 0.788] with a sensitivity and specificity of 66.7% [63.1% to 70.2%] and 66.7% [53.7% to 78.1%], respectively, at a cut-off value of ≥2. In multivariable analysis, left ventricular ejection fraction ≤30% and CHA₂DS₂-VASc ≥2 were found to be independent predictors with adjusted odds ratios of 2.19 [1.06–4.5] and 2.13 [1.13–4.01], respectively.

Conclusion

CHA₂DS₂-VASc score has a good predictive value for the prediction of CI-AKI after primary PCI. Criteria of CHA₂DS₂-VASc ≥2 can be used for the risk stratification of CI-AKI after primary PCI.

Inflammatory Indicators and Hematological Indices in Contrast-Induced Nephropathy Among Patients Receiving Coronary Intervention: A Systematic Review and Meta-Analysis

Strong inflammatory indicators such as C-reactive protein (CRP), high-sensitivity CRP (hsCRP), and hematological indices, including platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), hematocrit (HCT), and red blood cell distribution width (RDW), may be related with contrast-induced nephropathy (CIN). Our meta-analysis aimed at exploring the relationship between these indicators and CIN incidence among patients undergoing coronary intervention. Clinical studies were retrieved from the electronic databases of PubMed, EMBASE, Google Scholar, Clinical Trials, and Science Direct from their inception to June 3, 2020. Meta-analysis was performed on pooled eligible studies. Finally, 26 studies involving 29 454 patients were included. Pooled analysis revealed that patients with higher CRP (odds ratio [OR] = 1.06, 95% CI: 1.01-1.12, P = .02), hsCRP (OR = 1.03, 95% CI: 1.01-1.06, P = .004), NLR (OR = 1.11, 95% CI: 1.01-1.20, P = .02), RDW (OR = 1.35, 95% CI: 1.19-1.53, P < .001), and lower HCT (OR = 0.94, 95% CI: 0.92-0.97, P = .003) all exhibited significantly higher CIN rates, but there was no significant association between PLR and CIN risk (OR = 1.12, 95% CI: 0.99-1.26, P = .07). Pre-angiography CRP/hsCRP and some hematological indices are associated with CIN.

Biomarkers of Contrast-Induced Nephropathy:: Which Ones are Clinically Important?

Contrast-induced acute kidney injury (CI-AKI) is a common complication after intravascular injection of iodinated contrast media, and it is associated with a prolonged in-hospital stay and unfavorable outcome. CI-AKI occurs in 5% to 20% among hospitalized patients. Its diagnosis relies on the increase in serum creatinine levels, which is a late biomarker of kidney injury. Novel and early serum and urinary biomarkers have been identified to detect kidney damage before the expected serum creatinine increase.

The role of thiol levels in predicting contrast-induced nephropathy in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention

OBJECTIVE:

Contrast-induced nephropathy (CIN) is a common complication of diagnostic or interventional procedures that may arise from administration of intravascular contrast media. Recent studies have reported the thiol-disulfide ratio as a novel oxidative stress marker. Therefore, we investigated the role of thiol levels in predicting CIN in patients with ST-segment elevation myocardial infarction (STEMI) who had undergone primary percutaneous coronary intervention (PCI).

METHODS:

A total of 302 patients were enrolled in the study. CIN was defined as an increase in serum creatinine concentration ≥0.5 mg/dL compared with the admission value or a >25% relative rise during the first 48–72 hours after the procedure. To evaluate the relationship between thiol levels and CIN, the patients were divided into a CIN group and a non-CIN group.

RESULTS:

CIN occurred in 44 (15%) patients. Native thiol (274.8±84.7 μmol/L vs. 220.8±97.1 μmol/L, p=0.001) and total thiol (305.4±89.7 μmol/L vs. 260.1±102.1 μmol/L, p=0.009) levels were higher in patients within the non-CIN group. Disulfide (15.8±6.6 μmol/L vs. 19.6±8.4 μmol/L, p=0.002) levels, and mean disulfide/total thiol ratios (8.4±3.7 vs. 5.9±3.1, p=0.001) were higher in patients with CIN (+) group. In univariate analysis, the initial native thiol, total thiol, disulfide levels, and disulfide/total thiol ratio were found to have prognostic significance in the development of CIN. In the multivariate regression analysis, only the disulfide/total thiol ratio (OR=1.190; 95% CI: 1.090–1.300; p=0.001) was significantly and independently associated with CIN. The cutoff value of the disulfide/total thiol ratio to predict CIN on admission in patients with STEMI who underwent primary PCI was 7, with a sensitivity of 68.2% and a specificity of 79.8%.

CONCLUSION:

Our results suggest that thiol/disulfide homeostasis could be a good biochemical risk marker for CIN in STEMI patients who underwent primary PCI.

A new plasma biomarker enhance the clinical prediction of postoperative acute kidney injury in patients with hepatocellular carcinoma

BACKGROUND

The ratio of serum γ-glutamyl transferase (GGT) to alanine aminotransferase (ALT) (GGT/ALT) is a marker for evaluating effects to antivirotic treatment and a helpful predictive factor for the prognosis of Child-Pugh A hepatocellular carcinoma (HCC) patients after surgery. The relationship between the incidence of postoperative acute kidney injury (AKI) and preoperative GGT/ALT is studied in hepatectomized hepatitis B- or C- associated HCC patients.

METHODS

A total of 253 hepatitis B or C virus-related HCC patients undergoing hepatectomy between September 2012 and August 2016 at our hospital were included in the retrospective study. Serum ALT and GGT value were recorded, and the GGT/ALT was computed. AKI was defined that based on the "Kidney Disease Improving Global Outcomes (KDIGO) criteria".

RESULTS

AKI was observed in 22 (8.7%) patients. Mean GGT/ALT of patients with AKI was significantly higher than in those without it (6.0 vs 2.1, P<0.001). Multivariate analysis revealed an increase in GGT/ALT as an independent risk factor for AKI in hepatitis B- or C- associated HCC patients, particularly in patients with Barcelona Clinic Liver Cancer (BCLC) stage 0 or A staged HCC (odds ratio (OR) 1.400, P<0.001). Multivariate analysis showed that ALT (OR 0.966, P=0.044) was somewhat inversely associated with the incidence of AKI in hepatitis B- or C- associated HCC patients. The best cutoff point of GGT/ALT was 2.92. Multivariate analysis showed that preoperative GGT/ALT ≥2.92 predicted poor prognosis of postoperative AKI in patients with HCC after hepatectomy (odds ratio 17.697, P<0.001). After propensity score matching, preoperative GGT/ALT ≥2.92 remained an independent risk factor for AKI in HCC patients (OR 13.947, P=0.003).

CONCLUSIONS

The GGT/ALT of patients with AKI was significantly higher than those without it. Evaluation of GGT/ALT before surgery can be a helpful predictive tool for postoperative AKI in hepatitis B- or C- associated HCC patients undergoing hepatectomy, particularly in patients with BCLC stage 0 or A staged HCC. Hepatitis B- or C- associated HCC patients with low ALT especially within the normal range may have a high risk of AKI. However, the reason remains to be elucidated.

Gamma-glutamyl transferase and cardiovascular disease

Gamma-glutamyl transferase (GGT) is an enzyme located on the external surface of cellular membranes. GGT contributes in maintaining the physiological concentrations of cytoplasmic glutathione and cellular defense against oxidative stress via cleavage of extracellular glutathione and increased availability of amino acids for its intracellular synthesis. Increased GGT activity is a marker of antioxidant inadequacy and increased oxidative stress. Ample evidence suggests that elevated GGT activity is associated with increased risk of cardiovascular disease (CVD) such as coronary heart disease (CHD), stroke, arterial hypertension, heart failure, cardiac arrhythmias and all-cause and CVD-related mortality. The evidence is weaker for an association between elevated GGT activity and acute ischemic events and myocardial infarction. The risk for CVD or CVD-related mortality mediated by GGT may be explained by the close correlation of GGT with conventional CVD risk factors and various comorbidities, particularly non-alcoholic fatty liver disease, alcohol consumption, oxidative stress, metabolic syndrome, insulin resistance and systemic inflammation. The finding of GGT activity in atherosclerotic plaques and correlation of intra-plaque GGT activity with histological indexes of plaque instability may suggest a participation of GGT in the pathophysiology of CVD, particularly atherosclerosis. However, whether GGT has a direct role in the pathophysiology of CVD or it is an epiphenomenon of coexisting CVD risk factors or comorbidities remains unknown and Hill's criteria of causality relationship between GGT and CVD are not fulfilled. The exploration whether GGT provides prognostic information on top of the information provided by known cardiovascular risk factors regarding the CVD or CVD-related outcome and exploration of molecular mechanisms of GGT involvement in the pathophysiology of CVD and eventual use of interventions to reduce circulating GGT activity remain a duty of future studies.

The potential use of biomarkers in predicting contrast-induced acute kidney injury

Contrast-induced acute kidney injury (CI-AKI) is a problem associated with the use of iodinated contrast media, causing kidney dysfunction in patients with preexisting renal failure. It accounts for 12% of all hospital-acquired kidney failure and increases the length of hospitalization, a situation that is worsening with increasing numbers of patients with comorbidities, including those requiring cardiovascular interventional procedures. So far, its diagnosis has relied upon the rise in creatinine levels, which is a late marker of kidney damage and is believed to be inadequate. Therefore, there is an urgent need for biomarkers that can detect CI-AKI sooner and more reliably. In recent years, many new biomarkers have been characterized for AKI, and these are discussed particularly with their use in known CI-AKI models and studies and include neutrophil gelatinase-associated lipocalin, cystatin C (Cys-C), kidney injury molecule-1, interleukin-18, N-acetyl-β-d-glucosaminidase, and L-type fatty acid-binding protein (L-FABP). The potential of miRNA and metabolomic technology is also mentioned. Early detection of CI-AKI may lead to early intervention and therefore improve patient outcome, and in future any one or a combination of several of these markers together with development in technology for their analysis may prove effective in this respect.