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Sharma NK, Panda SS, Ratan SK, Neogi S, Goswami B, Kumar R. Role of Urinary Biomarkers (Transforming Growth Factor β1, Neutrophil Gelatinase-Associated Lipocalin, and Cystatin C) as a Prognostic Factor of Renal Outcome in the Posterior Urethral Valve. J Indian Assoc Pediatr Surg 2024; 29:204-212. [PMID: 38912012 PMCID: PMC11192255 DOI: 10.4103/jiaps.jiaps_210_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/17/2023] [Accepted: 12/30/2023] [Indexed: 06/25/2024] Open
Abstract
Background The urinary biomarker response precedes the appearance of any renal structural or functional derangement. Transforming growth factor-β1 (TGF-β1), neutrophil gelatinase associated lipocalin (NGAL), and Cystatin C (CysC) can act as the early prognostic markers in posterior urethral valve (PUV) patients. Aim To compare the urinary levels of TGF-β1, NGAL, and CysC between PUV cases and age matched controls and to correlate these with renal structural and functional parameters. Materials and Methods This prospective study included children with PUV diagnosed using the standard investigations and an equal number of age-matched controls with nonurological problems. For the study subjects, the urinary samples were collected at three different time points (pre- and postoperatively at 3 and 6 months), whereas for controls, only single-voided samples were studied. The urinary levels of TGF-β1, NGAL, and CysC were estimated by the standardized techniques using the ELISA kits. Statistical methods were used to drive the comparisons between cases and controls. Results Fifteen children with a median age of 10 (5-48) months were enrolled in each of the two groups. The mean uTGF-β1 in the case group was significantly higher at all three time points (43.20 ± 6.13 pg/ml, 43.33 ± 11.89 pg/ml and 40.71 ± 9.01 pg/ml) as compared to the control group (29.12 ± 8.31 pg/ml) (P ≤ 0.001). The median uNGAL in the case group was also higher (17.78 ng/ml, 2.35 ng/ml and 2.536 ng/ml) as compared to the control group (1.31 ng/ml). However, the difference was significant only preoperatively (P = 0.02). The median uCysC in case group was similarly higher (0.347 μg/ml, 0.439 μg/ml, and 0.382 μg/ml) than the control group (0.243 μg/ml) (P > 0.05). Serum creatinine in the case group (0.49 mg/dl) showed no significant rise above that of control (0.24 mg/dl). A cutoff value of uTGF-β1 = 36.55 pg/ml (P < 0.001), uNGAL = 0.879 ng/ml (P = 0.02), and uCysC = 0.25 μg/ml (P = 0.22) was found to be associated with renal damage in PUV. A significant correlation was found between uNGAL and S. creatinine at 3 months (r = 0.43, P = 0.017) and 6 months (r = 0.47, P = 0.08). Conclusion The elevated uTGF-β1, a decline in uNGAL and an increase in uCysC suggests ongoing inflammation, improvement in hydronephrosis and a prolonged proximal tubular dysfunction in PUV patients, respectively.
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Affiliation(s)
- Nitesh Kumar Sharma
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Shasanka Shekhar Panda
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Simmi K. Ratan
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Sujoy Neogi
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Binita Goswami
- Department of Biochemistry, Maulana Azad Medical College, New Delhi, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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Robinson EJ, Bayne A. Pyeloplasty may reverse the effect of growth delay from ureteropelvic junction obstruction in infants. Int Urol Nephrol 2024; 56:1227-1233. [PMID: 37991603 DOI: 10.1007/s11255-023-03870-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To determine if children with UPJO demonstrate a clinically significant change in somatic growth following pyeloplasty. METHODS We retrospectively evaluated the growth chart data of infants with SFU grade 3 or 4 congenital hydronephrosis at our institution from 2015 to 2022. Of those, 35 patients underwent pyeloplasty and 66 had no surgical intervention. Patients met criteria if they had SFU 3 or 4 hydronephrosis and MAG3 renal scan. If patients underwent surgery, height and weight percentiles were recorded from the pre-op and 6-16-month follow-up visits. In non-surgery patients, measurements were taken near the median age of surgery in the intervention group and 6-16 months later. Interval changes in group height and weight percentiles are compared for significant changes. RESULTS The surgery and non-surgery groups did not differ in terms of gender (71% vs 74% Male), starting age (296 vs 244 days), starting weight (58th vs 52nd percentile), or time between measurements (255 vs 260 days), though the surgery group had significantly less height in the pre-operative period (43rd vs 55th percentile, p = 0.050) and were more likely to have delayed drainage on renal scan (83% w/delay vs 35%). The surgery group showed a significant increase in height (18.9 percentiles; 95% CI 11-27) and weight (6.0 percentiles; 95% CI 0.50-12) after intervention. CONCLUSIONS Patients with congenital hydronephrosis due to UPJO that underwent pyeloplasty showed a significant increase in weight and height at 6-16 months postoperatively compared to those that were managed with close observation. This suggests UPJO might lead to growth delay in infants.
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Affiliation(s)
- Eric J Robinson
- Department of Urology, Kaiser Permanente, Los Angeles, CA, USA.
| | - Aaron Bayne
- Department of Urology, Oregon Health and Science University, Portland, OR, USA
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Comella F, Lama A, Pirozzi C, Annunziata C, Piegari G, Sodano F, Melini S, Paciello O, Lago Paz F, Meli R, Mattace Raso G. Oleoylethanolamide attenuates acute-to-chronic kidney injury: in vivo and in vitro evidence of PPAR-α involvement. Biomed Pharmacother 2024; 171:116094. [PMID: 38183745 DOI: 10.1016/j.biopha.2023.116094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/08/2024] Open
Abstract
Chronic kidney disease (CKD) development after acute kidney injury (AKI) involves multiple mechanisms, including inflammation, epithelial-mesenchymal transition (EMT), and extracellular matrix deposition, leading to progressive tubulointerstitial fibrosis. Recently, a central role for peroxisome-proliferator activated receptor (PPAR)-α has been addressed in preserving kidney function during AKI. Among endogenous lipid mediators, oleoylethanolamide (OEA), a PPAR-α agonist, has been studied for its metabolic and anti-inflammatory effects. Here, we have investigated OEA effects on folic acid (FA)-induced kidney injury in mice and the underlying mechanisms. OEA improved kidney function, normalized urine output, and reduced serum BUN, creatinine, and albuminuria. Moreover, OEA attenuated tubular epithelial injury, as shown by histological analysis, and decreased expression of neutrophil gelatinase-associated lipocalin and kidney injury molecule-1. Gene expression analysis of kidney tissue indicated that OEA limited immune cell infiltration and inflammation. Moreover, OEA significantly inhibited Wnt7b and Catnb1 gene transcription and α-smooth muscle actin expression, indicating suppression of EMT. Accordingly, OEA exhibited an anti-fibrotic effect, as shown by Masson staining and the reduced levels of transforming growth factor (TGF)-β1, fibronectin, and collagen IV. Mechanistically, the nephroprotective effect of OEA was related to PPAR-α activation since OEA failed to exert its beneficial activity in FA-insulted PPAR-α-/- mice. PPAR-α involvement was also confirmed in HK2 cells where GW6471, a PPAR-α antagonist, blunted OEA activity on the TGF-β1 signalling pathway and associated pro-inflammatory and fibrotic patterns. Our findings revealed that OEA counteracts kidney injury by controlling inflammation and fibrosis, making it an effective therapeutic tool for limiting AKI to CKD progression.
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Affiliation(s)
- Federica Comella
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Adriano Lama
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Claudio Pirozzi
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Chiara Annunziata
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Giuseppe Piegari
- Department of Veterinary Medicine and Animal Production, University of Naples "Federico II", 80137 Naples, Italy
| | - Federica Sodano
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Stefania Melini
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Orlando Paciello
- Department of Veterinary Medicine and Animal Production, University of Naples "Federico II", 80137 Naples, Italy
| | - Francisca Lago Paz
- University Clinic Hospital of Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Rosaria Meli
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy
| | - Giuseppina Mattace Raso
- Department of Pharmacy, School of Medicine, University of Naples "Federico II, 80131 Naples, Italy.
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Vukmirović Papuga M, Bukumirić Z, Ilinčić B, Mijović R, Šašić Ostojić T, Žeravica R. Serum Uromodulin, a Potential Biomarker of Tubulointerstitial Damage, Correlates Well with Measured GFR and ERPF in Patients with Obstructive Nephropathy. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121729. [PMID: 36556931 PMCID: PMC9785409 DOI: 10.3390/medicina58121729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/13/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
Background and Objectives: In chronic kidney obstruction, the severity of tubulointerstitial damage correlates best with the loss of kidney function and the risk for progression to end-stage kidney disease. The present study aimed to investigate the potential clinical significance of serum uromodulin (sUmod) as a marker of early kidney disfunction in patient with obstructive nephropathy (ON). Materials and Methods: Serum Umod level was measured by sensitive ELISA method in 57 adult patients with obstructive nephropathy and 25 healthy subjects in control group. Kidney function was precisely evaluated via measured glomerular filtration rate (mGFR) (renal clearance of 99 mTc-diethylenetriamine penta-acetic acid), effective renal plasma flow (ERPF) and Cystatin C level. Recruited patients were divided into subgroups based on the mGFR: group I—GFR ≤ 60 mL/min/1.73 m2 (N = 31), group II—GFR > 60 mL/min/1.73 m2 (N = 26). Results: A significantly lower level of serum uromodulin was measured in patients with ON (50.2 ± 26.3 ng/mL) compared to the control group (78.3 ± 24.5 ng/mL) (p < 0.001). The mean level of serum Umod was significantly different between group I (30.5 ng/mL ± 11.1) and group II (73.6 ng/mL ± 18.6) (p < 0.001), but not between group II (73.6 ng/mL ± 18.6) and control group (78.3 ± 24.5 ng/mL). There was a positive correlation between sUmod and mGFR (R = 0.757, p < 0.001) and ERPF (R = 0.572 p < 0.001), with lower sUmod levels in patients with impaired renal function. An inverse relationship was detected between sUmod and filtration markers—cystatin C (R = −0.625, p < 0.001), creatinine, urea and uric acid. ROC analysis of sUmod to differentiate between ON patients with GFR below 60 mL/min/1.73 m2 and above 60 mL/min/1.73 m2 resulted in AUC of 0.98 (p < 0.001, 95% CI 0.922 vs. 0.998) at a cut-off value of 46 ng/mL (specificity 96.8%, sensitivity 92.2%). Conclusions: The significant correlation of sUmod with kidney function parameters may imply potential clinical significance as a noninvasive biomarker of early kidney disfunction in obstructive nephropathy.
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Affiliation(s)
- Marija Vukmirović Papuga
- Department of Pathophysiology and Laboratory Medicine, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Center of Laboratory Medicine, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Zoran Bukumirić
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Branislava Ilinčić
- Department of Pathophysiology and Laboratory Medicine, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Center of Laboratory Medicine, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Romana Mijović
- Department of Pathophysiology and Laboratory Medicine, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Center of Laboratory Medicine, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Tanja Šašić Ostojić
- Department of Pathophysiology and Laboratory Medicine, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Center of Laboratory Medicine, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Radmila Žeravica
- Department of Pathophysiology and Laboratory Medicine, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Center of Laboratory Medicine, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
- Correspondence:
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5
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Biomarker bei ureteropelviner Stenose. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01644-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sangeetha G, Babu R. Comparing accuracy of urinary biomarkers in differentiation of ureteropelvic junction obstruction from nonobstructive dilatation in children. Pediatr Nephrol 2022; 37:2277-2287. [PMID: 35237864 DOI: 10.1007/s00467-022-05488-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/05/2022] [Accepted: 01/25/2022] [Indexed: 12/20/2022]
Abstract
Multiple urinary biomarkers have been reported in differentiation of nonobstructive dilatation (NOD) from ureteropelvic junction obstruction (UPJO). In this meta-analysis, we compared the accuracy of common urinary biomarkers applicable to UPJO. A systematic literature review of electronic databases was conducted for: (UPJO) OR (NOD) AND (urinary biomarkers) AND (children) for articles published in the last decade. PRISMA guidelines were used to exclude duplicate and erroneous articles. Meta-analysis involved risk of bias analysis, heterogeneity assessment, and comparison of sensitivity/specificity by forest plot analysis using MetaXL 5.3. Among the 264 articles analyzed, 19 articles met the inclusion criteria and reported the following: neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemotactic protein-1 (MCP1), carbohydrate antigen 19-9 (CA 19-9), kidney injury molecule (KIM1), epidermal growth factor (EGF), and interferon gamma induced protein-10 (IP10). There was substantial heterogeneity among articles. There was wide variation in applied cut-offs among studies. Overall sensitivity was highest at 87% for CA 19-9 while overall specificity was highest at 76% for NGAL. Overall accuracy was highest at 78% for CA 19-9 followed by 77% for NGAL and 75% for KIM1. In this meta-analysis, the overall accuracy was highest for CA 19-9 followed by NGAL and KIM1. The small number of studies for CA 19-9 and considerable heterogeneity for all should be considered while interpreting these findings. Based on the current meta-analysis, we support a panel of biomarkers combining NGAL, KIM, and CA 19-9 for the best diagnostic accuracy of UPJO in children.
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Affiliation(s)
- Geminiganesan Sangeetha
- Pediatric Nephrology Unit, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India.
| | - Ramesh Babu
- Pediatric Urology Unit, Sri Ramachandra Institute of Higher Education & Research, 600116, Chennai, India
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Rai A, Hsieh A, Smith A. Contemporary Diagnosis and Management of Ureteropelvic Junction Obstruction. BJU Int 2022; 130:285-290. [DOI: 10.1111/bju.15689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Arun Rai
- Smith Institute for Urology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Northwell Health New Hyde Park NY 11042 USA
| | - Alan Hsieh
- Scott Department of Urology Baylor College of Medicine 1 Baylor Plaza Houston TX 77030 USA
| | - Arthur Smith
- Smith Institute for Urology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Northwell Health New Hyde Park NY 11042 USA
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Karmakova ТА, Sergeeva NS, Kanukoev КY, Alekseev BY, Kaprin АD. Kidney Injury Molecule 1 (KIM-1): a Multifunctional Glycoprotein and Biological Marker (Review). Sovrem Tekhnologii Med 2021; 13:64-78. [PMID: 34603757 PMCID: PMC8482821 DOI: 10.17691/stm2021.13.3.08] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Indexed: 12/17/2022] Open
Abstract
KIM-1 (kidney injury molecule 1) is a transmembrane glycoprotein also known as HAVcr-1 and TIM-1 belongs to the T-cell immunoglobulin and mucin domain family (TIM) of proteins. TIM glycoproteins are presented on the immune cells and participate in the regulation of immune reactions. KIM-1 differs from other members of its family in that it is expressed not only by immunocompetent cells but epithelial cells as well. Cellular and humoral effects mediated by KIM-1 are involved in a variety of physiological and pathophysiological processes. Current understanding of the mechanisms determining the participation of KIM-1 in viral invasion, the immune response regulation, adaptive reactions of the kidney epithelium to acute ischemic or toxic injury, in progression of chronic renal diseases, and kidney cancer development have been presented in this review. Data of clinical researches demonstrating the association of KIM-1 with viral diseases and immune disorders have also been analyzed. Potential application of KIM-1 as urinary or serological marker in renal and cardiovascular diseases has been considered.
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Affiliation(s)
- Т А Karmakova
- Leading Researcher, Department of Predicting the Effectiveness of Conservative Therapy; P. Hertsen Moscow Oncology Research Institute - Branch of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 3, 2 Botkinsky Proezd, Moscow, 125284, Russia
| | - N S Sergeeva
- Professor, Head of the Department of Predicting the Effectiveness of Conservative Therapy; P. Hertsen Moscow Oncology Research Institute - Branch of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 3, 2 Botkinsky Proezd, Moscow, 125284, Russia; Professor, Department of Biology; Pirogov Russian National Research Medical University, 1 Ostrovitianova St., Moscow, 117997, Russia
| | - К Yu Kanukoev
- Urologist, Department of Urology with Chemotherapy; P. Hertsen Moscow Oncology Research Institute - Branch of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 3, 2 Botkinsky Proezd, Moscow, 125284, Russia
| | - B Ya Alekseev
- Professor, Deputy General Director for Science; National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 4 Koroleva St., Obninsk, 249036, Russia
| | - А D Kaprin
- Professor, Academician of the Russian Academy of Sciences, General Director; National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 4 Koroleva St., Obninsk, 249036, Russia
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Begou O, Pavlaki A, Deda O, Bollenbach A, Drabert K, Gika H, Farmaki E, Dotis J, Printza N, Theodoridis G, Tsikas D. Diminished Systemic Amino Acids Metabolome and Lipid Peroxidation in Ureteropelvic Junction Obstruction (UPJO) Infants Requiring Surgery. J Clin Med 2021; 10:jcm10071467. [PMID: 33918213 PMCID: PMC8038180 DOI: 10.3390/jcm10071467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 12/19/2022] Open
Abstract
Congenital anomalies of the urinary tract, and particularly of obstructive nephropathy such as ureteropelvic junction obstruction (UPJO) in infants, can later lead to chronic kidney disease and hypertension. Fundamental questions regarding underlying mechanisms remain unanswered. The aim of the present study was to quantitate the systemic amino acids metabolome in 21 UPJO infants requiring surgery (Group A) and 21 UPJO infants under conservative treatment (Group B). Nineteen healthy age-matched infants served as controls (Group C). Serum amino acids involved in several pathways and representative metabolites, including the L-arginine-derived nitric oxide (NO) metabolites nitrite and nitrate and the lipid peroxidation biomarker malondialdehyde (MDA) were measured by gas chromatography–mass spectrometry (GC–MS) methods using their stable-isotope labeled analogs as internal standards after derivatization to their methyl esters N-pentafluoropropionic amides (amino acids) and to their pentafluorobenzyl derivatives (nitrite, nitrate, MDA). The concentrations of the majority of the biomarkers were found to be lower in Group A compared to Group B. Statistical analysis revealed clear differentiation between the examined study groups. Univariate statistical analysis highlighted serum homoarginine (q = 0.006), asymmetric dimethylarginine (q = 0.05) and malondialdehyde (q = 0.022) as potential biomarkers for UPJO infants requiring surgery. Group A also differed from Group B with respect to the diameter of the preoperative anterior–posterior renal pelvis (AP) as well as regarding the number and extent of inverse correlations between AP and the serum concentrations of the biomarkers. In Group A, but not in Group B, the AP diameter strongly correlated with hydroxy-proline (r = −0.746, p = 0.0002) and MDA (r = −0.754, p = 0.002). Our results indicate a diminished amino acids metabolome in the serum of UPJO infants requiring surgery comparing to a conservative group.
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Affiliation(s)
- Olga Begou
- Laboratory of Analytical Chemistry, Department of Chemistry, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece;
- Biomic_AUTh, Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Balkan Center, B1.4, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001 Thessaloniki, Greece; (O.D.); (H.G.)
- Core Unit Proteomics, Hannover Medical School, Institute of Toxicology, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; (A.B.); (K.D.); (D.T.)
- Correspondence: ; Tel.: +30-2310-990596
| | - Antigoni Pavlaki
- Paediatric Nephrology Unit, First Department of Paediatrics, Hippokratio Hospital, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece; (A.P.); (J.D.); (N.P.)
| | - Olga Deda
- Biomic_AUTh, Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Balkan Center, B1.4, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001 Thessaloniki, Greece; (O.D.); (H.G.)
- Laboratory of Forensic Medicine and Toxicology, School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Alexander Bollenbach
- Core Unit Proteomics, Hannover Medical School, Institute of Toxicology, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; (A.B.); (K.D.); (D.T.)
| | - Kathrin Drabert
- Core Unit Proteomics, Hannover Medical School, Institute of Toxicology, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; (A.B.); (K.D.); (D.T.)
| | - Helen Gika
- Biomic_AUTh, Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Balkan Center, B1.4, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001 Thessaloniki, Greece; (O.D.); (H.G.)
- Laboratory of Forensic Medicine and Toxicology, School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Evangelia Farmaki
- Paediatric Immunology and Rheumatology Referral Center, First Department of Paediatrics, Hippokratio Hospital, University Campus, 54124 Thessaloniki, Greece;
| | - John Dotis
- Paediatric Nephrology Unit, First Department of Paediatrics, Hippokratio Hospital, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece; (A.P.); (J.D.); (N.P.)
| | - Nikoleta Printza
- Paediatric Nephrology Unit, First Department of Paediatrics, Hippokratio Hospital, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece; (A.P.); (J.D.); (N.P.)
| | - Georgios Theodoridis
- Laboratory of Analytical Chemistry, Department of Chemistry, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece;
- Biomic_AUTh, Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Balkan Center, B1.4, 10th km Thessaloniki-Thermi Rd, P.O. Box 8318, 57001 Thessaloniki, Greece; (O.D.); (H.G.)
| | - Dimitrios Tsikas
- Core Unit Proteomics, Hannover Medical School, Institute of Toxicology, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; (A.B.); (K.D.); (D.T.)
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Can serum Neutrophil Gelatinase Associated Lipocalin and Kidney Injury Molecule-1 help in decision making for surgery in antenatally dedected hydronephrosis. J Pediatr Urol 2021; 17:71.e1-71.e7. [PMID: 33139211 DOI: 10.1016/j.jpurol.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Congenital obstructive uropathies are among leading reasons for renal failure in children. Answers to questions such as what the critical threshold of obstruction is or which degree of obstruction disrupts the development of the kidney still remain unclear. Several biomarkers such as Kidney Injury Molecule 1 (KIM-1) and Neutrophil Gelatinase Associated Lipocalin (NGAL) may help clinicians in the clinical evaluation and appropriate planning of the disease. OBJECTIVE This study aimed to investigate whether serum and urinary KIM-1 and NGAL levels contribute to conventional methods in decision-making for surgery in the postnatal period of infants with antenatal hydronephrosis. STUDY DESIGN 34 patients with the diagnosis of antenatal hydronephrosis were evaluated prospectively. Renal pelvis diameters of all patients were above 10 mm in the ultrasonography (USG). Patients underwent diuretic renal scintigraphy after neonatal period. Patients were divided into two groups as surgery or follow-up based on USG and scintigraphy findings. Blood and urine samples were collected at first visits in both groups and again at the 3. Postoperative month in the surgery group. Serum and urinary NGAL and KIM-1 levels were measured by ELISA method. Study data were compared through the Mann-Whitney U and Wilcoxon Signed-Ranks test. RESULTS There were 10 patients in the surgery group and 24 patients in the follow-up group. The age and gender did not differ between the groups. The surgery group had significantly higher median serum NGAL values (259.2 ng/mL) than that in the follow-up group (46.8 ng/mL, p = 0.028). The postoperative reduction of the median serum NGAL to 68.1 ng/mL compared to preoperative level was also found to be significant (p = 0.037) in the surgery group. Between the groups and within the surgery group no statistically significant difference was detected in terms of median urinary NGAL, and serum and urine KIM-1 levels. DISCUSSION USG and renal scintigraphy are frequently used in determining whether patients with antenatal hydronephrosis need surgical intervention in the postnatal period. Several new biomarkers might help clinicians in decision making for surgery. KIM-1 and NGAL levels can be measured both in urine and serum. To our knowledge, this is the only study where serum NGAL and KIM-1 levels were measured in patients with antenatal diagnosis. Small sample size, lack of long term findings and control group are limitations of our study. CONCLUSION Serum NGAL levels of patients with antenatal hydronephrosis may help in decision making on the surgical intervention.
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Kazlauskas V, Bilius V, Jakutis V, Komiagiene R, Burnyte B, Verkauskas G. Urine Biomarkers Combined With Ultrasound for the Diagnosis of Obstruction in Pediatric Hydronephrosis. Front Pediatr 2021; 9:762417. [PMID: 35071129 PMCID: PMC8771629 DOI: 10.3389/fped.2021.762417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: To establish the efficacy of ultrasound (US) combined with urine biomarkers in differentiating patients who require surgical management from those who do not, avoiding invasive investigations. Materials and Methods: From February 2019 to February 2021, all pediatric patients who presented with hydronephrosis were selected for the study. All renal units (RU) were evaluated by US, and fresh frozen voided urine samples were collected at the time of inclusion. Hydronephrosis grade was evaluated by the Society for Fetal Urology (SFU) and an alternative grading system (AGS). Patients who had high-grade hydronephrosis on US were referred to renal scan (RS) or intervention, when there was an increase of dilatation in subsequent follow-up images. Fresh frozen urine from the control group with no history of renal diseases and no renal anomalies on US was collected. We compared differences of US parameters combined with urine biomarkers between surgically and non-surgically managed patients and between the groups of patients when they were stratified by different RS findings and analyzed whether urinary biomarkers give any additional value to US. Instead of the anterior-posterior diameter (APD), we used its ratio with mid-parenchymal thickness. The additional efficacy of biomarkers to US was calculated when the US component was derived to a cumulative APD/mid-parenchymal ratio. Results: Sixty-four patients with hydronephrosis were prospectively included in the study accounting for a total of 81 patient visits and 162 RUs evaluated. A control group of 26 patients was collected. The mean age at inclusion in the hydronephrosis group was 43.7(±45.5) months, and a mean age in a control group was 61.2(±41.3) months. The cumulative APD/mid-parenchymal ratio combined with urinary albumin, β2 microglobulin (β2-M), and urinary neutrophil gelatinase-associated lipocalcin may have a better performance in the prediction of surgical intervention than the cumulative APD/mid-parenchymal ratio alone (p = 0.1). The best performance to detect the increased tissue transit time and obstructive curve on RS was demonstrated by the β2-M creatinine ratio. An increased cumulative APD/mid-parenchymal ratio with biomarkers together had a fairly good sensitivity and specificity for detection of DRF < 40%. Conclusions: According to our data, the APD/mid-parenchymal ratio alone has good efficacy in prediction of surgery and abnormal RS findings especially when combined with urine biomarkers.
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Affiliation(s)
- Vytis Kazlauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Vytautas Bilius
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Virginijus Jakutis
- Clinic of Anesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Renata Komiagiene
- Department of Radiology, Nuclear Medicine and Medical Physis, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Birute Burnyte
- Department of Human and Clinical Genetics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gilvydas Verkauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Özkuvancı Ü, Dönmez Mİ, Ziylan O, Oktar T, Küçükgergin C, Çetin B, Erdem S, Seçkin Ş. Can urinary biomarkers detect obstruction defined by renal functional loss in antenatal hydronephrosis? J Pediatr Urol 2020; 16:844.e1-844.e7. [PMID: 32988771 DOI: 10.1016/j.jpurol.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/16/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Diagnosing obstruction and thus, assessment of need for surgery in the management of antenatal hydronephrosis may be challenging. Current diagnostic tests are not capable of indicating which patients are at risk for obstructive nephropathy. Biomarkers may play an important role in distinguishing these patients. OBJECTIVE The aim of this study is to evaluate if urinary biomarkers could differentiate obstruction (OBS) from non-obstructive dilation (NOD) in patients with antenatal hydronephrosis (AH) that underwent pyeloplasty due to loss of differential renal function (DRF). STUDY DESIGN Children with a history of AH and postnatal anteroposterior (AP) diameter ≥15 mm were included in this study of prospectively collected data between 2010 and 2018. The OBS group included patients who underwent pyeloplasty due to solely ≥10% subsequent decrease in DRF on a MAG-3 scan during follow-up. Patients with stable or improving hydronephrosis with no significant reduction in ipsilateral DRF (<10%) during follow-up formed the NOD group. Healthy children with no history of AH and a normal urinary ultrasound were taken as the control group. Urinary IP-10, MCP-1, KIM-1, NGAL, and Ca19-9 levels using ELISA were measured. In the OBS group, urine samples were obtained preoperatively and at 3rd post operative-month whereas in the NOD and control groups, samples were collected at the time of enrollment. RESULTS There were 24 children in the OBS and 27 children in the NOD groups. The control group consisted of 27 healthy children. The pre-operative bladder urine levels of biomarkers of the OBS group were significantly higher than in the NOD and control group (p < 0.05, for all). In terms of differentiating OBS from NOD, results of ROC analyses for the given cut-off values were as follows: 135.06 ng/mgCr (sensitivity 75%; specificity 66%, AUC = 0.735) for IP-10, 0.89 ng/mgCr (sensitivity 79.2%; specificity 88%, AUC = 0.802) for KIM-1, 367.65 pg/mgCr (sensitivity 62.5%; specificity 52%, AUC = 0.660) for MCP-1, 16.15 ng/mgCr (sensitivity 70.8%; specificity 70.4%, AUC = 0.669) for NGAL, and 55.5 U/mgCr (sensitivity 75%; specificity 66%, AUC = 0.676) for Ca 19-9. Moreover, when KIM-1 was combined with IP-10 and Ca19-9, sensitivity and specificity levels were 83% and 85% (AUC = 0.919), respectively. CONCLUSION In this novel study, which focused on scintigraphic DRF loss, KIM-1 was the most successful among all the biomarkers evaluated. Combination of IP-10, Ca19-9 and KIM-1 resulted increased diagnostic ability.
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Affiliation(s)
- Ünsal Özkuvancı
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Turkey.
| | - M İrfan Dönmez
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Turkey.
| | - Orhan Ziylan
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Turkey.
| | - Tayfun Oktar
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Turkey.
| | - Canan Küçükgergin
- İstanbul University, İstanbul Faculty of Medicine, Department of Biochemistry, Turkey.
| | - Bilal Çetin
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Turkey.
| | - Selçuk Erdem
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Turkey.
| | - Şule Seçkin
- İstanbul University, İstanbul Faculty of Medicine, Department of Biochemistry, Turkey.
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Turgut D, Pişkinpaşa SV, Çoşkun Yenigün E, Aydemir N, Dede F. Urinay neutrophil gelatinase-associated lipocalin as a biomarker in different renal problems. Turk J Med Sci 2020; 50:1566-1572. [PMID: 32927927 PMCID: PMC7605094 DOI: 10.3906/sag-2002-130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/08/2020] [Indexed: 11/18/2022] Open
Abstract
Background/aim Neutrophil gelatinase-associated lipocalin (NGAL) is used previously to estimate the etiology, severity, and clinical outcomes of acute kidney injury (AKI). However, the role of urinary NGAL (uNGAL) in the postrenal setting is not clear. In our study, we aimed to discover the cut-off value of uNGAL that can be used in the differential diagnosis of underlying AKI etiologies. Materials and methods In this prospective cross-sectional study, we examined 82 subjects in four groups: patients that had (1) postrenal AKI; (2) AKI other than postrenal etiologies; (3) stable chronic kidney disease; and (4) healthy subjects. A renal function assessment was carried out by measuring serum creatinine (sCr) and uNGAL at the time of diagnosis [0th min (T0)]. We followed the study group for three months. Results At the time of diagnosis, sCr (T0) was highest in the postrenal AKI and AKI groups in contrast to stable chronic kidney disease patients and healthy subjects (P < 0.001), as expected. T0 median uNGAL was highest in the postrenal group (P < 0.001). Area under curve (AUC) of uNGAL to estimate postrenal AKI presence was 0.957 (95% CI, 0.897–1.000; P < 0.001). The cut-off point of uNGAL was 42.625 ng/mL for this estimation. Conclusion Patients with AKI must be classified according to the underlying etiologies as soon as possible. uNGAL may be useful to estimate the etiologies, and whether the problem is acute or chronic in the course. In postrenal kidney problems, to plan the urgency of the urologic procedures, it is crucial.
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Affiliation(s)
- Didem Turgut
- Division of Nephrology, Department of Internal Medicine, Başkent University Ankara Hospital, Ankara, Turkey
| | | | - Ezgİ Çoşkun Yenigün
- Department of Nephrology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Nihal Aydemir
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Fatih Dede
- Department of Nephrology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Roles Played by Biomarkers of Kidney Injury in Patients with Upper Urinary Tract Obstruction. Int J Mol Sci 2020; 21:ijms21155490. [PMID: 32752030 PMCID: PMC7432915 DOI: 10.3390/ijms21155490] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/25/2020] [Accepted: 07/29/2020] [Indexed: 12/11/2022] Open
Abstract
Partial or complete obstruction of the urinary tract is a common and challenging urological condition caused by a variety of conditions, including ureteral calculi, ureteral pelvic junction obstruction, ureteral stricture, and malignant ureteral obstruction. The condition, which may develop in patients of any age, induces tubular and interstitial injury followed by inflammatory cell infiltration and interstitial fibrosis, eventually impairing renal function. The serum creatinine level is commonly used to evaluate global renal function but is not sensitive to early changes in the glomerular filtration rate and unilateral renal damage. Biomarkers of acute kidney injury are useful for the early detection and monitoring of kidney injury induced by upper urinary tract obstruction. These markers include levels of neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemotactic protein-1, kidney injury molecule 1, N-acetyl-b-D-glucosaminidase, and vanin-1 in the urine and serum NGAL and cystatin C concentrations. This review summarizes the pathophysiology of kidney injury caused by upper urinary tract obstruction, the roles played by emerging biomarkers of obstructive nephropathy, the mechanisms involved, and the clinical utility and limitations of the biomarkers.
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Assadi F, Mazaheri M. Urinary polyomavirus: novel biomarker of congenital ureteropelvic junction obstruction. J Pediatr Urol 2020; 16:107.e1-107.e5. [PMID: 31818677 DOI: 10.1016/j.jpurol.2019.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/19/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pregnancy is associated with reactivation and transmission of latent polyomavirus to fetus. Polyomavirus is also known to cause ureteral stenosis and hydronephrosis. OBJECTIVE The aim of this study was to investigate whether the urinary polyomavirus could be used as a potential biomarker in newborns with ureteropelvic junction obstruction (UPJO). STUDY DESIGN Urinary polyomavirus virus was measured by PCR in 42 newborn infants with fetal hydronephrosis history. Random urine samples were obtained from newborns immediately after birth and from their mothers at the time of delivery. Results were compared with 25 healthy infants matched for gestational and postnatal ages. The diagnosis of UPJO was established by diuretic renal scintigraphy. UPJO was graded according to the Society for Fetal Urology (SFU) classification. RESULTS The urine samples of healthy infants showed no detectable polyomavirus. No statistically significant difference was found in the median urinary polyomavirus level between grade 1 (1000 copies/mL) and grade 2 (1500 copies/mL) UPJO infants. When the median urinary BKV values were compared for each grade of UPJO, patients with grade 3 and 4 had significantly higher urinary polyomavirus levels than those with grades 1 or 2 (P < 0.001). There was a strong correlation between the median polyomavirus in the urine of pregnant women and the urine of newborns with UPJO (P < 0.001). DISCUSSION Data suggest that routine screening of urinary polyomavirus may help to identify infants with severe obstruction in whom early surgical intervention could reduce the risk of developing progressive kidney disease. To the best of our knowledge this is the first prospective study to present the role of urinary polyomavirus in newborn infants with UPJO to distinguish between patients who would benefit from early surgical intervention. CONCLUSION Urinary polyomavirus is a potential biomarker of UPJO in newborns with fetal hydronephrosis.
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Affiliation(s)
- Farahnak Assadi
- Department of Pediatric Nephrology, Rush University Medical Center, Chicago, IL, USA.
| | - Mojgan Mazaheri
- Department of Pediatrics, Section of Nephrology, Semnan University of Medical Sciences, Semnan, Iran
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Passoni NM, Peters CA. Managing Ureteropelvic Junction Obstruction in the Young Infant. Front Pediatr 2020; 8:242. [PMID: 32537441 PMCID: PMC7267033 DOI: 10.3389/fped.2020.00242] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022] Open
Abstract
In the last decade, management of congenital UPJ obstruction has become progressively observational despite the lack of precise predictors of outcome. While it is clear that many children will have resolution of their hydronephrosis and healthy kidneys, it is equally clear that there are those in whom renal functional development is at risk. Surgical intervention for the young infant, under 6 months, has become relatively infrequent, yet can be necessary and poses unique challenges. This review will address the clinical evaluation of UPJO in the very young infant and approaches to determining in whom surgical intervention may be preferable, as well as surgical considerations for the small infant. There are some clinical scenarios where the need for intervention is readily apparent, such as the solitary kidney or in child with infection. In others, a careful evaluation and discussion with the family must be undertaken to identify the most appropriate course of care. Further, while minimally invasive pyeloplasty has become commonly performed, it is often withheld from those under 6 months. This review will discuss the key elements of that practice and offer a perspective of where minimally invasive pyeloplasty is of value in the small infant. The modern pediatric urologist must be aware of the various possible clinical situations that may be present with UPJO and feel comfortable in their decision-making and surgical care. Simply delaying an intervention until a child is bigger may not always be the best approach.
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Desanti De Oliveira B, Xu K, Shen TH, Callahan M, Kiryluk K, D'Agati VD, Tatonetti NP, Barasch J, Devarajan P. Molecular nephrology: types of acute tubular injury. Nat Rev Nephrol 2019; 15:599-612. [PMID: 31439924 PMCID: PMC7303545 DOI: 10.1038/s41581-019-0184-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 12/29/2022]
Abstract
The acute loss of kidney function has been diagnosed for many decades using the serum concentration of creatinine - a muscle metabolite that is an insensitive and non-specific marker of kidney function, but is now used for the very definition of acute kidney injury (AKI). Fortunately, myriad new tools have now been developed to better understand the relationship between acute tubular injury and elevation in serum creatinine (SCr). These tools include unbiased gene and protein expression analyses in kidney, urine and blood, the localization of specific gene transcripts in pathological biopsy samples by rapid in-situ RNA technology and single-cell RNA-sequencing analyses. However, this molecular approach to AKI has produced a series of unexpected problems, because the expression of specific kidney-derived molecules that are indicative of injury often do not correlate with SCr levels. This discrepancy between kidney injury markers and SCr level can be reconciled by the recognition that many separate subtypes of AKI exist, each with distinct patterning of molecular markers of tubular injury and SCr data. In this Review, we describe the weaknesses of isolated SCr-based diagnoses, the clinical and molecular subtyping of acute tubular injury, and the role of non-invasive biomarkers in clinical phenotyping. We propose a conceptual model that synthesizes molecular and physiological data along a time course spanning from acute cellular injury to organ failure.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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