Serum cystatin C is an easy to obtain biomarker for the onset of renal impairment in heart transplant recipients

Value of serum cystatin C in estimating renal function in children with non-renal solid organ transplantation

Children with non-renal solid organ transplants are surviving longer, but outcome is complicated by CKD. Accurate and frequent renal function monitoring is imperative to recognize and institute measures early to reverse, prevent, or arrest progression. This study of 59 children determined the accuracy (P30), bias, sensitivity and specificity between measured renal function by NM-GFR, and estimated GFR by three formulas: Filler (serum cystatin C), mSchwartz (serum creatinine), and CKiD (serum cystatin C, creatinine, urea, and height). Mean GFR by all formulas differed significantly from NM-GFR. Filler and mSchwartz formulas significantly increased the proportion of patients with GFR ≥ 90 mL/min/1.73 m(2) (CKD stage 1) while decreasing those with GFR 60-89 mL/min/1.73 m(2) (CKD stage 2). All formulas overestimated GFR. CKiD showed the highest P30 and lowest bias (79.7%; 6.9 mL/min/1.73 m(2) ) followed by Filler (67.7%; 19.9 mL/min/1.73 m(2) ) and Schwartz (57.6%; 26.8 mL/min/1.73 m(2) ) for all GFR values. All formulas performed best with GFR ≥ 90 mL/min/1.73 m(2) , but CKiD was the only formula to achieve 91.1% accuracy. All formulas showed high sensitivities, but low specificities at NM-GFR cutoff at 90. Thus, GFR estimated by CKiD followed by Filler formula is an adequate method to monitor renal function closely and frequently in these children.

End-stage kidney disease after pediatric nonrenal solid organ transplantation

OBJECTIVES

Adult solid organ transplant (SOT) recipients commonly develop advanced kidney disease; however, the burden of end-stage kidney disease (ESKD) in children after SOT is not well-described. The objectives of this study were to determine the incidence of ESKD after pediatric SOT and the relative risk by SOT type.

METHODS

Retrospective multicenter cohort study of children, ages ≤ 18 years, who received SOTs from 1990 through 2010 using Scientific Registry of Transplant Recipients data linked to the US Renal Data System. We performed a competing risks analysis to determine cumulative incidence of ESKD (chronic dialysis or kidney transplant), treating death as a competing risk, and fit a multivariable Cox regression model to assess hazard of ESKD by organ type.

RESULTS

The cohort included 16,604 pediatric SOT recipients (54% liver, 34% heart, 6% lung, 6% intestine, and 1% heart-lung). During a median follow-up of 6.2 years (interquartile range 2.2-12.1), 426 (3%) children developed ESKD. Compared with liver transplant recipients, in whom the incidence of ESKD was 2.1 cases per 1000 person-years, in adjusted analyses the highest risk of ESKD was among intestinal (hazard ratio [HR] 7.37, P < .001), followed by lung (HR 5.79, P < .001) and heart transplant recipients (HR 1.79, P < .001).

CONCLUSIONS

In a 20-year national cohort of pediatric SOT recipients, the risk of ESKD was highest among intestinal and lung transplant recipients. The burden of earlier stages of chronic kidney disease is probably much higher; modifiable risk factors should be targeted to prevent progressive kidney damage in this high-risk population.

Recombinant human erythropoietin pretreatment alleviates renal glomerular injury induced by cardiopulmonary bypass by reducing transient receptor potential channel 6-nuclear factor of activated T-cells pathway activation

OBJECTIVE

Acute renal injury after cardiopulmonary bypass is common and associated with high mortality. We aimed to demonstrate the glomerular protective effects of recombinant human erythropoietin using an in vivo rat cardiopulmonary bypass model and to explore the possible mechanism.

METHODS

Dose-related renal protective effects of recombinant human erythropoietin were studied in phase I. Male Sprague Dawley rats were randomly divided into 5 groups: sham group, cardiopulmonary bypass group, and 3 recombinant human erythropoietin-treated cardiopulmonary bypass groups (bolus doses of 500, 3000, and 5000 U/kg 24 hours before surgery). Blood and urine samples were collected just before surgery and at 2, 4, 24, 48, and 72 hours after surgery. In phase II, rats were divided into 3 groups: sham group, cardiopulmonary bypass group, and 5000 U/kg recombinant human erythropoietin group. Kidneys were harvested at 4, 24, 48, and 72 hours after surgery. Ultra-organization of glomeruli was observed. Glomerular transient receptor potential channel 6 (TRPC6) expression was studied by immunofluorescence and Western blot. Nuclei nuclear factor of activated T-cells, cytoplasmic, calcineurin-dependent 1 (NFATc1) activity was analyzed by enzyme-linked immunosorbent assays and electrophoretic mobility shift assay.

RESULTS

Pretreatment of 5000 U/kg recombinant human erythropoietin decreased the urine protein (72 hours: 7.82 ± 1.13 g/L vs 11.28 ± 1.73 g/L), serum creatinine (72 hours: 35.0 ± 3.5 μmol/L vs 60.7 ± 7.6 μmol/L), and cystatin-C (2 hours: 336.5 ± 28.2 μg/L vs 452.6 ± 63.8 μg/L) compared with the control group (P < .01). Cardiopulmonary bypass induced morphologic abnormalities of podocyte foot processes and slit diaphragms, which was improved by recombinant human erythropoietin. Furthermore, recombinant human erythropoietin significantly relieved glomerular TRPC6 increase and NFATc1 activation induced by cardiopulmonary bypass.

CONCLUSIONS

Pretreatment of 5000 U/kg recombinant human erythropoietin elicited potent glomerular protection against cardiopulmonary bypass. This protection may be partly due to downregulation of glomerular TRPC6-NFATc1 pathway.

The effect of amlodipine besylate, losartan potassium, olmesartan medoxomil, and other antihypertensives on central aortic blood pressure and biomarkers of vascular function

Biomarkers are being increasingly used in the study of cardiovascular disease because they provide readily quantifiable surrogate endpoints and allow accurate assessment of the effects of therapy on particular pathological processes. However, in order to be useful, biomarkers must be relevant, predictable, accurate, and reproducible. There is compelling evidence from large-scale clinical trials that inhibitors of the renin-angiotensin system [angiotensin-converting enzyme inhibitors and angiotensin type II receptor blockers (ARBs)] and calcium channel blockers (CCBs) may have beneficial effects beyond blood pressure control in the treatment of hypertension. Biomarkers are expected to provide further insight into these beneficial effects and allow for quantitative assessment. This review summarizes the published clinical evidence on the effects of various antihypertensive drugs, particularly ARBs (e.g. losartan and olmesartan medoxomil) and CCBs (e.g. amlodipine), alone and in combination with other agents (e.g. hydrochlorothiazide), on central aortic pressure and the biomarkers high-sensitivity C-reactive protein (hsCRP), adiponectin, cystatin C, homeostasis model assessment of insulin resistance (HOMA-IR), procollagen, tumor necrosis factor-α, and interleukin-6. Of these biomarkers, the benefits of antihypertensive therapy on hsCRP, adiponectin, and HOMA-IR reflect a potential for quantifiable long-term vascular benefits.

Emergence of biomarkers in nephropharmacology

Blood-urea nitrogen, serum creatinine and urine output have long been used as markers of kidney function despite their known limitations. In the past few years, a number of novel biomarkers have been identified in the urine and blood that can detect kidney injury early. Although, to date, none of these biomarkers are in clinical use, many have been validated as reliable and sensitive, allowing detection of kidney injury before serum creatinine levels rise and urine output drops. These markers have been evaluated in great detail in animal models and to a lesser extent in humans in postcardiopulmonary bypass and sepsis. There is relatively scarse data on the use of these biomarkers in the detection of kidney injury associated with the use of pharmacologic agents. The purpose of this article is to summarize these data and highlight the potential utility of these biomarkers in nephropharmacology.