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Abadeer M, Swartz MF, Martin SD, Groves AM, Kent AL, Schwartz GJ, Brophy P, Alfieris GM, Cholette JM. Using Serum Cystatin C to Predict Acute Kidney Injury Following Infant Cardiac Surgery. Pediatr Cardiol 2023; 44:855-866. [PMID: 36637459 DOI: 10.1007/s00246-022-03080-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 12/16/2022] [Indexed: 01/14/2023]
Abstract
Acute kidney injury (AKI) following cardiopulmonary bypass (CPB) is associated with increased morbidity and mortality. Serum Cystatin C (CysC) is a novel biomarker synthesized by all nucleated cells that may act as an early indicator of AKI following infant CPB. Prospective observational study of infants (< 1 year) requiring CPB during cardiac surgery. CysC was measured at baseline and 12, 24, 48, and 72 h following CPB initiation. Each post-op percent difference in CysC (e.g. %CysC12h) from baseline was calculated. Clinical variables along with urine output (UOP) and serum creatinine (SCr) were followed. Subjects were divided into two groups: AKI and non-AKI based upon the Kidney Disease Improving Global Outcomes (KDIGO) classification. AKI occurred in 41.9% (18) of the 43 infants enrolled. Patient demographics and baseline CysC levels were similar between groups. CysC levels were 0.97 ± 0.28 mg/L over the study period, and directly correlated with SCr (R = 0.71, p < 0.0001). Although absolute CysC levels were not significant between groups, the %CysC12h was significantly greater in the AKI group (AKI: - 16% ± 22% vs. Non-AKI - 28% ± 9% mg/L; p = 0.003). However, multivariate analysis demonstrated that a lower UOP (Odds Ratio:0.298; 95% CI 0.073, 0.850; p = 0.02) but not %CysC12h was independently associated with AKI. Despite a significant difference in the %CysC12h, only UOP was independently associated with AKI. Larger studies of a more homogenous population are needed to understand these results and to explore the variability in this biomarker seen across institutions.
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Affiliation(s)
- Maher Abadeer
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Michael F Swartz
- Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Susan D Martin
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Angela M Groves
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Alison L Kent
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,College of Health and Medicine, Australian National University, Canberra, ACT, Australia
| | - George J Schwartz
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Patrick Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - George M Alfieris
- Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jill M Cholette
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.
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Zakaria M, Hassan T, Refaat A, Fathy M, Hashem MI, Khalifa N, Ali AA, Elhewala A, Ramadan A, Nafea A. Role of serum cystatin C in the prediction of acute kidney injury following pediatric cardiac surgeries: A single center experience. Medicine (Baltimore) 2022; 101:e31938. [PMID: 36626503 PMCID: PMC9750614 DOI: 10.1097/md.0000000000031938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Intense contemporary research is directed towards validating novel biomarkers to predict acute kidney injury (AKI) in children undergoing cardiothoracic surgeries. We aimed to evaluate the role of cystatin C in early prediction of AKI following cardiac surgery in children with congenital heart disease. Prospective observational cohort study was conducted on 40 children with congenital heart disease undergoing cardiac surgery. 40 healthy children with matched age and sex were enrolled as a control group. Children were subjected to physical examination, routine blood tests, echocardiography, and measurement of plasma cystatin C level on different occasions. The median age of the patients was 3.65 years, a range from 1 to 5 years with no significant difference regarding the age and sex of cases and control groups. The mean serum cystatin C level in patients was 0.75 ± 0.15, 1.35 ± 0.34 and 1.21 ± 0.38 mg/dL (preoperative, at 6 h and at 24 h postoperative, respectively) with statistically significant difference P < .05. 30% of the patients developed postoperative AKI with significantly higher serum cystatin C at 6 hours postoperative >1.33 mg/dL compared to preoperative level p P < .05. Serum cystatin C level was positively correlated with cardiac bypass time, ischemic time and length of hospital stay at 6 hours postoperative. Serum cystatin C is a sensitive marker for early detection of AKI following cardiac surgery in children with congenital heart disease and it was positively correlated with cardiac bypass time, ischemic time and length of hospital stay.
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Affiliation(s)
- Marwa Zakaria
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
- *Correspondence: Marwa Zakaria, Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig 44519, Egypt (e-mail: )
| | - Tamer Hassan
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ali Refaat
- Cardiothoracic Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Manar Fathy
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mustafa I.A. Hashem
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Naglaa Khalifa
- Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed A. Ali
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Elhewala
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Ramadan
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Alaa Nafea
- Pediatrics Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Chung EYM, Trinh K, Li J, Hahn SH, Endre ZH, Rogers NM, Alexander SI. Biomarkers in Cardiorenal Syndrome and Potential Insights Into Novel Therapeutics. Front Cardiovasc Med 2022; 9:868658. [PMID: 35669475 PMCID: PMC9163439 DOI: 10.3389/fcvm.2022.868658] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Heart and kidney failure often co-exist and confer high morbidity and mortality. The complex bi-directional nature of heart and kidney dysfunction is referred to as cardiorenal syndrome, and can be induced by acute or chronic dysfunction of either organ or secondary to systemic diseases. The five clinical subtypes of cardiorenal syndrome are categorized by the perceived primary precipitant of organ injury but lack precision. Traditional biomarkers such as serum creatinine are also limited in their ability to provide an early and accurate diagnosis of cardiorenal syndrome. Novel biomarkers have the potential to assist in the diagnosis of cardiorenal syndrome and guide treatment by evaluating the relative roles of implicated pathophysiological pathways such as hemodynamic dysfunction, neurohormonal activation, endothelial dysfunction, inflammation and oxidative stress, and fibrosis. In this review, we assess the utility of biomarkers that correlate with kidney and cardiac (dys)function, inflammation/oxidative stress, fibrosis, and cell cycle arrest, as well as emerging novel biomarkers (thrombospondin-1/CD47, glycocalyx and interleukin-1β) that may provide prediction and prognostication of cardiorenal syndrome, and guide potential development of targeted therapeutics.
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Affiliation(s)
- Edmund Y. M. Chung
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- *Correspondence: Edmund Y. M. Chung,
| | - Katie Trinh
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Jennifer Li
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
| | | | - Zoltan H. Endre
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Natasha M. Rogers
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen I. Alexander
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
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Cavalcante CTDMB, Cavalcante MB, Castello Branco KMP, Chan T, Maia ICL, Pompeu RG, de Oliveira Telles AC, Brito AKM, Libório AB. Biomarkers of acute kidney injury in pediatric cardiac surgery. Pediatr Nephrol 2022; 37:61-78. [PMID: 34036445 DOI: 10.1007/s00467-021-05094-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/05/2021] [Accepted: 04/23/2021] [Indexed: 12/20/2022]
Abstract
Acute kidney injury (AKI) is characterized by a sudden decrease in kidney function. Children with congenital heart disease are a special group at risk of developing AKI. We performed a systematic review of the literature to search for studies reporting the usefulness of novel urine, serum, and plasma biomarkers in the diagnosis and progression of AKI and their association with clinical outcomes in children undergoing pediatric cardiac surgery. In thirty studies, we analyzed the capacity to predict AKI and poor outcomes of five biomarkers: Cystatin C, Neutrophil gelatinase-associated lipocalin, Interleukin-18, Kidney injury molecule-1, and Liver fatty acid-binding protein. In conclusion, we suggest the need for further meta-analyses with the availability of additional studies.
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Affiliation(s)
- Candice Torres de Melo Bezerra Cavalcante
- Pediatric Cardiac Center of the Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, CE, Brazil.
- Department of Pediatrics, Fortaleza University (UNIFOR), Av. Washington Soares, 1321 - Edson Queiroz, CEP, Fortaleza, CE, 60811-905, Brazil.
| | - Marcelo Borges Cavalcante
- Department of Obstetrics and Gynecology, Fortaleza University (UNIFOR), Av. Washington Soares, 1321 - Edson Queiroz, CEP, Fortaleza, CE, 60811-905, Brazil
- Medical Sciences Postgraduate Program, Fortaleza University (UNIFOR), Av. Washington Soares, 1321 - Edson Queiroz, CEP, Fortaleza, CE, 60811-905, Brazil
| | | | - Titus Chan
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Isabel Cristina Leite Maia
- Pediatric Cardiac Center of the Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, CE, Brazil
| | - Ronald Guedes Pompeu
- Pediatric Cardiac Center of the Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, CE, Brazil
| | | | - Anna Karina Martins Brito
- Pediatric Cardiac Center of the Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, CE, Brazil
| | - Alexandre Braga Libório
- Medical Sciences Postgraduate Program, Fortaleza University (UNIFOR), Av. Washington Soares, 1321 - Edson Queiroz, CEP, Fortaleza, CE, 60811-905, Brazil
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Acute Kidney Injury following Cardiopulmonary Bypass: A Challenging Picture. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:8873581. [PMID: 33763177 PMCID: PMC7963912 DOI: 10.1155/2021/8873581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 01/10/2023]
Abstract
Recent studies have recognized several risk factors for cardiopulmonary bypass- (CPB-) associated acute kidney injury (AKI). However, the lack of early biomarkers for AKI prevents practitioners from intervening in a timely manner. We reviewed the literature with the aim of improving our understanding of the risk factors for CPB-associated AKI, which may increase our ability to prevent or improve this condition. Some novel early biomarkers for AKI have been introduced. In particular, a combinational use of these biomarkers would be helpful to improve clinical outcomes. Furthermore, we discuss several interventions that are aimed at managing CPB-associated AKI, may increase the effect of renal replacement therapy (RRT), and may contribute to preventing CPB-associated AKI. Collectively, the conclusions of this paper are limited by the availability of clinical trial evidence and conflicting definitions of AKI. A guideline is urgently needed for CPB-associated AKI.
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Taha MM, Shahy EM, Mahdy-Abdallah H, Ibrahim KS, El Tahlawy EM. Evaluation of the effect of serum cystatin-C and ACE I/D and ACE G2350A polymorphisms on kidney function among hypertensive sewage workers. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:1619-1626. [PMID: 32851527 DOI: 10.1007/s11356-020-10579-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/20/2020] [Indexed: 06/11/2023]
Abstract
Cadmium (Cd) as nephrotoxicant metal exerts its potent effect mainly on renal tubules disturbing its functions. A cross-sectional study was conducted on 55 sewage workers occupationally exposed to Cd and 50 control subjects. The study aimed to assess the effect of low-level Cd exposure on blood pressure and renal function in terms of serum cystatin-C levels. The associations between genetic polymorphisms of ACEI/D and ACE G2350A and hypertension and tubular injury among workers were studied. We analyzed blood and urine Cd concentration (U-Cd), serum cystatin-C, ACE I/D polymorphisms, and ACE G2350A, and blood pressure was measured. Results recorded a significant rise in serum and U-Cd and cystatin-C levels in sewage workers compared with controls. Significant distribution in genotype frequency of ACE I/D and ACE G2350A gene was detected. An association in DD genotype of ACE I/D with a rise in serum and U-Cd was observed in workers. In wild type genotype GG of ACE G2350A gene, a significant rise in serum cystatin-C levels and diastolic pressure was found while in heterozygote genotype GA significant rise in U-Cd levels was detected. Also, the association of AA genotype of ACE G2350A gene with a significant rise in serum and U-Cd and cystatin-C levels was shown among workers compared with control groups. Our findings indicated an association of ACE DD polymorphism in conjugation with GG genotype of ACE2 with hypertension and tubular injury in sewage workers.
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Affiliation(s)
- Mona M Taha
- Environmental and Occupational Medicine Department, Environmental Research Division, National Research Centre, Buhouth Street, Dokki, Cairo, 12622, Egypt
| | - Eman M Shahy
- Environmental and Occupational Medicine Department, Environmental Research Division, National Research Centre, Buhouth Street, Dokki, Cairo, 12622, Egypt
| | - Heba Mahdy-Abdallah
- Environmental and Occupational Medicine Department, Environmental Research Division, National Research Centre, Buhouth Street, Dokki, Cairo, 12622, Egypt
| | - Khadiga S Ibrahim
- Environmental and Occupational Medicine Department, Environmental Research Division, National Research Centre, Buhouth Street, Dokki, Cairo, 12622, Egypt.
| | - Eman M El Tahlawy
- Environmental and Occupational Medicine Department, Environmental Research Division, National Research Centre, Buhouth Street, Dokki, Cairo, 12622, Egypt
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Mutlu H, Gündüz E, Titiz TA, Küçükçetin İÖ. Investigation of AKI with Early Biomarkers After Cardiac Surgery. Braz J Cardiovasc Surg 2020; 35:722-731. [PMID: 33118738 PMCID: PMC7598966 DOI: 10.21470/1678-9741-2019-0178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Hüseyin Mutlu
- Akdeniz University Faculty of Medicine Department of Anesthesiology and Reanimation Antalya Turkey Department of Anesthesiology and Reanimation, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Emel Gündüz
- Akdeniz University Faculty of Medicine Department of Anesthesiology and Reanimation Antalya Turkey Department of Anesthesiology and Reanimation, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tülin Aydoğdu Titiz
- Akdeniz University Faculty of Medicine Department of Anesthesiology and Reanimation Antalya Turkey Department of Anesthesiology and Reanimation, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - İkbal Özen Küçükçetin
- Akdeniz University Faculty of Medicine Department of Anesthesiology and Reanimation Antalya Turkey Department of Anesthesiology and Reanimation, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Che M, Wang X, Xie B, Huang R, Liu S, Yan Y, Zhu M, Lu R, Qian J, Zhang W, Gu L, Mou S, Ni Z, Xue S. Use of Both Serum Cystatin C and Creatinine as Diagnostic Criteria for Cardiac Surgery-Associated Acute Kidney Injury and Its Correlation with Long-Term Major Adverse Events. Kidney Blood Press Res 2019; 44:415-425. [PMID: 31189155 DOI: 10.1159/000499647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Cardiac surgery-associated acute kidney injury (CSA-AKI) was traditionally defined as an increase in serum creatinine (sCr) after cardiac surgery. Recently, serum cystatin C (sCyC) has been proposed to be a better biomarker in the prediction of AKI. The clinical utility and performance of combining sCyC and sCr in patients with AKI, particularly for the prediction of long-term outcomes, remain unknown. METHODS We measured sCyC together with sCr in 628 patients undergoing cardiac surgery. sCyC and sCr were assessed at baseline and 24 and 48 h after surgery. CSA-AKI determined by sCr (CSA-AKIsCr) was defined as an sCr increase greater than 0.3 mg/dL or 50% from baseline. Major adverse events (MAEs; including death of any cause and dialysis) at 3 years were assessed. RESULTS CSA-AKIsCr developed in 178 patients (28.3%). Three-year follow-up was available for 621 patients; MAEs occurred in 42 patients (6.8%). An increase in sCyC concentration ≥30% within 48 h after surgery was detected in 228 patients (36.3%). This was the best sCyC cutoff for CSA-AKIsCr detection (negative predictive value = 88.8%, positive predictive value = 58.3%). To evaluate the use of both sCyC and sCr as CSA-AKI diagnostic criteria, we stratified patients into 3 groups: non-CSA-AKI, CSA-AKI detected by a single marker, and CSA-AKI detected by both markers. By multivariable logistic regression analysis, the independent predictors of MAEs at 3 years were group 2 (non-CSA-AKI group as the reference, CSA-AKI detected by a single marker: odds ratio [OR] = 3.48, 95% confidence interval [CI]: 1.27-9.58, p = 0.016), group 3 (CSA-AKI detected by both markers: OR = 5.12, 95% CI: 2.01-13.09; p = 0.001), and baseline glomerular filtration rate (OR = 2.24; 95% CI: 1.27-3.95; p = 0.005). CONCLUSION Combining sCyC and sCr to diagnose CSA-AKI would be beneficial for risk stratification and prognosis in patients after cardiac surgery.
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Affiliation(s)
- Miaolin Che
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xudong Wang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Xie
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ritai Huang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shang Liu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yucheng Yan
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mingli Zhu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Renhua Lu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaqi Qian
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weiming Zhang
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Leyi Gu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shan Mou
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,
| | - Song Xue
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Hall PS, Mitchell ED, Smith AF, Cairns DA, Messenger M, Hutchinson M, Wright J, Vinall-Collier K, Corps C, Hamilton P, Meads D, Lewington A. The future for diagnostic tests of acute kidney injury in critical care: evidence synthesis, care pathway analysis and research prioritisation. Health Technol Assess 2019; 22:1-274. [PMID: 29862965 DOI: 10.3310/hta22320] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is highly prevalent in hospital inpatient populations, leading to significant mortality and morbidity, reduced quality of life and high short- and long-term health-care costs for the NHS. New diagnostic tests may offer an earlier diagnosis or improved care, but evidence of benefit to patients and of value to the NHS is required before national adoption. OBJECTIVES To evaluate the potential for AKI in vitro diagnostic tests to enhance the NHS care of patients admitted to the intensive care unit (ICU) and identify an efficient supporting research strategy. DATA SOURCES We searched ClinicalTrials.gov, The Cochrane Library databases, Embase, Health Management Information Consortium, International Clinical Trials Registry Platform, MEDLINE, metaRegister of Current Controlled Trials, PubMed and Web of Science databases from their inception dates until September 2014 (review 1), November 2015 (review 2) and July 2015 (economic model). Details of databases used for each review and coverage dates are listed in the main report. REVIEW METHODS The AKI-Diagnostics project included horizon scanning, systematic reviewing, meta-analysis of sensitivity and specificity, appraisal of analytical validity, care pathway analysis, model-based lifetime economic evaluation from a UK NHS perspective and value of information (VOI) analysis. RESULTS The horizon-scanning search identified 152 potential tests and biomarkers. Three tests, Nephrocheck® (Astute Medical, Inc., San Diego, CA, USA), NGAL and cystatin C, were subjected to detailed review. The meta-analysis was limited by variable reporting standards, study quality and heterogeneity, but sensitivity was between 0.54 and 0.92 and specificity was between 0.49 and 0.95 depending on the test. A bespoke critical appraisal framework demonstrated that analytical validity was also poorly reported in many instances. In the economic model the incremental cost-effectiveness ratios ranged from £11,476 to £19,324 per quality-adjusted life-year (QALY), with a probability of cost-effectiveness between 48% and 54% when tests were compared with current standard care. LIMITATIONS The major limitation in the evidence on tests was the heterogeneity between studies in the definitions of AKI and the timing of testing. CONCLUSIONS Diagnostic tests for AKI in the ICU offer the potential to improve patient care and add value to the NHS, but cost-effectiveness remains highly uncertain. Further research should focus on the mechanisms by which a new test might change current care processes in the ICU and the subsequent cost and QALY implications. The VOI analysis suggested that further observational research to better define the prevalence of AKI developing in the ICU would be worthwhile. A formal randomised controlled trial of biomarker use linked to a standardised AKI care pathway is necessary to provide definitive evidence on whether or not adoption of tests by the NHS would be of value. STUDY REGISTRATION The systematic review within this study is registered as PROSPERO CRD42014013919. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Peter S Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | | | - Alison F Smith
- Academy of Primary Care, Hull York Medical School, Hull, UK.,National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | - David A Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael Messenger
- National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Leeds, Leeds, UK
| | | | - Judy Wright
- Academy of Primary Care, Hull York Medical School, Hull, UK
| | | | | | - Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - David Meads
- Academy of Primary Care, Hull York Medical School, Hull, UK
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Wijerathna TM, Gawarammana IB, Dissanayaka DM, Palanagasinghe C, Shihana F, Dassanayaka G, Shahmy S, Endre ZH, Mohamed F, Buckley NA. Serum creatinine and cystatin C provide conflicting evidence of acute kidney injury following acute ingestion of potassium permanganate and oxalic acid. Clin Toxicol (Phila) 2017; 55:970-976. [PMID: 28535124 DOI: 10.1080/15563650.2017.1326607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIM Acute kidney injury (AKI) is common following deliberate self-poisoning with a combination washing powder containing oxalic acid (H2C2O4) and potassium permanganate (KMnO4). Early and rapid increases in serum creatinine (sCr) follow severe poisoning. We investigated the relationship of these increases with direct nephrotoxicity in an ongoing multicenter prospective cohort study in Sri Lanka exploring AKI following poisoning. METHODS Multiple measures of change in kidney function were evaluated in 48 consenting patients who had serial sCr and serum cystatin C (sCysC) data available. RESULTS Thirty-eight (38/48, 79%) patients developed AKI (AKIN criteria). Twenty-eight (58%) had AKIN stage 2 or 3. Initial increases in urine creatinine (uCr) excretion were followed by a substantial loss of renal function. The AKIN stage 2 and 3 (AKIN2/3) group had very rapid rises in sCr (a median of 118% at 24 h and by 400% at 72 h post ingestion). We excluded the possibility that the rapid rise resulted from the assay used or muscle damage. In contrast, the average sCysC increase was 65% by 72 h. CONCLUSIONS In most AKI, sCysC increases to the same extent but more rapidly than sCr, as sCysC has a shorter half-life. This suggests either a reduction in Cystatin C production or, conversely, that the rapid early rise of sCr results from increased production of creatine and creatinine to meet energy demands following severe oxidative stress mediated by H2C2O4 and KMnO4. Increased early creatinine excretion supports the latter explanation, since creatinine excretion usually decreases transiently in AKIN2/3 from other causes.
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Affiliation(s)
- Thilini Madushanka Wijerathna
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka.,b Department of Pathology, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka
| | - Indika Bandara Gawarammana
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka.,c Department of Medicine, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka
| | | | - Chathura Palanagasinghe
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka
| | - Fathima Shihana
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka.,d Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney , Sydney , Australia
| | - Gihani Dassanayaka
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka
| | - Seyed Shahmy
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka
| | - Zoltan Huba Endre
- e Australian Kidney Biomarker Reference Laboratory, Department of Nephrology , Prince of Wales Hospital and Clinical School, University of New South Wales , Sydney , Australia
| | - Fahim Mohamed
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka.,d Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney , Sydney , Australia.,e Australian Kidney Biomarker Reference Laboratory, Department of Nephrology , Prince of Wales Hospital and Clinical School, University of New South Wales , Sydney , Australia.,f Department of Pharmacy, Faculty of Allied Health Science , University of Peradeniya , Peradeniya , Sri Lanka
| | - Nicholas Alan Buckley
- a South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine , University of Peradeniya , Peradeniya , Sri Lanka.,d Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney , Sydney , Australia
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11
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Zhang WF, Zhang T, Ding D, Sun SQ, Wang XL, Chu SC, Shen LH, He B. Use of Both Serum Cystatin C and Creatinine as Diagnostic Criteria for Contrast-Induced Acute Kidney Injury and Its Clinical Implications. J Am Heart Assoc 2017; 6:JAHA.116.004747. [PMID: 28087509 PMCID: PMC5523641 DOI: 10.1161/jaha.116.004747] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Contrast-induced acute kidney injury (CI-AKI) was traditionally defined as an increase in serum creatinine (sCr) after contrast media exposure. Recently, serum cystatin C (sCyC) has been proposed as an alternative to detect acute changes in renal function. The clinical implications of combining sCyC and sCr to diagnose CI-AKI remain unknown. METHODS AND RESULTS One thousand seventy-one consecutive patients undergoing coronary angiography/intervention were prospectively enrolled. SCyC and sCr were assessed at baseline and 24 to 48 hours after contrast media exposure. CI-AKI determined by sCr (CI-AKIsCr) was defined as an sCr increase greater than 0.3 mg/dL or 50% from baseline. Major adverse events at 12 months were assessed. CI-AKIsCr developed in 25 patients (2.3%). Twelve-month follow-up was available for 1063 patients; major adverse events occurred in 61 patients (5.7%). By receiver operating characteristic curve analysis, an sCyC increase of greater than 15% was the optimal cutoff for CI-AKIsCr detection, which occurred in 187 patients (17.4%). To evaluate the use of both sCyC and sCr as CI-AKI diagnostic criteria, we stratified patients into 3 groups: no CI-AKI, CI-AKI detected by a single marker, and CI-AKI detected by both markers. Multivariable logistic regression revealed that the predictability of major adverse events increased in a stepwise fashion in the 3 groups (no-CI-AKI group as the reference, CI-AKI detected by a single marker: odds ratio=2.25, 95% CI: 1.24-4.10, P<0.01; CI-AKI detected by both markers: odds ratio=10.00, 95% CI: 3.13-31.91, P<0.001). CONCLUSIONS Combining sCyC and sCr to diagnose CI-AKI would be beneficial for risk stratification and prognosis in patients after contrast media exposure.
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Affiliation(s)
- Wei-Feng Zhang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Tuo Zhang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ding Ding
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD
| | - Shi-Qun Sun
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Lei Wang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shi-Chun Chu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ling-Hong Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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12
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Garimella PS, Jaber BL, Tighiouart H, Liangos O, Bennett MR, Devarajan P, El-Achkar TM, Sarnak MJ. Association of Preoperative Urinary Uromodulin with AKI after Cardiac Surgery. Clin J Am Soc Nephrol 2017; 12:10-18. [PMID: 27797887 PMCID: PMC5220649 DOI: 10.2215/cjn.02520316] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 08/29/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES AKI is a serious complication after cardiac surgery. Although high urinary concentrations of the tubular protein uromodulin, a marker of tubular health, are associated with less AKI in animal models, its relationship in humans is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A post hoc analysis of a prospective cohort study of 218 adults undergoing on-pump cardiac surgery between 2004 and 2011 was conducted. Multivariable logistic and linear regression analyses were used to evaluate the associations of preoperative urinary uromodulin-to-creatinine ratio with postoperative AKI (defined as a rise in serum creatinine of >0.3 mg/dl or >1.5 times baseline); severe AKI (doubling of creatinine or need for dialysis) and peak postoperative serum creatinine over the first 72 hours. RESULTS Mean age was 68 years, 27% were women, 95% were white, and the median uromodulin-to-creatinine ratio was 10.0 μg/g. AKI developed in 64 (29%) patients. Lower urinary uromodulin-to-creatinine ratio was associated with higher odds for AKI (odds ratio, 1.49 per 1-SD lower uromodulin; 95% confidence interval, 1.04 to 2.13), which was marginally attenuated after multivariable adjustment (odds ratio, 1.43; 95% confidence interval, 0.99 to 2.07). The lowest uromodulin-to-creatinine ratio quartile was also associated with higher odds for AKI relative to the highest quartile (odds ratio, 2.94; 95% confidence interval, 1.19 to 7.26), which was slightly attenuated after multivariable adjustment (odds ratio, 2.43; 95% confidence interval, 0.91 to 6.48). A uromodulin-to-creatinine ratio below the median was associated with higher adjusted odds for severe AKI, although this did not reach statistical significance (odds ratio, 4.03; 95% confidence interval, 0.87 to 18.70). Each 1-SD lower uromodulin-to-creatinine ratio was associated with a higher adjusted mean peak serum creatinine (0.07 mg/dl per SD; 95% confidence interval, 0.02 to 0.13). CONCLUSIONS Lower uromodulin-to-creatinine ratio is associated with higher odds of AKI and higher peak serum creatinine after cardiac surgery. Additional studies are needed to confirm these preliminary results.
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Affiliation(s)
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Orfeas Liangos
- Division of Nephrology and Hypertension, III Medizinische Klinik, Klinikum Coburg, Coburg, Germany
| | - Michael R. Bennett
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio; and
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio; and
| | - Tarek M. El-Achkar
- Division of Nephrology, Roudebush Indianapolis Veterans Affairs Medical Center, Indianapolis, Indiana
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13
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Lau L, Al-Ismaili Z, Harel-Sterling M, Pizzi M, Caldwell JS, Piccioni M, Lands LC, Mottes T, Devarajan P, Goldstein SL, Bennett MR, Zappitelli M. Serum cystatin C for acute kidney injury evaluation in children treated with aminoglycosides. Pediatr Nephrol 2017; 32:163-171. [PMID: 27743042 PMCID: PMC5645790 DOI: 10.1007/s00467-016-3450-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Serum cystatin C (CysC) is a more accurate glomerular filtration rate marker than serum creatinine (SCr) and may rise more quickly with acute kidney injury (AKI). METHODS We performed a prospective cohort study of 81 non-critically ill children during 110 aminoglycoside (AG) treatments. We calculated area under the curve (AUC) for CysC to diagnose SCr-defined AKI and predict persistent AKI. SCr-AKI definition was based on the Kidney Disease: Improving Global Outcomes (≥stage 1: ≥50 % or 26.5 μmol/l SCr rise from baseline; stage 2: SCr doubling); CysC-AKI was based on a modified version using CysC rise. RESULTS SCr-AKI and CysC-AKI developed in 45 and 48 % treatments, respectively. CysC rise predicted stage 1 (AUC = 0.75, 95 % CI 0.60-0.90) and 2 (AUC = 0.85, 95 % CI 0.75-0.95) SCr-AKI 2 days before SCr-AKI attainment. The best combined sensitivity/specificity for percent CysC rise to predict stage 1 SCr-AKI was with a 44 % CysC rise (sensitivity = 65 %, specificity = 83 %). CysC rise on day of SCr-AKI development was associated with SCr-AKI ≥48 h (AUC = 0.73, 95 % CI 0.56-0.90) and ≥50 % persistent SCr rise at treatment end (AUC = 0.76, 95 % CI 0.61-0.90). CONCLUSIONS CysC is as an early AKI biomarker and predictive of persistent AKI on aminoglycoside treatment.
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Affiliation(s)
- Lorraine Lau
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Zubaida Al-Ismaili
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Maya Harel-Sterling
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Michael Pizzi
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Jillian S. Caldwell
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Melissa Piccioni
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Larry C. Lands
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec H3H 1P3, Canada
| | - Theresa Mottes
- Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stuart L. Goldstein
- Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael R. Bennett
- Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael Zappitelli
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, 2300 Tupper, Room E-213, Montreal, Quebec, H3H 1P3, Canada.
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14
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Kališnik JM, Hrovat E, Hrastovec A, Žibert J, Jerin A, Skitek M, Santarpino G, Klokocovnik T. Creatinine, Neutrophil Gelatinase-Associated Lipocalin, and Cystatin C in Determining Acute Kidney Injury After Heart Operations Using Cardiopulmonary Bypass. Artif Organs 2016; 41:481-489. [PMID: 27862029 DOI: 10.1111/aor.12779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 04/05/2016] [Accepted: 05/11/2016] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) represents frequent complication after cardiac surgery using cardiopulmonary bypass (CPB). In the hope to enhance earlier more reliable characterization of AKI, we tested the utility of neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (CysC) in addition to standard creatinine for early determination of AKI after cardiac surgery using CPB. Forty-one patients met the inclusion criteria. Arterial blood samples collected after induction of general anesthesia were used as baseline, further sampling occurred at CPB termination, 2 h after CPB, on the first and second day after surgery. According to AKIN classification 18 patients (44%) developed AKI (AKI1-2 groups) and 23 (56%) did not (non-AKI group). Groups were similar regarding demographics and operative characteristics. CysC levels differed already preoperatively (non-AKI vs. AKI2; P = 0.045; AKI1 vs. AKI2; P = 0.011), while postoperatively AKI2 group differed on the first day and AKI1 on the second regarding non-AKI group (P = 0.004; P = 0.021, respectively). NGAL and creatinine showed significant difference already 2 h after CPB between groups AKI2 and non-AKI and later on the first postoperative day between groups AKI1 and AKI2 (P = 0.028; P = 0.014, respectively). This study shows similar performance of early plasma creatinine and NGAL in patients with preserved preoperative renal function. It demonstrates that creatinine, as well as NGAL, differentiate subsets of patients developing AKI of clinically more advanced grade early after 2 h, also when used single and uncombined.
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Affiliation(s)
- Jurij Matija Kališnik
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia.,Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Germany
| | - Eva Hrovat
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia
| | - Alenka Hrastovec
- Department of Anesthesiology, University Medical Center, Ljubljana
| | - Janez Žibert
- Faculty of Health Sciences, University of Ljubljana, Ljubljana
| | - Aleš Jerin
- Department of Clinical Chemistry and Biochemistry, University Medical Centre, Ljubljana, Slovenia
| | - Milan Skitek
- Department of Clinical Chemistry and Biochemistry, University Medical Centre, Ljubljana, Slovenia
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Germany
| | - Tomislav Klokocovnik
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia
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15
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Yamada M, Nishi H, Sekiya N, Horikawa K, Takahashi T, Sawa Y. The efficacy of tolvaptan in the perioperative management of chronic kidney disease patients undergoing open-heart surgery. Surg Today 2016; 47:498-505. [DOI: 10.1007/s00595-016-1406-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
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16
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Svensson AS, Kvitting JPE, Kovesdy CP, Cederholm I, Szabó Z. Changes in serum cystatin C, creatinine, and C-reactive protein after cardiopulmonary bypass in patients with normal preoperative kidney function. Nephrology (Carlton) 2016; 21:519-25. [DOI: 10.1111/nep.12630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/20/2015] [Accepted: 09/21/2015] [Indexed: 02/03/2023]
Affiliation(s)
- Anders S. Svensson
- Department of Cardiothoracic Surgery and Anaesthesia; Linköping University Hospital; Linköping Sweden
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - John-Peder Escobar Kvitting
- Department of Cardiothoracic Surgery and Anaesthesia; Linköping University Hospital; Linköping Sweden
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - Csaba P. Kovesdy
- Division of Nephrology; University of Tennessee Health Science Center; Memphis Tennessee USA
- Memphis Veterans Affairs Medical Center; Memphis Tennessee USA
| | - Ingemar Cederholm
- Department of Cardiothoracic Surgery and Anaesthesia; Linköping University Hospital; Linköping Sweden
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - Zoltán Szabó
- Department of Cardiothoracic Surgery and Anaesthesia; Linköping University Hospital; Linköping Sweden
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences; Linköping University; Linköping Sweden
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17
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Novel biomarkers for early diagnosis of acute kidney injury after cardiac surgery in adults. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 13:31-8. [PMID: 27212976 PMCID: PMC4860432 DOI: 10.5114/kitp.2016.58962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 02/02/2016] [Accepted: 03/07/2016] [Indexed: 12/31/2022]
Abstract
Acute kidney injury after cardiac surgery with cardiopulmonary bypass is a common and serious complication and it is associated with increased morbidity and mortality. Diagnosis of acute kidney injury is based on the serum creatinine levels which rise several hours to days after the initial injury. Thus, novel biomarkers that will enable faster diagnosis are needed in clinical practice. There are numerous urine and serum proteins that indicate kidney injury and are under extensive research. Despite promising basic research results and assembled data, which indicate superiority of some biomarkers to creatinine, we are still awaiting clinical application.
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18
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Schley G, Köberle C, Manuilova E, Rutz S, Forster C, Weyand M, Formentini I, Kientsch-Engel R, Eckardt KU, Willam C. Comparison of Plasma and Urine Biomarker Performance in Acute Kidney Injury. PLoS One 2015; 10:e0145042. [PMID: 26669323 PMCID: PMC4682932 DOI: 10.1371/journal.pone.0145042] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 11/29/2015] [Indexed: 12/22/2022] Open
Abstract
Background New renal biomarkers measured in urine promise to increase specificity for risk stratification and early diagnosis of acute kidney injury (AKI) but concomitantly may be altered by urine concentration effects and chronic renal insufficiency. This study therefore directly compared the performance of AKI biomarkers in urine and plasma. Methods This single-center, prospective cohort study included 110 unselected adults undergoing cardiac surgery with cardiopulmonary bypass between 2009 and 2010. Plasma and/or urine concentrations of creatinine, cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), liver fatty acid-binding protein (L-FABP), kidney injury molecule 1 (KIM1), and albumin as well as 15 additional biomarkers in plasma and urine were measured during the perioperative period. The primary outcome was AKI defined by AKIN serum creatinine criteria within 72 hours after surgery. Results Biomarkers in plasma showed markedly better discriminative performance for preoperative risk stratification and early postoperative (within 24h after surgery) detection of AKI than urine biomarkers. Discriminative power of urine biomarkers improved when concentrations were normalized to urinary creatinine, but urine biomarkers had still lower AUC values than plasma biomarkers. Best diagnostic performance 4h after surgery had plasma NGAL (AUC 0.83), cystatin C (0.76), MIG (0.74), and L-FAPB (0.73). Combinations of multiple biomarkers did not improve their diagnostic power. Preoperative clinical scoring systems (EuroSCORE and Cleveland Clinic Foundation Score) predicted the risk for AKI (AUC 0.76 and 0.71) and were not inferior to biomarkers. Preexisting chronic kidney disease limited the diagnostic performance of both plasma and urine biomarkers. Conclusions In our cohort plasma biomarkers had higher discriminative power for risk stratification and early diagnosis of AKI than urine biomarkers. For preoperative risk stratification of AKI clinical models showed similar discriminative performance to biomarkers. The discriminative performance of both plasma and urine biomarkers was reduced by preexisting chronic kidney disease.
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Affiliation(s)
- Gunnar Schley
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Carmen Köberle
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | | | - Sandra Rutz
- Biomarker Assessments, Roche Diagnostics GmbH, Penzberg, Germany
| | - Christian Forster
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Weyand
- Department of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Ivan Formentini
- Biomarker & Experimental Medicine, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Carsten Willam
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- * E-mail:
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19
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Ho J, Tangri N, Komenda P, Kaushal A, Sood M, Brar R, Gill K, Walker S, MacDonald K, Hiebert BM, Arora RC, Rigatto C. Urinary, Plasma, and Serum Biomarkers’ Utility for Predicting Acute Kidney Injury Associated With Cardiac Surgery in Adults: A Meta-analysis. Am J Kidney Dis 2015; 66:993-1005. [DOI: 10.1053/j.ajkd.2015.06.018] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 06/09/2015] [Indexed: 11/11/2022]
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20
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Zhou J, Liu Y, Tang Y, Liu F, Zhang L, Zeng X, Feng Y, Tao Y, Yang L, Fu P. A comparison of RIFLE, AKIN, KDIGO, and Cys-C criteria for the definition of acute kidney injury in critically ill patients. Int Urol Nephrol 2015; 48:125-32. [PMID: 26560473 DOI: 10.1007/s11255-015-1150-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/26/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE AKI is a major clinical problem and predictor of prognosis in critically ill patients. The aim of our study was to determine whether the new Cys-C criteria for identification and prognosis of AKI were superior to the RIFLE, AKIN, and KDIGO criteria. METHODS In the retrospective and multicenter study, the incidence of AKI was identified by the four criteria. Receiver operating characteristic (ROC) curve was applied to compare the predictive ability for 28-day mortality, and logistic regression analysis was used for the calculation of odds ratios and 95 % confidence intervals. RESULTS In the 1036 patients enrolled, the incidences of AKI were 26.4, 34.1, 37.8, and 36.1 %, respectively, under the four criteria. Patients with AKI had higher mortality and longer length of stay than those without in all definitions. Concordance in AKI diagnosis between Cys-C and KDIGO criteria was 95.9 %, higher than AKIN and RIFLE criteria (p < 0.0001). The area under ROC curves was 0.7023 for Cys-C criteria, which was a significantly greater discrimination (p < 0.05). CONCLUSION KDIGO criteria identified significantly more AKI and AKI patients had significantly higher 28-day mortality than patients without AKI. The Cys-C criteria were more predictive for short-term outcomes than other three criteria among critically ill patients.
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Affiliation(s)
- Jiaojiao Zhou
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yun Liu
- Division of Nephrology, Chengdu Integrated TCM and Western Medicine Hospital, Chengdu First People's Hospital, Chengdu, Sichuan, China
| | - Yi Tang
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Fang Liu
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xiaoxi Zeng
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yuying Feng
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ye Tao
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China
| | - Lichuan Yang
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China.
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Biostatistics and Cost-Benefit Analysis Center, West China Hospital of Sichuan University, Chengdu, 610041, People's Republic of China.
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21
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Tung YC, Chang CH, Chen YC, Chu PH. Combined biomarker analysis for risk of acute kidney injury in patients with ST-segment elevation myocardial infarction. PLoS One 2015; 10:e0125282. [PMID: 25853556 PMCID: PMC4390355 DOI: 10.1371/journal.pone.0125282] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 03/23/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) complicating ST-segment elevation myocardial infarction (STEMI) increases subsequent morbidity and mortality. We combined the biomarkers of heart failure (HF; B-type natriuretic peptide [BNP] and soluble ST2 [sST2]) and renal injury (NGAL [neutrophil gelatinase-associated lipocalin] and cystatin C) in predicting the development of AKI in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS From March 2010 to September 2013, 189 STEMI patients were sequentially enrolled and serum samples were collected at presentation for BNP, sST2, NGAL and cystatin C analysis. 37 patients (19.6%) developed AKI of varying severity within 48 hours of presentation. Univariate analysis showed age, Killip class ≥2, hypertension, white blood cell counts, hemoglobin, estimated glomerular filtration rate, blood urea nitrogen, creatinine, and all the four biomarkers were predictive of AKI. Serum levels of the biomarkers were correlated with risk of AKI and the Acute Kidney Injury Network (AKIN) stage and all significantly discriminated AKI (area under the receiver operating characteristic [ROC] curve: BNP: 0.86, sST2: 0.74, NGAL: 0.75, cystatin C: 0.73; all P < 0.05). Elevation of ≥2 of the biomarkers higher than the cutoff values derived from the ROC analysis improved AKI risk stratification, regardless of the creatine level (creatinine < 1.24 mg/dL: odds ratio [OR] 11.25, 95% confidence interval [CI] 1.63-77.92, P = 0.014; creatinine ≥ 1.24: OR 15.0, 95% CI 1.23-183.6, P = 0.034). CONCLUSIONS In this study of STEMI patients undergoing primary PCI, the biomarkers of heart failure (BNP and sST2) and renal injury (NGAL and cystatin C) at presentation were predictive of AKI. High serum levels of the biomarkers were associated with an elevated risk and more advanced stage of AKI. Regardless of the creatinine level, elevation of ≥2 of the biomarkers higher than the cutoff values indicated a further rise in AKI risk. Combined biomarker approach may assist in risk stratification of AKI in patients with STEMI.
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Affiliation(s)
- Ying-Chang Tung
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- Healthcare Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Chang Gung University College of Medicine, Taipei, Taiwan
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Cystatin C in acute kidney injury diagnosis: early biomarker or alternative to serum creatinine? Pediatr Nephrol 2015; 30:665-76. [PMID: 25475610 PMCID: PMC4372053 DOI: 10.1007/s00467-014-2987-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 09/29/2014] [Accepted: 10/06/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Early acute kidney injury (AKI) diagnosis is needed to pursue treatment trials. We evaluated cystatin C (CysC) as an early biomarker of serum creatinine (SCr)-AKI and an alternative to define AKI. METHODS We studied 160 non-cardiac children in the intensive care unit (ICU). We measured daily CysC and SCr. AKI was staged by KDIGO (Kidney Disease: Improving Global Outcomes) guidelines using SCr and CysC (CysC-AKI). We calculated area under the curve (AUC) for (1) neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1) and urine CysC to diagnose SCr- and CysC-AKI; and (2) for CysC to diagnose SCr-AKI. We evaluated AKI associations with length of stay and ventilation duration. RESULTS We found that 44 % of patients developed SCr-AKI; 32 % developed CysC-AKI. Early ICU NGAL was most diagnostic of CysC-AKI (AUC 0.69, 95% CI 0.54-0.84); IL-18 was most diagnostic for SCr-AKI (AUC 0.69 95% CI 0.55-0.82). Combining SCr and CysC-AKI definition led to higher biomarker diagnostic AUC's. CysC-AKI was not more strongly associated with clinical outcomes. Early ICU CysC predicted SCr-AKI development (AUC 0.70, 95 % CI 0.53-0.89). CONCLUSIONS Our findings do not support replacing SCr by CysC to define AKI. Early ICU CysC predicts SCr-AKI development and combined SCr-CysC-AKI definition leads to stronger AKI biomarker associations.
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Basu RK, Wong HR, Krawczeski CD, Wheeler DS, Manning PB, Chawla LS, Devarajan P, Goldstein SL. Combining functional and tubular damage biomarkers improves diagnostic precision for acute kidney injury after cardiac surgery. J Am Coll Cardiol 2015; 64:2753-62. [PMID: 25541128 DOI: 10.1016/j.jacc.2014.09.066] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/09/2014] [Accepted: 09/29/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Increases in serum creatinine (ΔSCr) from baseline signify acute kidney injury (AKI) but offer little granular information regarding its characteristics. The 10th Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) suggested that combining AKI biomarkers would provide better precision for AKI course prognostication. OBJECTIVES This study investigated the value of combining a functional damage biomarker (plasma cystatin C [pCysC]) with a tubular damage biomarker (urine neutrophil gelatinase-associated lipocalin [uNGAL]), forming a composite biomarker for prediction of discrete characteristics of AKI. METHODS Data from 345 children after cardiopulmonary bypass (CPB) were analyzed. Severe AKI was defined as Kidney Disease Global Outcomes Initiative stages 2 to 3 (≥100% ΔSCr) within 7 days of CPB. Persistent AKI lasted >2 days. SCr in reversible AKI returned to baseline ≤48 h after CPB. The composite of uNGAL (>200 ng/mg urine Cr = positive [+]) and pCysC (>0.8 mg/l = positive [+]), uNGAL+/pCysC+, measured 2 h after CPB initiation, was compared to ΔSCr increases of ≥50% for correlation with AKI characteristics by using predictive probabilities, likelihood ratios (LR), and area under the curve receiver operating curve (AUC-ROC) values [Corrected]. RESULTS Severe AKI occurred in 18% of patients. The composite uNGAL+/pCysC+ demonstrated a greater likelihood than ΔSCr for severe AKI (+LR: 34.2 [13.0:94.0] vs. 3.8 [1.9:7.2]) and persistent AKI (+LR: 15.6 [8.8:27.5] versus 4.5 [2.3:8.8]). In AKI patients, the uNGAL-/pCysC+ composite was superior to ΔSCr for prediction of transient AKI. Biomarker composites carried greater probability for specific outcomes than ΔSCr strata. CONCLUSIONS Composites of functional and tubular damage biomarkers are superior to ΔSCr for predicting discrete characteristics of AKI.
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Affiliation(s)
- Rajit K Basu
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio; Division of Pediatric Critical Care, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | - Hector R Wong
- Division of Pediatric Critical Care, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Derek S Wheeler
- Division of Pediatric Critical Care, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Peter B Manning
- Division of Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, Missouri
| | - Lakhmir S Chawla
- Department of Medicine, Division of Intensive Care Medicine and Division of Nephrology, Veterans Affairs Medical Center, Washington, DC
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, University of Cincinnati, Cincinnati, Ohio
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Prowle JR, Calzavacca P, Licari E, Ligabo EV, Echeverri JE, Bagshaw SM, Haase-Fielitz A, Haase M, Ostland V, Noiri E, Westerman M, Devarajan P, Bellomo R. Combination of biomarkers for diagnosis of acute kidney injury after cardiopulmonary bypass. Ren Fail 2015; 37:408-16. [PMID: 25585949 DOI: 10.3109/0886022x.2014.1001303] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Novel acute kidney injury (AKI) biomarkers offer promise of earlier diagnosis and risk stratification, but have yet to find widespread clinical application. We measured urinary α and π glutathione S-transferases (α-GST and π-GST), urinary l-type fatty acid-binding protein (l-FABP), urinary neutrophil gelatinase-associated lipocalin (NGAL), urinary hepcidin and serum cystatin c (CysC) before surgery, post-operatively and at 24 h after surgery in 93 high risk patient undergoing cardiopulmonary bypass (CPB) and assessed the ability of these biomarkers alone and in combination to predict RIFLE-R defined AKI in the first 5 post-operative days. Twenty-five patients developed AKI. π-GST (ROCAUC = 0.75), lower urine Hepcidin:Creatine ratio at 24 h (0.77), greater urine NGAL:Cr ratio post-op (0.73) and greater serum CysC at 24 h (0.72) best predicted AKI. Linear combinations with significant improvement in AUC were: Hepcidin:Cr 24 h + post-operative π-GST (AUC = 0.86, p = 0.01), Hepcidin:Cr 24 h + NGAL:Cr post-op (0.84, p = 0.03) and CysC 24 h + post-operative π-GST (0.83, p = 0.03), notably these significant biomarkers combinations all involved a tubular injury and a glomerular filtration biomarker. Despite statistical significance in receiver-operator characteristic (ROC) analysis, when assessed by ability to define patients to two groups at high and low risk of AKI, combinations failed to significantly improve classification of risk compared to the best single biomarkers. In an alternative approach using Classification and Regression Tree (CART) analysis a model involving NGAL:Cr measurement post-op followed by Hepcidin:Cr at 24 h was developed which identified high, intermediate and low risk groups for AKI. Regression tree analysis has the potential produce models with greater clinical utility than single combined scores.
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Alesawi A, Nadeau G, Bergeron A, Dujardin T, Lacombe L, Caumartin Y. Cystatin C for early detection of acute kidney injury after laparoscopic partial nephrectomy. Urol Ann 2014; 6:298-304. [PMID: 25371605 PMCID: PMC4216534 DOI: 10.4103/0974-7796.140988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 01/12/2014] [Indexed: 01/20/2023] Open
Abstract
Introduction and Objectives: Mortality due to AKI has not changed significantly over the past 50 years. This is due in part to failure to detect early AKI and to initiate appropriate therapeutic measures. There is therefore a need to identify biomarkers that would improve the early detection of AKI. The objective of this study was to assess whether cystatin C levels obtained at specific timepoints during laparoscopic partial nephrectomy (PN) could be early predictors of AKI. Materials and Methods: Twenty-five patients underwent laparoscopic PN for organ-confined tumors. All procedures were performed by two surgeons in a single institution. Plasma samples were collected preoperatively, and post-unclamping at 5, 20, 120 min and on the day following surgery. Plasma cystatin C was measured by enzyme-linked immunosorbent assay. Correlation between levels of cystatin C and other parameters of interest were assessed in order to define cystatin C ability to predict AKI and loss of renal function following laparoscopic PN. Results: The mean baseline eGFR was 93 ml/min/1.73 m2. Warm ischemia time varied between 16 and 44 min. Post-operative day 1 (POD1) cystatin C levels compared to baseline were increased in 13 (52%) of the patients. There was a high correlation between the difference of POD 1 and baseline value, and eGFR in the immediate postoperative period (r = −0.681; P = 0.0002) and at 12-month follow-up (r = −0.460, P = 0.048). However, the variation in cystatin C levels at earlier timepoints were not associated to AKI nor renal function. Conclusions: High increase in POD 1 cystatin C levels from baseline may help identify patients with AKI and those at higher risk of chronic kidney disease, following laparoscopic PN.
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Affiliation(s)
- Anwar Alesawi
- Department of Urology of Laval University, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada ; Laval University Cancer Research Centre, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada
| | - Geneviève Nadeau
- Department of Urology of Laval University, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada ; Laval University Cancer Research Centre, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada
| | - Alain Bergeron
- Laval University Cancer Research Centre, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada
| | - Thierry Dujardin
- Department of Urology of Laval University, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada
| | - Louis Lacombe
- Department of Urology of Laval University, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada ; Laval University Cancer Research Centre, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada
| | - Yves Caumartin
- Department of Urology of Laval University, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada ; Laval University Cancer Research Centre, CHU de Québec - L'Hôtel-Dieu de Québec, Québec, Qc, Canada
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Leelahavanichkul A, Souza ACP, Street JM, Hsu V, Tsuji T, Doi K, Li L, Hu X, Zhou H, Kumar P, Schnermann J, Star RA, Yuen PST. Comparison of serum creatinine and serum cystatin C as biomarkers to detect sepsis-induced acute kidney injury and to predict mortality in CD-1 mice. Am J Physiol Renal Physiol 2014; 307:F939-48. [PMID: 25143457 DOI: 10.1152/ajprenal.00025.2013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) dramatically increases sepsis mortality, but AKI diagnosis is delayed when based on serum creatinine (SCr) changes, due in part, to decreased creatinine production. During experimental sepsis, we compared serum cystatin C (sCysC), SCr, and blood urea nitrogen (BUN) to inulin glomerular filtration rate (iGFR) before or 3-18 h after cecal ligation and puncture (CLP)-induced sepsis in CD-1 mice. sCysC had a faster increase and reached peak levels more rapidly than SCr in both sepsis and bilateral nephrectomy (BiNx) models. sCysC was a better surrogate of iGFR than SCr during sepsis. Combining sCysC with SCr values into a composite biomarker improved correlation with iGFR better than any biomarker alone or any other combination. We determined the renal contribution to sCysC handling with BiNx. sCysC and SCr were lower post-BiNx/CLP than post-BiNx alone, despite increased inflammatory and nonrenal organ damage biomarkers. Sepsis decreased CysC production in nephrectomized mice without changing body weight or CysC space. Sepsis decreased sCysC production and increased nonrenal clearance, similar to effects of sepsis on SCr. sCysC, SCr, and BUN were measured 6 h postsepsis to link AKI with mortality. Mice with above-median sCysC, BUN, or SCr values 6 h postsepsis died earlier than mice with below-median values, corresponding to a substantial AKI association with sepsis mortality in this model. sCysC performs similarly to SCr in classifying mice at risk for early mortality. We conclude that sCysC detects AKI early and better reflects iGFR in CLP-induced sepsis. This study shows that renal biomarkers need to be evaluated in specific contexts.
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Affiliation(s)
- Asada Leelahavanichkul
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ana Carolina P Souza
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Jonathan M Street
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Victor Hsu
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Takayuki Tsuji
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Kent Doi
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Lingli Li
- Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Xuzhen Hu
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Hua Zhou
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Parag Kumar
- Pharmacy Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Jürgen Schnermann
- Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Robert A Star
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
| | - Peter S T Yuen
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, and
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Kiessling AH, Dietz J, Reyher C, Stock UA, Beiras-Fernandez A, Moritz A. Early postoperative serum cystatin C predicts severe acute kidney injury following cardiac surgery: a post-hoc analysis of a randomized controlled trial. J Cardiothorac Surg 2014; 9:10. [PMID: 24397879 PMCID: PMC3896845 DOI: 10.1186/1749-8090-9-10] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 12/23/2013] [Indexed: 01/16/2023] Open
Abstract
Objective Acute kidney injury (AKI) after cardiac surgery procedures is associated with poor patient outcomes. Cystatin C as a marker for renal failure has been shown to be of prognostic value; however, a wide range of its predictive accuracy has been reported. The aim of the study was to evaluate whether the measurement of pre- and postoperative serum cystatin C improves the prediction of AKI. Methods In a single-centre, prospective study of 70 patients (74 ± 9ys; range 47-85ys; 77% male), cystatin C was measured six times: (T1 = preoperative, T2 = start cardiopulmonary bypass (CPB), T3 = 20 min after CPB, T4 = end of operation; T5 = 24 h postoperatively; T6 = 7d postoperatively). Predictive property, in terms of the need for renal replacement therapy (RRT), was analysed by receiver operating characteristics (ROC) statistics and described by the area under the curve (AUC). Results With respect to RRT (n = 8), serum cystatin C was significantly higher at the end of the operation (T4), 24 h postoperatively at T5 and at T6. The AUCs for preoperative T1 and intraoperative T2/3 cystatin C were <0.7 (95% CI, 0.47-0.85). The earliest significant predictive AUCs were found at the end of the operation (T4: p = 0.03 95% CI 0.58-0.88 AUC 0.73) and 24 h postoperatively (T5: p = 0.003 95% CI 0.74-0.96 AUC 0.85). Conclusions Early postoperative serum cystatin C increase appears to be a moderate biomarker in the prediction of AKI, whereas a preoperative and intraoperative cystatin C increase has only a limited diagnostic and predictive value.
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Affiliation(s)
- Arndt-Holger Kiessling
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor Stern Kai 7, Frankfurt am Main 60590, Germany.
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Zhang J, Feng G, Yang Y, Zhang P, Pu C, Zhao G. Acute kidney injury after radical gastrectomy: a single center study. Int Urol Nephrol 2013; 46:973-7. [PMID: 24318368 DOI: 10.1007/s11255-013-0618-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/25/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate the incidence of acute kidney injury (AKI) and identify risk factors for AKI in patients who undergo radical gastrectomy. METHODS This study included 536 patients underwent radical gastrectomy. Primary outcome was AKI, defined as a ≥ 50 % increase in serum creatinine relative to baseline during the first three postoperative days. Secondary outcomes were duration of hospitalization and all-cause hospital mortality within 30 days after radical gastrectomy. RESULTS A total of 37 (6.9 %) patients developed postoperative AKI. Age, body mass index (BMI), presence of hypertension, hyperlipidemia, poor blood glucose control, and preoperative higher cystatin C were associated with increased frequency of AKI. By multivariable analyses, the independent risk factors for AKI were age, BMI, hypertension, hyperlipidemia, and preoperative cystatin C. CONCLUSIONS Postoperative AKI is not infrequent after radical gastrectomy. Age, BMI, hypertension, hyperlipidemia, and preoperative cystatin C are independently associated with increased risk of postoperative AKI.
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Affiliation(s)
- Jingping Zhang
- Department of Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
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Hamed HM, El-Sherbini SA, Barakat NA, Farid TM, Rasheed EA. Serum cystatin C is a poor biomarker for diagnosing acute kidney injury in critically-ill children. Indian J Crit Care Med 2013; 17:92-8. [PMID: 23983414 PMCID: PMC3752874 DOI: 10.4103/0972-5229.114829] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Accurate diagnosis of acute kidney injury (AKI) is problematic especially in critically-ill patients in whom renal function is in an unsteady state. Aim: Our aim was to evaluate the role of serum (S.) cystatin C as an early biomarker of AKI in critically-ill children. Subjects and Methods: S. creatinine and S. cystatin C were measured in 32 critically-ill children who were at risk for developing AKI. AKI was defined by both: Risk,-injury,-failure,-loss, and-endstage renal disease (RIFLE) classification and glomerular filtration rate (GFR) <80 ml/min/1.73 m2. GFR was estimated by both Schwartz formula and S. cystatin C-based equation. Results: S. cystatin C was not statistically higher in AKI patients compared with non-AKI by RIFLE classification (median 1.48 mg/l vs. 1.16 mg/l, P = 0.1) while S. creatinine was significantly higher (median 0.8 mg/dl vs. 0.4 mg/dl, P = 0.001). On estimating GFR by the two equations we found, a lag between rise of S. cystatin C and creatinine denoted by lower GFR by Schwartz formula in four patients, on other hand, six patients had elevated S. cystatin C with low GFR despite normal creatinine and GFR, denoting poor concordance between the two equations and the two markers. The ability of S. creatinine in predicting AKI was superior to S. cystatin with area under the curve (AUC) 0.95 with sensitivity and specificity (100% and 84.6%, respectively) using the RIFLE classification. The same findings were found when using Schwartz formula. Conclusion: S. cystatin C is a poor biomarker for diagnosing AKI in critically-ill children.
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Affiliation(s)
- Hanan M Hamed
- Department of Pediatrics, National Research Centre, Cairo, Egypt
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Is serum cystatin C an early predictor for acute kidney injury following cardiopulmonary bypass surgery in infants and young children? Kaohsiung J Med Sci 2013; 29:494-9. [PMID: 24018153 DOI: 10.1016/j.kjms.2013.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 08/08/2012] [Indexed: 11/21/2022] Open
Abstract
Acute kidney injury (AKI) is a potential complication following cardiopulmonary bypass (CPB) surgery in infants and young children with congenital heart disease (CHD). The current pilot study evaluates the predictive value of serum cystatin C (CysC) for AKI after pediatric CPB surgery. We prospectively enrolled 43 children with CHD (30 males and 13 females) who underwent CPB surgery. They were aged 3 years or younger. Serum CysC was measured at baseline and at 6 hours, 12 hours, 24 hours, and 48 hours after initiating CBP. Twenty-one (48.8%) patients developed AKI after cardiac surgery. Children who developed AKI had more complex cardiac surgical procedures (based on the Risk Adjustment for Congenital Heart Surgery 1 [RACHS-1] category), a longer CPB duration, and a longer aortic clamping time (ACT). Serum concentrations of CysC postoperatively demonstrated an initial decline at 6 hours, a subsequent increase at 12 hours, and stabilized at 24-48 hours. The best predictive performance was achieved 6 hours after CPB with an area under receiver operating characteristic curve (AUC) value of 0.69. The optimal cut-off value was 0.47 mg/L (sensitivity, 85.7%; specificity, 50%). By contrast, the RACHS-1 category, CPB duration, and ACT had higher AUC values at 0.735, 0.791, and 0.731, respectively. In conclusion, serum CysC had limited predictive capacity and was not superior to clinical risk factors for the early detection of AKI after CPB surgery in this pilot study, which focused on infants and young children.
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Lassus J, Harjola VP. Cystatin C: a step forward in assessing kidney function and cardiovascular risk. Heart Fail Rev 2013; 17:251-61. [PMID: 21431356 DOI: 10.1007/s10741-011-9242-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The cardiorenal syndrome is a clinical manifestation of the bidirectional interaction between the heart and kidneys. Evaluating renal function is an essential part of the assessment of every cardiac patient. It has become clear that serum creatinine is not an accurate enough marker of glomerular filtration rate (GFR) and should not be used to evaluate kidney dysfunction. Creatinine-based estimates of GFR are preferred, but require renal function to be stable and are not suitable when changes in kidney function occur. Cystatin C (CysC) has been the target of much interest in the search for an alternative measure of GFR. As an endogenous biomarker, CysC possesses many of the properties required of a good marker of renal function. Compared with that of creatinine, plasma concentrations of CysC are less influenced by factors other than GFR. Consequently, CysC correlates with true GFR more accurately than creatinine. Equations for estimating GFR from CysC values have also been developed, which makes values easier to interpret and facilitates the clinical use of this new marker. The use of CysC in acute kidney injury has also shown promising results. CysC has been studied as a risk marker for prognosis in cardiovascular disease. This effect is attributed to the strong impact of renal dysfunction on progressive cardiovascular disease and impaired survival. Higher levels of CysC have consistently been predictive of incident or recurrent cardiovascular events and adverse outcomes. CysC is a predictor of the development of heart failure and increased levels of CysC have an independent association with higher mortality in both chronic and acute heart failure. In conclusion, CysC appears to be an interesting marker of renal function and is useful for risk stratification in heart failure.
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Affiliation(s)
- Johan Lassus
- Division of Cardiology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Vanmassenhove J, Vanholder R, Nagler E, Van Biesen W. Urinary and serum biomarkers for the diagnosis of acute kidney injury: an in-depth review of the literature. Nephrol Dial Transplant 2012; 28:254-73. [PMID: 23115326 DOI: 10.1093/ndt/gfs380] [Citation(s) in RCA: 248] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) remains associated with high morbidity and mortality, despite progress in medical care. Although the RIFLE (Risk, Injury, Failure, Loss, End-Stage Kidney Disease) and AKIN (Acute Kidney Injury Network) criteria, based on serum creatinine and urine output, were a step forward in diagnosing AKI, a reliable tool to differentiate between true parenchymal and pre-renal azotaemia in clinical practice is still lacking. In the last decade, many papers on the use of new urinary and serum biomarkers for the diagnosis and prognostication of AKI have been published. Thus, the question arises which biomarker is a reliable differential diagnostic tool under which circumstances. METHODS We searched Medline from inception to April 2012 using medical subject heading and text words for AKI and biomarkers [neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), Cystatin C, interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-18 (IL-18), N-acetyl-glucosaminidase (NAG), glutathione transferases (GST) and liver fatty acid binding protein (LFABP)] to identify relevant papers in five different settings (paediatrics, cardiac surgery, emergency department, critically ill and contrast-induced nephropathy). RESULTS We included 87 relevant papers, reporting on 74 studies. Depending upon the setting, 7-27 different definitions of AKI were used. Reported diagnostic performance of the different biomarkers was variable from poor to excellent, and no consistent generalizable conclusions can be drawn on their diagnostic value. CONCLUSIONS Early diagnosing of AKI in clinical conditions by using new serum and urinary biomarkers remains cumbersome, especially in those settings where timing and aetiology of AKI are not well defined. Putting too much emphasis on markers that have not convincingly proven reliability might lead to incorrect interpretation of clinical trials. Further research in this field is warranted before biomarkers can be introduced in clinical practice.
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Ostermann M, Philips BJ, Forni LG. Clinical review: Biomarkers of acute kidney injury: where are we now? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:233. [PMID: 23014769 PMCID: PMC3682238 DOI: 10.1186/cc11380] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The recognition that acute kidney injury (AKI) is a significant independent risk factor for morbidity and mortality has resulted in a substantial number of publications over the past 5 years or more. In no small part these have, to a degree, highlighted the inadequacy of conventional markers of renal insufficiency in the acute setting. Much effort has been invested in the identification of early, specific AKI markers in order to aid early diagnosis of AKI and hopefully improve outcome. The search for a 'biomarker' of AKI has seen early promise replaced by a degree of pessimism due to the lack of a clear candidate molecule and variability of results. We outline the major studies described to date as well as discuss potential reasons for the discrepancies observed and suggest that evolution of the field may result in success with ultimately an improvement in patient outcomes.
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Abstract
Identifying patients with impaired renal function is crucial in the setting of critical illness. Serum creatinine serves as the gold standard for assessing steady-state renal function, helping to define those with chronic kidney disease (CKD). Although these baseline creatinine values are often not available in the setting of critical illness, CKD, whether defined by serum creatinine or proteinuria, increases the risk of developing acute kidney injury (AKI). Despite delays in elevations following renal insults, serum creatinine remains the standard for assessing acute changes in renal function. Standardized definitions of AKI, using changes in serum creatinine and urine output, have informed the epidemiology of ICU-acquired AKI and have helped define the long-term outcomes in patients who experience AKI. A complex cyclical interplay exists between AKI and CKD, in which CKD predisposes patients to an increased risk of AKI, whereas those with AKI, regardless of baseline renal function, are more likely to suffer from post-AKI CKD. The clarification of the AKI-CKD dynamic remains a work in progress and will be aided by the implementation of novel measures of renal function. Several novel biomarkers of renal function have been proposed to augment serum creatinine in the diagnosis of AKI and CKD. These biomarkers, taken with recent clinical investigations, have laid the groundwork for the impending paradigm shift in risk stratifying and in diagnosing changes in renal function in the ICU.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Internal Medicine, University of Chicago, Chicago, IL.
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Spahillari A, Parikh CR, Sint K, Koyner JL, Patel UD, Edelstein CL, Passik CS, Thiessen-Philbrook H, Swaminathan M, Shlipak MG. Serum cystatin C- versus creatinine-based definitions of acute kidney injury following cardiac surgery: a prospective cohort study. Am J Kidney Dis 2012; 60:922-9. [PMID: 22809763 DOI: 10.1053/j.ajkd.2012.06.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 06/01/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND The primary aim of this study was to compare the sensitivity and rapidity of acute kidney injury (AKI) detection by cystatin C level relative to creatinine level after cardiac surgery. STUDY DESIGN Prospective cohort study. SETTINGS & PARTICIPANTS 1,150 high-risk adult cardiac surgery patients in the TRIBE-AKI (Translational Research Investigating Biomarker Endpoints for Acute Kidney Injury) Consortium. PREDICTOR Changes in serum creatinine and cystatin C levels. OUTCOME Postsurgical incidence of AKI. MEASUREMENTS Serum creatinine and cystatin C were measured at the preoperative visit and daily on postoperative days 1-5. To allow comparisons between changes in creatinine and cystatin C levels, AKI end points were defined by the relative increases in each marker from baseline (25%, 50%, and 100%) and the incidence of AKI was compared based on each marker. Secondary aims were to compare clinical outcomes among patients defined as having AKI by cystatin C and/or creatinine levels. RESULTS Overall, serum creatinine level detected more cases of AKI than cystatin C level: 35% developed a ≥25% increase in serum creatinine level, whereas only 23% had a ≥25% increase in cystatin C level (P < 0.001). Creatinine level also had higher proportions meeting the 50% (14% and 8%; P < 0.001) and 100% (4% and 2%; P = 0.005) thresholds for AKI diagnosis. Clinical outcomes generally were not statistically different for AKI cases detected by creatinine or cystatin C level. However, for each AKI threshold, patients with AKI confirmed by both markers had a significantly higher risk of the combined mortality/dialysis outcome compared with patients with AKI detected by creatinine level alone (P = 0.002). LIMITATIONS There were few adverse clinical outcomes, limiting our ability to detect differences in outcomes between subgroups of patients based on their definitions of AKI. CONCLUSIONS In this large multicenter study, we found that cystatin C level was less sensitive for AKI detection than creatinine level. However, confirmation by cystatin C level appeared to identify a subset of patients with AKI with a substantially higher risk of adverse outcomes.
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Affiliation(s)
- Aferdita Spahillari
- Division of General Internal Medicine, San Francisco VA Medical Center, University of California, San Francisco, CA, USA
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Calvert S, Shaw A. Perioperative acute kidney injury. Perioper Med (Lond) 2012; 1:6. [PMID: 24764522 PMCID: PMC3886265 DOI: 10.1186/2047-0525-1-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/04/2012] [Indexed: 01/04/2023] Open
Abstract
Acute kidney injury (AKI) is a serious complication in the perioperative period, and is consistently associated with increased rates of mortality and morbidity. Two major consensus definitions have been developed in the last decade that allow for easier comparison of trial evidence. Risk factors have been identified in both cardiac and general surgery and there is an evolving role for novel biomarkers. Despite this, there has been no real change in outcomes and the mainstay of treatment remains preventive with no clear evidence supporting any therapeutic intervention as yet. This review focuses on definition, risk factors, the emerging role of biomarkers and subsequent management of AKI in the perioperative period, taking into account new and emerging strategies.
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Affiliation(s)
| | - Andrew Shaw
- Dept of Anesthesiology and Critical Care Medicine, Duke University Medical Center/Durham VAMC, Durham, USA
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Hsiao PG, Hsieh CA, Yeh CF, Wu HH, Shiu TF, Chen YC, Chu PH. Early prediction of acute kidney injury in patients with acute myocardial injury. J Crit Care 2012; 27:525.e1-7. [PMID: 22762928 DOI: 10.1016/j.jcrc.2012.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 04/28/2012] [Accepted: 05/09/2012] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Previous studies have revealed that acute myocardial infarction (AMI) with acute kidney injury (AKI), about 17%, is strongly related to long-term mortality and heart failure. The dynamic changes in renal function during AMI are strongly related to long-term mortality and heart failure. OBJECTIVES Our study used clinical parameters and AKI biomarkers including neutrophil gelatinase-associated lipocalin, interleukin (IL)-6, IL-18, and cystatin C to evaluate prognostic relevance of AKI in the setting of AMI. METHODS This prospective study was conducted from November 2009 to January 2011 and enrolled sequential 96 patients with catheter-proven AMI; it was approved by the institutional review board of Chang Gung Memorial Hospital, Taiwan (institutional review board no. 99-0140B) and conformed to the tenets of the Declaration of Helsinki. The definition of AKI is the elevation of serum creatinine of more than 0.3 mg/dL within 48 hours. RESULTS Our results show that the incidence of AKI after AMI is 17.7% (17 patients). The following could be statistically related to AKI after AMI: age (P = .012), cardiac functions (Killip stage and echocardiogram; P = .003 each), Thrombolysis in Myocardial Infarction (TIMI) flow grade (P < .001), stenting (P < .001), neutrophil gelatinase-associated lipocalin (P = .005), IL-6 (P = .01), IL-18 (P = .002), and cystatin C (P = .002) in serum. The TIMI flow grade and serum cystatin C were shown to be important predictors by using multivariate analysis. Both TIMI flow lower than grade 2 and serum cystatin C of more than 1364 mg/L could be used to predict AKI (both overall correctness, 0.78). Moreover, IL-6 in serum is also associated with the major cardiovascular events after AMI (P = .02), as demonstrated in our study. CONCLUSION In conclusion, the worse TIMI flow and high plasma cystatin C can be used to predict AKI after AMI. Moreover, IL-6 can also be used as a 30-day major cardiovascular event indicator after AMI. A larger prospective and longitudinal study should follow the relationship between AKI predictors after AMI.
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Affiliation(s)
- Ping-Gune Hsiao
- The Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei 105, Taiwan
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Predictive power of serum cystatin C to detect acute kidney injury and pediatric-modified RIFLE class in children undergoing cardiac surgery. Pediatr Crit Care Med 2012; 13:435-40. [PMID: 22596066 DOI: 10.1097/pcc.0b013e318238b43c] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Acute kidney injury is a frequent and serious complication of cardiopulmonary bypass. In current clinical practice, serum creatinine is used to detect acute kidney injury. Cystatin C is a novel biomarker for kidney function that has been shown to be superior to serum creatinine in predicting acute kidney injury in adults after cardiopulmonary bypass. The aim of this study was to determine whether early cystatin C levels predict acute kidney injury associated with cardiopulmonary bypass in pediatric patients undergoing cardiac surgery and if cystatin C could predict pediatric-modified RIFLE (Risk, Injury, Failure, Loss, End-stage kidney disease) class and renal injury as determined by estimated glomerular filtration rate. We also investigated whether ultrafiltration during cardiopulmonary bypass affects cystatin C levels. DESIGN Prospective, observational cohort study. SETTING Cardiac intensive care unit in a tertiary, academic pediatric hospital. PATIENTS One hundred pediatric patients who underwent cardiac surgery involving cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Acute kidney injury was defined as a 50% increase in serum creatinine from a preoperative baseline anytime through postoperative day 4. Severity of acute kidney injury was determined by pediatric RIFLE class using estimated glomerular filtration rate criteria only. Renal injury was also determined by an absolute estimated glomerular filtration rate <80 mL/min/1.73 m. Cystatin C levels were measured before and after ultrafiltration. Twenty-eight patients (28%) developed acute kidney injury. Cystatin C predicted acute kidney injury as early as 8 hrs after surgery. When applying pediatric RIFLE criteria to the entire study, 30 patients reached "risk" and five developed "injury." Cystatin C was a good predictor of the development of "injury" (under the receiver operating characteristic curve, 0.834-0.875) and of renal injury by estimated glomerular filtration rate (under the receiver operating characteristic curve, 0.717-0.835) (all p < .05). Cystatin C levels decreased perioperatively and correlated with volume of fluid removed by ultrafiltration. CONCLUSIONS Cystatin C is an early predictor of acute kidney injury in children after cardiopulmonary bypass. Cystatin C is a good predictor of pediatric RIFLE classification and of decreased estimated glomerular filtration rate after cardiopulmonary bypass. Serum cystatin C may be cleared by ultrafiltration.
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Haase M, Bellomo R, Haase-Fielitz A. Serum Cystatin C May Diagnose Rather Than Predict Acute Kidney Injury. Am J Kidney Dis 2012; 59:582; author reply 582. [DOI: 10.1053/j.ajkd.2011.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 07/21/2011] [Indexed: 11/11/2022]
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Wagner D, Kniepeiss D, Stiegler P, Zitta S, Bradatsch A, Robatscher M, Müller H, Meinitzer A, Fahrleitner-Pammer A, Wirnsberger G, Iberer F, Tscheliessnigg K, Reibnegger G, Rosenkranz AR. The assessment of GFR after orthotopic liver transplantation using cystatin C and creatinine-based equations. Transpl Int 2012; 25:527-36. [PMID: 22369048 DOI: 10.1111/j.1432-2277.2012.01449.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The measurement of kidney function after orthotopic liver transplantation (OLT) is still a clinical challenge. Cystatin C (CysC) has been proposed as a more accurate marker of renal function than serum creatinine (sCr). The aim of this study was to evaluate sCr- and CysC-based equations including the Chronic kidney disease (CKD)-EPI to determine renal function in liver transplant recipients. CysC and sCr were measured in 49 patients 24 months after OLT. The glomerular filtration rate (GFR) was calculated using the MDRD 4, the Cockroft-Gault, Hoek, Larsson, and the CKD-EPI equations based on sCr and/or CysC. As reference method, inulin clearance (IC) was estimated. Bias, precision, and accuracy of each equation were assessed and compared with respect to IC. Forty-five percent had a GFR < 60 ml/min/1.73 m(2) according to the IC. The Larsson, the Hoek and the CKD-EPI-CysC formula identified the highest percentage of patients with CKD correctly (88%, 88%, and 84%, respectively). The sCr-based equations showed less bias than CysC-based formulas with a similar precision. All CysC-based equations were superior as compared with sCr-based equations in the assessment of renal function in patients with an IC < 60 ml/min/1.73 m(2).
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Affiliation(s)
- Doris Wagner
- Department of Surgery, Division of Transplant Surgery, Medical University of Graz, Graz, Austria.
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Cystatin C as a marker of glomerular filtration rate: prospects and limitations. Curr Opin Nephrol Hypertens 2012; 20:631-9. [PMID: 21926620 DOI: 10.1097/mnh.0b013e32834b8850] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is much interest in cystatin C to replace or supplement serum creatinine to estimate the glomerular filtration rate (GFR). Here we review the performance of cystatin C and combined creatinine-cystatin C estimating equations compared to creatinine-based estimating equations in chronic and acute kidney disease. RECENT FINDINGS Drift in the cystatin C assay has had a large effect on the results reported using cystatin C, but these issues are not routinely considered in evaluation of GFR-estimating equations. The recently released primary reference material for cystatin C will allow less difference among assays in the future. There does not appear to be a consistent message among published studies as to whether cystatin C-based equations are better than creatinine-based equations in the general population or those with chronic kidney disease (CKD), as well as those with reduced muscle mass or chronic illness, or acute kidney injury. Cystatin C could be used in combination with creatinine as a confirmatory test for estimated GFR from creatinine. SUMMARY Cystatin C may have a role to estimate GFR in selected circumstances, and the next set of studies should be directed at developing implementation strategies for its use.
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Zhang Z, Lu B, Sheng X, Jin N. Cystatin C in prediction of acute kidney injury: a systemic review and meta-analysis. Am J Kidney Dis 2011; 58:356-65. [PMID: 21601330 DOI: 10.1053/j.ajkd.2011.02.389] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 02/16/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cystatin C (CysC) has been proposed as a filtration marker for the early detection of acute kidney injury (AKI); however, a wide range of its predictive accuracy has been reported. STUDY DESIGN Meta-analysis of diagnostic test studies. SETTING & POPULATION Various clinical settings of AKI, including patients after cardiac surgery, pediatric patients, and critically ill patients. SELECTION CRITERIA Computerized search of PubMed, Current Contents, CINAHL, and EMBASE from inception until November 15, 2010, was performed to identify potentially relevant articles. Inclusion criteria were studies investigating the diagnostic accuracy of CysC level to predict AKI. There were no language restrictions in the search. INDEX TESTS Increasing or increased serum CysC level or urinary CysC excretion. REFERENCE TESTS The outcome was the development of AKI, primarily based on serum creatinine level (definition varied across studies). RESULTS We analyzed data from 19 studies and 11 countries involving 3,336 patients. Of these studies, 13 could be included in the meta-analysis. Across all settings, the diagnostic OR for serum CysC level to predict AKI was 27.7 (95% CI, 12.8-59.8), with sensitivity and specificity of 0.86 and 0.82, respectively. The area under the receiver operating characteristic curve (AUROC) of serum CysC levelto predict AKI was 0.87 (95% CI, 0.81-0.93). In an analysis excluding studies that did not clearly define the measurement time point, early serum CysC (within 24 hours after renal insult or intensive care unit admission) remained of diagnostic value. For the diagnostic value of urinary CysC excretion, the diagnostic OR was 3.10 (95% CI, 2.00-4.81), with sensitivity and specificity of0.61 and 0.67, respectively. TheAUROC of urinary CysC excretion to predict AKI was 0.67 (95% CI, 0.63-0.71) [corrected]. LIMITATIONS Variation in criteria for definitions of index and reference tests, absence of measured glomerular filtration rate in most studies. CONCLUSION Serum CysC appears to be a good biomarker in the prediction of AKI, whereas urinary CysC excretion has only moderate diagnostic value.
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Affiliation(s)
- Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Zhejiang, People's Republic of China.
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Shlipak MG, Coca SG, Wang Z, Devarajan P, Koyner JL, Patel UD, Thiessen-Philbrook H, Garg AX, Parikh CR. Presurgical serum cystatin C and risk of acute kidney injury after cardiac surgery. Am J Kidney Dis 2011; 58:366-73. [PMID: 21601336 DOI: 10.1053/j.ajkd.2011.03.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 03/11/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after cardiac surgery is associated with poor outcomes, but is challenging to predict from information available before surgery. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS The TRIBE-AKI (Translational Research Investigating Biomarker Endpoints in Acute Kidney Injury) Consortium enrolled 1,147 adults undergoing cardiac surgery at 6 hospitals from 2007-2009; participants were selected for high AKI risk. PREDICTORS Presurgical values for cystatin C, creatinine, and creatinine-based estimated glomerular filtration rate (eGFR) were categorized into quintiles and grouped as "best" (quintiles 1-2), "intermediate" (quintiles 3-4), and "worst" (quintile 5) kidney function. OUTCOMES The primary outcome was AKI Network (AKIN) stage 1 or higher; ≥0.3 mg/dL or 50% increase in creatinine level. MEASUREMENTS Analyses were adjusted for characteristics used clinically for presurgical risk stratification. RESULTS Average age was 71 ± 10 years (mean ± standard deviation); serum creatinine, 1.1 ± 0.3 mg/dL; eGFR-Cr, 74 ± 9 mL/min/1.73 m(2); and cystatin C, 0.9 ± 0.3 mg/L. 407 (36%) participants developed AKI during hospitalization. Adjusted odds ratios for intermediate and worst kidney function by cystatin C were 1.9 (95% CI, 1.4-2.7) and 4.8 (95% CI, 2.9-7.7) compared with 1.2 (95% CI, 0.9-1.7) and 1.8 (95% CI, 1.2-2.6) for creatinine and 1.0 (95% CI, 0.7-1.4) and 1.7 (95% CI, 1.1-2.3) for eGFR-Cr categories, respectively. After adjustment for clinical predictors, the C statistic to predict AKI was 0.70 without kidney markers, 0.69 with creatinine, and 0.72 with cystatin C. Cystatin C also substantially improved AKI risk classification compared with creatinine, based on a net reclassification index of 0.21 (P < 0.001). LIMITATIONS The ability of these kidney biomarkers to predict risk of dialysis-requiring AKI or death could not be assessed reliably in our study because of a small number of patients with either outcome. CONCLUSIONS Presurgical cystatin C is better than creatinine or creatinine-based eGFR at forecasting the risk of AKI after cardiac surgery.
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Affiliation(s)
- Michael G Shlipak
- Department of Medicine, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, CA, USA
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Bibliography. Neonatology and perinatology. Current world literature. Curr Opin Pediatr 2011; 23:253-7. [PMID: 21412083 DOI: 10.1097/mop.0b013e3283454167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Levey AS, Deo A, Jaber BL. Filtration Markers in Acute Kidney Injury. Am J Kidney Dis 2010; 56:619-22. [DOI: 10.1053/j.ajkd.2010.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 08/02/2010] [Indexed: 12/29/2022]
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