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Nadim MK, Kellum JA, Forni L, Francoz C, Asrani SK, Ostermann M, Allegretti AS, Neyra JA, Olson JC, Piano S, VanWagner LB, Verna EC, Akcan-Arikan A, Angeli P, Belcher JM, Biggins SW, Deep A, Garcia-Tsao G, Genyk YS, Gines P, Kamath PS, Kane-Gill SL, Kaushik M, Lumlertgul N, Macedo E, Maiwall R, Marciano S, Pichler RH, Ronco C, Tandon P, Velez JCQ, Mehta RL, Durand F. Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024:S0168-8278(24)00214-9. [PMID: 38527522 DOI: 10.1016/j.jhep.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lui Forni
- School of Medicine, University of Surrey and Critical Care Unit, Royal Surrey Hospital Guildford UK
| | - Claire Francoz
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France
| | | | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jody C Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, University and Teaching Hospital of Padua, Italy
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Scott W Biggins
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Akash Deep
- Pediatric Intensive Care Unit, King's College Hospital, London, UK
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuri S Genyk
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Division of Abdominal Organ Transplantation at Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Pere Gines
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi-Sunyer and Ciber de Enfermedades Hepàticas y Digestivas, Barcelona, Catalonia, Spain
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Nuttha Lumlertgul
- Excellence Centre in Critical Care Nephrology and Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, CA, USA
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Raimund H Pichler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza-Italy
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Juan-Carlos Q Velez
- Department of Nephrology, Ochsner Health, New Orleans, LA, USA; Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - François Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France; University Paris Cité, Paris, France.
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Belcher JM. Use of Terlipressin in AKI Associated with Hepatorenal Syndrome: PRO. Kidney360 2024:02200512-990000000-00303. [PMID: 38526157 DOI: 10.34067/kid.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/05/2023] [Indexed: 03/26/2024]
Affiliation(s)
- Justin M Belcher
- Associate Professor of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Belcher JM. Hepatorenal Syndrome Type 1: Diagnosis and Treatment. Adv Kidney Dis Health 2024; 31:100-110. [PMID: 38649214 DOI: 10.1053/j.akdh.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/16/2023] [Accepted: 05/08/2023] [Indexed: 04/25/2024]
Abstract
Hepatorenal syndrome (HRS) is a feared complication in patients with advanced cirrhosis and is associated with significant morbidity and mortality. While recognized as a distinct physiologic condition for well over one hundred years, a lack of objective diagnostic tests has made the diagnosis one of exclusion. Since 1979, multiple sets of diagnostic criteria have been proposed. Though varying in detail, the principal intent of these criteria is to identify patients with severe, functional acute kidney injury that is unresponsive to volume resuscitation and exclude those with structural injury. However, accurate differential diagnosis remains challenging. Recently, multiple urinary biomarkers of kidney injury, including neutrophil gelatinase-associated lipocalin, have been studied as a means of objectively phenotyping etiologies of acute kidney injury in patients with cirrhosis. Along with markers reflecting tubular functional integrity, including the fractional excretion of sodium, injury markers will likely be incorporated into future diagnostic criteria. Making an accurate diagnosis is critical, as therapeutic options exist for HRS but must be given in a timely manner and only to those patients likely to benefit. Terlipressin, an analog of vasopressin, is the first line of therapy for HRS in much of the world and has recently been approved for use in the United States. Significant questions remain regarding the optimal dosing strategy, metrics for titration, and the potential role of point-of-care ultrasound to help guide concurrent albumin administration.
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Affiliation(s)
- Justin M Belcher
- Yale University School of Medicine, Department of Internal Medicine, Section of Nephrology, New Haven, CT; Department of Internal Medicine, Section of Nephrology, VA Connecticut Healthcare, West Haven, CT.
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Patidar KR, Belcher JM, Regner KR, St Hillien SA, Simonetto DA, Asrani SK, Neyra JA, Sharma P, Velez JCQ, Wadei H, Nadim MK, Chung RT, Seethapathy R, Parada XV, Ouyang T, Ufere NN, Robinson JE, McLean Diaz P, Wilechansky RM, Przybyszewski EM, Smith TN, Ali AA, Orman ES, Schulz P, Siddiqui SM, Shabbir R, Liu LJ, Cama-Olivares A, Flannery AH, Baker ML, Gunasekaran D, Aswine A, Issa R, Li J, Verma S, Chalmers D, Varghese V, Lam W, Mohamed M, Kovacic R, Gaddy A, Attieh RM, Cortes P, Semnani S, Wang L, Khemichian S, Allegretti AS. Incidence and outcomes of acute kidney injury including hepatorenal syndrome in hospitalized patients with cirrhosis in the US. J Hepatol 2023; 79:1408-1417. [PMID: 37517455 PMCID: PMC10807505 DOI: 10.1016/j.jhep.2023.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) in cirrhosis is common and associated with high morbidity, but the incidence rates of different etiologies of AKI are not well described in the US. We compared incidence rates, practice patterns, and outcomes across etiologies of AKI in cirrhosis. METHODS We performed a retrospective cohort study of 11 hospital networks, including consecutive adult patients admitted with AKI and cirrhosis in 2019. The etiology of AKI was adjudicated based on pre-specified clinical definitions (prerenal/hypovolemic AKI, hepatorenal syndrome [HRS-AKI], acute tubular necrosis [ATN], other). RESULTS A total of 2,063 patients were included (median age 62 [IQR 54-69] years, 38.3% female, median MELD-Na score 26 [19-31]). The most common etiology was prerenal AKI (44.3%), followed by ATN (30.4%) and HRS-AKI (12.1%); 6.0% had other AKI, and 7.2% could not be classified. In our cohort, 8.1% of patients received a liver transplant and 36.5% died by 90 days. The lowest rate of death was observed in patients with prerenal AKI (22.2%; p <0.001), while death rates were higher but not significantly different from each other in those with HRS-AKI and ATN (49.0% vs. 52.7%; p = 0.42). Using prerenal AKI as a reference, the adjusted subdistribution hazard ratio (sHR) for 90-day mortality was higher for HRS-AKI (sHR 2.78; 95% CI 2.18-3.54; p <0.001) and ATN (sHR 2.83; 95% CI 2.36-3.41; p <0.001). In adjusted analysis, higher AKI stage and lack of complete response to treatment were associated with an increased risk of 90-day mortality (p <0.001 for all). CONCLUSION AKI is a severe complication of cirrhosis. HRS-AKI is uncommon and is associated with similar outcomes to ATN. The etiology of AKI, AKI stage/severity, and non-response to treatment were associated with mortality. Further optimization of vasoconstrictors for HRS-AKI and supportive therapies for ATN are needed. IMPACT AND IMPLICATIONS Acute kidney injury (AKI) in cirrhosis carries high morbidity, and management is determined by the etiology of injury. However, a large and well-adjudicated multicenter database from US centers that uses updated AKI definitions is lacking. Our findings demonstrate that acute tubular necrosis and hepatorenal syndrome have similar outcomes (∼50% mortality at 90 days), though hepatorenal syndrome is uncommon (12% of all AKI cases). These findings represent practice patterns at US transplant/tertiary centers and can be used as a baseline, presenting the situation prior to the adoption of terlipressin in the US.
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Affiliation(s)
- Kavish R Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University and VA Connecticut Healthcare, New Haven, CT, USA
| | - Kevin R Regner
- Division of Nephrology at the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shelsea A St Hillien
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Transplant Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pratima Sharma
- Department of Gastroenterology and Transplant Hepatology at University of Michigan Health, Ann Arbor, MI, USA
| | - Juan Carlos Q Velez
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Hani Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raymond T Chung
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ritu Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jevon E Robinson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paige McLean Diaz
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert M Wilechansky
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric M Przybyszewski
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas N Smith
- Division of Gastroenterology and Transplant Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Arzina Aziz Ali
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Lucas J Liu
- Division of Biomedical Informatics, Department of Medicine and Department of Computer Science, University of Kentucky, Lexington, KY, USA
| | - Augusto Cama-Olivares
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Megan L Baker
- Section of Nephrology, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Deepthi Gunasekaran
- Section of Nephrology, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Adeline Aswine
- Department of Internal Medicine at University of Michigan Health, Ann Arbor, MI, USA
| | - Rafik Issa
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jay Li
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shreya Verma
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dustin Chalmers
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Vipin Varghese
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Walter Lam
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Muner Mohamed
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Rosemary Kovacic
- Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA
| | - Anna Gaddy
- Division of Nephrology at the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rose Mary Attieh
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Pedro Cortes
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Sahar Semnani
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lin Wang
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Saro Khemichian
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Belcher JM. Good Enough? Terlipressin, Hepatorenal Syndrome, and the Usage of RRT. Kidney360 2023; 4:1011-1013. [PMID: 37651662 PMCID: PMC10484352 DOI: 10.34067/kid.0000000000000217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/11/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Justin M. Belcher
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
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Abstract
Hepatorenal syndrome (HRS) is a primarily functional form of acute kidney injury (AKI) that develops in patients with decompensated cirrhosis. The pathophysiologic cascade that leads to HRS begins with pooling of blood in the splanchnic system, resulting in a decrease in effective circulating arterial volume. The definitive treatment of HRS is liver transplantation. When this is not possible, HRS is treated with a combination of vasoconstrictor agents and intravenous albumin. Although the combination of midodrine and octreotide is used in the United States, the recently approved terlipressin, an analog of vasopressin, is likely to become the first-line standard of care.
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Affiliation(s)
- Justin M Belcher
- Section of Nephrology, Yale University School of Medicine, VA Connecticut Healthcare System, VA Connecticut Healthcare, Room G126B, 950 Campbell Avenue, West Haven, CT 06516, USA.
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Velez JCQ, Karakala N, Tayebi K, Wickman TJ, Mohamed MMB, Kovacic RA, Therapondos G, Kanduri SR, Allegretti AS, Belcher JM, Regner KR, Wentowski C. Responsiveness to Vasoconstrictor Therapy in Hepatorenal Syndrome Type 1. Kidney360 2023; 4:e448-e456. [PMID: 36763632 PMCID: PMC10278824 DOI: 10.34067/kid.0000000000000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/13/2023] [Indexed: 02/12/2023]
Abstract
Key Points Raising the mean arterial pressure (MAP) during management of hepatorenal syndrome type 1 (HRS-1) is associated with improvement in kidney function, independently of baseline MAP or model for end-stage liver disease. Raising the MAP by 15 mm Hg or greater leads to greater reduction in serum creatinine in HRS-1. Norepinephrine use confers greater probability of improvement in kidney function in HRS-1 compared with midodrine/octreotide. Background Raising mean arterial pressure (MAP) during treatment of hepatorenal syndrome type 1 (HRS-1) with vasoconstrictors (VCs) is associated with renal recovery. However, the optimal MAP target and factors associated with response to VCs remain unclear. Methods Records from hospitalized patients with HRS-1 treated with VCs without shock were reviewed searching for those who achieved ≥5 mm Hg rise in MAP within 48 hours. We examined the relationship between the mean MAP achieved during the first 48–72 hours of VC therapy and the change in serum creatinine (sCr) up to day 14. Endpoints were >30% reduction in sCr without need for dialysis or death by day 14 (primary) or by day 30 (secondary). Results Seventy-seven patients with HRS-1 treated for 2–10 days with either norepinephrine (n =49) or midodrine/octreotide (n =28) were included. The median age was 52 years (interquartile range [IQR], 46–60), 40% were female, and 48% had alcoholic cirrhosis. At VC initiation, median MAP was 70 mm Hg (IQR, 66–73), and median sCr was 3.8 mg/dl (IQR, 2.6–4.9). When analyzed by tertiles of mean MAP increment (5–9, 10–14, ≥15 mm Hg), there was greater reduction in sCr with greater rise in MAP (ANOVA for trend, P < 0.0001). By multivariate logistic regression analysis, mean MAP rise during the first 48–72 hours (odds ratio [OR], 1.15 [1.02 to 1.299], P =0.025), norepinephrine as VC (OR, 5.46 [1.36 to 21.86], P =0.017), and baseline sCr [OR, 0.63 [0.41 to 0.97], P =0.034) were associated with the primary endpoint, whereas mean MAP rise during the first 48–72 hours (OR, 1.17 [1.04 to 1.33], P =0.012) and baseline sCr (OR, 0.63 [0.39 to 0.98], P =0.043) were associated with the secondary endpoint. Conclusions Greater magnitude of rise in MAP with VC therapy in HRS-1, lower baseline sCr, and use of norepinephrine over midodrine/octreotide are associated with kidney recovery. Targeting an increment of MAP ≥15 mm Hg may lead to favorable renal outcomes.
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Affiliation(s)
- Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
- HRS-HARMONY Consortium
| | - Nithin Karakala
- HRS-HARMONY Consortium
- Division of Nephrology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kasra Tayebi
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Muner M. B. Mohamed
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | | | | | - Swetha R. Kanduri
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew S. Allegretti
- HRS-HARMONY Consortium
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Justin M. Belcher
- HRS-HARMONY Consortium
- Division of Nephrology, Department of Medicine, Yale University, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare, West Haven, Connecticut
| | - Kevin R. Regner
- HRS-HARMONY Consortium
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cathy Wentowski
- Department of Pulmonary and Critical Care Medicine, Ochsner Health, New Orleans, Louisiana
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Patidar KR, Piano S, Cullaro G, Belcher JM, Allegretti AS. Recent Advances in the Management of Hepatorenal Syndrome: A US Perspective. Clin Gastroenterol Hepatol 2023; 21:897-901.e1. [PMID: 36801201 PMCID: PMC10038893 DOI: 10.1016/j.cgh.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 02/23/2023]
Affiliation(s)
- Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Justin M Belcher
- Division of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Belcher JM. Towards a Better Crystal Ball: Urinary C-C Motif Chemokine Ligand 14 (CCL14) and Persistent Severe AKI. Kidney360 2022; 3:1124-1127. [PMID: 35919534 PMCID: PMC9337887 DOI: 10.34067/kid.0002162022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 01/11/2023]
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10
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Belcher JM, Parada XV, Simonetto DA, Juncos LA, Karakala N, Wadei HM, Sharma P, Regner KR, Nadim MK, Garcia-Tsao G, Velez JCQ, Parikh SM, Chung RT, Allegretti AS. Terlipressin and the Treatment of Hepatorenal Syndrome: How the CONFIRM Trial Moves the Story Forward. Am J Kidney Dis 2021; 79:737-745. [PMID: 34606933 DOI: 10.1053/j.ajkd.2021.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/13/2021] [Indexed: 12/13/2022]
Abstract
Hepatorenal syndrome (HRS) is a form of acute kidney injury occurring in patients with advanced cirrhosis and is associated with significant morbidity and mortality. The pathophysiology underlying HRS begins with increasing portal pressures leading to the release of vasodilatory substances which result in pooling blood in the splanchnic system and a corresponding reduction in effective circulating volume. Compensatory activation of the sympathetic nervous system, renin-angiotensin-aldosterone system and release of arginine vasopressin serve to defend mean arterial pressure but at the cost of severe constriction of the renal vasculature, leading to a progressive, often fulminant form of AKI. While there are no approved treatments for HRS in the United States, multiple countries, including much of Europe, utilize terlipressin, a synthetic vasopressin analogue, as first-line therapy. The recently published CONFIRM trial, the third randomized trial based in North America evaluating terlipressin, met its primary endpoint, showing greater rates of HRS reversal in the terlipressin arm. However, due to concerns about apparent increased rates of respiratory adverse events and a lack of evidence for mortality benefit, terlipressin was not approved by the Food and Drug Administration (FDA). In this Perspective, we explore the history of regulatory approval for terlipressin in the United States, examine the results from CONFIRM and the concerns they raised and consider the future role of terlipressin in this critical clinical area of continued unmet need.
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Affiliation(s)
- Justin M Belcher
- Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA and Section of Nephrology, VA-Connecticut Healthcare System, West Haven, CT, USA.
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Luis A Juncos
- Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Nithin Karakala
- Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Hani M Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
| | | | - Samir M Parikh
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess and Harvard Medical School, Boston, MA, USA; Division of Nephrology, UT Southwestern, Dallas, TX
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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11
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Allegretti AS, Parada XV, Endres P, Zhao S, Krinsky S, St. Hillien SA, Kalim S, Nigwekar SU, Flood JG, Nixon A, Simonetto DA, Juncos LA, Karakala N, Wadei HM, Regner KR, Belcher JM, Nadim MK, Garcia-Tsao G, Velez JCQ, Parikh SM, Chung RT. Urinary NGAL as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Cirrhosis: A Prospective Study. Clin Transl Gastroenterol 2021; 12:e00359. [PMID: 33979307 PMCID: PMC8116001 DOI: 10.14309/ctg.0000000000000359] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Urinary neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in differentiating acute tubular necrosis (ATN) from other types of acute kidney injuries (AKIs) in cirrhosis, particularly hepatorenal syndrome (HRS). However, NGAL is not currently available in clinical practice in North America. METHODS Urinary NGAL was measured in a prospective cohort of 213 US hospitalized patients with decompensated cirrhosis (161 with AKI and 52 reference patients without AKI). NGAL was assessed for its ability to discriminate ATN from non-ATN AKI and to predict 90-day outcomes. RESULTS Among patients with AKI, 57 (35%) had prerenal AKI, 55 (34%) had HRS, and 49 (30%) had ATN, with a median serum creatinine of 2.0 (interquartile range 1.5, 3.0) mg/dL at enrollment. At an optimal cutpoint of 244 μg/g creatinine, NGAL distinguished ATN (344 [132, 1,429] μg/g creatinine) from prerenal AKI (45 [0, 154] μg/g) or HRS (110 [50, 393] μg/g; P < 0.001), with a C statistic of 0.762 (95% confidence interval 0.682, 0.842). By 90 days, 71 of 213 patients (33%) died. Higher median NGAL was associated with death (159 [50, 865] vs 58 [0, 191] μg/g; P < 0.001). In adjusted and unadjusted analysis, NGAL significantly predicted 90-day transplant-free survival (P < 0.05 for all Cox models) and outperformed Model for End-Stage Liver Disease score by C statistic (0.697 vs 0.686; P = 0.04), net reclassification index (37%; P = 0.008), and integrated discrimination increment (2.7%; P = 0.02). DISCUSSION NGAL differentiates the type of AKI in cirrhosis and may improve prediction of mortality; therefore, it holds potential to affect management of AKI in cirrhosis.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Paul Endres
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Sophia Zhao
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Scott Krinsky
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Shelsea A. St. Hillien
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Sagar U. Nigwekar
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - James G. Flood
- Department of Pathology, Massachusetts General
Hospital, Boston, Massachusetts, USA;
| | - Andrea Nixon
- Department of Pathology, Massachusetts General
Hospital, Boston, Massachusetts, USA;
| | - Douglas A. Simonetto
- Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota, USA;
| | - Luis A. Juncos
- Department of Medicine, University of Arkansas for
Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock,
Arkansas, USA;
| | - Nithin Karakala
- Department of Medicine, University of Arkansas for
Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock,
Arkansas, USA;
| | - Hani M. Wadei
- Department of Transplantation, Mayo Clinic,
Jacksonville, Florida, USA;
| | - Kevin R. Regner
- Division of Nephrology, Medical College of Wisconsin,
Milwaukee, Wisconsin, USA;
| | - Justin M. Belcher
- Section of Nephrology, Yale University School of
Medicine, New Haven, Connecticut, USA and Section of Nephrology, VA-Connecticut
Healthcare System, West Haven, Connecticut, USA;
| | - Mitra K. Nadim
- Division of Nephrology and Hypertension, Keck School
of Medicine, University of Southern California, Los Angeles, California,
USA;
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut
Healthcare System, West Haven, Connecticut, USA;
| | | | - Samir M. Parikh
- Division of Nephrology, Department of Medicine,
Beth Israel Deaconess Medical Center, Boston, Massachusetts,
USA;
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division,
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts,
USA.
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12
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Allegretti AS, Belcher JM. Bile Acids Are Important Contributors to AKI Associated with Liver Disease: CON. Kidney360 2021; 3:21-24. [PMID: 35378020 PMCID: PMC8967622 DOI: 10.34067/kid.0006512020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023]
Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Justin M. Belcher
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut,Divison of Nephrology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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13
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Affiliation(s)
- Justin M. Belcher
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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14
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Zhao B, Lu Q, Cheng Y, Belcher JM, Siew ED, Leaf DE, Body SC, Fox AA, Waikar SS, Collard CD, Thiessen-Philbrook H, Ikizler TA, Ware LB, Edelstein CL, Garg AX, Choi M, Schaub JA, Zhao H, Lifton RP, Parikh CR. A Genome-Wide Association Study to Identify Single-Nucleotide Polymorphisms for Acute Kidney Injury. Am J Respir Crit Care Med 2017; 195:482-490. [PMID: 27576016 DOI: 10.1164/rccm.201603-0518oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Acute kidney injury is a common and severe complication of critical illness and cardiac surgery. Despite significant attempts at developing treatments, therapeutic advances to attenuate acute kidney injury and expedite recovery have largely failed. OBJECTIVES Identifying genetic loci associated with increased risk of acute kidney injury may reveal novel pathways for therapeutic development. METHODS We conducted an exploratory genome-wide association study to identify single-nucleotide polymorphisms associated with genetic susceptibility to in-hospital acute kidney injury. MEASUREMENTS AND MAIN RESULTS We genotyped 609,508 single-nucleotide polymorphisms and performed genotype imputation in 760 acute kidney injury cases and 669 controls. We then evaluated polymorphisms that showed the strongest association with acute kidney injury in a replication patient population containing 206 cases with 1,406 controls. We observed an association between acute kidney injury and four single-nucleotide polymorphisms at two independent loci on metaanalysis of discovery and replication populations. These include rs62341639 (metaanalysis P = 2.48 × 10-7; odds ratio [OR], 0.64; 95% confidence interval [CI], 0.55-0.76) and rs62341657 (P = 3.26 × 10-7; OR, 0.65; 95% CI, 0.55-0.76) on chromosome 4 near APOL1-regulator IRF2, and rs9617814 (metaanalysis P = 3.81 × 10-6; OR, 0.70; 95% CI, 0.60-0.81) and rs10854554 (P = 6.53 × 10-7; OR, 0.67; 95% CI, 0.57-0.79) on chromosome 22 near acute kidney injury-related gene TBX1. CONCLUSIONS Our findings reveal two genetic loci that are associated with acute kidney injury. Additional studies should be conducted to functionally evaluate these loci and to identify other common genetic variants contributing to acute kidney injury.
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Affiliation(s)
- Bixiao Zhao
- 1 Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
| | - Qiongshi Lu
- 2 Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Yuwei Cheng
- 3 Program of Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut
| | - Justin M Belcher
- 4 Program of Applied Translational Research and.,5 Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.,6 Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Connecticut
| | - Edward D Siew
- 7 Division of Nephrology and Hypertension and.,8 Vanderbilt Center for Kidney Disease, and.,9 Vanderbilt Integrated Program for Acute Kidney Injury Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Simon C Body
- 11 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda A Fox
- 12 Department of Anesthesiology and Pain Management and.,13 McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Charles D Collard
- 14 Department of Anesthesiology, Baylor St. Luke's Medical Center and the Texas Heart Institute, Houston, Texas
| | - Heather Thiessen-Philbrook
- 4 Program of Applied Translational Research and.,5 Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.,15 Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - T Alp Ikizler
- 7 Division of Nephrology and Hypertension and.,8 Vanderbilt Center for Kidney Disease, and.,9 Vanderbilt Integrated Program for Acute Kidney Injury Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lorraine B Ware
- 16 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | | | - Amit X Garg
- 15 Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,18 Division of Nephrology, Department of Medicine and Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,19 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; and
| | - Murim Choi
- 1 Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
| | | | - Hongyu Zhao
- 1 Department of Genetics, Yale University School of Medicine, New Haven, Connecticut.,2 Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Richard P Lifton
- 1 Department of Genetics, Yale University School of Medicine, New Haven, Connecticut.,20 Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut
| | - Chirag R Parikh
- 4 Program of Applied Translational Research and.,5 Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.,6 Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Connecticut
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15
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Williams KR, Colangelo CM, Hou L, Chung L, Belcher JM, Abbott T, Hall IE, Zhao H, Cantley LG, Parikh CR. Use of a Targeted Urine Proteome Assay (TUPA) to identify protein biomarkers of delayed recovery after kidney transplant. Proteomics Clin Appl 2017; 11. [PMID: 28261998 DOI: 10.1002/prca.201600132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/17/2017] [Accepted: 03/01/2017] [Indexed: 11/07/2022]
Abstract
PURPOSE Development of delayed graft function (DGF) following kidney transplant is associated with poor outcomes. An ability to rapidly identify patients with DGF versus those with immediate graft function (IGF) may facilitate the treatment of DGF and the research needed to improve prognosis. The purpose of this study was to use a Targeted Urine Proteome Assay to identify protein biomarkers of delayed recovery from kidney transplant. EXPERIMENTAL DESIGN Potential biomarkers were identified using the Targeted Urine Proteome (MRM) Assay to interrogate the relative DGF/IGF levels of expression of 167 proteins in urine taken 12-18 h after kidney implantation from 21 DGF, 15 SGF (slow graft function), and 16 IGF patients. An iterative Random Forest analysis approach evaluated the relative importance of each biomarker, which was then used to identify an optimum biomarker panel that provided the maximum sensitivity and specificity with the least number of biomarkers. CONCLUSIONS AND CLINICAL RELEVANCE Four proteins were identified that together distinguished DGF with a sensitivity of 77.4%, specificity of 82.6%, and AUC of 0.891. This panel represents an important step toward identifying DGF at an early stage so that more effective treatments can be developed to improve long-term graft outcomes.
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Affiliation(s)
- Kenneth R Williams
- W.M. Keck Foundation Biotechnology Laboratory, Yale University School of Medicine, New Haven, USA
- Molecular Biophysics and Biochemistry, Yale University School of Medicine, New Haven, USA
| | | | - Lin Hou
- Center for Statistical Science, Tsinghua University, Beijing, China
| | - Lisa Chung
- W.M. Keck Foundation Biotechnology Laboratory, Yale University School of Medicine, New Haven, USA
| | - Justin M Belcher
- Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Thomas Abbott
- W.M. Keck Foundation Biotechnology Laboratory, Yale University School of Medicine, New Haven, USA
| | - Isaac E Hall
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, USA
| | - Hongyu Zhao
- Epidemiology & Public Health, Yale University School of Medicine, New Haven, USA
| | - Lloyd G Cantley
- Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Chirag R Parikh
- Internal Medicine, Yale University School of Medicine, New Haven, USA
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, USA
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16
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Belcher JM. Acute Kidney Injury in Liver Disease: Role of Biomarkers. Adv Chronic Kidney Dis 2015; 22:368-75. [PMID: 26311598 DOI: 10.1053/j.ackd.2015.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 06/19/2015] [Accepted: 06/23/2015] [Indexed: 12/30/2022]
Abstract
Acute kidney injury (AKI) is a common complication in patients with advanced cirrhosis and is associated with significant mortality. The most common etiologies of AKI in this setting are prerenal azotemia, acute tubular necrosis, and hepatorenal syndrome. Despite the overall poor outcomes of patients with cirrhosis and AKI, potentially efficacious therapies exist but must be tailored to the specific AKI etiology. Unfortunately, determining the etiology of AKI in the setting of cirrhosis is notoriously difficult. Many of the standard diagnostic tools, such as urine microscopy and the fractional excretion of sodium, have traditionally been ineffective. Novel biomarkers of kidney tubular injury may be able to assist with differential diagnosis and the appropriate targeting of treatments by distinguishing structural from functional causes of AKI. In recent studies, both urinary neutrophil gelatinase-associated lipocalin and interleukin-18 have shown the ability to distinguish hepatorenal syndrome from prerenal azotemia and acute tubular necrosis. In addition, multiple biomarkers, including neutrophil gelatinase-associated lipocalin and interleukin-18, have demonstrated the ability to independently predict both progression of AKI and mortality. Critically, recent research also indicated that commonly available tests, fractional excretion of sodium and proteinuria, may also be able to distinguish etiologies of AKI in cirrhosis, but diagnostic cutoffs must be re-conceptualized specifically to this unique AKI setting.
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17
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Belcher JM, Garcia-Tsao G, Sanyal AJ, Thiessen-Philbrook H, Peixoto AJ, Perazella MA, Ansari N, Lim J, Coca SG, Parikh CR. Urinary biomarkers and progression of AKI in patients with cirrhosis. Clin J Am Soc Nephrol 2014; 9:1857-67. [PMID: 25183658 DOI: 10.2215/cjn.09430913] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is a common and severe complication in patients with cirrhosis. AKI progression was previously shown to correlate with in-hospital mortality. Therefore, accurately predicting which patients are at highest risk for AKI progression may allow more rapid and targeted treatment. Urinary biomarkers of structural kidney injury associate with AKI progression and mortality in multiple settings of AKI but their prognostic performance in patients with liver cirrhosis is not well known. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A multicenter, prospective cohort study was conducted at four tertiary care United States medical centers between 2009 and 2011. The study comprised patients with cirrhosis and AKI defined by the AKI Network criteria evaluating structural (neutrophil gelatinase-associated lipocalin, IL-18, kidney injury molecule-1 [KIM-1], liver-type fatty acid-binding protein [L-FABP], and albuminuria) and functional (fractional excretion of sodium [FENa]) urinary biomarkers as predictors of AKI progression and in-hospital mortality. RESULTS Of 188 patients in the study, 44 (23%) experienced AKI progression alone and 39 (21%) suffered both progression and death during their hospitalization. Neutrophil gelatinase-associated lipocalin, IL-18, KIM-1, L-FABP, and albuminuria were significantly higher in patients with AKI progression and death. These biomarkers were independently associated with this outcome after adjusting for key clinical variables including model of end stage liver disease score, IL-18 (relative risk [RR], 4.09; 95% confidence interval [95% CI], 1.56 to 10.70), KIM-1 (RR, 3.13; 95% CI, 1.20 to 8.17), L-FABP (RR, 3.43; 95% CI, 1.54 to 7.64), and albuminuria (RR, 2.07; 95% CI, 1.05-4.10) per log change. No biomarkers were independently associated with progression without mortality. FENa demonstrated no association with worsening of AKI. When added to a robust clinical model, only IL-18 independently improved risk stratification on a net reclassification index. CONCLUSIONS Multiple structural biomarkers of kidney injury, but not FENa, are independently associated with progression of AKI and mortality in patients with cirrhosis. Injury marker levels were similar between those without progression and those with progression alone.
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Affiliation(s)
- Justin M Belcher
- Program of Applied Translational Research, Sections of Nephrology and Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Connecticut
| | - Guadalupe Garcia-Tsao
- Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Connecticut; Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut; Veterans Affairs-Connecticut Healthcare System, West Haven, Connecticut
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Heather Thiessen-Philbrook
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, Ontario, Canada; and
| | - Aldo J Peixoto
- Sections of Nephrology and Veterans Affairs-Connecticut Healthcare System, West Haven, Connecticut
| | - Mark A Perazella
- Sections of Nephrology and Veterans Affairs-Connecticut Healthcare System, West Haven, Connecticut
| | - Naheed Ansari
- Division of Nephrology, Department of Internal Medicine, Jacobi Medical Center, South Bronx, New York
| | - Joseph Lim
- Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Steven G Coca
- Program of Applied Translational Research, Sections of Nephrology and Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Connecticut
| | - Chirag R Parikh
- Program of Applied Translational Research, Sections of Nephrology and Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Connecticut;
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18
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Belcher JM, Sanyal AJ, Peixoto AJ, Perazella MA, Lim J, Thiessen-Philbrook H, Ansari N, Coca SG, Garcia-Tsao G, Parikh CR. Kidney biomarkers and differential diagnosis of patients with cirrhosis and acute kidney injury. Hepatology 2014; 60:622-32. [PMID: 24375576 PMCID: PMC4065642 DOI: 10.1002/hep.26980] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/17/2013] [Indexed: 12/14/2022]
Abstract
UNLABELLED Acute kidney injury (AKI) is common in patients with cirrhosis and associated with significant mortality. The most common etiologies of AKI in this setting are prerenal azotemia (PRA), acute tubular necrosis (ATN), and hepatorenal syndrome (HRS). Accurately distinguishing the etiology of AKI is critical, as treatments differ markedly. However, establishing an accurate differential diagnosis is extremely challenging. Urinary biomarkers of kidney injury distinguish structural from functional causes of AKI and may facilitate more accurate and rapid diagnoses. We conducted a multicenter, prospective cohort study of patients with cirrhosis and AKI assessing multiple biomarkers for differential diagnosis of clinically adjudicated AKI. Patients (n = 36) whose creatinine returned to within 25% of their baseline within 48 hours were diagnosed with PRA. In addition, 76 patients with progressive AKI were diagnosed by way of blinded retrospective adjudication. Of these progressors, 39 (53%) patients were diagnosed with ATN, 19 (26%) with PRA, and 16 (22%) with HRS. Median values for neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), liver-type fatty acid binding protein (L-FABP), and albumin differed between etiologies and were significantly higher in patients adjudicated with ATN. The fractional excretion of sodium (FENa) was lowest in patients with HRS, 0.10%, but did not differ between those with PRA, 0.27%, or ATN, 0.31%, P = 0.54. The likelihood of being diagnosed with ATN increased step-wise with the number of biomarkers above optimal diagnostic cutoffs. CONCLUSION Urinary biomarkers of kidney injury are elevated in patients with cirrhosis and AKI due to ATN. Incorporating biomarkers into clinical decision making has the potential to more accurately guide treatment by establishing which patients have structural injury underlying their AKI. Further research is required to document biomarkers specific to HRS.
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Affiliation(s)
- Justin M. Belcher
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
| | - Arun J. Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Aldo J. Peixoto
- Section of Nephrology, Yale University School of Medicine, New Haven, CT,VA-Connecticut Healthcare System, West Haven, CT
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, CT,VA-Connecticut Healthcare System, West Haven, CT
| | - Joseph Lim
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
| | | | - Naheed Ansari
- Division of Nephrology, Department of Internal Medicine, Jacobi Medical Center, South Bronx, NY
| | - Steven G. Coca
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
| | - Guadalupe Garcia-Tsao
- Clinical Epidemiology Research Center, VAMC, West Haven, CT,VA-Connecticut Healthcare System, West Haven, CT,Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
| | - Chirag R. Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
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19
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Parikh CR, Belcher JM. Reconsidering a "chopped liver": the need for improving glomular filtration rate estimation for hepatic transplantation. Hepatology 2014; 59:1242-5. [PMID: 24470267 DOI: 10.1002/hep.27031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/22/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Chirag R Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT; Section of Nephrology, Yale University School of Medicine, New Haven, CT; Clinical Epidemiology Research Center, VAMC, West Haven, CT
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20
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Affiliation(s)
- Justin M. Belcher
- Section of Nephrology; Yale University School of Medicine; New Haven Connecticut
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21
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Belcher JM, Garcia-Tsao G, Sanyal AJ, Bhogal H, Lim JK, Ansari N, Coca SG, Parikh CR. Association of AKI with mortality and complications in hospitalized patients with cirrhosis. Hepatology 2013; 57:753-62. [PMID: 22454364 PMCID: PMC3390443 DOI: 10.1002/hep.25735] [Citation(s) in RCA: 249] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 03/16/2012] [Indexed: 12/15/2022]
Abstract
UNLABELLED Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. However, the definitions of AKI employed in studies involving patients with cirrhosis have not been standardized, lack sensitivity, and are often limited to narrow clinical settings. We conducted a multicenter, prospective observational cohort study of patients with cirrhosis and AKI, drawn from multiple hospital wards, utilizing the modern acute kidney injury network (AKIN) definition and assessed the association between AKI severity and progression with in-hospital mortality. Of the 192 patients who were enrolled and included in the study, 85 (44%) progressed to a higher AKIN stage after initially fulfilling AKI criteria. Patients achieved a peak severity of AKIN stage 1, 26%, stage 2, 24%, and stage 3, 49%. The incidence of mortality, general medical events (bacteremia, pneumonia, urinary tract infection), and cirrhosis-specific complications (ascites, encephalopathy, spontaneous bacterial peritonitis) increased with severity of AKI. Progression was significantly more common and peak AKI stage higher in nonsurvivors than survivors (P < 0.0001). After adjusting for baseline renal function, demographics, and critical hospital- and cirrhosis-associated variables, progression of AKI was independently associated with mortality (adjusted odds ratio = 3.8, 95% confidence interval 1.3-11.1). CONCLUSION AKI, as defined by AKIN criteria, in patients with cirrhosis is frequently progressive and severe and is independently associated with mortality in a stage-dependent fashion. Methods for earlier diagnosis of AKI and its progression may result in improved outcomes by facilitating targeted and timely treatment of AKI.
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Affiliation(s)
- Justin M. Belcher
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
| | - Guadalupe Garcia-Tsao
- Clinical Epidemiology Research Center, VAMC, West Haven, CT,Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA-Connecticut Healthcare System, West Haven, CT
| | - Arun J. Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Harjit Bhogal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Joseph K. Lim
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT
| | - Naheed Ansari
- Division of Nephrology, Department of Internal Medicine, Jacobi Medical Center, South Bronx, NY
| | - Steven G. Coca
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
| | - Chirag R. Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Clinical Epidemiology Research Center, VAMC, West Haven, CT
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Belcher JM, Edelstein CL, Parikh CR. Clinical Applications of Biomarkers for Acute Kidney Injury. Am J Kidney Dis 2011; 57:930-40. [DOI: 10.1053/j.ajkd.2010.11.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 11/02/2010] [Indexed: 01/20/2023]
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24
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Belcher JM. A perspective on periodontal microsurgery. INT J PERIODONT REST 2001; 21:191-6. [PMID: 11829393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
The surgical microscope offers the periodontist increased illumination and visual acuity to perform procedures with greater precision than with other methods of magnification. This review article outlines the advantages of using smaller instruments and sutures, explores the possibility of enhanced calculus removal under magnification, and offers suggestions for integrating the microscope into periodontal practice.
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Affiliation(s)
- J M Belcher
- Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, Florida, USA
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25
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Perkins SL, Belcher JM, Livesey JF. A Canadian tertiary care centre study of maternal and umbilical cord cotinine levels as markers of smoking during pregnancy: relationship to neonatal effects. Can J Public Health 1997. [PMID: 9336091 DOI: 10.1007/bf03404788] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study describes the prevalence of smoking among 3,220 pregnant women. Maternal and umbilical cord cotinine levels were compared with the women's self-reported cigarette consumption, infant birth weight and antepartum and perinatal complications. Of the women who reported themselves as being active smokers (23%), 76% had a partner who smoked, and 38% reported exposure to environmental smoke in the workplace. Only 15% of nonsmokers had a partner who smoked, and 13% reported workplace exposure. The mean number of cigarettes/day was 20.5 (95% CI 19.6-21.4). The relative risk of having a small-for-gestational-age infant was significantly higher in smokers for mothers of both preterm (34-36 wks, RR = 3.38, 95% CI 1.25-9.16) and term babies (> or = 37 wks, RR = 2.04, 95% CI 1.58-2.63). Mean infant birth weight was 207 g lighter in the infants of smokers (p < 0.001) and was inversely correlated to maternal serum cotinine level. Birth weight dropped by 0.99 g for every 1 ug/L increase in cotinine (r = -0.19, p < 0.01).
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Affiliation(s)
- S L Perkins
- Department of Laboratory Medicine, Ottawa Civic Hospital, Ontario.
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26
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Perkins SL, Livesey JF, Escares EA, Belcher JM, Dudley DK. High-performance liquid-chromatographic method compared with a modified radioimmunoassay of cotinine in plasma. Clin Chem 1991. [DOI: 10.1093/clinchem/37.11.1989] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Cotinine is a sensitive and specific biochemical marker of exposure to cigarette smoke. We describe a simple solid-phase extraction of cotinine from plasma before quantification by HPLC. Extraction recovery was 97.9% +/- 11.0% for plasma concentrations of 5-400 micrograms/L. Baseline separation of cotinine and caffeine was achieved within 11 min of injection onto a C18 reversed-phase column. The mobile phase was citric acid/dibasic potassium phosphate (30 mmol/L each, pH 6.0) containing 100 mL of acetonitrile per liter. Within-day and day-to-day precision (CV) were 4.7% and 8.4%, respectively. We also describe a modification of the Nicotine Metabolite RIA kit (Diagnostic Products Corp.) for quantifying cotinine in plasma. Recovery of cotinine from supplemented plasma was within 10% of the expected value with this RIA kit. Interassay precision averaged 8.1% for samples in the range 50-400 micrograms/L; intra-assay precision averaged 3.6% at 230 micrograms/L and 8.7% at 53 micrograms/L. Correlation between the two methods was RIA = 1.13 HPLC + 14.8 (n = 128, r = 0.957, P less than 0.001). Both methods are technically simple to perform.
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Affiliation(s)
- S L Perkins
- Department of Laboratory Medicine, Ottawa Civic Hospital, Canada
| | - J F Livesey
- Department of Laboratory Medicine, Ottawa Civic Hospital, Canada
| | - E A Escares
- Department of Laboratory Medicine, Ottawa Civic Hospital, Canada
| | - J M Belcher
- Department of Laboratory Medicine, Ottawa Civic Hospital, Canada
| | - D K Dudley
- Department of Laboratory Medicine, Ottawa Civic Hospital, Canada
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Perkins SL, Livesey JF, Escares EA, Belcher JM, Dudley DK. High-performance liquid-chromatographic method compared with a modified radioimmunoassay of cotinine in plasma. Clin Chem 1991; 37:1989-93. [PMID: 1934477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Cotinine is a sensitive and specific biochemical marker of exposure to cigarette smoke. We describe a simple solid-phase extraction of cotinine from plasma before quantification by HPLC. Extraction recovery was 97.9% +/- 11.0% for plasma concentrations of 5-400 micrograms/L. Baseline separation of cotinine and caffeine was achieved within 11 min of injection onto a C18 reversed-phase column. The mobile phase was citric acid/dibasic potassium phosphate (30 mmol/L each, pH 6.0) containing 100 mL of acetonitrile per liter. Within-day and day-to-day precision (CV) were 4.7% and 8.4%, respectively. We also describe a modification of the Nicotine Metabolite RIA kit (Diagnostic Products Corp.) for quantifying cotinine in plasma. Recovery of cotinine from supplemented plasma was within 10% of the expected value with this RIA kit. Interassay precision averaged 8.1% for samples in the range 50-400 micrograms/L; intra-assay precision averaged 3.6% at 230 micrograms/L and 8.7% at 53 micrograms/L. Correlation between the two methods was RIA = 1.13 HPLC + 14.8 (n = 128, r = 0.957, P less than 0.001). Both methods are technically simple to perform.
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Affiliation(s)
- S L Perkins
- Department of Laboratory Medicine, Ottawa Civic Hospital, Canada
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