In Reply to ‘Instability of Urinary NGAL During Long-Term Storage' and ‘NGAL and Cardiac Surgery–Associated Acute Kidney Injury'

Abstract Background Acute kidney injury (AKI) subtypes combining kidney functional parameters and injury biomarkers may have prognostic value. We aimed to determine whether neutrophil gelatinase-associated lipocalin (NGAL)/hepcidin-25 ratio (urinary concentrations of NGAL divided by that of hepcidin-25) defined subtypes are of prognostic relevance in cardiac surgery patients. Methods We studied 198 higher-risk cardiac surgery patients. We allocated patients to four groups: Kidney Disease Improving Global Outcomes (KDIGO)-AKI-negative and NGAL/hepcidin-25 ratio-negative (no AKI), KDIGO AKI-negative and NGAL/hepcidin-25 ratio-positive (subclinical AKI), KDIGO AKI-positive and NGAL/hepcidin-25 ratio-negative (clinical AKI), KDIGO AKI-positive and NGAL/hepcidin-25 ratio-positive (combined AKI). Outcomes included in-hospital mortality (primary) and long-term mortality (secondary). Results We identified 127 (61.6%) patients with no AKI, 13 (6.6%) with subclinical, 40 (20.2%) with clinical and 18 (9.1%) with combined AKI. Subclinical AKI patients had a 23-fold greater in-hospital mortality than no AKI patients. For combined AKI vs. no AKI or clinical AKI, findings were stronger (odds ratios (ORs): 126 and 39, respectively). After adjusting for EuroScore, volume of intraoperative packed red blood cells, and aortic cross-clamp time, subclinical and combined AKI remained associated with greater in-hospital mortality than no AKI and clinical AKI (adjusted ORs: 28.118, 95% CI 1.465–539.703; 3.737, 95% CI 1.746–7.998). Cox proportional hazard models found a significant association of biomarker-informed AKI subtypes with long-term survival compared with no AKI (adjusted ORs: pooled subclinical and clinical AKI: 1.885, 95% CI 1.003–3.542; combined AKI: 1.792, 95% CI 1.367–2.350). Conclusions In the presence or absence of KDIGO clinical criteria for AKI, the urinary NGAL/hepcidin-25-ratio appears to detect prognostically relevant AKI subtypes. Trial registration number NCT00672334, clinicaltrials.gov, date of registration: 6th May 2008, https://clinicaltrials.gov/ct2/show/NCT00672334. Graphic abstract Definition of AKI subtypes: subclinical AKI (KDIGO negative AND Ratio-positive), clinical AKI (KDIGO positive AND Ratio-negative) and combined AKI (KDIGO positive AND Ratio-positive) with urinary NGAL/hepcidin-25 ratio-positive cut-off at 85% specificity for in-hospital death. AKI, acute kidney injury. AUC, area under the curve. NGAL, neutrophil gelatinase-associated lipocalin. KDIGO, Kidney Disease Improving Global Outcomes Initiative AKI definition.

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Long Term Renal Outcomes in Children with Acute Kidney Injury Post-Cardiac Surgery

Kidney International Reports ◽

10.1016/j.ekir.2021.04.018 ◽

2021 ◽

Author(s):

Sidharth Kumar Sethi ◽

Rajesh Sharma ◽

Aditi Gupta ◽

Abhishek Tibrewal ◽

Romel Akole ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Injury ◽

Renal Outcomes ◽

Post Cardiac Surgery

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Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

Nature Reviews Nephrology ◽

10.1038/s41581-021-00418-2 ◽

2021 ◽

Author(s):

John R. Prowle ◽

Lui G. Forni ◽

Max Bell ◽

Michelle S. Chew ◽

Mark Edwards ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury ◽

Adverse Outcomes ◽

Baseline Risk ◽

Major Surgery ◽

Increased Risk

AbstractPostoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.

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Instability of Urinary NGAL During Long-Term Storage

American Journal of Kidney Diseases ◽

10.1053/j.ajkd.2009.01.009 ◽

2009 ◽

Vol 53 (3) ◽

pp. 564-565 ◽

Cited By ~ 23

Author(s):

Anja Haase-Fielitz ◽

Michael Haase ◽

Rinaldo Bellomo

Keyword(s):

Urinary Ngal ◽

Long Term Storage ◽

Term Storage

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Risk Factors for Long-Term Mortality and Progressive Chronic Kidney Disease Associated With Acute Kidney Injury After Cardiac Surgery

Medicine ◽

10.1097/md.0000000000002025 ◽

2015 ◽

Vol 94 (45) ◽

pp. e2025 ◽

Cited By ~ 46

Author(s):

Jia-Rui Xu ◽

Jia-Ming Zhu ◽

Jun Jiang ◽

Xiao-Qiang Ding ◽

Yi Fang ◽

...

Keyword(s):

Risk Factors ◽

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury ◽

Long Term Mortality

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Acute Kidney Injury following Cardiac Surgery

Advances in Medical Technologies and Clinical Practice - Modern Concepts and Practices in Cardiothoracic Critical Care ◽

10.4018/978-1-4666-8603-8.ch017 ◽

2015 ◽

pp. 451-480

Author(s):

Bryan Romito ◽

Joseph Meltzer

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Surgical Techniques ◽

Kidney Injury ◽

Renal Physiology ◽

General Management ◽

Novel Biomarkers ◽

Short And Long Term ◽

And Function

The primary goal of this chapter is to provide the reader with an overview of basic renal physiology and function and to review the identification, pathogenesis, and treatment of acute kidney injury following cardiac surgery. Particular focus will be directed toward the diagnostic criteria for acute kidney injury, short- and long-term impacts on patient outcomes, role of novel biomarkers, mechanisms of acute renal injury, general management principles, preventative strategies, and the influence of anesthetic and surgical techniques on its development. The content of this chapter will serve to underscore a particularly harmful but likely underappreciated problem affecting patients in the cardiothoracic critical care setting.

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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 Pressure Research ◽

10.1159/000499647 ◽

2019 ◽

Vol 44 (3) ◽

pp. 415-425

Author(s):

Miaolin Che ◽

Xudong Wang ◽

Bo Xie ◽

Ritai Huang ◽

Shang Liu ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Adverse Events ◽

Predictive Value ◽

Kidney Injury ◽

Serum Cystatin C ◽

Serum Cystatin ◽

Single Marker ◽

Major Adverse Events

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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