Plasma neutrophil gelatinase-associated lipocalin in acute kidney injury superimposed on chronic kidney disease after cardiac surgery: a multicenter prospective study.

Kent Doi,Seiichiro Murata,Motoyuki Hisagi,Naoki Yahagi,Takeshi Ishii,Takehiro Matsubara,Daisuke Katagiri,Masahiro Urata,Minoru Ono,Mikako Inamori,Masaomi Nangaku,Eisei Noiri

doi:10.1186/cc13104

Abstract

IntroductionPlasma neutrophil gelatinase-associated lipocalin (NGAL) is reportedly useful for post-cardiac surgery acute kidney injury (AKI). Although chronic kidney disease (CKD) is a strong risk factor for AKI development, no clinical evaluation of plasma NGAL has specifically examined AKI occurring in patients with CKD. This study evaluated plasma NGAL in AKI superimposed on CKD after cardiac surgery.MethodsThis study prospectively evaluated 146 adult patients with scheduled cardiac surgery at 2 general hospitals. Plasma NGAL was measured before surgery, at ICU arrival after surgery (0 hours), and 2, 4, 12, 24, 36, and 60 hours after ICU arrival.ResultsBased on the Kidney Disease Improving Global Outcomes (KDIGO) CKD guideline, 72 (49.3%) were diagnosed as having CKD. Of 146 patients, 53 (36.3%) developed AKI after surgery. Multiple logistic regression analysis revealed that preoperative plasma NGAL, estimated glomerular filtration rate (eGFR), and operation time are significantly associated with AKI occurrence after surgery. Plasma NGAL in AKI measured after surgery was significantly higher than in non-AKI irrespective of CKD complication. However, transient decrease of plasma NGAL at 0 to 4 hours was observed especially in AKI superimposed on CKD. Plasma NGAL peaked earlier than serum creatinine and at the same time in mild AKI and AKI superimposed on CKD with increased preoperative plasma NGAL (>300 ng/ml). Although AKI superimposed on CKD showed the highest plasma NGAL levels after surgery, plasma NGAL alone was insufficient to discriminate de novo AKI from CKD without AKI after surgery. Receiver operating characteristics analysis revealed different cutoff values of AKI for CKD and non-CKD patients.ConclusionsResults show the distinct features of plasma NGAL in AKI superimposed on CKD after cardiac surgery: 1) increased preoperative plasma NGAL is an independent risk factor for post-cardiac surgery AKI; 2) plasma NGAL showed an earlier peak than serum creatinine did, indicating that plasma NGAL can predict the recovery of AKI earlier; 3) different cutoff values of post-operative plasma NGAL are necessary to detect AKI superimposed on CKD distinctly from de novo AKI. Further investigation is necessary to confirm these findings because this study examined a small number of patients.

Highlights

Plasma neutrophil gelatinase-associated lipocalin (NGAL) is reportedly useful for post-cardiac surgery acute kidney injury (AKI)
receiver operating characteristic (ROC) analysis in this study revealed that the cutoff values of plasma NGAL for AKI defined by the Youden index in the nonCKD patients were all below 150 ng/ml, whereas results obtained with the chronic kidney disease (CKD) patients showed cutoff values that were mostly greater than 150 ng/ml
This study demonstrated that preoperative plasma NGAL measurement is useful for identifying a high-risk population of AKI

Summary

Introduction

Plasma neutrophil gelatinase-associated lipocalin (NGAL) is reportedly useful for post-cardiac surgery acute kidney injury (AKI). New AKI biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and L-type fatty acid-binding protein (L-FABP), have been studied intensively in recent years [3,4,5,6]. These putatively more sensitive and more accurate biomarkers are expected to facilitate early intervention before the increase of serum creatinine. During the first clinical evaluations, new AKI biomarkers were examined mostly in pediatric post-cardiac surgery patients, who have fewer comorbid diseases and who show more readily apparent onset of renal insult In such studies, these new biomarkers showed excellent performance for AKI prediction and detection [7,8]. Results of several clinical studies addressing baseline renal dysfunction have shown strong effects on the performance of new AKI biomarkers [13,14]

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Discussion

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