Neutrophil gelatinase-associated lipocalin as a biomarker of disease progression in patients with chronic kidney disease

Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population

Background

A serious problem in cirrhosis is acute renal injury. The study aimed to examine the urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a diagnostic and prognostic marker of acute kidney injury (AKI) in cirrhotic patients.

Methods

A prospective study was carried out over a period of 1 year. A total of 490 patients suffering from cirrhosis who visited an indoor hospital were screened, and after the exclusion, a total of 90 subjects admitted to the medicine intensive care unit (MICU) fulfilling inclusion criteria were enrolled. Those having a history of renal diseases, on nephrotoxic drugs, in septic shock, peritonitis, UTI, and no urine output were excluded. On admission, for the estimation of uNGAL, urinary levels of sodium, creatinine, fresh urine samples were obtained, and blood samples were taken for serum creatinine estimation.

Results

Out of 90 patients, 33.3% did not develop AKI, and 66.7% developed AKI. Urinary neutrophil gelatinase-associated lipocalin levels were six times higher in patients with acute tubular necrosis (259.08 ± 118.41 ng/mL) and three times higher in Hepatorenal syndrome (HRS)-AKI (124.97 ± 16.38) as compared with patients with normal kidney function (39.76 + 5.7). Those who died had a higher uNGAL (171.6 ng/mL) in comparison to those who survived (133.7 ng/mL). At a cutoff value of ≥114.9 (ng/mL), urinary NGAL represents a sensitivity of 86.92% and specificity of 100% to diagnose AKI and AUC 0.966 (95% CI: 0.919-0.990) in cirrhotic patients.

Conclusion

Urinary NGAL is good for diagnosing AKI and is a marker to distinguish the types of AKI in liver cirrhosis.

How to cite this article

Patel ML, Shyam R, Chaudhary A, Sachan R, Ali W. Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population. Indian J Crit Care Med 2023;27(8):545-551.

Lipocalin-2 as a biomarker for diabetic nephropathy

Diabetes is a major global public health issue. The prevalence of type 1 diabetes is comparatively static, as hereditary and genetic causes are involved, while type 2 diabetes (T2D) prevalence is increasing day by day. T2D is associated with chronic complications, including diabetic neuropathy (DN), nephropathy, retinopathy, and other complications like diabetic foot. DN is the main complication of both types of diabetes. DN can be diagnosed by routine laboratory tests, microalbuminuria > 300 mg/24 h, and a gradual decrease in glomerular filtration rate. As the appearance of microalbuminuria is a late manifestation, an early marker for renal damage is needed. Lipocalin-2, also known as neutrophil gelatinase-associated lipocalin (NGAL), is a small protein purified from neutrophil granules and a good marker for kidney disease. NGAL is a transporter protein responsible for many physiological processes, such as inflammation, generation of the immune response, and metabolic homeostasis. NGAL has been reported to depict the early changes in renal damage when urine microalbumin is still undetecable. Therefore, elucidating the role of NGAL in detecting DN and understanding its mechanism can help establish it as a potential early marker for DN.

Association between neutrophil gelatinase-associated lipocalin (NGAL) and iron profile in chronic renal disease

NGAL, also known as lipocalin 2, is a stress protein located on the cell surface that is known for its involvement in iron transport. This study is aimed to evaluate the correlation between the iron profile and NGAL concentration in serum among chronic kidney disease patients under dialysis in order to find its diagnostic value with regards to iron deficiency anaemia (IDA). 47 patients under chronic haemodialysis in end-stage renal disease (ESRD) and 15 healthy controls were evaluated to determine the correlation between serum NGAL concentration and IDA characteristics. Our results recorded a significant correlation between IDA (TSAT < 20%) and NGAL serum concentration with a Spearman's coefficient of 0.314. Serum NGAL was also significantly related to serum ferritin, TIBC, uric acid, creatinine and blood sugar whereas, an inverse relationship with albumin, total cholesterol and LDL. Our study reports a positive correlation between IDA and serum NGAL levels in CKD patients.

Novel nanoliposomes alleviate contrast-induced acute kidney injury in New Zealand rabbits by mediating inflammatory response

Background

The purpose of the research was to investigate the preventive effect of nanoliposomes on contrast-induced nephropathy (CIN) in New Zealand rabbits and to provide a theoretical basis for clinically effective prevention and treatment of CIN and the development of new contrast agents.

Methods

A total of 48 New Zealand rabbits were divided into four groups randomly, there were 12 rabbits in eacj group: (I) control group; (II) contrast group; (III) hydration prevention group; and (IV) nanoliposome group. The changes of serum creatinine (SCr) and blood urea nitrogen (BUN) were messured before and after injection of iopromide. Enzyme-linked immunosorbent assay (ELISA) was used to detect inflammatory and oxidative stress indexes, including neutrophil gelatinase-associated lipoprotein (NGAL), tumor necrosis factor-α (TNF-α), superoxide dismutase (SOD), and malondialdehyde (MDA). Twenty-four hours after injection of the contrast medium, the rabbits were killed and the pathological changes were observed under an electron microscope.

Results

There were statistical significances in sCr and BUN values among the four groups at both 8 hours and 24 hours after injection of the contrast medium. Serum NGAL and TNF-α levels were also significantly different among the four groups (P<0.05) 24 hours after injection of the contrast medium. The incidence rate of CIN in each group was statistically significant. Nanoliposomes had obvious advantages over hydration prevention in NGAL and TNF-α levels.

Conclusions

Nanoliposomes can prevent the occurrence of CIN and reduce the damage of contrast agent to the kidney by reducing inflammatory reaction.

Diagnostic value of urinary biomarkers excretion in estimation of morphological lesions in patients with primary glomerulopathies

Aim. To investigate the diagnostic value of biomarkers in assessing the severity of sclerotic and atrophic lesions in primary glomerulopathies. Materials and methods. One hundred patients were included in the study, according to the results of kidney biopsy in 9 (9%) cases minimal change disease was diagnosed, in 28 (28%) focal segmental glomerulosclerosis, in 26 (26%) membranous nephropathy and in 37 (37%) IgA nephropathy. The clinical course of nephropathy was evaluated, standard laboratory tests were performed, and urinary excretions of cystatin C, 1-microglobulin, 2-microglobulin and NGAL were measured. The degree of glomerulosclerosis was assessed quantitatively, tubulointerstitial sclerosis and tubular atrophy semiquantitatively. Results. According to the results of linear correlations and ROC-analysis, urinary excretion of cystatin C and 1-microglobulin had diagnostic value for early degree of tubulointerstitial sclerosis (cut-off value 319.9 and 10.94 mg/day, respectively). Urinary excretion of 2-microglobulin reflected the initial degree of tubalar atrophy (cut-off value of 0.224 mcg/day), as well as tubulointerstitial sclerosis of various degrees of severity (cut-off value 0.224 and 0.240 mkg/day). NGAL urinary excretion was the only marker of early degree of glomerulosclerosis with its excretion of more than 1445.4 ng/day and tubular atrophy, with a severity of 50% or more (cut-off value 4897.8 ng/day). Conclusion. A comprehensive assessment of sclerotic and atrophic lesions in the renal parenchyma, can be performed using a panel of traditional (GFR, proteinuria) and specific biomarkers (1-, 2-microglobulins, cystatin C, NGAL) to implement a comprehensive, personalized approach, as well as to assess the prognosis of nephropathy. In addition, the evaluation of the panel of different biomarkers can be used in those clinical situations where kidney biopsy can not be performed.

Cardiorenal syndrome in thalassemia patients

Background

Cardiorenal syndrome (CRS), a serious condition with high morbidity and mortality, is characterized by the coexistence of cardiac abnormality and renal dysfunction. There is limited information about CRS in association thalassemia. This study aimed to investigate the prevalence of CRS in thalassemia patients and also associated risk factors.

Methods

Thalassemia patients who attended the out-patient clinic of a tertiary care university hospital from October 2016 to September 2017 were enrolled onto this cross-sectional study. Clinical and laboratory findings from 2 consecutive visits, 3 months apart, were assessed. The criteria for diagnosis of CRS was based on a system proposed by Ronco and McCullough. Cardiac abnormalities are assessed by clinical presentation, establishment of acute or chronic heart failure using definitions from 2016 ESC guidelines or from structural abnormalities shown in an echocardiogram. Renal dysfunction was defined as chronic kidney disease according to the 2012 KDIGO guidelines.

Results

Out of 90 thalassemia patients, 25 (27.8%) had CRS. The multivariable analysis showed a significant association between CRS and extramedullary hematopoiesis (EMH) (odds ratio (OR) 20.55, p = 0.016); thalassemia type [β⁰/β^E vs β⁰/β⁰ thalassemia (OR 0.005, p = 0.002)]; pulmonary hypertension (OR 178.1, p = 0.001); elevated serum NT-proBNP (OR 1.028, p = 0.022), and elevated 24-h urine magnesium (OR 1.913, p = 0.016). There was no association found between CRS and frequency of blood transfusion, serum ferritin, liver iron concentration, cardiac T2*, type of iron chelating agents, or urine neutrophil gelatinase-associated lipocalin level.

Conclusions

CRS is relatively common in thalassemia patients. Its occurrence is associated with laboratory parameters which are easily measured in clinical practice.

Neutrophil gelatinase-associated lipocalin accurately predicts renal tubular injury in patients with chronic hepatitis B treated with nucleos(t)ide analogs

AIM

Little is known about the impact of long-term use of nucleos(t)ide analogs on tubular function in patients with chronic hepatitis B. Previous studies showed that neutrophil gelatinase-associated lipocalin (NGAL) elevation was associated with renal tubular injury. We evaluated renal function markers and bone mineral density in patients treated long-term with adefovir dipivoxil (ADV) or entecavir (ETV).

METHODS

In this cross-sectional study, we enrolled 78 patients (ADV, 36; ETV: 42), and 21 patients matched for age, observation time, and baseline estimated glomerular filtration rate from each group.

RESULTS

Patients treated with ADV showed a significant increase in serum creatinine and urine β₂ -microglobulin, and decreased estimated glomerular filtration rate and bone mineral density. Furthermore, the median levels of NGAL in patients treated with ADV were significantly higher than those of ETV (12.5 ng/mL vs. 2.5 ng/mL, P = 0.020). The proportions of patients with proteinuria and phosphate <1 mmol/L in the ADV group were higher than those in the ETV group. Additionally, age, β₂ -microglobulin, phosphate, and ADV use were associated with altered NGAL levels on multivariate analysis. Among the commonly used biomarkers, NGAL was the most useful (odds ratio = 5.72; P = 0.005) and specific (92% specificity at 18.1 ng/mL cut-off) in predicting low bone mass.

CONCLUSIONS

Patients with chronic hepatitis B treated long-term with ADV showed elevated urinary NGAL levels. Neutrophil gelatinase-associated lipocalin was more specific in predicting low bone mass during therapy compared with β₂ -microglobulin, phosphate, and creatinine. In general, this analysis examined the value of NGAL as a renal tubular injury indicator, resulting from ADV use.

Neutrophil Gelatinase-Associated Lipocalin as a Marker for Renal Dysfunction Detection in Critically Ill Patients with Increased Intraabdominal Pressure

Introduction

Elevated intraabdominal pressure (IAP) it is known to have an impact on renal function trough the pressure transmitted from the abdominal cavity to the vasculature responsible for the renal blood flow. Intraabdominal pressure is found to be frequent in intensive care patients and also to be a predictor of mortality. Intra-abdominal high pressure is an entity that can have serious impact on intensive care admitted patients, studies concluding that if this condition progresses to abdominal compartment syndrome mortality is as high as 80%.

Aim

The aim of this study was to observe if a link between increased intraabdominal pressure and modification in renal function exists (NGAL, creatinine clearance).

Material and Method

The study enrolled 30 critically ill patients admitted in the Intensive Care Unit of SCJU TîrguMures between November 2015 and August 2016. The study enrolled adult, hemodynamically stable patients admitted in intensive critical care - defined by a normal blood pressure maintained without any vasopressor or inotropic support, invasive monitoring using PICCO device and abdominal pressure monitoring.

Results

The patients were divided into two groups based on the intraabdominal pressure values: normal intraabdominal pressure group= 52 values and increased intraabdominal group= 35 values. We compared the groups in the light of NGAL values, 24 hours diuresis, GFR and creatinine clearance. The groups are significantly different when compared in the light of NGAL values and GFR values. We obtained a statistically significant correlation between NGAL value and 24 hour diuresis. No other significant correlations were encountered between the studied items.

Conclusions

NGAL values are increased in patients with high intraabdominal pressure which may suggest its utility as a cut off marker for patients with increased intraabdominal pressure. There is a significant decreased GFR in patient with elevated intraabdominal pressure, observation which can help in early detection of renal injury in patients due to high intraabdominal pressure. No correlation was found between creatinine clearance and increased intraabdominal pressure.

Are Urinary Tubular Injury Markers Useful in Chronic Kidney Disease? A Systematic Review and Meta Analysis

Background

Adverse outcome of chronic kidney disease, such as end stage renal disease, is a significant burden on personal health and healthcare costs. Urinary tubular injury markers, such as NGAL, KIM-1 and NAG, could provide useful prognostic value for the early identification of high-risk patients. However, discrepancies between recent large prospective studies have resulted in controversy regarding the potential clinical value of these markers. Therefore, we conducted the first meta-analysis to provide a more persuasive argument to this debate.

Methods

In the current meta-analysis, based on ten prospective studies involving 29366 participants, we evaluated the role of urinary tubular injury markers (NGAL, KIM-1 and NAG) in predicting clinical outcomes including CKD stage 3, end stage renal disease and mortality. The prognostic values of these biomarkers were estimated using relative risks and 95% confidence interval in adjusted models. All risk estimates were normalized to those of 1 standard deviation increase in log-scale concentrations to minimize heterogeneity. Fixed-effects models were adopted to combine risk estimates. The quality of the research and between-study heterogeneity were evaluated. The level of research evidence was identified according to the GRADE profiler.

Results

uNGAL was identified as an independent risk predictor of ESRD (pooled adjusted relative risk: 1.40[1.21 to 1.61], p<0.001) and of overall mortality (pooled adjusted relative risk: 1.10[1.03 to 1.18], p = 0.001) in patients with chronic kidney disease. A borderline significance of uKIM-1 in predicting CKD stage 3 independently in the community-based population was observed (pooled adjusted relative risk: 1.13[1.00 to 1.27], p = 0.057). Only the prognostic value of uNGAL for ESRD was supported by a grade B level of evidence.

Conclusion

The concentration of uNGAL can be used in practice as an independent predictor of end stage renal disease among patients with chronic kidney disease, but it may be not useful in predicting disease progression to CKD stage 3 among community-based population.