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Chakradhar A, Baron RM, Vera MP, Devarajan P, Chawla L, Hou PC. Plasma renin as a novel prognostic biomarker of sepsis-associated acute respiratory distress syndrome. Sci Rep 2024; 14:6667. [PMID: 38509149 PMCID: PMC10954703 DOI: 10.1038/s41598-024-56994-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
Sepsis-associated acute respiratory distress syndrome (ARDS) is a life-threatening condition in critical care medicine for which there is a substantial need for early prognostic biomarkers of outcome. The present study seeks to link plasma renin levels and 30-day mortality in sepsis-associated ARDS patients treated at our institution. The Registry of Critical Illness (RoCI) prospectively enrolled patients from the intensive care units (ICU) within a single academic medical center, and a convenience sample of patients with sepsis-associated ARDS was analyzed from this cohort. This study was approved by the Mass General Brigham Institutional Review Boards (IRB) as part of the RoCI, and all procedures performed were in accordance with the ethical standards of the institutional board. From April 2012 to February 2019, a cohort of 32 adult sepsis-associated ARDS patients with 500 µL of plasma samples available on Day 0 and Day 3 of their ICU stay were enrolled. Renin levels were measured twice, on Day 0 and Day 3 via the direct renin enzyme-linked immunosorbent assay (ELISA EIA-525) by DRG diagnostics. Day 0 and Day 3 renin were statistically evaluated via logistic regression to predict 30-day mortality. Direct renin levels of 64 samples were assayed from 32 sepsis-associated ARDS patients (50% male; mean ± SD, 55 ± 13.8 years old). The 30-day hospital mortality rate was 59.4%. Patients who died within 30 days of admission were more likely to have an elevated Day 3 Renin (Odds ratio [OR] = 6, 95% CI 1.25-28.84) and have received vasopressors (OR = 13.33, 95% CI 1.43-123.95). Adjusting for vasopressor use as a proxy for septic shock status, patients with an Elevated Day 3 Renin had a 6.85 (95% CI 1.07-43.75) greater odds of death than those with Low-Normal Day 3 Renin. Patients with sustained Elevated Renin levels from Day 0 to Day 3 had the highest risk of death in a 30-day window. In this study, we found that renin may be a novel biomarker that has prognostic value for patients with sepsis-associated ARDS. Future studies evaluating renin levels in patients with sepsis-associated ARDS are needed to validate these findings.
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Affiliation(s)
- Anjali Chakradhar
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mayra Pinilla Vera
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lakhmir Chawla
- Silver Creek Pharmaceuticals, Inc., San Francisco, CA, USA
| | - Peter C Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Mottes T, Menon S, Conroy A, Jetton J, Dolan K, Arikan AA, Basu RK, Goldstein SL, Symons JM, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Ray ONB, Bjornstad E, Brophy P, Charlton J, Chanchlani R, Conroy AL, Deep A, Devarajan P, Fuhrman D, Gist KM, Gorga SM, Greenberg JH, Hasson D, Heydari E, Iyengar A, Krawczeski C, Meigs L, Morgan C, Morgan J, Neumayr T, Ricci Z, Selewski DT, Soranno D, Stanski N, Starr M, Sutherland SM, Symons J, Tavares M, Vega M, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M. Pediatric AKI in the real world: changing outcomes through education and advocacy-a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:1005-1014. [PMID: 37934273 PMCID: PMC10817828 DOI: 10.1007/s00467-023-06180-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/26/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is independently associated with increased morbidity and mortality across the life course, yet care for AKI remains mostly supportive. Raising awareness of this life-threatening clinical syndrome through education and advocacy efforts is the key to improving patient outcomes. Here, we describe the unique roles education and advocacy play in the care of children with AKI, discuss the importance of customizing educational outreach efforts to individual groups and contexts, and highlight the opportunities created through innovations and partnerships to optimize lifelong health outcomes. METHODS During the 26th Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations on AKI research, education, practice, and advocacy in children. RESULTS The consensus statements developed in response to three critical questions about the role of education and advocacy in pediatric AKI care are presented here along with a summary of available evidence and recommendations for both clinical care and research. CONCLUSIONS These consensus statements emphasize that high-quality care for patients with AKI begins in the community with education and awareness campaigns to identify those at risk for AKI. Education is the key across all healthcare and non-healthcare settings to enhance early diagnosis and develop mitigation strategies, thereby improving outcomes for children with AKI. Strong advocacy efforts are essential for implementing these programs and building critical collaborations across all stakeholders and settings.
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Affiliation(s)
- Theresa Mottes
- Division of Nephrology, Robert Lurie Children's Hospital of Chicago, Ann &, Chicago, IL, USA.
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Andrea Conroy
- Department of Pediatrics, Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jennifer Jetton
- Section of Pediatric Nephrology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristin Dolan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Ayse Akcan Arikan
- Section of Critical Care Medicine and Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Rajit K Basu
- Division of Critical Care Medicine, Department of Pediatrics, Robert Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Ann &, Chicago, IL, USA
| | - Stuart L Goldstein
- Division of Pediatric Nephrology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jordan M Symons
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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3
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Starr MC, Barreto E, Charlton J, Vega M, Brophy PD, Ray Bignall ON, Sutherland SM, Menon S, Devarajan P, Akcan Arikan A, Basu R, Goldstein S, Soranno DE. Advances in pediatric acute kidney injury pathobiology: a report from the 26th Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:941-953. [PMID: 37792076 PMCID: PMC10817846 DOI: 10.1007/s00467-023-06154-y] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND In the past decade, there have been substantial advances in our understanding of the pathobiology of pediatric acute kidney injury (AKI). In particular, animal models and studies focused on the relationship between kidney development, nephron number, and kidney health have identified a number of heterogeneous pathophysiologies underlying AKI. Despite this progress, gaps remain in our understanding of the pathobiology of pediatric AKI. METHODS During the 26th Acute Disease Quality Initiative (ADQI) Consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for opportunities to advance translational research in pediatric AKI. The current state of research understanding as well as gaps and opportunities for advancement in research was discussed, and recommendations were summarized. RESULTS Consensus was reached that to improve translational pediatric AKI advancements, diverse teams spanning pre-clinical to epidemiological scientists must work in concert together and that results must be shared with the community we serve with patient involvement. Public and private research support and meaningful partnerships with adult research efforts are required. Particular focus is warranted to investigate the pediatric nuances of AKI, including the effect of development as a biological variable on AKI incidence, severity, and outcomes. CONCLUSIONS Although AKI is common and associated with significant morbidity, the biologic basis of the disease spectrum throughout varying nephron developmental stages remains poorly understood. An incomplete understanding of factors contributing to kidney health, the diverse pathobiologies underlying AKI in children, and the historically siloed approach to research limit advances in the field. The recommendations outlined herein identify gaps and outline a strategic approach to advance the field of pediatric AKI via multidisciplinary translational research.
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Affiliation(s)
- Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Riley Hospital for Children, 1044 W. Walnut Street, Indianapolis, IN, 46202, USA
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia, Charlottesville, VA, USA
| | - Molly Vega
- Renal and Apheresis Services, Texas Children's Hospital, Houston, TX, USA
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - O N Ray Bignall
- Department of Pediatrics, Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shina Menon
- Division of Pediatric Nephrology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Prasad Devarajan
- Department of Pediatrics, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care and Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rajit Basu
- Department of Pediatrics, Division of Critical Care, Northwestern University, Chicago, IL, USA
| | - Stuart Goldstein
- Department of Pediatrics, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Riley Hospital for Children, 1044 W. Walnut Street, Indianapolis, IN, 46202, USA.
- Department of Bioengineering, Purdue University, West Lafayette, IN, USA.
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Wong Vega M, Starr MC, Brophy PD, Devarajan P, Soranno DE, Akcan-Arikan A, Basu R, Goldstein SL, Charlton JR, Barreto E. Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:981-992. [PMID: 37878137 PMCID: PMC10817838 DOI: 10.1007/s00467-023-06178-4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND In the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI. METHODS During the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized. RESULTS Two consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-"omics" in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments. CONCLUSIONS Neonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.
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Affiliation(s)
- Molly Wong Vega
- Renal and Apheresis Services, Texas Children's Hospital, Houston, TX, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Bioengineering, Purdue University, West Lafayette, IN, USA
| | - Ayse Akcan-Arikan
- Divisions of Critical Care and Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rajit Basu
- Division of Critical Care, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22901, USA.
| | - Erin Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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Rudman-Melnick V, Adam M, Stowers K, Potter A, Ma Q, Chokshi SM, Vanhoutte D, Valiente-Alandi I, Lindquist DM, Nieman ML, Kofron JM, Chung E, Park JS, Potter SS, Devarajan P. Single-cell sequencing dissects the transcriptional identity of activated fibroblasts and identifies novel persistent distal tubular injury patterns in kidney fibrosis. Sci Rep 2024; 14:439. [PMID: 38172172 PMCID: PMC10764314 DOI: 10.1038/s41598-023-50195-0] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024] Open
Abstract
Examining kidney fibrosis is crucial for mechanistic understanding and developing targeted strategies against chronic kidney disease (CKD). Persistent fibroblast activation and tubular epithelial cell (TEC) injury are key CKD contributors. However, cellular and transcriptional landscapes of CKD and specific activated kidney fibroblast clusters remain elusive. Here, we analyzed single cell transcriptomic profiles of two clinically relevant kidney fibrosis models which induced robust kidney parenchymal remodeling. We dissected the molecular and cellular landscapes of kidney stroma and newly identified three distinctive fibroblast clusters with "secretory", "contractile" and "vascular" transcriptional enrichments. Also, both injuries generated failed repair TECs (frTECs) characterized by decline of mature epithelial markers and elevation of stromal and injury markers. Notably, frTECs shared transcriptional identity with distal nephron segments of the embryonic kidney. Moreover, we identified that both models exhibited robust and previously unrecognized distal spatial pattern of TEC injury, outlined by persistent elevation of renal TEC injury markers including Krt8 and Vcam1, while the surviving proximal tubules (PTs) showed restored transcriptional signature. We also found that long-term kidney injuries activated a prominent nephrogenic signature, including Sox4 and Hox gene elevation, which prevailed in the distal tubular segments. Our findings might advance understanding of and targeted intervention in fibrotic kidney disease.
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Affiliation(s)
- Valeria Rudman-Melnick
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA
| | - Mike Adam
- Division Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kaitlynn Stowers
- Division Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew Potter
- Division Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Qing Ma
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA
| | - Saagar M Chokshi
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA
| | - Davy Vanhoutte
- Division of Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | | | - Diana M Lindquist
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle L Nieman
- Department of Pharmacology and Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
| | - J Matthew Kofron
- Division Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Eunah Chung
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, USA
| | - Joo-Seop Park
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, USA
| | - S Steven Potter
- Division Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA.
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
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Chui H, McMahon KR, Rassekh SR, Schultz KR, Blydt-Hansen TD, Mammen C, Pinsk M, Cuvelier GDE, Carleton BC, Tsuyuki RT, Ross CJD, Devarajan P, Huynh L, Yordanova M, Crépeau-Hubert F, Wang S, Cockovski V, Palijan A, Zappitelli M. Urinary TIMP-2*IGFBP-7 to diagnose acute kidney injury in children receiving cisplatin. Pediatr Nephrol 2024; 39:269-282. [PMID: 37365422 DOI: 10.1007/s00467-023-06007-8] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Cisplatin is associated with acute kidney injury (AKI) and electrolyte abnormalities. Urine tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP-7) may be early cisplatin-AKI biomarkers. METHODS We conducted a 12-site prospective cohort study with pediatric patients treated with cisplatin (May 2013-December 2017). Blood and urine (measured for TIMP-2, IGFBP-7) were collected pre-cisplatin, 24-h post-cisplatin, and near hospital discharge during the first or second cisplatin cycle (early visit (EV)) and during second-to-last or last cisplatin cycle (late visit (LV)). PRIMARY OUTCOME serum creatinine (SCr)-defined AKI (≥ stage 1). RESULTS At EV (median (interquartile (IQR)) age: 6 (2-12) years; 78 (50%) female), 46/156 (29%) developed AKI; at LV, 22/127 (17%) experienced AKI. At EV, TIMP-2, IGFBP-7, and TIMP-2*IGFBP-7 pre-cisplatin infusion concentrations were significantly higher in participants with vs. those without AKI. At EV and LV, biomarker concentrations were significantly lower in participants with vs. those without AKI at post-infusion and near-hospital discharge. Biomarker values normalized to urine creatinine were higher in patients with AKI compared to without (LV post-infusion, median (IQR): TIMP-2*IGFBP-7: 0.28 (0.08-0.56) vs. 0.04 (0.02-0.12) (ng/mg creatinine)2/1000; P < .001). At EV, pre-infusion biomarker concentrations had the highest area under the curves (AUC) (range: 0.61-0.62) for AKI diagnosis; at LV, biomarkers measured post-infusion and near discharge yielded the highest AUCs (range: 0.64-0.70). CONCLUSIONS TIMP-2*IGFBP-7 were poor to modest at detecting AKI post-cisplatin. Additional studies are needed to determine whether raw biomarker values or biomarker values normalized to urinary creatinine are more strongly associated with patient outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Hayton Chui
- Department of Pediatrics, Division of Nephrology, Peter Gilgan Centre For Research and Learning, Child Health Evaluative Sciences, Toronto Hospital for Sick Children, University of Toronto, Room 11th Floor, 11.9722, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Kelly R McMahon
- Department of Pediatrics, Division of Nephrology, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Shahrad Rod Rassekh
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplantation, University of British Columbia, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Kirk R Schultz
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplantation, University of British Columbia, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, Division of Pediatric Nephrology, University of British Columbia, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Cherry Mammen
- Department of Pediatrics, Division of Pediatric Nephrology, University of British Columbia, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Maury Pinsk
- Department of Pediatrics and Child Health, Section of Pediatric Nephrology, University of Manitoba, Winnipeg, MB, Canada
| | - Geoffrey D E Cuvelier
- Department of Pediatrics and Child Health, Division of Pediatric Oncology-Hematology-BMT, University of Manitoba, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Bruce C Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia and BC Children's Hospital and Research Institute, Vancouver, BC, Canada
| | - Ross T Tsuyuki
- Epidemiology Coordinating and Research (EPICORE) Centre, Departments of Medicine and Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Colin J D Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Louis Huynh
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Mariya Yordanova
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Frédérik Crépeau-Hubert
- Department of Pediatrics, Division of Nephrology, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Stella Wang
- Department of Pediatrics, Division of Nephrology, Peter Gilgan Centre For Research and Learning, Child Health Evaluative Sciences, Toronto Hospital for Sick Children, University of Toronto, Room 11th Floor, 11.9722, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
| | - Vedran Cockovski
- Department of Pediatrics, Division of Nephrology, Peter Gilgan Centre For Research and Learning, Child Health Evaluative Sciences, Toronto Hospital for Sick Children, University of Toronto, Room 11th Floor, 11.9722, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
| | - Ana Palijan
- Department of Pediatrics, Division of Nephrology, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Peter Gilgan Centre For Research and Learning, Child Health Evaluative Sciences, Toronto Hospital for Sick Children, University of Toronto, Room 11th Floor, 11.9722, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
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7
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Wen Y, Su E, Xu L, Menez S, Moledina DG, Obeid W, Palevsky PM, Mansour SG, Devarajan P, Cantley LG, Cahan P, Parikh CR. Analysis of the human kidney transcriptome and plasma proteome identifies markers of proximal tubule maladaptation to injury. Sci Transl Med 2023; 15:eade7287. [PMID: 38091407 DOI: 10.1126/scitranslmed.ade7287] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/20/2023] [Indexed: 12/18/2023]
Abstract
Acute kidney injury (AKI) is a major risk factor for long-term adverse outcomes, including chronic kidney disease. In mouse models of AKI, maladaptive repair of the injured proximal tubule (PT) prevents complete tissue recovery. However, evidence for PT maladaptation and its etiological relationship with complications of AKI is lacking in humans. We performed single-nucleus RNA sequencing of 120,985 nuclei in kidneys from 17 participants with AKI and seven healthy controls from the Kidney Precision Medicine Project. Maladaptive PT cells, which exhibited transcriptomic features of dedifferentiation and enrichment in pro-inflammatory and profibrotic pathways, were present in participants with AKI of diverse etiologies. To develop plasma markers of PT maladaptation, we analyzed the plasma proteome in two independent cohorts of patients undergoing cardiac surgery and a cohort of marathon runners, linked it to the transcriptomic signatures associated with maladaptive PT, and identified nine proteins whose genes were specifically up- or down-regulated by maladaptive PT. After cardiac surgery, both cohorts of patients had increased transforming growth factor-β2 (TGFB2), collagen type XXIII-α1 (COL23A1), and X-linked neuroligin 4 (NLGN4X) and had decreased plasminogen (PLG), ectonucleotide pyrophosphatase/phosphodiesterase 6 (ENPP6), and protein C (PROC). Similar changes were observed in marathon runners with exercise-associated kidney injury. Postoperative changes in these markers were associated with AKI progression in adults after cardiac surgery and post-AKI kidney atrophy in mouse models of ischemia-reperfusion injury and toxic injury. Our results demonstrate the feasibility of a multiomics approach to discovering noninvasive markers and associating PT maladaptation with adverse clinical outcomes.
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Affiliation(s)
- Yumeng Wen
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Emily Su
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Leyuan Xu
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT 06504, USA
| | - Steven Menez
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Dennis G Moledina
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT 06504, USA
| | - Wassim Obeid
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Paul M Palevsky
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Kidney Medicine Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Sherry G Mansour
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT 06504, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Lloyd G Cantley
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT 06504, USA
| | - Patrick Cahan
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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8
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Stone HK, Huang B, Chen C, Ma Q, Bennett MR, Devarajan P. External Validation of a Urinary Biomarker Risk Score for the Prediction of Steroid Responsiveness in Adults With Nephrotic Syndrome. Kidney Int Rep 2023; 8:2458-2468. [PMID: 38025209 PMCID: PMC10658279 DOI: 10.1016/j.ekir.2023.08.039] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction In idiopathic nephrotic syndrome, response to corticosteroids remains the best indicator of prognosis. Noninvasive markers to predict a patient's response to steroids would allow improved prognostication and a more personalized approach to management. We have previously derived a urinary biomarker risk score which can differentiate steroid sensitive nephrotic syndrome (SSNS) from steroid resistant nephrotic syndrome (SRNS) in children. The goal of this study was to validate this previously derived biomarker risk score in a cohort of steroid-naïve adult patients, to determine whether the panel could be used to predict steroid responsiveness at the time of initial diagnosis. Methods In this external validation study, clinical data, and urinary specimens (obtained before initiation of steroid treatment) from adult patients were used in the Nephrotic Syndrome Study Network (NEPTUNE) cohort. A panel of 5 previously identified and validated urinary biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL), vitamin D binding protein (VDBP), Fetuin-A (FetA), Transthyretin (TTR), and alpha-1 acid glycoprotein 2 (AGP2) was measured. A summary risk score for steroid resistance was calculated based on biomarker concentrations. Receiver operating characteristic curves were created for each log-transformed biomarker concentration and for the individual and combined biomarker risk score. Results The urine biomarker risk score predicted development of steroid resistance, with optimal sensitivity and specificity of 0.74, and area under the receiver operating characteristic curve (AUC) of 0.79 using both absolute and creatinine-corrected concentrations. Conclusion This study validates the previously derived urinary biomarker risk score to predict steroid resistance in adult patients with nephrotic syndrome at initial diagnosis.
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Affiliation(s)
- Hillarey K. Stone
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Qing Ma
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael R. Bennett
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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9
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Rheault MN, McLaughlin HM, Mitchell A, Blake LE, Devarajan P, Warady BA, Gibson KL, Lieberman KV. COL4A gene variants are common in children with hematuria and a family history of kidney disease. Pediatr Nephrol 2023; 38:3625-3633. [PMID: 37204491 DOI: 10.1007/s00467-023-05993-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/24/2023] [Accepted: 04/15/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Inherited kidney diseases are a common cause of chronic kidney disease (CKD) in children. Identification of a monogenic cause of CKD is more common in children than in adults. This study evaluated the diagnostic yield and phenotypic spectrum of children who received genetic testing through the KIDNEYCODE sponsored genetic testing program. METHODS Unrelated children < 18 years of age who received panel testing through the KIDNEYCODE sponsored genetic testing program from September 2019 through August 2021 were included (N = 832). Eligible children met at least one of the following clinician-reported criteria: estimated GFR ≤ 90 ml/min/1.73 m2, hematuria, a family history of kidney disease, or suspected or biopsy confirmed Alport syndrome or focal segmental glomerulosclerosis (FSGS) in the tested individual or family member. RESULTS A positive genetic diagnosis was observed in 234 children (28.1%, 95% CI [25.2-31.4%]) in genes associated with Alport syndrome (N = 213), FSGS (N = 9), or other disorders (N = 12). Among children with a family history of kidney disease, 30.8% had a positive genetic diagnosis. Among those with hematuria and a family history of CKD, the genetic diagnostic rate increased to 40.4%. CONCLUSIONS Children with hematuria and a family history of CKD have a high likelihood of being diagnosed with a monogenic cause of kidney disease, identified through KIDNEYCODE panel testing, particularly COL4A variants. Early genetic diagnosis can be valuable in targeting appropriate therapy and identification of other at-risk family members. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Michelle N Rheault
- Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA.
| | | | | | | | - Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Bradley A Warady
- Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Kenneth V Lieberman
- Joseph M. Sanzari Children's Hospital, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
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10
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Hasson DC, Zhang B, Krallman K, Rose JE, Kempton KM, Steele P, Devarajan P, Goldstein SL, Alder MN. Acute kidney injury biomarker olfactomedin 4 predicts furosemide responsiveness. Pediatr Nephrol 2023; 38:3153-3161. [PMID: 37010559 DOI: 10.1007/s00467-023-05920-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/13/2022] [Revised: 01/20/2023] [Accepted: 02/16/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with increased morbidity and mortality in critically ill patients. Olfactomedin 4 (OLFM4), a secreted glycoprotein expressed in neutrophils and stressed epithelial cells, is upregulated in loop of Henle (LOH) cells following AKI. We hypothesized that urine OLFM4 (uOLFM4) will increase in patients with AKI and may predict furosemide responsiveness. METHODS Urine from critically ill children was collected prospectively and tested for uOLFM4 concentrations with a Luminex immunoassay. Severe AKI was defined by KDIGO (stage 2/3) serum creatinine criteria. Furosemide responsiveness was defined as > 3 mL/kg/h of urine output in the 4 h after a 1 mg/kg IV furosemide dose administered as part of standard of care. RESULTS Fifty-seven patients contributed 178 urine samples. Irrespective of sepsis status or AKI cause, uOLFM4 concentrations were higher in patients with AKI (221 ng/mL [IQR 93-425] vs. 36 ng/mL [IQR 15-115], p = 0.007). uOLFM4 concentrations were higher in patients unresponsive to furosemide (230 ng/mL [IQR 102-534] vs. 42 ng/mL [IQR 21-161], p = 0.04). Area under the receiver operating curve for association with furosemide responsiveness was 0.75 (95% CI, 0.60-0.90). CONCLUSIONS AKI is associated with increased uOLFM4. Higher uOLFM4 is associated with a lack of response to furosemide. Further testing is warranted to determine whether uOLFM4 could identify patients most likely to benefit from earlier escalation from diuretics to kidney replacement therapy to maintain fluid balance. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Denise C Hasson
- Division of Pediatric Critical Care Medicine, NYU Langone Health, Hassenfeld Children's Hospital, 430 East 34Th Street, New York, NY, 10016, USA.
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelli Krallman
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James E Rose
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristalynn M Kempton
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Paul Steele
- Division of Anatomic and Clinical Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew N Alder
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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11
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Cody EM, Wenderfer SE, Sullivan KE, Kim AHJ, Figg W, Ghumman H, Qiu T, Huang B, Devarajan P, Brunner HI. Urine biomarker score captures response to induction therapy with lupus nephritis. Pediatr Nephrol 2023; 38:2679-2688. [PMID: 36715772 PMCID: PMC10393841 DOI: 10.1007/s00467-023-05888-z] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Renal Activity Index for Lupus (RAIL) consists of urine protein assessment of neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, monocyte chemotactic protein 1, adiponectin, hemopexin, and ceruloplasmin, which non-invasively identifies lupus nephritis (LN). We aimed to delineate RAIL scores with inactive versus active LN and changes over time with response to LN induction therapy. METHODS There were 128 pediatric patients with systemic lupus erythematosus (SLE) and age-matched healthy controls recruited in a prospective case control study, with kidney biopsy confirmation of LN. Laboratory and clinical information was recorded and urine collected at diagnosis and end of induction and during maintenance therapy. Response to therapy was assessed by repeat kidney biopsy or laboratory parameters. Urine was assayed for RAIL biomarkers and the RAIL score calculated. RESULTS Pediatric RAIL (pRAIL) scores from 128 children and young adults with SLE (with/without LN: 70/38) including 25 during LN induction therapy, differentiated clinically active LN from inactive LN or without LN, and controls (all p < 0.0017). pRAIL scores significantly decreased with complete LN remission by 1.07 ± 1.7 (p = 0.03). CONCLUSIONS The RAIL biomarkers differentiate LN patients based on activity of kidney disease, with decreases of ≥ 1 in pRAIL scores indicating complete response to induction therapy. Significantly lower RAIL scores in healthy controls and in SLE patients without known LN raise the possibility of subclinical kidney disease. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ellen M Cody
- Division of Nephrology, Hypertension and Pheresis, Department of Pediatrics, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus, Box 8116, St. Louis, MO, 63110, USA.
| | - Scott E Wenderfer
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Nephrology, B.C. Children's Hospital, Vancouver, BC, Canada
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alfred H J Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Wesley Figg
- Medical School, Baylor College of Medicine, Houston, TX, USA
| | - Harneet Ghumman
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Hermine I Brunner
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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Rudman-Melnick V, Adam M, Stowers K, Potter A, Ma Q, Chokshi SM, Vanhoutte D, Valiente-Alandi I, Lindquist DM, Nieman ML, Kofron JM, Potter SS, Devarajan P. Single-cell sequencing dissects the transcriptional identity of activated fibroblasts and identifies novel persistent distal tubular injury patterns in kidney fibrosis. Res Sq 2023:rs.3.rs-2880248. [PMID: 37293022 PMCID: PMC10246229 DOI: 10.21203/rs.3.rs-2880248/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Examining kidney fibrosis is crucial for mechanistic understanding and developing targeted strategies against chronic kidney disease (CKD). Persistent fibroblast activation and tubular epithelial cell (TEC) injury are key CKD contributors. However, cellular and transcriptional landscapes of CKD and specific activated kidney fibroblast clusters remain elusive. Here, we analyzed single cell transcriptomic profiles of two clinically relevant kidney fibrosis models which induced robust kidney parenchymal remodeling. We dissected the molecular and cellular landscapes of kidney stroma and newly identified three distinctive fibroblast clusters with "secretory", "contractile" and "vascular" transcriptional enrichments. Also, both injuries generated failed repair TECs (frTECs) characterized by decline of mature epithelial markers and elevation of stromal and injury markers. Notably, frTECs shared transcriptional identity with distal nephron segments of the embryonic kidney. Moreover, we identified that both models exhibited robust and previously unrecognized distal spatial pattern of TEC injury, outlined by persistent elevation of renal TEC injury markers including Krt8, while the surviving proximal tubules (PTs) showed restored transcriptional signature. Furthermore, we found that long-term kidney injuries activated a prominent nephrogenic signature, including Sox4 and Hox gene elevation, which prevailed in the distal tubular segments. Our findings might advance understanding of and targeted intervention in fibrotic kidney disease.
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Affiliation(s)
| | - Mike Adam
- Cincinnati Children's Hospital Medical Center
| | | | | | - Qing Ma
- Cincinnati Children's Hospital Medical Center
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13
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Abstract
PURPOSE OF REVIEW This review focuses on the pathogenesis of intrinsic acute kidney injury (AKI), emphasizing recent advances that hold therapeutic promise. RECENT FINDINGS Enhanced endothelin and reduced endothelium-derived nitric oxide release in AKI can be blocked using endothelin receptor antagonists or nitric oxide supplementation. Vasodilatory agents such as theophylline and caffeine may prevent AKI. Free labile iron is a potent factor in the generation of reactive oxygen species and tubule damage in AKI. Apoptosis via induction of p53 is an important mechanism of cell death in AKI, which can be blocked using small interfering RNA. The AKI-driven reduction in nicotinamide adenine dinucleotide can be countered using oral supplements. Surviving tubule cells regenerate after AKI, by upregulating genes encoding growth factors, such as hepatocyte growth factor. Pro-angiogenic agents (statins and erythropoietin) that can mobilize endothelial progenitor cells after AKI are currently being tested. The inflammatory response in AKI, including activation of C5a, can be therapeutically targeted. Contemporary single cell profiling technologies have identified novel genes with altered expression, new signalling pathways and drug targets in AKI. SUMMARY Recent advances in the pathogenesis of intrinsic AKI have provided a better understanding of the clinical continuum and the rational deployment of promising therapeutics.
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Affiliation(s)
- Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
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14
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DeFoor W, Nehus E, Schulte M, Huesman S, Libs A, Niehaus R, Devarajan P. Enteral nutrition and the risk of nephrolithiasis in complex pediatric patients. J Pediatr Urol 2022; 18:743.e1-743.e6. [PMID: 35760671 DOI: 10.1016/j.jpurol.2022.06.003] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Medically complex, non-ambulatory children can often suffer from nephrolithiasis. The purpose of this study is to determine risk factors which are predictive for recurrent stone formation in this patient population. MATERIAL AND METHODS A retrospective cohort study was performed on non-ambulatory patients with cerebral palsy and/or severe developmental delay presenting to a high-volume Pediatric Stone Center from 2015 to 2019. Two 24-hour urine collections were performed as a baseline prior to pharmacotherapeutic and/or dietary intervention. Healthy stone-forming children served as a control group. RESULTS 28 non-ambulatory subjects and 38 healthy controls were evaluated. The study group had a higher rate of bilateral nephrolithiasis but a similar history of previous surgical procedures. 89% of the non-ambulatory children were fed via a gastrostomy. The median calcium excretion was the same in both groups (3.0 mg/kg/day). The median 24-hour excretion of oxalate was significantly increased in the study group (54 vs 31 mg/1.73 m2/day, p = 0.0001). Urinary citrate and phosphorus excretions, and the supersaturations of calcium oxalate and calcium phosphate were similar between study subjects and controls. Calcium oxalate stones were noted in 57% of those with known stone composition in the study group. Enteral feeding formulas were primarily based on soy protein, a known high oxalate food. CONCLUSIONS Urinary oxalate excretion is significantly increased in a cohort of medically complex, non-ambulatory stone-forming children. Urinary calcium excretion was not elevated between study subjects and healthy controls. Further analysis is needed to assess if dietary intervention to limit oxalate excretion results in decreased stone formation.
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Affiliation(s)
- William DeFoor
- From the Divisions of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Edward Nehus
- Department of Pediatrics, Marshall University Joan C Edwards School of Medicine, Huntington, WV, USA
| | - Marion Schulte
- From the Divisions of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sydney Huesman
- Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ashleigh Libs
- Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Renee Niehaus
- From the Divisions of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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15
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Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. OBJECTIVE To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. EVIDENCE REVIEW At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. FINDINGS The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. CONCLUSIONS AND RELEVANCE Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
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Hasson DC, Watanabe-Chailland M, Romick-Rosendale L, Koterba A, Miner DS, Lahni P, Ma Q, Goldstein SL, Devarajan P, Standage SW. Choline supplementation attenuates experimental sepsis-associated acute kidney injury. Am J Physiol Renal Physiol 2022; 323:F255-F271. [PMID: 35834274 PMCID: PMC9394731 DOI: 10.1152/ajprenal.00033.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/10/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/22/2022] Open
Abstract
Acute kidney injury (AKI) is common in critically ill patients, and sepsis is its leading cause. Sepsis-associated AKI (SA-AKI) causes greater morbidity and mortality than other AKI etiologies, yet the underlying mechanisms are incompletely understood. Metabolomic technologies can characterize cellular energy derangements, but few discovery analyses have evaluated the metabolomic profile of SA-AKI. To identify metabolic derangements amenable to therapeutic intervention, we assessed plasma and urine metabolites in septic mice and critically ill children and compared them by AKI status. Metabolites related to choline and central carbon metabolism were differentially abundant in SA-AKI in both mice and humans. Gene expression of enzymes related to choline metabolism was altered in the kidneys and liver of mice with SA-AKI. Treatment with intraperitoneal choline improved renal function in septic mice. Because pediatric patients with sepsis displayed similar metabolomic profiles to septic mice, choline supplementation may attenuate pediatric septic AKI.NEW & NOTEWORTHY Altered choline metabolism plays a role in both human and murine sepsis-associated acute kidney injury (SA-AKI), and choline administration in experimental SA-AKI improved renal function. These findings indicate that 1) mouse models can help interrogate clinically relevant mechanisms and 2) choline supplementation may ameliorate human SA-AKI. Future research will investigate clinically the impact of choline supplementation on human renal function in sepsis and, using model systems, how choline mediates its effects.
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Affiliation(s)
- Denise C Hasson
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Miki Watanabe-Chailland
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lindsey Romick-Rosendale
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adeleine Koterba
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dashiell S Miner
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Qing Ma
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stephen W Standage
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Hasson DC, Krallman K, VanDenHeuvel K, Menon S, Piraino G, Devarajan P, Goldstein SL, Alder M. Olfactomedin 4 as a novel loop of Henle-specific acute kidney injury biomarker. Physiol Rep 2022; 10:e15453. [PMID: 36117416 PMCID: PMC9483618 DOI: 10.14814/phy2.15453] [Citation(s) in RCA: 4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 06/15/2023] Open
Abstract
Acute kidney injury (AKI) is associated with morbidity and mortality. Urinary biomarkers may disentangle its clinical heterogeneity. Olfactomedin 4 (OLFM4) is a secreted glycoprotein expressed in stressed neutrophils and epithelial cells. In septic mice, OLFM4 expression localized to the kidney's loop of Henle (LOH) and was detectable in the urine. We hypothesized that urine OLFM4 (uOLFM4) will be increased in patients with AKI and sepsis. Urine from critically ill pediatric patients was obtained from a prospective study based on AKI and sepsis status. uOLFM4 was quantified with a Luminex immunoassay. AKI was defined by KDIGO severe criteria. Sepsis status was extracted from the medical record based on admission diagnosis. Immunofluorescence on pediatric kidney biopsies was performed with NKCC2, uromodulin and OLFM4 specific antibodies. Eight patients had no sepsis, no AKI; 7 had no sepsis but did have AKI; 10 had sepsis, no AKI; 11 had sepsis and AKI. Patients with AKI had increased uOLFM4 compared to no/stage 1 AKI (p = 0.044). Those with sepsis had increased uOLFM4 compared to no sepsis (p = 0.026). uOLFM4 and NGAL were correlated (r2 0.59, 95% CI 0.304-0.773, p = 0.002), but some patients had high uOLFM4 and low NGAL, and vice versa. Immunofluorescence on kidney biopsies demonstrated OLFM4 colocalization with NKCC2 and uromodulin, suggesting expression in the thick ascending LOH (TALH). We conclude that AKI and sepsis are associated with increased uOLFM4. uOLFM4 and NGAL correlated in many patients, but was poor in others, suggesting these markers may differentiate AKI subgroups. Given OLFM4 colocalization to human TALH, we propose OLFM4 may be a LOH-specific AKI biomarker.
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Affiliation(s)
- Denise C. Hasson
- Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Nephrology and HypertensionCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Kelli Krallman
- Division of Nephrology and HypertensionCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Katherine VanDenHeuvel
- Division of Pathology and Laboratory MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Shina Menon
- Division of Nephrology and HypertensionSeattle Children's HospitalSeattleWashingtonUSA
| | - Giovanna Piraino
- Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Prasad Devarajan
- Division of Nephrology and HypertensionCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Stuart L. Goldstein
- Division of Nephrology and HypertensionCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Matthew N. Alder
- Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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Abstract
Background The Renal Activity Index for Lupus (RAIL) is a composite score of six urinary biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemoattractant protein-1 (MCP-1), kidney injury molecule-1 (KIM-1), ceruloplasmin, adiponectin, and hemopexin) used to monitor lupus nephritis activity in children. We tested stability of RAIL biomarkers prior to meaningful clinical use. Methods Urine samples were tested by ELISA under shipping conditions, freeze/thaw, ambient and longer-term storage. Statistical analysis was performed via Deming Regression, Bland-Altman and Spearman Correlation Coefficient. Results Biomarker concentration were comparable to freshly collected urine following storage at -80 °C for up to 3 months, and at 4 or 25 °C up to 48 h followed by -80 °C. Neither shipping on dry or wet ice exposure nor addition of two freeze-thaw cycles led to loss of signal, with excellent Spearman Correlation coefficients under all conditions. Conclusions RAIL biomarkers are stable following short-term storage at clinically relevant conditions.
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Affiliation(s)
- Ellen M. Cody
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - James E. Rose
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Bin Huang
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Division of Biostatics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- School of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Tingting Qiu
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Division of Biostatics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Hermine I. Brunner
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- School of Medicine, University of Cincinnati, Cincinnati, OH, United States
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- School of Medicine, University of Cincinnati, Cincinnati, OH, United States
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Pode-Shakked N, Devarajan P. Human Stem Cell and Organoid Models to Advance Acute Kidney Injury Diagnostics and Therapeutics. Int J Mol Sci 2022; 23:ijms23137211. [PMID: 35806216 PMCID: PMC9266524 DOI: 10.3390/ijms23137211] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Acute kidney injury (AKI) is an increasingly common problem afflicting all ages, occurring in over 20% of non-critically ill hospitalized patients and >30% of children and >50% of adults in critical care units. AKI is associated with serious short-term and long-term consequences, and current therapeutic options are unsatisfactory. Large gaps remain in our understanding of human AKI pathobiology, which have hindered the discovery of novel diagnostics and therapeutics. Although animal models of AKI have been extensively studied, these differ significantly from human AKI in terms of molecular and cellular responses. In addition, animal models suffer from interspecies differences, high costs and ethical considerations. Static two-dimensional cell culture models of AKI also have limited utility since they have focused almost exclusively on hypoxic or cytotoxic injury to proximal tubules alone. An optimal AKI model would encompass several of the diverse specific cell types in the kidney that could be targets of injury. Second, it would resemble the human physiological milieu as closely as possible. Third, it would yield sensitive and measurable readouts that are directly applicable to the human condition. In this regard, the past two decades have seen a dramatic shift towards newer personalized human-based models to study human AKI. In this review, we provide recent developments using human stem cells, organoids, and in silico approaches to advance personalized AKI diagnostics and therapeutics.
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Affiliation(s)
- Naomi Pode-Shakked
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Correspondence:
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Cody E, Brunner H, Huang B, Qiu T, Devarajan P, Ramaswamy M, Sinibaldi D, Brohawn PZ, Knagenhjelm J, Jones F, Tummala R, Lindholm C, White W. POS0739 THE RENAL ACTIVITY INDEX FOR LUPUS (RAIL) DIFFERENTIATES ACTIVE AND INACTIVE NEPHRITIS IN ADULT PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE). Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundLupus nephritis (LN) confers a poor prognosis, with lack of effective laboratory tests to diagnose and evaluate therapies. We have demonstrated that the RAIL score, based on a set of six urinary biomarkers (NGAL, KIM-1, MCP-1, adiponectin, hemopexin, ceruloplasmin) is sensitive and specific in adult patients with active LN, using renal biopsy as reference.1,2 RAIL has been shown in the pediatric population to be effective in distinguishing inactive vs active LN with no effect from mycophenolate mofetil (MMF) treatment. A comparable study has not been conducted in an adult population.ObjectivesTo assess the ability of RAIL to discriminate patients with active LN vs active non-renal SLE and to evaluate if RAIL performance varies by MMF treatment using urine samples from adult LN patients.MethodsUrine samples were obtained at baseline in two clinical trials: a phase 2 study in adult patients with biopsy-proven active Class III and IV LN (NCT02547922) and a subset of patients from the phase 3 trial in adults with active non-renal SLE (NCT02446912) who had baseline renal BILAG scores C, D, or E. RAIL biomarkers were assayed using single-plex assays. Patient demographics and clinical characteristics were compared between studies. Wilcoxon rank sum test was performed comparing the urinary biomarkers between the two studies and RAIL score was then calculated. Receiver operating characteristic (ROC) analyses were conducted assessing the ability for RAIL scores to distinguish patients with renal activity and involvement.ResultsComparison of the patient demographic, clinical characteristics, and biomarkers is in the Table 1. Wilcoxon rank sum test showed the six urinary biomarkers were significantly different between two groups of patients as demonstrated (Table 1). Each of the RAIL biomarker concentrations and the creatinine-adjusted median score were higher in the active LN group than the SLE group (P<0.001). ROC analyses including RAIL score showed an area under the ROC curve of 0.8 (Figure 1), with odds ratio of log-transformed RAIL 2.027 (95% CI [1.587, 2.589]). There were no significant interactions between RAIL and MMF. RAIL remained significant after adjusting for estimated glomerular filtration rate (eGFR), which was not statistically significant.Table 1.Study Demographics and BiomarkersVariablesLN study (N=131)SLE study (N=59)Observed NObserved Median (IQR) or %Observed NObserved Median (IQR) or %DemographicsAge13134 (25, 42)5936 (28, 44)Sex, Female10983.21%5593.22%Race, White5642.75%4576.27%Ethnicity, Hispanic or Latino6146.56%915.25%OCS use, yes12797.69%5796.61%MMF use, yes9572.52%2135.59%Spot UPCR (mg/mg)1282.13 (1.22, 4.04)591.11 (0.55, 2.61)eGFR13091.8 (63.1, 125)5998.06 (81.91, 116.54)Non-renal SLEDAI-2K score1304 (4, 6)5912 (9, 13)Renal SLEDAI-2K score1304 (4, 8)590 (0, 0)BiomarkersNGAL (ng/mL)12833.33 (17.55, 56.7)5819.47 (11.37, 42.05)MCP-1 (pg/mL)128658.24 (271.58, 1049.95)58275.62 (106.09, 481.99)Ceruloplasmin (ng/mL)12893.55 (44.5, 311.25)5847.2 (13.05, 231.25)Adiponectin (ng/mL)12842.45 (16.71, 139.64)589.33 (3.35, 25.51)Hemopexin (ng/mL)1281876.8 (745.07, 4743.4)58513.4 (236.36, 1388.74)KIM-1 (pg/mL)1281673.5 (772.5, 2767)58864 (394, 1480)Creatinine (mg/mL)1280.7 (0.46, 1.3)580.99 (0.46, 1.74)Adult RAIL score (creatinine adjusted)1285.59 (4.31, 6.47)583.57 (2.78, 4.47)eGFR, estimated glomerular filtration rate; IQR, interquartile range; KIM, kidney injury molecule; LN, lupus nephritis; MCP, monocyte chemotactic protein; MMF, mycophenolate mofetil; NGAL, neutrophil gelatinase-associated lipocalin; OCS, oral corticosteroid; SLEDAI-2K, SLE Disease Activity Index 2000; UPCR, urine protein/creatinine ratio.ConclusionThe analyses performed suggest that creatinine-corrected RAIL discriminates between active LN and non-renal adult SLE, with RAIL scores not influenced by MMF use.References[1]Brunner HI. Arthritis Care Res (Hoboken). 2016;68:1003–11.[2]Gulati G. Lupus. 2017;26:927–36.AcknowledgementsWriting assistance by Kelly M. Hunter, PhD (Fishawack). This study was sponsored by AstraZeneca.Disclosure of InterestsEllen Cody: None declared, Hermine Brunner Speakers bureau: Novartis, Pfizer, GSK, Consultant of: AbbVie, Astra Zeneca-Medimmune, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Lilly,EMD Serono, Idorsia, Cerocor, Janssen, GSK, F. Hoffmann-La Roche, Merck, Novartis, R-Pharm, Sanofi, Grant/research support from: Pfizer, Bin Huang: None declared, Tingting Qiu: None declared, Prasad Devarajan Speakers bureau: Reata, Alnylam, Dicerna, Consultant of: BioPorto Inc, Madhu Ramaswamy Shareholder of: AstraZeneca, Employee of: AstraZeneca, Dominic Sinibaldi Shareholder of: AstraZeneca, Employee of: AstraZeneca, Philip Z Brohawn Shareholder of: AstraZeneca, Employee of: AstraZeneca, Jacob Knagenhjelm Shareholder of: AstraZeneca, Employee of: AstraZeneca, Frederick Jones Shareholder of: AstraZeneca, Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca, Wendy White Shareholder of: AstraZeneca, Employee of: AstraZeneca
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Dillman JR, Benoit SW, Gandhi DB, Trout AT, Tkach JA, VandenHeuvel K, Devarajan P. Multiparametric quantitative renal MRI in children and young adults: comparison between healthy individuals and patients with chronic kidney disease. Abdom Radiol (NY) 2022; 47:1840-1852. [PMID: 35237897 DOI: 10.1007/s00261-022-03456-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Multiparametric quantitative renal MRI may provide noninvasive radiologic biomarkers of chronic kidney disease (CKD) based on investigations in animal models and adults. We aimed to (1) obtain normative multiparametric quantitative MRI data from the kidneys of healthy children and young adults, (2) compare MRI measurements between healthy control participants and patients with CKD, and (3) determine if MRI measurements correlate with clinical and laboratory data as well as histology. METHODS This was a prospective, case-control study of 20 healthy controls and 12 CKD patients who underwent percutaneous renal biopsy ranging from 12 to 23 years of age between October 2018 and March 2020. Kidney function was documented and pathology assessed for fibrosis/inflammation. Utilizing a field strength of 1.5T, we examined renal T1, T2, and T2* relaxation mapping, MR elastography (MRE), and diffusion-weighted imaging (DWI). A single analyst made all manual measurements for quantitative MRI pulse sequences. Independent measurements from cortex, medulla, and whole kidney were obtained by drawing regions of interest on single slices from the upper, mid, and lower kidney. A weighted average was calculated for each kidney; if two kidneys, the right and left were averaged. Continuous variables were compared with Mann-Whitney U test; bivariate relationships were assessed using Spearman rank-order correlation. RESULTS Median estimated glomerular filtration rate (eGFR) was 112.3 ml/min/1.73 m2 in controls (n = 20, 10 females) and 55.0 ml/min/m2 in CKD patients (n = 12, 2 females) (p < 0.0001). Whole kidney (1333 vs. 1291 ms; p = 0.018) and cortical (1212 vs 1137 ms; p < 0.0001) T1 values were higher in CKD patients. Cortical T1 values correlated with eGFR (rho = - 0.62; p = 0.0003) and cystatin C (rho = 0.58; p = 0.0007). Whole kidney (1.87 vs. 2.02 10-3 mm2/s; p = 0.007), cortical (1.89 vs. 2.04 10-3 mm2/s; p = 0.008), and medullary (1.87 vs. 1.98 10-3 mm2/s; p = 0.0095) DWI apparent diffusion coefficients (ADC) were lower in CKD patients. Whole kidney ADC correlated with eGFR (rho = 0.45; p = 0.012) and cystatin C (rho = - 0.46; p = 0.009). Cortical histologic inflammation correlated with DWI ADC (rho = - 0.71; p = 0.011). CONCLUSION Renal T1 relaxation and DWI ADC measurements differ between pediatric healthy controls and CKD patients, correlate with laboratory markers of CKD, and may have histologic correlates.
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Affiliation(s)
- Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45244, USA.
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Deep B Gandhi
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45244, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45244, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45244, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katherine VandenHeuvel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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22
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Aljaberi N, Wenderfer SE, Mathur A, Qiu T, Jose S, Merritt A, Rose J, Devarajan P, Huang B, Brunner H. Clinical measurement of lupus nephritis activity is inferior to biomarker-based activity assessment using the renal activity index for lupus nephritis in childhood-onset systemic lupus erythematosus. Lupus Sci Med 2022; 9:e000631. [PMID: 35568436 PMCID: PMC9109101 DOI: 10.1136/lupus-2021-000631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/24/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The renal activity index for lupus (RAIL) measures lupus nephritis (LN) activity considering urine levels of 6 biomarkers (neutrophil gelatinase-associated lipocalin, monocyte chemoattractant protein-1, kidney injury molecule-1, adiponectin, haemopexin, ceruloplasmin). We aimed to compare the accuracy of the RAIL and the renal domain-score of the SLE disease activity index (rSLEDAI) in detecting LN activity. METHODS Random urine samples of patients with childhood-onset SLE with and without LN were assayed and scores of the RAIL, and RAIL standardised for urine creatinine (RAIL-Cr) were calculated. Clinical LN activity was measured by the rSLEDAI, and histological activity of LN was categorised as inactive/low-moderate/high for National Institute of Health-activity index scores of <2/2-10/>10, respectively. RESULTS 115 patients were included in the analysis (47 patients without and 68 with LN). RAIL, RAIL-Cr and rSLEDAI scores at the time (±3 months) of kidney biopsy were available for 32 patients. Median rSLEDAI, RAIL and RAIL-Cr values were 4, -0.04, 0.02 for inactive LN, 12, 0.7 and 0.9 for low-moderate LN activity and 12, 2 and 1.8 for high LN activity, respectively. The area under the receiver operating characteristic curve (AUC) to capture high LN activity was the lowest for the rSLEDAI (AUC=0.62), followed by the RAIL-Cr (AUC=0.73) and RAIL (AUC=0.79). Notably, when testing urine samples collected during routine clinic visits remote (>3 months) from a kidney biopsy, 50% patients with rSLEDAI scores of 0 had RAIL scores reflecting low-moderate LN activity. CONCLUSION Monitoring of renal inflammation in children and adolescents with SLE can be improved by the measurement of urine biomarkers. The RAIL may constitute important auxiliary tool for the surveillance of LN in a clinical setting and assist with the decision to obtain a kidney biopsy.
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Affiliation(s)
- Najla Aljaberi
- Department of Pediatrics, United Arab Emirates University College of Medicine and Health Sciences, Al Ain, UAE
| | | | - Arjun Mathur
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Steffy Jose
- Renal Section, Texas Children's Hospital, Houston, Texas, USA
| | - Angela Merritt
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Rose
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Odum JD, Standage S, Alder M, Zingarelli B, Devarajan P, Wong HR. Candidate Biomarkers for Sepsis-Associated Acute Kidney Injury Mechanistic Studies. Shock 2022; 57:687-693. [PMID: 35234208 PMCID: PMC9117431 DOI: 10.1097/shk.0000000000001916] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Sepsis-associated acute kidney injury (SA-AKI) is a frequent complication of sepsis, yet the pathophysiologic mechanisms of SA-AKI are incompletely understood. PERSEVERE is a clinically validated serum biomarker panel with high sensitivity in predicting mortality from sepsis, and recent evidence suggests it can also predict severe, persistent SA-AKI at day 3 of hospitalization among septic children. We developed a murine model of PERSEVERE (mPERSEVERE) to further interrogate the sepsis-related biological underpinnings of SA-AKI using candidate biomarkers within mPERSEVERE. METHODS Eight-week-old C57BL/6 male mice underwent induction of sepsis by cecal ligation and puncture (CLP). mPERSEVERE biomarkers were collected at 8-hours and kidneys were harvested at 24-hours post-CLP Classification and regression tree analysis (CART) was used to generate a SA-AKI predictive model. Kidney gene expression levels of candidate biomarkers were quantified using real time polymerase chain reaction. RESULTS Thirty- five mice underwent CLP Among mice identified by mPERSEVERE as high-risk for mortality, 70% developed SA-AKI at 24-hours compared to 22% of low-risk mice. CART analysis identified two mPERSEVERE biomarkers-C-C motif chemokine ligand 3 (CCL3) and keratinocyte-derived chemokine (KC)-as most predictive for SA-AKI with an area under the receiver operating curve of 0.90. In mice that developed SA-AKI, renal expression of KC was significantly increased compared to mice without SA-AKI (p = 0.013), whereas no difference was seen in renal expression of CCL3 in mice with SA-AKI vs. no SA-AKI. KC and CCL3 localized to renal tubule epithelial cells as opposed to infiltrating immune cells by immunohistochemistry. CONCLUSIONS The combination of plasma CCL3+KC can predict SA-AKI development in mice at 24-hours following CLP Of these two biomarkers, only renal expression of KC is increased in mice with SA-AKI. Further studies are required to determine if KC directly contributes to the underlying pathobiology of SA-AKI.
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Affiliation(s)
- James D Odum
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Steve Standage
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew Alder
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Basilia Zingarelli
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hector R Wong
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Abstract
Chronic kidney disease (CKD) afflicts 15% of adults in the United States, of whom 25% have a family history. Genetic testing is supportive in identifying and possibly confirming diagnoses of CKD, thereby guiding care. Advances in the clinical genetic evaluation include next-generation sequencing with targeted gene panels, whole exome sequencing, and whole genome sequencing. These platforms provide DNA sequence reads with excellent coverage throughout the genome and have identified novel genetic causes of CKD. New pathologic genetic variants identified in previously unrecognized biological pathways have elucidated disease mechanisms underlying CKD etiologies, potentially establishing prognosis and guiding treatment selection. Molecular diagnoses using genetic sequencing can detect rare, potentially treatable mutations, avoid misdiagnoses, guide selection of optimal therapy, and decrease the risk of unnecessary and potentially harmful interventions. Genetic testing has been widely adopted in pediatric nephrology; however, it is less frequently used to date in adult nephrology. Extension of clinical genetic approaches to adult patients may achieve similar benefits in diagnostic refinement and treatment selection. This review aimed to identify clinical CKD phenotypes that may benefit the most from genetic testing, outline the commonly available platforms, and provide examples of successful deployment of these approaches in CKD.
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Chalhoub NE, Wenderfer SE, Levy DM, Rouster-Stevens K, Aggarwal A, Savani SI, Ruth NM, Arkachaisri T, Qiu T, Merritt A, Onel K, Goilav B, Khubchandani RP, Deng J, Fonseca AR, Ardoin SP, Ciurtin C, Kasapcopur O, Jelusic M, Huber AM, Ozen S, Klein-Gitelman MS, Appenzeller S, Cavalcanti A, Fotis L, Lim SC, Silva RM, Miramontes JR, Rosenwasser NL, Saad-Magalhaes C, Schonenberg-Meinema D, Scott C, Silva CA, Enciso S, Terreri MT, Torres-Jimenez AR, Trachana M, Al-Mayouf SM, Devarajan P, Huang B, Brunner HI. International Consensus for the Dosing of Corticosteroids in Childhood-Onset Systemic Lupus Erythematosus With Proliferative Lupus Nephritis. Arthritis Rheumatol 2022; 74:263-273. [PMID: 34279063 PMCID: PMC8766607 DOI: 10.1002/art.41930] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 03/14/2021] [Accepted: 07/15/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To develop a standardized steroid dosing regimen (SSR) for physicians treating childhood-onset systemic lupus erythematosus (SLE) complicated by lupus nephritis (LN), using consensus formation methodology. METHODS Parameters influencing corticosteroid (CS) dosing were identified (step 1). Data from children with proliferative LN were used to generate patient profiles (step 2). Physicians rated changes in renal and extrarenal childhood-onset SLE activity between 2 consecutive visits and proposed CS dosing (step 3). The SSR was developed using patient profile ratings (step 4), with refinements achieved in a physician focus group (step 5). A second type of patient profile describing the course of childhood-onset SLE for ≥4 months since kidney biopsy was rated to validate the SSR-recommended oral and intravenous (IV) CS dosages (step 6). Patient profile adjudication was based on majority ratings for both renal and extrarenal disease courses, and consensus level was set at 80%. RESULTS Degree of proteinuria, estimated glomerular filtration rate, changes in renal and extrarenal disease activity, and time since kidney biopsy influenced CS dosing (steps 1 and 2). Considering these parameters in 5,056 patient profile ratings from 103 raters, and renal and extrarenal course definitions, CS dosing rules of the SSR were developed (steps 3-5). Validation of the SSR for up to 6 months post-kidney biopsy was achieved with 1,838 patient profile ratings from 60 raters who achieved consensus for oral and IV CS dosage in accordance with the SSR (step 6). CONCLUSION The SSR represents an international consensus on CS dosing for use in patients with childhood-onset SLE and proliferative LN. The SSR is anticipated to be used for clinical care and to standardize CS dosage during clinical trials.
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Affiliation(s)
| | | | - Deborah M Levy
- The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | | | - Amita Aggarwal
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | | - Tingting Qiu
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela Merritt
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen Onel
- Hospital for Special Surgery, New York, New York
| | | | | | - Jianghong Deng
- Capital Medical University and National Center for Children's Health, Beijing, China
| | | | | | | | - Ozgur Kasapcopur
- Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Marija Jelusic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Seza Ozen
- Hacettepe University, Ankara, Turkey
| | - Marisa S Klein-Gitelman
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - André Cavalcanti
- Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
| | - Lampros Fotis
- National and Kapodistian University of Athens, Athens, Greece
| | | | - Rodrigo M Silva
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Christiaan Scott
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Sandra Enciso
- Hospital de la Beneficencia Española, Mexico City, Mexico
| | | | | | - Maria Trachana
- Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sulaiman M Al-Mayouf
- King Faisal Specialist Hospital and Research Center and Alfaisal University, Riyadh, Saudi Arabia
| | - Prasad Devarajan
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bin Huang
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hermine I Brunner
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Elitok S, Kuppe H, Devarajan P, Bellomo R, Isermann B, Westphal S, Kube J, Albert C, Ernst M, Kropf S, Haase-Fielitz A, Haase M. Urinary Neutrophil Gelatinase-Associated Lipocalin/Hepcidin-25 Ratio for Early Identification of Patients at Risk for Renal Replacement Therapy After Cardiac Surgery: A Substudy of the BICARBONATE Trial. Anesth Analg 2021; 133:1510-1519. [PMID: 34543256 DOI: 10.1213/ane.0000000000005741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute kidney injury requiring renal replacement therapy (AKI-RRT) is strongly associated with mortality after cardiac surgery; however, options for early identification of patients at high risk for AKI-RRT are extremely limited. Early after cardiac surgery, the predictive ability for AKI-RRT even of one of the most extensively evaluated novel urinary biomarkers, neutrophil gelatinase-associated lipocalin (NGAL), appears to be only moderate. We aimed to determine whether the NGAL/hepcidin-25 ratio (urinary concentrations of NGAL divided by that of hepcidin-25) early after surgery may compare favorably to NGAL for identification of high-risk patients after cardiac surgery. METHODS This is a prospective substudy of the BICARBONATE trial, a multicenter parallel-randomized controlled trial comparing perioperative bicarbonate infusion for AKI prevention to usual patient care. At a tertiary referral center, 198 patients at increased kidney risk undergoing cardiac surgery with cardiopulmonary bypass were included into the present study. The primary outcome measure was defined as AKI-RRT. Secondary outcomes were in-hospital mortality and long-term mortality. We compared area under the curve of the receiver operating characteristic (AUC-ROC) of urinary NGAL with that of the urinary NGAL/hepcidin-25 ratio within 60 minutes after end of surgery. We compared adjusted AUC and performed cross-validated reclassification statistics of the (logarithmic) urinary NGAL/hepcidin-25 ratio adjusted to Cleveland risk score/EuroScore, cross-clamp time, age, volume of packed red blood cells, and (logarithmic) urinary NGAL concentration. The association of the NGAL/hepcidin-25 ratio with long-term patient survival was assessed using Cox proportional hazard regression analysis adjusting for EuroScore, aortic cross-clamp time, packed red blood cells and urinary NGAL. RESULTS Patients with AKI-RRT (n = 13) had 13.7-times higher NGAL and 3.3-times lower hepcidin-25 concentrations resulting in 46.9-times higher NGAL/hepcidin-25 ratio early after surgery compared to patients without AKI-RRT. The NGAL/hepcidin-25 ratio had higher AUC-ROC compared with NGAL for risk of AKI-RRT and in-hospital mortality (unadjusted AUC-ROC difference 0.087, 95% confidence interval [CI], 0.036-0.138, P < .001; 0.082, 95% CI, 0.018-0.146, P = .012). For AKI-RRT, the NGAL/hepcidin-25 ratio increased adjusted category-free net reclassification improvement (cfNRI; 0.952, 95% CI, 0.437-1.468; P < .001) and integrated discrimination improvement (IDI; 0.040, 95% CI, 0.008-0.073; P = .016) but not AUC difference. For in-hospital mortality, the ratio improved AUC of the reference model (AUC difference 0.056, 95% CI, 0.003-0.108; P = .037) and cfNRI but not IDI. The urinary NGAL/hepcidin-25 ratio remained significantly associated with long-term mortality after adjusting for the model covariates. CONCLUSIONS The urinary NGAL/hepcidin-25 ratio appears to early identify high-risk patients and outperform NGAL after cardiac surgery. Confirmation of our findings in other cardiac surgery centers is now needed.
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Affiliation(s)
- Saban Elitok
- From the Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany
| | - Hermann Kuppe
- Institute of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, German Heart Center Berlin & Charité-University Medicine Berlin, Berlin, Germany
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia.,Department of Integrated Critical Care, Center for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Berend Isermann
- Department of Laboratory Medicine, Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostic, Leipzig University Hospital, Leipzig, Germany
| | - Sabine Westphal
- Department of Laboratory Medicine, Institute of Laboratory Medicine, Tertiary Hospital Dessau, Dessau-Roßlau, Germany
| | - Johanna Kube
- Department of Anesthesiology and Intensive Care, Helios Klinikum Leisnig, Leisnig, Germany
| | - Christian Albert
- Diaverum Renal Care Center, Potsdam, Germany.,Medical Faculty, University Clinic for Cardiology and Angiology
| | - Martin Ernst
- From the Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany.,Medical Faculty
| | - Siegfried Kropf
- Medical Faculty, Institute for Biometrics and Medical Informatics, Otto von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Anja Haase-Fielitz
- Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.,Faculty of Health Sciences Brandenburg, Potsdam, Germany.,Institute of Integrated Health Care Systems Research & Social Medicine, Otto von-Guericke-University Magdeburg, Magdeburg, Germany.,Department of Cardiology, Brandenburg Heart Center, Immanuel Hospital, Bernau, Germany
| | - Michael Haase
- Department of Anesthesiology and Intensive Care, Helios Klinikum Leisnig, Leisnig, Germany.,Medical Faculty
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McMahon KR, Chui H, Rassekh SR, Schultz KR, Blydt-Hansen TD, Mammen C, Pinsk M, Cuvelier GDE, Carleton BC, Tsuyuki RT, Ross CJ, Devarajan P, Huynh L, Yordanova M, Crépeau-Hubert F, Wang S, Cockovski V, Palijan A, Zappitelli M. Urine Neutrophil Gelatinase-Associated Lipocalin and Kidney Injury Molecule-1 to Detect Pediatric Cisplatin-Associated Acute Kidney Injury. Kidney360 2021; 3:37-50. [PMID: 35368557 PMCID: PMC8967607 DOI: 10.34067/kid.0004802021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/29/2021] [Indexed: 01/12/2023]
Abstract
Background Few studies have described associations between the AKI biomarkers urinary neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1) with AKI in cisplatin-treated children. We aimed to describe excretion patterns of urine NGAL and KIM-1 and associations with AKI in children receiving cisplatin. Methods Participants (n=159) were enrolled between 2013 and 2017 in a prospective cohort study conducted in 12 Canadian pediatric hospitals. Participants were evaluated at early cisplatin infusions (at first or second cisplatin cycle) and late cisplatin infusions (last or second-to-last cycle). Urine NGAL and KIM-1 were measured (1) pre-cisplatin infusion, (2) post-infusion (morning after), and (3) at hospital discharge at early and late cisplatin infusions. Primary outcome: AKI defined by serum creatinine rise within 10 days post-cisplatin, on the basis of Kidney Disease Improving Global Outcomes guidelines criteria (stage 1 or higher). Results Of 159 children, 156 (median [interquartile range (IQR)] age: 5.8 [2.4-12.0] years; 78 [50%] female) had biomarker data available at early cisplatin infusions and 127 had data at late infusions. Forty six of the 156 (29%) and 22 of the 127 (17%) children developed AKI within 10 days of cisplatin administration after early and late infusions, respectively. Urine NGAL and KIM-1 concentrations were significantly higher in patients with versus without AKI (near hospital discharge of late cisplatin infusion, median [IQR] NGAL levels were 76.1 [10.0-232.7] versus 14.9 [5.4-29.7] ng/mg creatinine; KIM-1 levels were 4415 [2083-9077] versus 1049 [358-3326] pg/mg creatinine; P<0.01). These markers modestly discriminated for AKI (area under receiver operating characteristic curve [AUC-ROC] range: NGAL, 0.56-0.72; KIM-1, 0.48-0.75). Biomarker concentrations were higher and better discriminated for AKI at late cisplatin infusions (AUC-ROC range, 0.54-0.75) versus early infusions (AUC-ROC range, 0.48-0.65). Conclusions Urine NGAL and KIM-1 were modest at discriminating for cisplatin-associated AKI. Further research is needed to determine clinical utility and applicability of these markers and associations with late kidney outcomes.
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Affiliation(s)
- Kelly R. McMahon
- Division of Nephrology, Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University Health Centre, Montreal Children’s Hospital, Montreal, Quebec, Canada,Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Hayton Chui
- Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada,Faculty of Health Sciences, McMaster Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Shahrad Rod Rassekh
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Pediatrics, University of British Columbia, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Kirk R. Schultz
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Pediatrics, University of British Columbia, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Tom D. Blydt-Hansen
- Division of Pediatric Nephrology, Department of Pediatrics, University of British Columbia, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Cherry Mammen
- Division of Pediatric Nephrology, Department of Pediatrics, University of British Columbia, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Maury Pinsk
- Department of Pediatrics and Child Health, Section of Pediatric Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Geoffrey D. E. Cuvelier
- Division of Pediatric Oncology-Hematology-BMT, Department of Pediatrics and Child Health, University of Manitoba, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Bruce C. Carleton
- Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia and BC Children’s Hospital and Research Institute, Vancouver, British Columbia, Canada
| | - Ross T. Tsuyuki
- EPICORE Centre, Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Colin J.D. Ross
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Louis Huynh
- Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Mariya Yordanova
- Faculty of Medicine and Health Sciences, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Frédérik Crépeau-Hubert
- Division of Nephrology, Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University Health Centre, Montreal Children’s Hospital, Montreal, Quebec, Canada
| | - Stella Wang
- Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Vedran Cockovski
- Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Ana Palijan
- Division of Nephrology, Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University Health Centre, Montreal Children’s Hospital, Montreal, Quebec, Canada
| | - Michael Zappitelli
- Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada,Department of Pediatrics, Division of Nephrology, Toronto Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Elitok S, Isermann B, Westphal S, Devarajan P, Albert C, Kuppe H, Ernst M, Bellomo R, Haase M, Haase-Fielitz A. Urinary biomarkers to predict severe fluid overload after cardiac surgery: a pilot study. Biomark Med 2021; 15:1451-1464. [PMID: 34672680 DOI: 10.2217/bmm-2021-0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 01/20/2023] Open
Abstract
Aim: To assess the predictive ability of urinary and plasma biomarkers and clinical routine parameters for subsequent severe fluid overload. Patients & methods: In a pilot study, we studied 100 adult patients after cardiac surgery. On intensive care unit admission, we measured biomarkers in urine (midkine, IL-6, neutrophil gelatinase-associated lipocalin [NGAL], hepcidin-25) and plasma (creatinine, urea, B-type natriuretic peptide, lactate, C-reactive protein, leukocytes, IL-6, NGAL, hepcidin-25) to predict postoperative severe fluid overload. Results: Urinary midkine, IL-6, NGAL and hepcidin-25 (all AUCs ≥0.79) predicted postoperative severe fluid overload (n = 5 patients). Urinary NGAL/hepcidin-25 ratio (AUC 0.867) predicted postoperative severe fluid overload after adjustment to EuroScore and need for norepinephrine on surgery day (odds ratio: 2.4). Conclusion: Urinary biomarkers on intensive care unit admission might be helpful to predict subsequent severe fluid overload after cardiac surgery.
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Affiliation(s)
- Saban Elitok
- Department of Nephrology & Endocrinology, Ernst von Bergmann Hospital Potsdam, Charlottenstr. 72, Potsdam, 14467, Germany
| | - Berend Isermann
- Institute of Laboratory Medicine, Leipzig University Hospital, Paul-List-Str. 13/15, Leipzig, 04103, Germany
| | - Sabine Westphal
- Institute of Laboratory Medicine, Tertiary Hospital Dessau, Auenweg 38, Dessau-Roßlau, 06847, Germany
| | - Prasad Devarajan
- Department of Nephrology & Hypertension, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Christian Albert
- Diaverum Renal Care Center, Am Neuen Garten 11, 14469 Potsdam, Germany & Diaverum AB, Hyllie Boulevard 35, Malmö, 21532, Sweden.,Medical Faculty, University Clinic for Cardiology & Angiology, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Hermann Kuppe
- Institute of Anesthesiology, German Heart Center, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Martin Ernst
- Department of Nephrology & Endocrinology, Ernst von Bergmann Hospital Potsdam, Charlottenstr. 72, Potsdam, 14467, Germany.,Medical Faculty, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, 145 Studley Rd, Heidelberg VIC 3084, Melbourne, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Michael Haase
- Diaverum Renal Care Center, Am Neuen Garten 11, 14469 Potsdam, Germany & Diaverum AB, Hyllie Boulevard 35, Malmö, 21532, Sweden.,Medical Faculty, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Brandenburg Heart Center, Immanuel Hospital, Ladeburger Str. 17, Bernau, 16321, Germany.,Brandenburg Medical School Theodor Fontane, Fehrbelliner Str. 38, Neuruppin, 16816, Germany.,Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany.,Institute of Social Medicine & Health Care Systems Research, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
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29
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Cody EM, Bennett MR, Gulati G, Ma Q, Altaye M, Devarajan P, Brunner HI. Corrigendum to "Successful Urine Multiplex Bead Assay to Measure Lupus Nephritis Activity" Kidney Int. Rep. 2021;6:1949-1960. Kidney Int Rep 2021; 6:2735. [PMID: 34622116 PMCID: PMC8484113 DOI: 10.1016/j.ekir.2021.08.023] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ellen M Cody
- Department of Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael R Bennett
- Department of Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Gaurav Gulati
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Qing Ma
- Nephrology and Hypertension Clinical Laboratory, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hermine I Brunner
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Flannery AH, Ortiz-Soriano V, Li X, Gianella FG, Toto RD, Moe OW, Devarajan P, Goldstein SL, Neyra JA. Serum renin and major adverse kidney events in critically ill patients: a multicenter prospective study. Crit Care 2021; 25:294. [PMID: 34391450 PMCID: PMC8364694 DOI: 10.1186/s13054-021-03725-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/04/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Preliminary studies have suggested that the renin-angiotensin system is activated in critical illness and associated with mortality and kidney outcomes. We sought to assess in a larger, multicenter study the relationship between serum renin and Major Adverse Kidney Events (MAKE) in intensive care unit (ICU) patients. METHODS Prospective, multicenter study at two institutions of patients with and without acute kidney injury (AKI). Blood samples were collected for renin measurement a median of 2 days into the index ICU admission and 5-7 days later. The primary outcome was MAKE at hospital discharge, a composite of mortality, kidney replacement therapy, or reduced estimated glomerular filtration rate to ≤ 75% of baseline. RESULTS Patients in the highest renin tertile were more severely ill overall, including more AKI, vasopressor-dependence, and severity of illness. MAKE were significantly greater in the highest renin tertile compared to the first and second tertiles. In multivariable logistic regression, this initial measurement of renin remained significantly associated with both MAKE as well as the individual component of mortality. The association of renin with MAKE in survivors was not statistically significant. Renin measurements at the second time point were also higher in patients with MAKE. The trajectory of the renin measurements between time 1 and 2 was distinct when comparing death versus survival, but not when comparing MAKE versus those without. CONCLUSIONS In a broad cohort of critically ill patients, serum renin measured early in the ICU admission is associated with MAKE at discharge, particularly mortality.
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Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Victor Ortiz-Soriano
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fabiola G Gianella
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert D Toto
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA.
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Stenvinkel P, Chertow GM, Devarajan P, Levin A, Andreoli SP, Bangalore S, Warady BA. Chronic Inflammation in Chronic Kidney Disease Progression: Role of Nrf2. Kidney Int Rep 2021; 6:1775-1787. [PMID: 34307974 PMCID: PMC8258499 DOI: 10.1016/j.ekir.2021.04.023] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 12/16/2022] Open
Abstract
Despite recent advances in the management of chronic kidney disease (CKD), morbidity and mortality rates in these patients remain high. Although pressure-mediated injury is a well-recognized mechanism of disease progression in CKD, emerging data indicate that an intermediate phenotype involving chronic inflammation, oxidative stress, hypoxia, senescence, and mitochondrial dysfunction plays a key role in the etiology, progression, and pathophysiology of CKD. A variety of factors promote chronic inflammation in CKD, including oxidative stress and the adoption of a proinflammatory phenotype by resident kidney cells. Regulation of proinflammatory and anti-inflammatory factors through NF-κB- and nuclear factor, erythroid 2 like 2 (Nrf2)-mediated gene transcription, respectively, plays a critical role in the glomerular and tubular cell response to kidney injury. Chronic inflammation contributes to the decline in glomerular filtration rate (GFR) in CKD. Whereas the role of chronic inflammation in diabetic kidney disease (DKD) has been well-elucidated, there is now substantial evidence indicating unresolved inflammatory processes lead to fibrosis and eventual end-stage kidney disease (ESKD) in several other diseases, such as Alport syndrome, autosomal-dominant polycystic kidney disease (ADPKD), IgA nephropathy (IgAN), and focal segmental glomerulosclerosis (FSGS). In this review, we aim to clarify the mechanisms of chronic inflammation in the pathophysiology and disease progression across the spectrum of kidney diseases, with a focus on Nrf2.
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Affiliation(s)
- Peter Stenvinkel
- Department of Renal Medicine M99, Karolinska University Hospital at Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Glenn M Chertow
- Division of Nephrology, Stanford University, Stanford, California, USA
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adeera Levin
- Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Sharon P Andreoli
- Department of Pediatrics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Sripal Bangalore
- Division of Cardiology, New York University, New York, New York, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Lebel A, Chui H, McMahon KR, Lim YJ, Macri J, Wang S, Devarajan P, Blydt-Hansen TD, Zappitelli M, Urquhart BL. Association of Urine Platinum With Acute Kidney Injury in Children Treated With Cisplatin for Cancer. J Clin Pharmacol 2021; 61:871-880. [PMID: 33599997 PMCID: PMC8283690 DOI: 10.1002/jcph.1839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/13/2020] [Accepted: 02/15/2021] [Indexed: 01/19/2023]
Abstract
Cisplatin is a chemotherapeutic agent highly excreted in urine and known to cause acute kidney injury (AKI). As AKI diagnosis by serum creatinine (SCr) is usually delayed, endeavors for finding early AKI biomarkers continue. This study aims to determine if urine platinum (UP) concentration 24 hours after cisplatin infusion is associated with AKI, and to evaluate the association between urine platinum and tubular damage biomarkers: neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). Children treated with cisplatin in 12 Canadian centers (April 2013 to December 2017) were included. Urine from the morning after the first cisplatin infusion of the first or second cisplatin cycle was measured for urine platinum, NGAL, and KIM-1. SCr and serum electrolytes were used to detect AKI by either SCr elevation or urinary electrolyte wasting (potassium, magnesium, phosphate). The associations of urine platinum with AKI, NGAL, and KIM-1 were assessed. A total of 115 participants (54% boys, median age, 8.5 years; interquartile range, 4.0-13.4) were included, of which 29 (25%) and 105 (91%) developed AKI defined by SCr and electrolyte criteria, respectively. Higher urine platinum was associated with higher cisplatin dose (Spearman rho, 0.21) and with younger age (Spearman rho, -0.33). Urine platinum was not associated with postinfusion AKIor KIM-1, but was weakly associated with NGAL, particularly in participants without SCr AKI (Pearson's r, 0.22). Urine platinum may be a marker of mild tubular injury but is not likely to be a useful biomarker of clinically evident AKI.
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Affiliation(s)
- Asaf Lebel
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hayton Chui
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kelly R. McMahon
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Yong Jin Lim
- Schulich School of Medicine and Dentistry, Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Joseph Macri
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Stella Wang
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tom D. Blydt-Hansen
- British Columbia Children's Hospital, Division of Pediatric Nephrology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bradley L. Urquhart
- Schulich School of Medicine and Dentistry, Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
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Fredric D, Greenberg JH, Parikh CR, Devarajan P, Chui H, Cockovski V, Pizzi M, Palijan A, Hessey E, Jia Y, Thiessen-Philbrook HR, Zappitelli M. 24-hour ambulatory blood pressure monitoring 9 years after pediatric cardiac surgery: a pilot and feasibility study. Pediatr Nephrol 2021; 36:1533-1541. [PMID: 33411068 PMCID: PMC10942669 DOI: 10.1007/s00467-020-04847-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/20/2019] [Revised: 09/30/2020] [Accepted: 10/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Children undergoing cardiac surgery are at risk of high blood pressure (BP), a risk factor for cardiovascular and kidney disease. Twenty-four-hour ambulatory BP monitoring (ABPM) is a reference standard hypertension (HTN) test. Little data exist on ABPM abnormalities in children several years post cardiac surgery. This study aimed to (a) determine ABPM feasibility; (b) describe and compare ABPM measures and abnormalities (percent load, masked HTN [MH]; non-dipping, mean systolic/diastolic BP > 95th percentile; pre-HTN (ABPM); white-coat HTN [WCH]) to casual BP; and (c) compare BP in patients with and without acute kidney injury (AKI). METHODS Prospective, follow-up pilot study of children (0-18 years) who underwent cardiac surgery from 2007 to 2009 at Montreal Children's Hospital. We recorded if participants had post-operative AKI and assessed the following outcomes at 9-year follow-up: casual BP classified by three single-visit measures (normal; elevated BP [eBPSingleVisit]; HTNSingleVisit); ABPM. Bivariable analyses were used to compare characteristics between groups. RESULTS Twenty-three patients (median [interquartile range], 8.6 [8.0, 9.0] years post cardiac surgery) were included; 16 (70%) male. Six participants (26%) had eBPSingleVisit or higher. On ABPM, 11 (48%) had ≥ 1 abnormality: 9 (39%) had non-dipping; 3 (13%) had pre-HTN; 3 (13%) had WCH; none had HTN or MH. There were no differences in ABPM according to AKI status. CONCLUSION Our pilot study determined that ABPM was feasible in children years after cardiac surgery and frequently identified ABPM abnormalities. Future research in larger populations is needed to define specific risk factors for HTN in children after cardiac surgery.
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Affiliation(s)
- Daniel Fredric
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada
| | - Jason H Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Hayton Chui
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada
| | - Vedran Cockovski
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada
| | - Michael Pizzi
- McGill University Health Centre Research Institute, Montreal, QC, Canada
| | - Ana Palijan
- McGill University Health Centre Research Institute, Montreal, QC, Canada
| | - Erin Hessey
- Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Yaqi Jia
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada.
- McGill University Health Centre Research Institute, Montreal, QC, Canada.
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Elitok S, Devarajan P, Bellomo R, Isermann B, Haase M, Haase-Fielitz A. NGAL/hepcidin-25 ratio and AKI subtypes in patients following cardiac surgery: a prospective observational study. J Nephrol 2021; 35:597-605. [PMID: 34028701 PMCID: PMC8926978 DOI: 10.1007/s40620-021-01063-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/09/2021] [Indexed: 11/25/2022]
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. Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01063-5.
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Affiliation(s)
- Saban Elitok
- Department of Nephrology and Endocrinology, Ernst Von Bergmann Hospital Potsdam, 14467, Potsdam, Germany
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, OH, 45229, USA
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, Melbourne, VIC, 3052, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Melbourne, VIC, 3084, Australia.,Center for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Berend Isermann
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostic, Leipzig University Hospital, 04103, Leipzig, Germany
| | - Michael Haase
- Diaverum AB, Renal Care Center Potsdam, 21532, Malmö, Sweden. .,Medical Faculty, Otto Von-Guericke-University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Anja Haase-Fielitz
- Brandenburg Medical School Theodor Fontane, 16816, Neuruppin, Germany.,Faculty of Health Sciences Brandenburg, Potsdam, Germany.,Institute of Integrated Health Care Systems Research and Social Medicine, Otto Von-Guericke-University Magdeburg, 39120, Magdeburg, Germany.,Department of Cardiology, Brandenburg Heart Center, Immanuel Hospital, 16321, Bernau, Germany
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Standage SW, Xu S, Brown L, Ma Q, Koterba A, Lahni P, Devarajan P, Kennedy MA. NMR-based serum and urine metabolomic profile reveals suppression of mitochondrial pathways in experimental sepsis-associated acute kidney injury. Am J Physiol Renal Physiol 2021; 320:F984-F1000. [PMID: 33843271 DOI: 10.1152/ajprenal.00582.2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Sepsis-associated acute kidney injury (SA-AKI) is a significant problem in the critically ill that causes increased death. Emerging understanding of this disease implicates metabolic dysfunction in its pathophysiology. This study sought to identify specific metabolic pathways amenable to potential therapeutic intervention. Using a murine model of sepsis, blood and tissue samples were collected for assessment of systemic inflammation, kidney function, and renal injury. Nuclear magnetic resonance (NMR)-based metabolomics quantified dozens of metabolites in serum and urine that were subsequently submitted to pathway analysis. Kidney tissue gene expression analysis confirmed the implicated pathways. Septic mice had elevated circulating levels of inflammatory cytokines and increased levels of blood urea nitrogen and creatinine, indicating both systemic inflammation and poor kidney function. Renal tissue showed only mild histological evidence of injury in sepsis. NMR metabolomic analysis identified the involvement of mitochondrial pathways associated with branched-chain amino acid metabolism, fatty acid oxidation, and de novo NAD+ biosynthesis in SA-AKI. Renal cortical gene expression of enzymes associated with those pathways was predominantly suppressed. Renal cortical fatty acid oxidation rates were lower in septic mice with high inflammation, and this correlated with higher serum creatinine levels. Similar to humans, septic mice demonstrated renal dysfunction without significant tissue disruption, pointing to metabolic derangement as an important contributor to SA-AKI pathophysiology. Metabolism of branched-chain amino acid and fatty acids and NAD+ synthesis, which all center on mitochondrial function, appeared to be suppressed. Developing interventions to activate these pathways may provide new therapeutic opportunities for SA-AKI.NEW & NOTEWORTHY NMR-based metabolomics revealed disruptions in branched-chain amino acid metabolism, fatty acid oxidation, and NAD+ synthesis in sepsis-associated acute kidney injury. These pathways represent essential processes for energy provision in renal tubular epithelial cells and may represent targetable mechanisms for therapeutic intervention.
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Affiliation(s)
- Stephen W Standage
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Shenyuan Xu
- Department of Chemistry and Biochemistry, Miami University, Oxford, Ohio
| | - Lauren Brown
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Qing Ma
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adeleine Koterba
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.,Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael A Kennedy
- Department of Chemistry and Biochemistry, Miami University, Oxford, Ohio
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36
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Greenberg JH, Parsons M, Zappitelli M, Jia Y, Thiessen-Philbrook HR, Devarajan P, Everett AD, Parikh CR. Cardiac Biomarkers for Risk Stratification of Acute Kidney Injury After Pediatric Cardiac Surgery. Ann Thorac Surg 2021; 111:191-198. [PMID: 32283087 PMCID: PMC7554084 DOI: 10.1016/j.athoracsur.2020.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/13/2020] [Accepted: 03/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Children undergoing a cardiac surgical procedure are at increased risk for acute kidney injury (AKI). Novel biomarkers are needed to improve risk stratification of AKI after cardiac surgery. METHODS We enrolled children aged 1 month to 18 years old from July 2007 to December 2010 undergoing cardiopulmonary bypass. Three United States Food and Drug Administration-approved plasma biomarkers of cardiac stretch, N-terminal pro B-type natriuretic peptide (NTproBNP), inflammation (ST2), or fibrosis (galectin-3), were measured preoperatively and postoperatively within 6 hours of cardiac surgery. All analyses were stratified by age (<2 or ≥2 years old) to account for changing biomarker distributions during childhood and due to a significant interaction between biomarker and age for galectin-3 and NTproBNP (P < .05). RESULTS Postoperatively, AKI, defined by a doubling of baseline serum creatinine, was diagnosed in 51 of 194 children <2 years and in 28 of 201 children ≥2 years. After multivariable adjustment, for children <2 years, none of the biomarkers were independently associated with AKI, whereas for children ≥2 years, the highest tertile of preoperative galectin-3 and NTproBNP as well as the postoperative galectin-3 and ST2 were associated with AKI. CONCLUSIONS Preoperative plasma galectin-3 and NTproBNP and the first postoperative galectin-3 and ST2 levels were independently associated with AKI in children ≥2 years old. The performance of cardiac biomarkers after cardiac surgical procedure is affected by age, and research is required to develop biomarkers for children <2 years old.
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Affiliation(s)
- Jason H Greenberg
- Section of Nephrology, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut; Program of Applied Translational Research, Yale School of Medicine, New Haven, Connecticut
| | - Michael Parsons
- Division of Cardiology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Michael Zappitelli
- Division of Nephrology, Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaqi Jia
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Chirag R Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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Steubl D, Buzkova P, Garimella PS, Ix JH, Devarajan P, Bennett MR, Chaves PHM, Shlipak MG, Bansal N, Sarnak MJ. Association of serum uromodulin with mortality and cardiovascular disease in the elderly-the Cardiovascular Health Study. Nephrol Dial Transplant 2020; 35:1399-1405. [PMID: 30903163 DOI: 10.1093/ndt/gfz008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/09/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Uromodulin (UMOD) is released by renal tubular cells into the serum (sUMOD) and urine. Lower urine UMOD has been linked to mortality and cardiovascular disease but much less is known about sUMOD. We evaluated the association of sUMOD with these outcomes in community-dwelling older adults. METHODS We measured sUMOD in a random subcohort of 933 participants enrolled in the Cardiovascular Health Study. The associations of sUMOD with all-cause mortality, incident heart failure (HF) and incident cardiovascular disease (CVD; myocardial infarction, stroke and mortality due to coronary disease or stroke) were evaluated using multivariable Cox regression, adjusting for study participants' demographics, estimated glomerular filtration rate (eGFR), albuminuria and CVD risk factors. Generalized additive models with splines were used to address the functional form of sUMOD with outcomes. Due to nonlinear associations of sUMOD with all outcomes, 2.5% of the values on either end of the sUMOD distribution were excluded from the analyses, limiting the range of sUMOD to 34.3-267.1 ng/mL. RESULTS The mean age was 78 ± 5 years, 40% were male, sUMOD level was 127 ± 64 ng/mL, eGFR was 63 mL/min/1.73 m2 and 42% had CKD defined as eGFR <60 mL/min/1.73 m2. Patients in the lower sUMOD quartiles had lower eGFR and higher albuminuria (P < 0.01, respectively). During a median follow-up of 9.9 years, 805 patients died, 283 developed HF and 274 developed CVD. In multivariable analysis, higher sUMOD was significantly associated with a lower hazard for mortality {hazard ratio [HR] 0.89 [95% confidence interval (CI) 0.80-0.99] per 1 standard deviation (SD) higher sUMOD}, CVD [HR 0.80 (95% CI 0.67-0.96)] and the composite endpoint [HR 0.88 (95% CI 0.78-0.99)]; the association with HF was not statistically significant [HR 0.84 (95% CI 0.70-1.01)]. CONCLUSION Higher sUMOD is independently associated with a lower risk for mortality and CVD in older adults.
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Affiliation(s)
- Dominik Steubl
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Tufts University, Boston, MA, USA.,Division of Nephrology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Petra Buzkova
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Pranav S Garimella
- Division of Nephrology, University of California, San Diego, San Diego, CA, USA
| | - Joachim H Ix
- Division of Nephrology, University of California, San Diego, San Diego, CA, USA
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Michael R Bennett
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Paulo H M Chaves
- Benjamin Leon Center for Geriatric Research and Education, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael G Shlipak
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Tufts University, Boston, MA, USA
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Benoit SW, Kathman T, Patel J, Stegman M, Cobb C, Hoehn J, Devarajan P, Nehus EJ. GFR Estimation After Cystatin C Reference Material Change. Kidney Int Rep 2020; 6:429-436. [PMID: 33615068 PMCID: PMC7879112 DOI: 10.1016/j.ekir.2020.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Glomerular filtration rate (GFR) is routinely estimated with cystatin C. In June 2010, the International Federation of Clinical Chemistry (IFCC) released a certified cystatin C reference material (ERM-DA471/IFCC), and new cystatin C glomerular filtration rate estimation (eGFR) equations were developed with the IFCC standard. Early in 2018, Siemens discontinued their nonstandardized cystatin C reagent kits and replaced them with IFCC-calibrated kits in the US market. The aim of the current study was to assess the effect of IFCC calibration on cystatin C values and corresponding GFR estimations. Methods Cystatin C concentration was measured in 81 pediatric patients using a plasma sample from their nuclear GFR measurement with 99mTc-diethylenetriaminepentaaccetic acid. Calibration curves were generated using Siemens nonstandardized and IFCC-standardized kits to measure paired cystatin C concentrations in each sample. GFR-estimating equations using pre-IFCC and IFCC cystatin C values were compared using Bland-Altman analyses. Results The IFCC-standardized assay resulted in a mean increase in the measured cystatin C value of 24%. Estimating equations consistently overestimated GFR prior to IFCC standardization. Following incorporation of the IFCC standard, the Full Age Spectrum equation demonstrated the best overall performance, whereas the Chronic Kidney Disease in Children (CKiD) equation was more accurate in children with decreased GFR. Conclusion Incorporation of the IFCC standard significantly increased cystatin C values and affected the performance of GFR estimating equations. Clinical laboratories and providers may need to update the equation used for cystatin C-based estimation of GFR following adoption of the IFCC reference standard.
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Affiliation(s)
- Stefanie W Benoit
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Thelma Kathman
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jay Patel
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Melinda Stegman
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cristina Cobb
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jonathan Hoehn
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Edward J Nehus
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
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Albert C, Zapf A, Haase M, Röver C, Pickering JW, Albert A, Bellomo R, Breidthardt T, Camou F, Chen Z, Chocron S, Cruz D, de Geus HRH, Devarajan P, Di Somma S, Doi K, Endre ZH, Garcia-Alvarez M, Hjortrup PB, Hur M, Karaolanis G, Kavalci C, Kim H, Lentini P, Liebetrau C, Lipcsey M, Mårtensson J, Müller C, Nanas S, Nickolas TL, Pipili C, Ronco C, Rosa-Diez GJ, Ralib A, Soto K, Braun-Dullaeus RC, Heinz J, Haase-Fielitz A. Neutrophil Gelatinase-Associated Lipocalin Measured on Clinical Laboratory Platforms for the Prediction of Acute Kidney Injury and the Associated Need for Dialysis Therapy: A Systematic Review and Meta-analysis. Am J Kidney Dis 2020; 76:826-841.e1. [PMID: 32679151 PMCID: PMC8283708 DOI: 10.1053/j.ajkd.2020.05.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 05/24/2020] [Indexed: 01/02/2023]
Abstract
RATIONALE & OBJECTIVE The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction. STUDY DESIGN Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines. SETTING & STUDY POPULATIONS Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms. SELECTION CRITERIA FOR STUDIES PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI. DATA EXTRACTION Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis. ANALYTICAL APPROACH Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses. RESULTS We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively. LIMITATIONS Practice variability in initiation of dialysis. Imperfect harmonization of data across studies. CONCLUSIONS Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.
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Affiliation(s)
- Christian Albert
- University Clinic for Cardiology and Angiology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany; Diaverum Renal Services Germany, Potsdam, Germany.
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Michael Haase
- Faculty of Medicine, Otto-von-Guericke University, Magdeburg, Germany; Diaverum Renal Services Germany, Potsdam, Germany
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - John W Pickering
- Department of Medicine, University of Otago Christchurch; Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Annemarie Albert
- Diaverum Renal Services Germany, Potsdam, Germany; Department for Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, The Austin Hospital, Melbourne, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Tobias Breidthardt
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Nephrology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Fabrice Camou
- Service de réanimation médicale, hôpital Saint-André, CHU de Bordeaux, France
| | - Zhongquing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangdong, China
| | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Dinna Cruz
- Division of Nephrology-Hypertension, University of California, San Diego, CA
| | - Hilde R H de Geus
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH
| | - Salvatore Di Somma
- Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sapienza' University of Rome S. Andrea Hospital, Rome, Italy
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | | | - Peter B Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Cemil Kavalci
- Emergency Department, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Hanah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Paolo Lentini
- Department of Nephrology and Dialysis, San Bassiano Hospital, Bassano del Grappa, Italy
| | | | - Miklós Lipcsey
- CIRRUS, Hedenstierna laboratory, Anaesthesiology and Intensive care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Mårtensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Christian Müller
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Nephrology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Serafim Nanas
- First Critical Care Department, 'Evangelismos' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas L Nickolas
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Chrysoula Pipili
- First Critical Care Department, 'Evangelismos' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Claudio Ronco
- Department of Nephrology, Dialysis & Transplantation, University of Padova, Vicenza, Italy; International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Guillermo J Rosa-Diez
- Department of Nephrology, Dialysis and Transplantation, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Azrina Ralib
- Department of Anaesthesiology and Intensive Care, International Islamic University Malaysia, Pahang, Malaysia
| | - Karina Soto
- Department of Nephrology, Hospital Fernando Fonseca, Lisbon, Portugal; CEAUL, Centro de Estatística e Aplicações da Universidade de Lisboa, Lisbon, Portugal
| | - Rüdiger C Braun-Dullaeus
- University Clinic for Cardiology and Angiology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| | - Judith Heinz
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane, Faculty of Health Sciences, University of Potsdam, Potsdam, Germany
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Nunes S, Brown J, Parikh CR, Greenberg JH, Devarajan P, Philbrook HT, Pizzi M, Palijan A, Zappitelli M. The association of acute kidney injury with hospital readmission and death after pediatric cardiac surgery. JTCVS Open 2020; 4:70-85. [PMID: 36004303 PMCID: PMC9390193 DOI: 10.1016/j.xjon.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/08/2020] [Accepted: 07/20/2020] [Indexed: 11/17/2022]
Abstract
Background Acute kidney injury (AKI) in children undergoing cardiac surgery (CS) is strongly associated with increased hospital mortality and length of stay. The association of AKI with postdischarge outcomes is unclear. We evaluated the association of AKI with all-cause readmissions and death within 30 days and 1 year of CS discharge. Methods This was a prospective, 3-center cohort study of children after CS with cardiopulmonary bypass. The primary exposures were postoperative ≥stage 1 AKI and ≥stage 2 AKI defined by Kidney Disease: Improving Global Outcomes AKI definition. Two separate outcomes were hospital readmission and death within 30 days and 1 year of discharge. Association of AKI with time to outcomes was determined using multivariable Cox-proportional hazards analysis. Age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk adjustment tool score ≥3, cardiopulmonary bypass >120 minutes, and cyanotic heart disease were evaluated as effect modifiers. Results Of 402 participants included (median age 1.8 years [interquartile range 0.4, 5.2]), 32 (8.0%) and 109 (27.1%) were readmitted; 7 (1.7%) and 9 (2.2%) died within 30 days and 1 year of CS, respectively. AKI was not associated with readmission at 30 days or 1 year postdischarge. ≥Stage 2 AKI (adjusted hazard ratio, 11.68 [1.88, 72.61]) was associated with mortality 30 days post-CS. Conclusions Postoperative AKI was not associated with readmission at 30 days and 1-year postdischarge. However, more severe AKI (≥stage 2) appears to be associated with increased morality risk at 30 days post-CS.
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Affiliation(s)
- Sophia Nunes
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeremiah Brown
- Departments of Epidemiology and Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jason H. Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Michael Pizzi
- McGill University Health Research Institute Centre, Montreal, Québec, Canada
| | - Ana Palijan
- McGill University Health Research Institute Centre, Montreal, Québec, Canada
| | - Michael Zappitelli
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Address for reprints: Michael Zappitelli, MD, MSc, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St, 11th Floor, Room 11.9722, Toronto, Ontario, M5G 0A4 Canada.
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Rudman-Melnick V, Adam M, Potter A, Chokshi SM, Ma Q, Drake KA, Schuh MP, Kofron JM, Devarajan P, Potter SS. Single-Cell Profiling of AKI in a Murine Model Reveals Novel Transcriptional Signatures, Profibrotic Phenotype, and Epithelial-to-Stromal Crosstalk. J Am Soc Nephrol 2020; 31:2793-2814. [PMID: 33115917 DOI: 10.1681/asn.2020010052] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/26/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Current management of AKI, a potentially fatal disorder that can also initiate or exacerbate CKD, is merely supportive. Therefore, deeper understanding of the molecular pathways perturbed in AKI is needed to identify targets with potential to lead to improved treatment. METHODS We performed single-cell RNA sequencing (scRNA-seq) with the clinically relevant unilateral ischemia-reperfusion murine model of AKI at days 1, 2, 4, 7, 11, and 14 after AKI onset. Using real-time quantitative PCR, immunofluorescence, Western blotting, and both chromogenic and single-molecule in situ hybridizations, we validated AKI signatures in multiple experiments. RESULTS Our findings show the time course of changing gene expression patterns for multiple AKI stages and all renal cell types. We observed elevated expression of crucial injury response factors-including kidney injury molecule-1 (Kim1), lipocalin 2 (Lcn2), and keratin 8 (Krt8)-and of several novel genes (Ahnak, Sh3bgrl3, and Col18a1) not previously examined in kidney pathologies. AKI induced proximal tubule dedifferentiation, with a pronounced nephrogenic signature represented by Sox4 and Cd24a. Moreover, AKI caused the formation of "mixed-identity cells" (expressing markers of different renal cell types) that are normally seen only during early kidney development. The injured tubules acquired a proinflammatory and profibrotic phenotype; moreover, AKI dramatically modified ligand-receptor crosstalk, with potential pathologic epithelial-to-stromal interactions. Advancing age in AKI onset was associated with maladaptive response and kidney fibrosis. CONCLUSIONS The scRNA-seq, comprehensive, cell-specific profiles provide a valuable resource for examining molecular pathways that are perturbed in AKI. The results fully define AKI-associated dedifferentiation programs, potential pathologic ligand-receptor crosstalk, novel genes, and the improved injury response in younger mice, and highlight potential targets of kidney injury.
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Affiliation(s)
- Valeria Rudman-Melnick
- Division of Developmental Biology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Mike Adam
- Division of Developmental Biology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Andrew Potter
- Division of Developmental Biology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Saagar M Chokshi
- Division of Nephrology and Hypertension, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Qing Ma
- Division of Nephrology and Hypertension, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Keri A Drake
- Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Meredith P Schuh
- Division of Nephrology and Hypertension, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - J Matthew Kofron
- Division of Developmental Biology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - S Steven Potter
- Division of Developmental Biology, Cincinnati Children's Medical Center, Cincinnati, Ohio
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Stone HK, Parameswaran S, Eapen AA, Chen X, Harley JB, Devarajan P, Weirauch MT, Kottyan L. Comprehensive Review of Steroid-Sensitive Nephrotic Syndrome Genetic Risk Loci and Transcriptional Regulation as a Possible Mechanistic Link to Disease Risk. Kidney Int Rep 2020; 6:187-195. [PMID: 33426398 PMCID: PMC7783560 DOI: 10.1016/j.ekir.2020.09.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/01/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction The etiology of steroid-sensitive nephrotic syndrome (SSNS) is not well understood. Genetic studies have established common single nucleotide polymorphisms (SNPs) that are associated with increased SSNS disease risk. We review previous genetic association studies of SSNS and nominate particular transcriptional regulators and immune cells as potential key players in the etiology of this disease. Methods A list of SNPs associated with SSNS was compiled from published genome wide association and candidate gene studies. The Regulatory Element Locus Intersection (RELI) tool was used to calculate the enrichment of the overlap between disease risk SNPs and the genomic coordinates of data from a collection of >10,000 chromatin immunoprecipitation sequencing experiments. Results After linkage disequilibrium expansion of the previously reported tag associated SNPs, we identified 192 genetic variants at 8 independent risk loci. Using the Regulatory Element Locus Intersection algorithm, we identified transcriptional regulators with enriched binding at SSNS risk loci (10-05 < Pcorrected < 10-124), including ZNF530, CIITA, CD74, RFX5, and ZNF425. Many of these regulators have well-described roles in the immune response. RNA polymerase II binding in B cells also demonstrated enriched binding at SSNS risk loci (10-37<Pcorrected<10-5). Conclusion SSNS is a complex disease, and immune dysregulation has been previously implicated as a potential underlying cause. This assessment of established SSNS risk loci and analysis of possible function implicates transcriptional dysregulation, and specifically particular transcriptional regulators with known roles in the immune response, as important in the genetic etiology of SSNS.
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Affiliation(s)
- Hillarey K Stone
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sreeja Parameswaran
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Amy A Eapen
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Xiaoting Chen
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John B Harley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew T Weirauch
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Leah Kottyan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Zappitelli M, Parikh CR, Kaufman JS, Go AS, Kimmel PL, Hsu CY, Coca SG, Chinchilli VM, Greenberg JH, Moxey-Mims MM, Ikizler TA, Cockovski V, Dyer AM, Devarajan P. Acute Kidney Injury and Risk of CKD and Hypertension after Pediatric Cardiac Surgery. Clin J Am Soc Nephrol 2020; 15:1403-1412. [PMID: 32948644 PMCID: PMC7536759 DOI: 10.2215/cjn.00150120] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 08/04/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES The association of AKI after pediatric cardiac surgery with long-term CKD and hypertension development is unclear. The study objectives were to determine whether AKI after pediatric cardiac surgery is associated with incident CKD and hypertension. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a prospective cohort study of children of 1 month to 18 years old who were undergoing cardiac surgery at two tertiary care centers (Canada, United States). Participants were recruited before cardiac surgery and were followed during hospitalization and at 3, 12, 24, 36, and 48 months after discharge. Exposures were postoperative AKI, based on the Kidney Disease Improving Global Outcomes (KDIGO) definition, and age <2 years old at surgery. Outcomes and measures were CKD (low eGFR or albuminuria for age) and hypertension (per the 2017 American Academy of Pediatrics guidelines) at follow-up, with the composite outcome of CKD or hypertension. RESULTS Among 124 participants, 57 (46%) developed AKI. AKI versus non-AKI participants had a median (interquartile range) age of 8 (4.8-40.8) versus 46 (6.0-158.4) months, respectively, and higher preoperative eGFR. From the 3- to 48-month follow-up, the cohort prevalence of CKD was high (17%-20%); hypertension prevalence was also high (22%-30%). AKI was not significantly associated with the development of CKD throughout follow-up. AKI was associated with hypertension development at 12 months after discharge (adjusted relative risk, 2.16; 95% confidence interval, 1.18 to 3.95), but not at subsequent visits. Children aged <2 years old at surgery had a significantly higher prevalence of hypertension during follow-up than older children (40% versus 21% at 3-month follow-up; 32% versus 13% at 48-month follow-up). CONCLUSIONS CKD and hypertension burden in the 4 years after pediatric cardiac surgery is high. Young age at surgery, but not AKI, is associated with their development.
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Affiliation(s)
- Michael Zappitelli
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Chirag R. Parikh
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James S. Kaufman
- Veterans Affairs New York Harbor Healthcare System, New York University School of Medicine, New York, New York
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Chi-yuan Hsu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Steven G. Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine, Mount Sinai, New York
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Jason H. Greenberg
- Division of Nephrology, Department of Pediatrics, Yale University, New Haven, Connecticut
| | | | - T. Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Veteran’s Health Administration, Nashville, Tennessee
- Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vedran Cockovski
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Marie Dyer
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Abstract
INTRODUCTION Chronic kidney disease (CKD) is common, occurring in over 10% of individuals globally, and is increasing in prevalence. The limitations of traditional biomarkers of renal dysfunction, such as serum creatinine, have been well demonstrated in the literature. Therefore, augmenting clinical assessment with newer biomarkers, such as serum cystatin C, has the potential to improve disease monitoring and patient care. AREAS COVERED The present paper assesses the utility and limitations of serum cystatin C as a biomarker for CKD in light of the current literature. EXPERT OPINION Serum cystatin C has been well established as an early and accurate biomarker of CKD that is particularly helpful in patients for whom creatinine is an inadequate marker or for whom more cumbersome methods of glomerular filtration rate (GFR) measurement are impractical. Current research questions are no longer focused on if, but rather when and how often cystatin C should be used in the evaluation of CKD patients. However, transition of all reagents and estimated GFR equations to the newly established International Standard is critical for developing generalizable data.
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Affiliation(s)
- Stefanie Benoit
- Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Eileen A. Ciccia
- Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
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Chui H, Caldwell J, Yordanova M, Cockovski V, Fredric D, Harel-Sterling M, Haasz M, Al-Ismaili Z, Pizzi M, Ma Q, Devarajan P, Goldstein SL, Zappitelli M. Tubular injury and cell-cycle arrest biomarkers to predict acute kidney injury in noncritically ill children receiving aminoglycosides. Biomark Med 2020; 14:879-894. [PMID: 32808826 DOI: 10.2217/bmm-2019-0419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 12/20/2022] Open
Abstract
Aim: NGAL, IL-18, KIM-1 as well as urinary TIMP2 and IGFBP7 and their mathematical product (TIMP2*IGFBP7) were evaluated for detecting pediatric aminoglycoside acute kidney injury (AG-AKI). Methods: In a prospective study, noncritically ill children received aminoglycosides (AG) ≥3 days. The area under the curve (AUC) for biomarkers to detect AKI was calculated by a) days before AKI onset; b) treatment days. Results: There were 113 AG episodes (68% febrile neutropenia). The AKI group had a higher proportion with febrile neutropenia. The AKI group had significantly lower NGAL 3 days before AKI, as patients with febrile neutropenia had a lower NGAL during AG treatment (p < 0.05). NGAL, IL-18 and TIMP2*IGFBP7 had AUC ≥0.73 at 3, 2 and 2 days before AKI onset. Conclusion: NGAL, IL-18 and TIMP2*IGFBP7 were modest early biomarkers of AG-AKI. Febrile neutropenia was associated with lower NGAL.
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Affiliation(s)
- Hayton Chui
- Department of Pediatrics, Division of Nephrology, Toronto Hospital for Sick Children, Toronto, ON, Canada
| | - Jillian Caldwell
- Department of Pediatrics, Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Mariya Yordanova
- Department of Pediatrics, Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Vedran Cockovski
- Department of Pediatrics, Division of Nephrology, Toronto Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel Fredric
- Department of Pediatrics, Division of Nephrology, Toronto Hospital for Sick Children, Toronto, ON, Canada
| | - Maya Harel-Sterling
- Department of Pediatrics, Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Maya Haasz
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Zubaida Al-Ismaili
- Department of Pediatrics, Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Michael Pizzi
- Department of Pediatrics, Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Qing Ma
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Prasad Devarajan
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Toronto Hospital for Sick Children, Toronto, ON, Canada.,Formerly, McGill University Health Centre Research Institute, McGill University Health Centre, Montreal, QC, Canada
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Abstract
Pediatric medicine is growing in complexity and an increasing number of children with co-morbidities are exposed to potential renal damage. Initially ill-defined and thought to be mostly a transient phenomenon in children, acute kidney injury (AKI) has now emerged as a complex clinical syndrome independently associated with increased mortality and morbidity, including the development of chronic renal sequelae. Recent advances in molecular nephrology have better elucidated the early phase of AKI, where evidence of renal tissue damage is associated with adverse outcomes even without decrease in glomerular filtration rate, illustrating the flaws of the old paradigm based solely on an insensitive filtration marker, the serum creatinine. Prevention, prompt evaluation and early interventions are of essence to decrease AKI incidence and severity. Emerging data reveal that AKI is commonly encountered in hospitalized children, especially critically ill ones, hence the importance for all clinicians to be able to identify high risk patients, recognize AKI early and be comfortable with the initial medical management. In recent years, significant advances have been made in AKI definition and prediction, allowing early preventive measures in high risk children that are now proven to reduce AKI incidence. This review covers recent advances in the diagnosis, risk stratification, prevention and management of AKI in children.
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Affiliation(s)
- Jean-Philippe Roy
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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47
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Devarajan P, Block G, Gibson K, McKay J, Meyer C, Robinson K, Warady B, Chang A. P0066KIDNEYCODE: A GENETIC TESTING PROGRAM FOR PATIENTS WITH CHRONIC KIDNEY DISEASE. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] Open
Abstract
Abstract
Background and Aims
Knowledge about genetic causes of chronic kidney disease (CKD) is one of the key gaps in global kidney research and recent International Society of Nephrology recommendations encourage the adoption of genetic testing to enable a goal of providing precision medicine based on individual risk (1). A recent whole-exome sequencing study showed that genetic inheritance may be responsible for up to 10% of CKD diagnoses, many of which may be previously undiagnosed or mis-diagnosed (2). Continued advances in DNA sequencing technology have made genetic testing, even whole-exome sequencing, applicable to routine clinical diagnoses. In order to test the hypothesis that genetic testing can provide valuable information to increase the accuracy and precision of diagnosis in CKD, we designed a gene panel to prospectively provide genetic testing in a subset of patients with CKD defined by a specific set of inclusion criteria.
Method
Reata Pharmaceuticals is partnering with Invitae on a program called KidneyCode, which provides no-charge genetic testing to enable diagnosis of three specific rare monogenic causes of CKD: Alport syndrome (AS), autosomal dominant polycystic kidney disease (ADPKD) due to PKD2 mutations, and focal segmental glomerulosclerosis (FSGS), as well as detection of variants in one of the autosomal recessive polycystic kidney disease gene, PKHD1. Invitae’s renal disease panel includes 17 genes (ACTN4, ANLN, CD2AP, COL4A3, COL4A4, COL4A5, CRB2, HNF1A, INF2, LMX1B, MYO1E, NPHS1, NPHS2, PAX2, PKD2, PKHD1, and TRPC6), and its assay includes both full-gene sequencing and intragenic deletion/duplication analysis using next-generation sequencing (NGS). The assay targets the coding exons and flanking 10bp of intronic sequences. Invitae’s method of variant classification uses a systematic process for assessing evidence based on guidelines published by the American College of Medical Genetics (3). Patients in the US at risk for hereditary CKD (eGFR ≤ 90 mL/min/1.73m2 plus hematuria or a family history of CKD) or with a known diagnosis of AS or FSGS are eligible. Family members of those with suspected or known AS or FSGS are also eligible. All participants in the KidneyCode program have access to genetic counseling follow-up at no additional charge.
Results
In the first five months of the KidneyCode program, 152 genetic tests have been completed. A genetic variant was reported in 87 patients. Of those 87 patients, 67 patients had 75 variants in COL4A3, 4, or 5 genes (34 Pathogenic/Likely Pathogenic (P/LP), 41 Variants of Uncertain Significance (VUS)), 20 patients had 24 variants in genes associated with FSGS (3 P/LP, 21 VUS), 15 patients had 20 variants in PKHD1 (1 P/LP, 19 VUS), and 2 patients had variants in PKD2 (1 P/LP, 1 VUS).
Of the 34 patients with Pathogenic or Likely Pathogenic COL4A variants, 19 reported a previous diagnosis of Alport syndrome. Other diagnoses in patients with COL4A mutations included FSGS, thin basement membrane disease, and familial hematuria. Extra-renal manifestations such as hearing loss and eye disease were reported in 7 of the 34 patients with COL4A variants.
Conclusion
Initial results with the KidneyCode panel demonstrate the utility of NGS and support the hypothesis that combining genetic testing with clinical presentation and medical history can significantly improve accuracy and precision of diagnosis in patients with hereditary CKD.
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Affiliation(s)
- Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Cincinnati, United States of America
| | - Geoffrey Block
- Reata Pharmaceuticals, Clinical Development, Plano, United States of America
| | - Keisha Gibson
- University of North Carolina at Chapel Hill, Department of Medicine, United States of America
| | - Jim McKay
- Reata Pharmaceuticals, Inc., Medical Affairs, Plano, United States of America
| | - Colin Meyer
- Reata Pharmaceuticals, Product Development, Plano, United States of America
| | | | - Bradley Warady
- Children's Mercy Kansas City, Department of Nephrology, Kansas City, United States of America
| | - Alexander Chang
- Geisinger Medical Center, Department of Nephrology, Danville, United States of America
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48
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Stark JE, Opoka AM, Mallela J, Devarajan P, Ma Q, Levinsky NC, Stringer KF, Wong HR, Alder MN. Juvenile OLFM4-null mice are protected from sepsis. Am J Physiol Renal Physiol 2020; 318:F809-F816. [PMID: 32068457 PMCID: PMC7099509 DOI: 10.1152/ajprenal.00443.2019] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pediatric sepsis is a leading cause of morbidity and mortality in children. One of the most common and devastating morbidities is sepsis-related acute kidney injury (AKI). AKI was traditionally thought to be related to low perfusion and acute tubular necrosis. However, little acute tubular necrosis can be found following septic AKI, and little is known about the mechanism of septic AKI. Olfactomedin-4 (OLFM4) is a secreted glycoprotein that marks a subset of neutrophils. Increased expression of OLFM4 in the blood is associated with worse outcomes in sepsis. Here, we investigated a pediatric model of murine sepsis using murine pups to investigate the mechanisms of OLFM4 in sepsis. When sepsis was induced in murine pups, survival was significantly increased in OLFM4-null pups. Immunohistochemistry at 24 h after the induction of sepsis demonstrated increased expression of OLFM4 in the kidney, which was localized to the loop of Henle. Renal cell apoptosis and plasma creatinine were significantly increased in wild-type versus OLFM4-null pups. Finally, bone marrow transplant suggested that increased OLFM4 in the kidney reflects local production rather than filtered from the plasma. These results demonstrate renal expression of OLFM4 for the first time and suggest that a kidney-specific mechanism may contribute to survival differences in OLFM4-null animals.
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Affiliation(s)
- Julie E Stark
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amy M Opoka
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jaya Mallela
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Prasad Devarajan
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Qing Ma
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nick C Levinsky
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Keith F Stringer
- Division of Pathology and Laboratory Medicine, University of Cincinnati Department of Pediatrics, Cincinnati, Ohio
| | - Hector R Wong
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew N Alder
- Department of Pediatrics, University of Cincinnati College of Medicine, and Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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49
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Hsu CY, Chinchilli VM, Coca S, Devarajan P, Ghahramani N, Go AS, Hsu RK, Ikizler TA, Kaufman J, Liu KD, Parikh CR, Reeves WB, Wurfel M, Zappitelli M, Kimmel PL, Siew ED. Post-Acute Kidney Injury Proteinuria and Subsequent Kidney Disease Progression: The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study. JAMA Intern Med 2020; 180:402-410. [PMID: 31985750 PMCID: PMC6990681 DOI: 10.1001/jamainternmed.2019.6390] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Among patients who had acute kidney injury (AKI) during hospitalization, there is a need to improve risk prediction such that those at highest risk for subsequent loss of kidney function are identified for appropriate follow-up. OBJECTIVE To evaluate the association of post-AKI proteinuria with increased risk of future loss of renal function. DESIGN, SETTING, AND PARTICIPANTS The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) Study was a multicenter prospective cohort study including 4 clinical centers in North America included 1538 patients enrolled 3 months after hospital discharge between December 2009 and February 2015. EXPOSURES Urine albumin-to-creatinine ratio (ACR) quantified 3 months after hospital discharge. MAIN OUTCOMES AND MEASURES Kidney disease progression defined as halving of estimated glomerular filtration rate (eGFR) or end-stage renal disease. RESULTS Of the 1538 participants, 769 (50%) had AKI durring hospitalization. The baseline study visit took place at a mean (SD) 91 (23) days after discharge. The mean (SD) age was 65 (13) years; the median eGFR was 68 mL/min/1.73 m2; and the median urine ACR was 15 mg/g. Overall, 547 (37%) study participants were women and 195 (13%) were black. After a median follow-up of 4.7 years, 138 (9%) participants had kidney disease progression. Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (hazard ratio [HR], 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, 0.82). The performance of urine ACR was stronger in patients who had had AKI than in those who had not (C statistic, 0.70). A comprehensive model of clinical risk factors (eGFR, blood pressure, and demographics) including ACR provided better discrimination for predicting kidney disease progression after hospital discharge among those who had had AKI (C statistic, 0.85) vs those who had not (C statistic, 0.76). In the entire matched cohort, after taking into account urine ACR, eGFR, demographics, and traditional chronic kidney risk factors determined 3 months after discharge, AKI (HR, 1.46; 95% CI, 0.51-4.13 for AKI vs non-AKI) or severity of AKI (HR, 1.54; 95% CI, 0.50-4.72 for AKI stage 1 vs non-AKI; HR, 0.56; 95% CI, 0.07-4.84 for AKI stage 2 vs non-AKI; HR, 2.24; 95% CI, 0.33-15.29 for AKI stage 3 vs non-AKI) was not independently associated with more rapid kidney disease progression. CONCLUSIONS AND RELEVANCE Proteinuria level is a valuable risk-stratification tool in the post-AKI period. These results suggest there should be more widespread and routine quantification of proteinuria after hospitalized AKI.
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Affiliation(s)
- Chi-Yuan Hsu
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey
| | - Steven Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Prasad Devarajan
- Cincinnati Children's Hospital, Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
| | - Nasrollah Ghahramani
- Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey
| | - Alan S Go
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco.,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Raymond K Hsu
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco
| | - T Alp Ikizler
- Vanderbilt Center for Kidney Disease, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Kaufman
- Renal Section, Veterans Affairs New York Harbor Health Care System, New York University School of Medicine, New York
| | - Kathleen D Liu
- Division of Nephrology, University of California School of Medicine, San Francisco, San Francisco
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - W Brian Reeves
- University of Texas, Long School of Medicine, San Antonio
| | - Mark Wurfel
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle
| | - Michael Zappitelli
- Hospital for Sick Children, Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Edward D Siew
- Vanderbilt Center for Kidney Disease, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee.,Tennessee Valley Health Services, Nashville Veterans Affairs Hospital, Nashville, Tennessee
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50
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Abstract
Decades of pre-clinical research have revealed biologic pathways that have suggested potential therapies for acute kidney injury (AKI) in experimental models. However, translating these to human AKI has largely yielded disappointing results. Fortunately, recent discoveries in AKI molecular mechanisms are providing new opportunities for early detection and novel interventions. This review identifies technologies that are revealing the exceptionally complex nature of the normal kidney, the remarkable heterogeneity of the AKI syndrome, and the myriad responses of the kidney to AKI. Based on the current state of the art, novel approaches to improve the bench-to-bedside translation of novel discoveries are proposed. These strategies include the use of unbiased approaches to improve our understanding of human AKI, establishment of irrefutable biologic plausibility for proposed biomarkers and therapies, identification of patients at risk for AKI pre-injury using clinical scores and non-invasive biomarkers, initiation of safe, and effective preventive interventions of pre-injury in susceptible patients, identification of patients who may develop AKI post-injury using electronic triggers, clinical scores, and novel biomarkers, employment of sequential biomarkers to initiate appropriate therapies based on knowledge of the underlying pathophysiology, use of new biomarkers as criteria for enrollment in randomized clinical trials, assessing efficacy, and empowering the drug development process, and early initiation of anti-fibrotic therapies. These strategies are immediately actionable and hold tremendous promise for effective bench-to-bedside translation of novel discoveries that will change the current dismal prognosis of human AKI.
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Affiliation(s)
- Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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