The Ratio of Plasma Neutrophil Gelatinase-Associated Lipocalin

Predicts Acute Kidney Injury in Patients Undergoing Liver

Transplantation
C.-W. Cheng, Y.-C. Chen, C.-H. Chang, H.-P. Yu, C.-C. Lin, M.-W. Yang, W.-C. Lee, and C.-J. Chang
ABSTRACT
Background. Postoperative acute kidney injury (AKI) is associated with high morbidity
and mortality after liver transplantation (OLT). Previous studies have shown the value of
plasma neutrophil gelatinase-associated lipocalin (NGAL) taken 2 hours after reperfusion
of the liver graft as an early marker predicting AKI. The study was performed to determine
whether plasma NGAL concentrations obtained as early as 1 hour after reperfusion was
predictive of AKI and whether the NGAL ratio was an early predictor for AKI in the rst
48 hours after OLT.
Methods. Twenty-six liver transplant recipients donated plasma samples for NGAL
determinations at induction (T1), at graft reperfusion (T3) as well as after 1 (T4) and hours
2 (T5), and at the end of the surgery (T7). AKI was dened at 48 hours after liver
transplantation according to the acute kidney injury network criteria. Predictive ability was
assessed using areas under the curve of receiver operator characteristic analyses.
Results. The area under the curve of the receiver operator characteristics curve of
(plasma NGAL concentration at T4)/(plasma NGAL concentration at T1) to predict AKI
was 0.717 at T5, 0.765 at T7, 0.714 at T8 (24 hours post-OLT), and 0.781 at T9 (48 hours
post-OLT).
Conclusion. The plasma NGAL concentrations taken 1 hour after reperfusion of the
liver graft seem to be predictive of AKI; the NGAL changing ratio may be an early
predictor for AKI in the rst 48 hours after OLT.
A
CUTE kidney injury (AKI) is an independent risk
factor of poor prognosis after liver transplantation
(OLT) prevention of this complication may improve the
survival rate.
1
The incidence of AKI has been reported to
range between 17% and 95% according to various crite-
ria.
25
AKI, which may increase the risk of chronic renal
failure, which requires renal replacement therapy (RRT),
leading to an high postoperative mortality.
69
In addition,
AKI among patients undergoing OLT inuences mortality
even after 5 years, which is most likely due to the greater
incidence of chronic kidney disease and cardiovascular
event.
1013
The etiology of AKI after OLT is multifactorial:
From the Department of Anesthesiology (C.-W.C., H.-P.Y.,
C.-C.L., M.-W.Y.), Chang-Gung Memorial Hospital, Taoyuan,
Taiwan; Department of Nephrology, Chang-Gung Memorial
Hospital (Y.-C.C.), Taoyuan, Taiwan; the College of Medicine
(Y.-C.C., H.-P.Y., C.-C.L., M.-W.Y., W.-C.-L.), Chang-Gung Uni-
versity, Taoyuan, Taiwan; the Department of Anesthesiology,
Saint Pauls Hospital (C.-H.C.), Taoyuan, Taiwan; the Depart-
ment of General Surgery (W.-C.L., C.-J.C.), Chang-Gung Memo-
rial Hospital, Taoyuan, Taiwan; Biostatistical Center for Clinical
Research, Chang-Gung Memorial Hospital (C.-J.C.), Taoyuan,
Taiwan; the Graduate Institute of Clinical Medical Science
(C.-J.C.), and the Clinical Informatics and Medical Statistics
Research Center, Chang-Gung University, Taoyuan, Taiwan.
Address reprint requests to Huang-Ping Yu, Anesthesiology
department, Chang-Gung Memorial Hospital, No.5, Fuxing
Street., Guishan Township, Taoyuan County 333, Taiwan
(R.O.C.). E-mail: yuhp2001@adm.cgmh.org.tw; or Chih-Chung
Lin, Anesthesiology Department, Chang-Gung Memorial Hospi-
tal, No.5, Fuxing Street., Guishan Township, Taoyuan County
333, Taiwan (R.O.C.). E-mail: chihchung@adm.cgmh.org.tw
0041-1345/12/$see front matter 2012 by Elsevier Inc. All rights reserved.
doi:10.1016/j.transproceed.2012.01.068 360 Park Avenue South, New York, NY 10010-1710
776 Transplantation Proceedings, 44, 776779 (2012)
Pretransplant AKI, serum albumin, surgery duration, intra-
operative blood transfusion, treatment duration with dopa-
mine, liver graft dysfunction, bacterial infection, early post-
operative ischemia, and immunosuppressant toxicity.
6, 7, 14
The denition of AKI is not uniform in the current
literature. An elevated serum creatinine value is usually
considered to be an indicator of AKI. However, creatinine
is a delayed, unreliable indicator of AKI for a variety of
reasons.
15, 16
Current, promising, novel biomarkers for AKI
include neutrophil gelatinase-associated lipocalin (NGAL),
kidney injury molecule-1, liver-type fatty acid binding pro-
tein, and interleukin-18.
17
NGAL has been identied to be
among the most upregulated genes in the kidney early after
acute injury in animal models.
18
NGAL expression has been
studied in various clinical settings, such as cardiopulmonary
bypass, renal transplantation, chronic kidney disease, and
contrast-induced nephropathy. Elevated NGAL plasma or
urine concentrations, may be related to renal disorders.
19
Previous studies concerning NGAL in OLT have shown
intraoperative NGAL concentrations to be strongly associ-
ated with postoperative AKI.
20
A combination of postop-
erative plasma NGAL and APACHE II score predict AKI
with an high sensitivity and specicity after OLT.
21
The
intraoperative NGAL concentrations obtained 2 hours after
reperfusion of the liver graft and the absolute NGAL value
have been chosen to predict postoperative AKI in OLT.
The current study was performed to determine whether the
plasma NGAL concentration at 1 hour after liver graft
perfusion was predictive of AKI, and whether the NGAL
ratio was an alternative early marker for postoperative AKI
among OLT.
MATERIALS AND METHODS
Study Population
Twenty-six adult enrolled patients all underwent OLT using the
piggyback technique. Exclusion criteria were end-stage renal dis-
ease (glomerular ltration rate estimated by Modication of Diet
in Renal Disease equation of 15 mL/min), age 18 years, and
inability to complete the informed consent. This prospective,
clinical study was approved by our institutional Review Board;
valid, written, informed consents were obtained from each patient
prior to undergoing the operation.
Study Design
Blood samples containing sodium heparin as the anticoagulant
were obtained for the measurements of sCr and NGAL. The blood
samples were obtained at anesthesia induction (T1), 1 hour after
the surgical incision (T2), the time of reperfusion (T3) as well as 1
(T4), 2 (T5), 4 hours (T6), and the end of the surgery (T7). In
addition samples were obtained at 24 (T8), and 48 hours after liver
transplantation (T9). The samples were immediately placed in ice
water at 4C. Plasma separated by immediate centrifugation (3500
rpm/10 minutes) as the supernate was stored at 80C until the
analysis within one week.
Clinical Outcomes
The primary outcome was AKI, which was modied according to
the criteria of the Acute Kidney Injury Network (AKIN).
9
AKI was
dened as an increase in Serum creatinine of 0.3 mg/dL or
150% from baseline within 48 hours of OLT. Secondary out-
comes included lengths of intensive care and hospital stays after
OLT, the necessity of RRT, and mortality.
Measurement of Creatinine and NGAL
Serum creatinine samples were analyzed at our central laboratory.
The plasma levels of NGAL were analyzed via are enzyme-linked
immunosorbent assay (R&D Systems, Minneapolis, Minn) accord-
ing to the manufacturers instructions.
Statistical Analysis
Categorical variables were expressed as number (%), and contin-
uous variables as mean values and standard deviations. Categorical
variables were analyzed using the Fisher exact test, whereas
continuous variables, using the MannWhitney U test. Logistic
regression was used to evaluate the relationship between AKI and
plasma NGAL or plasma NGAL ratio at each time. The ability of
a biomarker to predict an outcome was assessed using the area
under the curve generated by receiver operator characteristic
analysis. The area under the receiver operating curve (AUROC)
was calculated to assess the ability of the continuous variable to
distinguish the categorical state. Statistical analysis was performed
using SPSS statistical software version 17.0 (Chicago, Ill). P .05
was considered signicant.
RESULTS
Clinical Characteristics of Recipients
The demographic features of the 26 patients undergoing
OLT who were enrolled into this study are shown in
Table 1.
Outcomes and Plasma NGAL
Thirteen patients (50%) developed AKI within 48 hours
after OLT. Their average intensive care stay was 14.6
Table 1. Demographic Data
Non-AKI AKI All P
Patient number 13 (50%) 13 (50%) 126 (100%)
Age (y) 56.8 8.0 56.1 8.1 56.5 7.9 .797
Male 10 (77%) 10 (77%) 20 (77%) 1
Height (cm) 166.9 10.8 160.6
8.9
163.8 10.2 .091
Weight (kg) 69.2 13.8 60.7 8.5 65.0 12.1 .048
BMI (kg/m
2
) 24.9 5.7 23.6 3.3 24.3 4.6 .701
MELD score 16.0 10.1 17.2 7.8 16.6 8.9 .520
Disease
Hepatitis B 11 (85%) 6 (46%) 17 (65%) .097
Hepatitis C 2 (15%) 6 (46%) 8 (31%) .202
HCC 11 (85%) 8 (62%) 19 (73%) .378
Liver cirrhosis 13 (100%) 10 (77%) 23 (88%) .220
Diabetes 5 (38%) 1 (8%) 6 (23%) .160
Hypertension 4 (31%) 1 (8%) 5 (19%) .322
Alcoholism 3 (23%) 3 (23%) 6 (23%) 1
Abbreviations: AKI, acute kidney injury; BMI, body mass index; MELD, Model
for End-Stage Liver Disease; HCC, hepatocellular carcinoma.
Note. Data are given as mean values standard deviation or number (%);
AKI was dened as increase in serum creatinine of 0.3 mg/dL or increase to
150% from baseline within 48 hours of liver transplantation.
PREDICTING ACUTE KIDNEY INJURY IN OLT 777
11.5 days, and hospital stay 26.4 5.6 days. We analyzed
data for 22 patients but not those of expired patients.
The plasma NGAL concentration at baseline of 64.72
60.30 ng/mL increased gradually over time, peaking at 2
hours after reperfusion of the liver graft (117.01 163.68
ng/mL). After the peak, the plasma NGAL concentration
maintained a steady concentration until the end of OLT.
The concentration ratio of plasma NGAL at T4 and
plasma NGAL at T1 is represented as pNGAL (T4/T1).
The AUROC of pNGAL (T4/T1) to predict our primary
outcome, AKI occurrence, was 0.717 at T5, 0.780 at T6,
0.765 at T7, 0.714 at T8, and 0.781 at T9. Additionally, the
AUROC of pNGAL (T4/T1) to predict AKI occurred
within 48 hours after the OLT was 0.710. In contrast,
plasma NGAL concentrations at T4 were not a signicant
predictor of AKI at T5, T6, T7, T8, T9, or T5T9 (Table 2).
However, pNGAL T4/T1 was not an early indicator of
impending adverse outcomes, such as the need for RRT or
the occurrence of mortality (Table 2).
DISCUSSION
In this prospective study, plasm NGAL obtained at 1 hour
after liver graft reperfusion could be used as an early
predictor of AKI. The pNGAL ratio may be an alternative
method for the early prediction of AKI. However, no single
pNGAL value predicted postoperative AKI in this study.
Currently, the diagnostic criteria for AKI are based on
acute serum creatinine alterations or urine output. The
criteria used in this study were modied from those of
AKIN an independent network with the goals to develop
uniform standards to dene, to classify and to improve care
for patients with or at risk of AKI.
9
NGAL is considered to be a vigorous outcome marker
for AKI using both plasma and urine NGAL, which show
similar patient outcome patterns.
22
However, patients may
have decreased or even no urine output for hours during an
operation. Therefore, pNGAL rather than urine NGAL
(uNGAL) was chosen in the present study. Plasma NGAL
was as good predictor of AKI as uNGAL; it is easier to
collect than uNGAL.
Previous studies were shown NGAL concentrations ap-
plied for the early diagnosis of AKI in OLT.
20,21
Niemann
et al
20
showed that the NGAL concentration difference
between 2 hours after reperfusion versus the induction of
anesthesia was predictive of AKI. In addition, a single
NGAL determination 2 hours after liver graft reperfusion
correlated with AKI especially among patients with preop-
erative creatinine concentrations 1.5 mg/dL
20
Portal et al
reported that the AUROC for pNGAL levels within 24
hours of OLT were predictive of the development of AKI.
21
In our study, the pNGAL concentration taken 1 hour
after liver graft reperfusion, which is 1 hour earlier than
most of the prior studies, could be used to predict future
AKI within 48 hours; the ratio with baseline pNGAL was an
alternative to predict AKI. Therefore, if a single pNGAL
value did not exceed the cutoff dening AKI in patients at
high risk of AKI, the pNGAL ratio may potentially be
helpful clinically.
This study had some limitations. First, in large, multi-
center, pooled studies, NGAL-positive AKI with or without
elevation of serum creatinine was associated with poor
outcomes, such as prolonged intensive care or hospital
stays, need for RRT, and mortality.
22
In this study, pNGAL
did not reect similar ndings concerning outcomes, which
was probably due to the fact that the number of adverse
outcomes other than AKI was small. Second, the study was
not designed to evaluate mechanisms of AKI risk during
OLT. Therefore, a comprehensive evaluation of AKI risk
factors was not performed. Last, in some clinical settings,
blood samples may only be taken after the critical event
leading to AKI and it may not be possible to establish a
baseline pNGAL value. In this way, the application of the
pNGAL ratio may be limited to detect AKI.
In conclusion, the pNGAL concentration taken at 1 hour
after reperfusion of the liver graft seemed to be predictive
of AKI and the NGAL ratio might be an alternative
predictor of AKI in the rst 48 hours after OLT.
REFERENCES
1. Zhu ML, Li Y, Qian JQ, et al: [Analysis of independent risk
factor in patients with poor prognosis after liver transplantation].
Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 21:69, 2009
Table 2. Prediction of pNGAL Ratio and pNGAL Absolute Value
for AKI at Different Time Points, RRT, and Mortality
Outcome Parameter OR
95% CI for OR
P AUROC Lower Upper
AKI at T5 pNGAL T4/T1 2.70 1.03 7.08 .044* 0.717
AKI at T6 pNGAL T4/T1 3.42 1.16 10.05 .026* 0.780
AKI at T7 pNGAL T4/T1 4.91 1.22 19.79 .025* 0.765
AKI at T8 pNGAL T4/T1 4.87 1.12 21.10 .034* 0.714
AKI at T9 pNGAL T4/T1 2.74 1.01 7.46 .048* 0.781
AKI T59 pNGAL T4/T1 4.41 1.04 18.67 .044* 0.710
RRT pNGAL T4/T1 0.19 0.02 2.25 .186
Mortality pNGAL T4/T1 0.36 0.05 2.60 .311
AKI at T5 pNGAL T4 1.00 0.99 1.01 .708
AKI at T6 pNGAL T4 1.00 0.99 1.01 .688
AKI at T7 pNGAL T4 0.99 0.98 1.01 .362
AKI at T8 pNGAL T4 1.01 1.00 1.02 .220
AKI at T9 pNGAL T4 0.99 0.98 1.01 .449
AKI at T59 pNGAL T4 1.00 1.00 1.01 .318
RRT pNGAL T4 1.00 0.99 1.01 .750
Mortality pNGAL T4 0.99 0.97 1.01 .303
Abbreviations: pNGAL, plasma neutrophil gelatinase-associated lipocalin;
pNGAL T4/T1, (plasma NGAL concentration at T4)/(plasma NGAL concentra-
tion at T1); pNGAL T4, plasma NGAL concentration at T4; AKI, acute kidney
injury; RRT, renal replacement therapy; OR, odds ratio; CI, condence interval;
AUROC, area under the receiver operating curve; T1, anesthesia induction; T4,
1 hour after liver graft reperfusion; T5, 2 hours after liver graft reperfusion; T6,
4 hours after liver graft reperfusion; T7 the end of the surgery; T8, 24 hours after
liver transplantation; T9, 48 hours after liver transplantation.
Note. AKI was dened as an increase in serum creatinine of 3 mg/dL or an
increase to 150% from baseline within 48 hours of liver transplantation.
*Signicant difference comparing plasma NGAL ratio with acute kidney injury
outcome.
778 CHENG, CHEN, CHANG ET AL
2. Fraley DS, Burr R, Bernardini J, et al: Impact of acute renal
failure on mortality in end-stage liver disease with or without
transplantation. Kidney Int 54:518, 1998
3. McCauley J, Van Thiel DH, Starzl TE, et al: Acute and
chronic renal failure in liver transplantation. Nephron 55:121, 1990
4. Lima EQ, Zanetta DM, Castro I, et al: Risk factors for
development of acute renal failure after liver transplantation. Ren
Fail 25:553, 2003
5. Bilbao I, Charco R, Balsells J, et al: Risk factors for acute
renal failure requiring dialysis after liver transplantation. Clin
Transplant 12:123, 1998
6. Wei Y, Zhang L, Lin H, et al: Factors related to post-liver
transplantation acute renal failure. Transplant Proc 38:2982, 2006
7. Lewandowska L, Matuszkiewicz-Rowinska J: Acute kidney
injury after procedures of orthotopic liver transplantation. Ann
Transplant 16:103, 2011
8. Mehta RL, Chertow GM: Acute renal failure denitions and
classication: time for change? J Am Soc Nephrol 14:2178, 2003
9. Mehta RL, Kellum JA, Shah SV, et al: Acute Kidney Injury
Network: report of an initiative to improve outcomes in acute
kidney injury. Crit Care 11:R31, 2007
10. Lutkes P, Lutz J, Loock J, et al: Continuous venovenous
hemodialysis treatment in critically ill patients after liver transplan-
tation. Kidney Int Suppl S71, 1999
11. Altintepe L, Guney I, Tonbul Z, et al: Assessment of acute
renal failure patients treated in our nephrology clinic between 1996
and 2002. Transplant Proc 36:3002, 2004
12. Mann JF, Gerstein HC, Pogue J, et al: Renal insufciency as
a predictor of cardiovascular outcomes and the impact of ramipril:
the HOPE randomized trial. Ann Intern Med 134:629, 2001
13. Barri YM, Sanchez EQ, Jennings LW, et al: Acute kidney
injury following liver transplantation: denition and outcome.
Liver Transpl 15:475, 2009
14. Cabezuelo JB, Ramirez P, Rios A, et al: Risk factors of acute
renal failure after liver transplantation. Kidney Int 69:1073, 2006
15. Nickolas TL, Barasch J, Devarajan P: Biomarkers in acute
and chronic kidney disease. Curr Opin Nephrol Hypertens 17:127,
2008
16. Devarajan P: Neutrophil gelatinase-associated lipocalin
(NGAL): a new marker of kidney disease. Scand J Clin Lab Invest
Suppl 241:89, 2008
17. Devarajan P: Biomarkers for the early detection of acute
kidney injury. Curr Opin Pediatr 23:194, 2011
18. Supavekin S, Zhang W, Kucherlapati R, et al: Differential
gene expression following early renal ischemia/reperfusion. Kidney
Int 63:174, 2003
19. Shavit L, Dolgoker I, Ivgi H, et al: Neutrophil gelatinase-
associated lipocalin as a predictor of complications and mortality in
patients undergoing non-cardiac major surgery. Kidney Blood
Press Res 34:116, 2011
20. Niemann CU, Walia A, Waldman J, et al: Acute kidney
injury during liver transplantation as determined by neutrophil
gelatinase-associated lipocalin. Liver Transpl 15:1852, 2009
21. Portal AJ, McPhail MJ, Bruce M, et al: Neutrophil gelati-
nase-associated lipocalin predicts acute kidney injury in patients
undergoing liver transplantation. Liver Transpl 16:1257, 2010
22. Haase M, Devarajan P, Haase-Fielitz A, et al: The outcome
of neutrophil gelatinase-associated lipocalin-positive subclinical
acute kidney injury a multicenter pooled analysis of prospective
studies. J Am Coll Cardiol 57:1752, 2011
PREDICTING ACUTE KIDNEY INJURY IN OLT 779