Aki biomarker 2016 updated

1. Novel AKI biomarker
CHAKEN MANIYAN M.D.
Nephrology fellow ,
Phramongkutklao hospital
19 Aug 2016

2. Conceptual model for AKI
Adaptedfrom KDIGO® AKI Guideline2012
Who is at risk?
Differential diagnosis?
Early diagnosis?
Prognosis?

3. Limitation of Serum creatinine
Lisowska-Myjak B.Blood Purif2010;29:357–365
Endre ZH, et al.Clin Biochem Rev 2011 I 121-4.

4. Sources of creatinine error in
GFR estimation
Source of error Example
Factors affectingcreatinine
generation
• Race/ethnicity
• Extremes of muscle mass
• Extremes of body size
• Diet and nutritionalstatus
- High protein diet
-Creatine supplements
• Muscle wasting diseases
• Ingestionof cookedmeat
KDIGO CKD 2012.Kidney InternationalSupplements(2013)3, 5–14

5. Source of error Example
Factors affectingtubular
secretionof creatinine
Decrease by drug-induced
inhibition
• Trimethoprim
• Cimetidine
• Fenofibrate
Factors affectingextra-renal
eliminationofcreatinine
• Dialysis
• Decrease by inhibitionofgut
creatininaseby antibiotics
• Increasedby large volume
lossesof extracellularfluid
KDIGO CKD 2012.Kidney InternationalSupplements(2013)3, 5–14
Sources of creatinine error in
GFR estimation

6. Eme rgin g
Bi omark ers

7. Kidney biomarkers for AKI
Belcher, JM, et al. AmJ Kidney Dis. 2011:57(6):930-940

8. KoynerJL et al. nd critical illness.Clin JAm Soc Nephrol.2013; 8(6): 1034–42
Anatomical correlation of AKI biomarkers

9. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Serumand Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

10. Cystatin C
13.3 kDa
• Freely filtered by glomerulus, reabsorbed completelyby
PCT, and not secreted
glomerularfiltration
• Urinaryexcretion of the cystatinC : correlates with
severity of acute tubular damage
• Serum cystatin C : early markerof impairedGFR, not
significantlyaffectedbyage, gender, race, or overall
muscle mass
Nguyen MT, et al. Pediatr Nephrol 2008; 23: 2151–2157.
CocaSG, et al. Kidney Int 2008; 73: 1008–1016.

11. Serum cystatinC and creatinine on the
three days prior on the day AKI
In 85 critically ill patients at high risk for developing AKI
Serum cystatin C increased already by 50% 1.5±0.6
days earlier compared to creatinine
Adapted from Herget-Rosenthal S. Kidney Int 2004; 66: 1115–1122.
0
50
100
150
200
250
300
R-Day-3 R-day-2 R-Day-1 R-Day-0
Cystatin C
Creatinine

12. Urinary cystatinC as an early
biomarker of AKI following adult
cardiothoracicsurgery
KoynerJL, et al. Kidney Int 2008; 74: 1059–1069
Pre CPB Post CPB ICU 6 h ICU Day 1
UrineCyC/urinecreatinine(mg/g)
5.0-
4.0-
3.0-
2.0-
1.0-
0.0-
* ** **
*
Urinary CyC at the time of ICU arrival and the urinary CyC level 6 hours after
ICUadmission were most useful for predicting AKI
AKI with RRT
NO AKI

13. SerumCystacinC : prognostic
factor to death, CV death, ESRD
MichaelG.Shlipak, N EnglJ Med2013;369:932-943

14. Sources of cystatinC error in GFR
estimation
Source of error Example
Factors affecting cystatin C generation • Disorders of thyroid function
• Administration of corticosteroids
• Other hypothesized factors based
on epidemiologic associations
(diabetes, adiposity)
Factorsaffecting tubular reabosrption
of cystatinC
None identified
Factorsaffecting extra-renal
elimination ofcystatinC
Increased by severe decrease in
GFR
KDIGO CKD 2012.Kidney InternationalSupplements(2013)3, 5–14
No effect by gender, age, race or muscle mass, unlike serum
creatinine

15. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

16. Kidney Injury Molecule-1 (KIM-1)
• Type 1 transmembrane proteinof renaltubular origin
• KIM-1 is not detectable in a healthykidney
• KIM-1-positiveproximaltubules (90%) in various human
renal diseases)
Ichimura T, et al. AmJPhysiol Renal Physiol2004; 286:F552–F563.
Waanders F, et al. Journal of Pathology 2010; 7–16.

17. Comparison of urinary KIM-1
concentration in various forms of renal
diseases
Adapted from Kidney International, Vol. 62 (2002), pp. 237–244
Urinary KIM-1 levels were higher in patients with ischemic ATN (2.92±0.61;
N=7)compared to levels in patients with other forms of AKI (0.63±0.17, P<
0.01) orCKD (0.72±0.37,P <0.01).
0
1
2
3
4
ischemic ATN CIN other ARF CRF normal
N=7
N=7
N=9
N=8
N=9
KIM-1level,ng/mL

18. Preoperative cardiac surgery
KIM-1 predicted development of stage 1 and 3 AKI
(subclinical proximal tubular injury) N=123
KoynerJL,et alClin J Am Soc Nephrol. 2010Dec; 5(12):2154–2165.

19. vanTimmeren et al. AmJ PhysiolRenal Physiol 2006; 291(2): F456–464.
KIM-1 and tubulointerstitial damage
Kim-1 expression was limited toareas with
inflammation and fibrosis (α-smoothmuscle
actin)
0 1 2 3 4 5
KIM-1 expression (% area)
R=0.950
p<0.001
100-
75-
50-
25-
0-
Macrophages
(number/interstitialflield)
Alpha-SMAexpressionMacrophageexpression

20. Urinary KIM-1 markers of kidney injury can predict
adverse clinical outcomes in patients with AKI
Second quartile of KIM-1
groups:1.4-fold(95% CI 0.6
to 3.0)
Third quartile of KIM-1
groups:1.4-fold(95% CI 0.6
to 3.0)
Forth quartile of KIM-1
groups:3.2-fold (95%CI 1.4
to 7.4)
Liangos O, et al. J Am SocNephrol 2007; 18: 904–912.
0 5 10 15 20 25 30
Urinary KIM-1 (ng/mg creatinine)
0.8-
0.7-
0.6-
0.5-
0.4-
0.3-
Predictedprbabilityofdialysisrequirementor
hospitaldeath
Dialysisrequirement or hospital death
(P =0.034)

21. KIM-1 : prognostic factor to ESRD

22. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

23. NeutrophilGelatinase-Associated
Lipocalin (NGAL)
•NGAL is expressed by neutrophils
•Major renal source of urinary NGAL is from the
TAL and collecting ducts
•NGAL gene is strongly induced after kidney
injury by ischemia, sepsis or nephrotoxins
Lisowska-Myjak B.Blood Purif 2010;29:357–365

24. Neutrophil Gelatinase-
Associated Lipocalin (NGAL)
• DuringAKI, both urine and plasmaNGAL are elevated
• Urine NGAL: productionfromTAL andCCD 3 hrs after
injury
• PlasmaNGAL: increasedhepaticproduction after injury
YamamotoT, et al.J Am Soc Nephrol. 2007 Nov. 18(11):2894-902

25. KoynerJL, et al. J Am Soc Nephrol.2012 May. 23(5):905-14.
TRIBE AKI
• Large prospective, multicenter international
cohort of adult patients undergoing cardiac
surgery (N = 1219)
• What biomarkers measured at time of first
clinical diagnosis of AKI after cardiac surgery can
potentially predict AKI severity

26. • plasma NGAL performing the best
(category-free net reclassification
improvement of 0.69, P < 0.0001).
• Plasma NGAL on day of AKI
diagnosis improve risk stratification
and identify patients at higher risk
for progression of AKI and worse
patient outcomes
KoynerJL, et al. J Am Soc Nephrol.2012 May. 23(5):905-14.

27. NGAL expression in
ischmia-reperfusion mice
Neal Paragas,et al Nat Med. 2011Feb; 17(2): 216–222

28. Volume depletion failed to
activate NGAL expression
Neal Paragas,et al Nat Med. 2011Feb; 17(2): 216–222

29. J. Mishara et al. Lancet 2005; 365:1231–38

30. J. Mishara et al. Lancet 2005; 365:1231–38

31. Major studies reporting use of NGAL as an
early biomarker in AKI
SoniSS, et al. Blood Purif 2009;28:165–174

32. Soni SS, et al. Blood Purif 2009;28:165–174
Major studies reporting use of NGAL as an
early biomarker in AKI

33. Early diagnosis of cardiac surgery-
associatedAKI : a meta-analysis
Zhou F,. Eur J Cardiothorac Surg 2016;49:746–55.

34. NGAL as a Biomarker in AKI
Dent CL, et al. Crit Care 2007; 11:R127.
Bachorzewska H, et al. Nephrol Dial Transplant 2007; 22: 295–296.
Wagener G, et al. Anesthesiology 2006;105: 485–491.
Xin C, : et al. Ren Fail 2008; 30: 904–913.

35. NGAL and Progression of CKD
Bolignano D,. Clin J Am Soc Nephrol 2009;4:337-344

36. Factors Influencing NGAL
Measurement
Wagener G, et al. Am J Kidney Dis 2008; 52: 425–433.
Mitsnefes M, et al. Pediatr Nephrol 2007;22:101–8.

37. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

38. Liver-Type FattyAcid-Binding
Protein (L-FABP)
Tan H.L.et al Blood Purif 2016;41:144-150

39. Urinary LFABP in AKI: A Meta-analysis
P.Susantitaphong,Am J KidneyDis.2013 Mar; 61(3):430–439.

40. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

41. Interleukin-18 (IL-18)
Tan H.L.et al Blood Purif 2016;41:144-150

42. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

43. Urinary Enzymes of Renal Origin
Lisowska-Myjak B. Blood Purif 2010;29:357–365

44. Urinary Enzymes of Renal Origin
• Cytoplasmic enzymes: Isoenzymesof glutathione S
transferase(GST):
• GST- α: proximal tubule
• GST-π : distal tubule
• Lysosomesof proximal tubular cells: N-acetyl- β-D-
glucosaminidase(NAG)
• Brush border enzyme:Alkalinephosphatase,γ-
glutamyl transpeptidase,and alanine aminopeptidase
• Proximal renal tubular epithelial antigen (HRTE-1)
Lisowska-Myjak B. Blood Purif 2010;29:357–365

45. N-acetyl- β -D -glucosaminidase
(NAG)
Liangos O, et al. J Am SocNephrol 2007; 18: 904–912.

46. Urinary NAG ActivityAre Associated
with Adverse Outcomes in AKI
Liangos O, et al. J Am SocNephrol 2007; 18: 904–912.
0 50 100 150 200 250 300
Urinary NAG (ng/mg creatinine)
0.8-
0.7-
0.6-
0.5-
0.4-
0.3-
Predictedprbabilityofdialysis
requirementorhospitaldeath

47. N-acetyl- β -D -glucosaminidase (NAG)
Liangos O, et al. J Am SocNephrol 2007; 18: 904–912.

48. Type of AKI biomarkers
BiomarkerType Biomarker
Functional marker
Serum creatinin
Serum cystatin C
Urinealbumin
Up-regulated proteins
Kidneyinjurymolecule1(KIM-1)
Neutrophil gelatinase-associated lipocalin (NGAL)
Liver-typefattyacid–binding protein (L-FABP)
Interleukin 18 (IL-18)
β-traceprotein(BTP)
Asymmetricdimethylarginine(ADMA)
Low-molecular-weightproteins Urinecystatin C
Enzymes
N-acetyl-glucosaminidase(NAG)
Glutathione-s-transferase(GST)
Gamma-glutamyltranspeptidase(GGT)
Alanineaminopeptidase(AAP)
Lactatedehydrogenase(LDH)
Geneproduct(cell cyclearrest)
TIMP2
IGFBP7
Adapted from Betjes MG,,et al.Clin Kidney J. 2012; 5 (2): 102-108.

49. UrinaryTissue Inhibitor of Metalloproteinase-2
Insulin-Like Growth Factor-Binding Protein 7
A. Sharfuddin et al. Nat Rev Nephrol 2011;7:189-200

50. TIMP-2 and IGFBP-7
A. Sharfuddin et al. Nat Rev Nephrol 2011;7:189-200

51. SAPPHIRE study : methodology
Kianoush Kashanietal Crit Care.2013; 17(1):R25.

52. SAPPHIRE STUDY
§ [TIMP-2]·[IGFBP7]
identified – risk
§ Improved risk
stratification forAKI
well ahead ofCr,UOP
§ These markers
performed well in
patients with
§ sepsis (with area under
receiver operating
characteristics curve
[AUC] of 0.82)
§ postsurgery (AUC 0.85)
Kianoush Kashanietal Crit Care.2013; 17(1):R25.

53. 0.3
>2.0
SAPPHIRE STUDY
Kianoush Kashanietal Crit Care.2013; 17(1):R25.

55. (TIMP-2)⋅ (IGFBP7) LevelsAre
Associated with Long-Term
Outcomes in Patients with AKI
Jay L. Koyner,JAm Soc Nephrol 26:, 2015

56. Biomarkers of AKI and cardiac surgery

57. Biomarkers ofAKI and outcomes in critically ill

58. Biomarkers of AKI and outcomes in
cardiorenal syndrome

59. Biomarkers of AKI and outcomes in
kidney transplantation

60. Future of biomarker-assisted approaches
forAKI management
PatrickT. Murray, et al, Kidney Int. 2014March ; 85(3): 513–521.

61. Proposed new AKI criteria
Functional criteria Damage criteria
PatrickT. Murray, et al, Kidney Int. 2014March ; 85(3): 513–521.

62. Modified conceptual model of AKI
PatrickT. Murray, et al, Kidney Int. 2014March ; 85(3): 513–521.

63. Thank you for your attention