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Abstract Details
Urinary NGAL as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Cirrhosis: A Prospective Study
Clin Transl Gastroenterol. 2021 May 11;12(5):e00359. doi: 10.14309/ctg.0000000000000359.
Andrew S Allegretti1, Xavier Vela Parada1, Paul Endres1, Sophia Zhao1, Scott Krinsky1, Shelsea A St Hillien1, Sahir Kalim1, Sagar U Nigwekar1, James G Flood2, Andrea Nixon2, Douglas A Simonetto3, Luis A Juncos4, Nithin Karakala4, Hani M Wadei5, Kevin R Regner6, Justin M Belcher7, Mitra K Nadim8, Guadalupe Garcia-Tsao9, Juan Carlos Q Velez10, Samir M Parikh11, Raymond T Chung12, HRS-HARMONY study investigators
Author information
1Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
2Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA.
3Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
4Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA.
5Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA.
6Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
7Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA and Section of Nephrology, VA-Connecticut Healthcare System, West Haven, Connecticut, USA.
8Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
9Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, Connecticut, USA.
10Department of Nephrology, Ochsner Health System, Baton Rouge, Louisiana, USA.
11Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
12Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
Abstract
Introduction: Urinary neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in differentiating acute tubular necrosis (ATN) from other types of acute kidney injuries (AKIs) in cirrhosis, particularly hepatorenal syndrome (HRS). However, NGAL is not currently available in clinical practice in North America.
Methods: Urinary NGAL was measured in a prospective cohort of 213 US hospitalized patients with decompensated cirrhosis (161 with AKI and 52 reference patients without AKI). NGAL was assessed for its ability to discriminate ATN from non-ATN AKI and to predict 90-day outcomes.
Results: Among patients with AKI, 57 (35%) had prerenal AKI, 55 (34%) had HRS, and 49 (30%) had ATN, with a median serum creatinine of 2.0 (interquartile range 1.5, 3.0) mg/dL at enrollment. At an optimal cutpoint of 244 μg/g creatinine, NGAL distinguished ATN (344 [132, 1,429] μg/g creatinine) from prerenal AKI (45 [0, 154] μg/g) or HRS (110 [50, 393] μg/g; P < 0.001), with a C statistic of 0.762 (95% confidence interval 0.682, 0.842). By 90 days, 71 of 213 patients (33%) died. Higher median NGAL was associated with death (159 [50, 865] vs 58 [0, 191] μg/g; P < 0.001). In adjusted and unadjusted analysis, NGAL significantly predicted 90-day transplant-free survival (P < 0.05 for all Cox models) and outperformed Model for End-Stage Liver Disease score by C statistic (0.697 vs 0.686; P = 0.04), net reclassification index (37%; P = 0.008), and integrated discrimination increment (2.7%; P = 0.02).
Discussion: NGAL differentiates the type of AKI in cirrhosis and may improve prediction of mortality; therefore, it holds potential to affect management of AKI in cirrhosis.