Clinical Implementation and Initial Experience of Neutrophil Gelatinase-Associated Lipocalin Testing for the Diagnostic and Prognostic Assessment of Acute Kidney Injury Events in Hospitalized Patients

Abstract

<b><i>Introduction:</i></b> The use of novel kidney injury biomarkers has been shown to improve diagnostic assessment and prognostic prediction in various populations with acute kidney injury (AKI), but their use in a standard clinical practice have been rarely reported. <b><i>Methods:</i></b> We reported the clinical implementation of neutrophil gelatinase-associated lipocalin (NGAL) measurement for routine AKI diagnostic workup of patients receiving nephrology consultation in a tertiary academic centre. Specific focus was made on the diagnostic performance to discriminate functional (“pre-renal”) from intra-renal AKI and to predict AKI progression. <b><i>Results:</i></b> Forty-five urine NGAL (uNGAL) and 25 plasma NGAL (pNGAL) samples in the first 50 consecutive patients were analysed. KDIGO Stage 1, 2, 3 AKI, and renal replacement therapy occurred in 10%, 40%, 50%, and 24% of cases, respectively. The uNGAL was lower in patients with transient AKI (<48 h) and no sign of urinary tract infections (37 [25–167] ng/mL) than sustained or progressive AKI (298 [74–1,308] ng/mL) (<i>p</i> = 0.016), while pNGAL did not discriminate transient (264 [100–373] ng/mL) from persistent AKI (415 [220–816] ng/mL) (<i>p</i> = 0.137). The median uNGAL level was 63 (35–1,123) ng/mL for functional/pre-renal AKI and 451 (177–1,315) ng/mL for intra-renal AKI (<i>p</i> = 0.043), while the pNGAL was 264 (114–468) and 415 (230–816) ng/mL (<i>p</i> = 0.235), respectively. <b><i>Conclusion:</i></b> NGAL, as part of the routine workup, is useful for diagnostic and prognostic assessment of new-onset AKI in clinical practice. Interpretation of an increased NGAL level should be clinically evaluated in its clinical context, particularly considering concomitant infection (urinary or systemic). Clinical adoption of emerging AKI biomarkers as diagnostic tests in clinical practice should be further encouraged.

Global Perspectives in Acute Kidney Injury: Ireland

“…There is limited use of kidney injury biomarkers in a clinical context. However, some nephrologists have recently begun to use neutrophil gelatinase-associated lipocalin (NGAL) to improve diagnostic discrimination and aid management of AKI in routine clinical practice (13). Cote et al reported on the use of plasma and urinary NGAL in a heterogeneous cohort of AKI patients in their institution.…”

Clinical Implementation of NGAL Testing to Improve Diagnostic Assessment of AKI Episodes in a Canadian Center

“…Urine NGAL (uNGAL) and plasma NGAL (pNGAL) could be measured, but uNGAL was generally preferred based on previous experiences showing a lower specificity and overall accuracy for pNGAL in hospitalized patients with already confirmed AKI. 8 The NGAL was validated and measured using an automated AU5800 Chemistry Analyzer (BeckmanCoulter © ) with the NGAL Test™ by BioPorto Diagnostics © (Hellerup, Denmark) by turbidimetric immunoassay. The limit of quantification and measurable ranges for both uNGAL and pNGAL were 25 to 3000 ng/mL.…”

“… 6 Indeed, the presence of tubular damage biomarkers such as the neutrophil gelatinase-associated lipocalin (NGAL) is clinically associated with intrinsic AKI, mostly acute tubular injury, while its absence is more in favor of functional (prerenal) causes. 7 , 8 Recently, the 23nd Acute Disease Quality Initiative Consensus Conference recommended that a combination of functional and damage biomarkers should now be integrated with clinical information, to identify high-risk patients and to improve diagnostic assessment and management of AKI episodes in various clinical settings. 9 …”

“…6 Indeed, the presence of tubular damage biomarkers such as the neutrophil gelatinase-associated lipocalin (NGAL) is clinically associated with intrinsic AKI, mostly acute tubular injury, while its absence is more in favor of functional (prerenal) causes. 7,8 Recently, the 23nd Acute Disease Quality Initiative Consensus Conference recommended that a combination of functional and damage biomarkers should now be integrated with clinical information, to identify high-risk patients and to improve diagnostic assessment and management of AKI episodes in various clinical settings. 9 Based on a favorable experience from a previous clinical implementation of NGAL testing in a tertiary hospital in Ireland, 8 our group decided to implement NGAL testing at the Centre hospitalier de l'Université de Montréal (CHUM), the second largest Canadian hospital, with more than 800 beds, as a diagnostic tool for new-onset AKI episodes where uncertainties remain regarding the suspected cause at the time of nephrology consultation.…”

“…7,8 Recently, the 23nd Acute Disease Quality Initiative Consensus Conference recommended that a combination of functional and damage biomarkers should now be integrated with clinical information, to identify high-risk patients and to improve diagnostic assessment and management of AKI episodes in various clinical settings. 9 Based on a favorable experience from a previous clinical implementation of NGAL testing in a tertiary hospital in Ireland, 8 our group decided to implement NGAL testing at the Centre hospitalier de l'Université de Montréal (CHUM), the second largest Canadian hospital, with more than 800 beds, as a diagnostic tool for new-onset AKI episodes where uncertainties remain regarding the suspected cause at the time of nephrology consultation. This constitutes a large and comprehensive report on the clinical experience and associated biomarker accuracy with a combination of traditional and novel AKI biomarkers and the first to report a real-life setting clinical implementation and experience using NGAL testing in Canada.…”