Urine NGAL in the critically ill
preliminary results of the
FINNAKI study
Sara Nisula
Intensive Care Units, Division of Anaesthesia
and Intensive Care Medicine,
•
Excellent predictor of AKI in isolated cohorts (cardiac surgery,
children)
•
Performance varies in critically ill populations
•
Appears to be useful in prediction of the initiation of RRT
•
Accuracy in mortality prediction?
Background
Neutrophil gelatinase-associated lipocalin (NGAL)
Haase M, Bellomo R, Devarajan P et al. Meta-analysis Am J Kidney Dis. 2009
3494 Admissions
1654
Excluded
89 <18 years
15 Previously in study with RRT 755 Elective admission < 24h 33 On chronic RRT 15 Organ donor 1 Initiation of chronic RRT 89 Declined 20 Foreigner 81 No consent
14 > 5 days in study already 415 Intermediate care 72 Other/unknown 7 Transfers 48 Readmissions
487 No AKI
(62.7%)
90-day mortality
14.6 %
1840 patients
777 patients
290 AKI
(37.3%)
90-day mortality
26.2 %
56 AKIN stage 2
(7.2%)
90-day mortality
23.2 %
89 AKIN stage 3
(11.5%)
90-day mortality
31.5 %
145 AKIN stage 1
(18.7%)
90-day mortality
24.1 %
61 RRT (7.8%)
90-day mortality
31.1 %
1063 patients
U-NGAL not analyzed
1.Half (1.9. – 1.12.2011)
Method
www.bioporto.com
NGAL Rapid ELISA kit
(Bioporto diagnostics)
Aim & hypothesis
AIM:
• Test U-NGAL’s power in predicting AKI, RRT and 90-day
mortality in a mixed ICU setting
HYPOTHESIS
• U-NGAL has additional value in predicting AKI, RRT and
90-day mortality in a mixed ICU setting
Evolution
Evolution
of U
of U
-
-
NGAL
NGAL
over
over
time
time
p < 0.001 in all timepoints
N=731
(all AKIN stages)
N=688 N=596 N=527 N=448 N=348 N=187Log
U-NGA
Evolution of U-NGAL over time
Patients with samples from all 7 timepoints
*
*
*
*
p < 0.01
Log
U-NGAL,
median (IQR)
P
No AKI
29.1 (10.0 – 84.2)
< 0.001
AKI
91.5 (25.2 – 487.6)
No RRT
37.1 (12.4 – 125.3)
< 0.001
RRT
607.8 (124.4 – 1000.0)
90-day survivor
38.3 (12.4 – 148.2)
< 0.001
90-day non-survivor
67.5 (22.7 – 306.8)
U-NGAL between groups
U-NGAL
median (IQR)
P
No AKI
53.8 ( 18.1 – 178.3)
< 0.001
AKI
228.2 (58.6 – 1000.0)
No RRT
72.2 (24.4. – 291.6)
< 0.001
RRT
1000.0 (284.8 – 1000.0)
90-day survivor
70.6 (23.5 – 316.4)
< 0.001
90-day non-survivor
139.7 (45.2 – 661.7)
U-NGAL between groups
U-NGAL in prediction of
AKI
AUC= 0.699 (0.661 - 0.737)
U-NGAL in prediction of
RRT
AUC= 0.794 (0.734 – 0.854)
U-NGAL in prediction of 90-day mortality
AUC= 0.603 (0.554 – 0.654)
AUC
Cut off
(ng/ml)
LR+
AKI
0.699 (0.661 - 0.737)
111.2
2.0 (1.7 – 2.3)
RRT
0.794 (0.734 – 0.854)
376.5
3.5 (2.9 – 4.4)
90-day mortality
0.603 (0.554 – 0.654)
81.2
1.5 (1.3 – 1.7)
U-NGAL in prediction of
AKI, RRT and 90-day mortality
AUC
Cut off
(ng/ml)
LR+
AKI
0.719 (0.638 – 0.800)
175.6
2.01 (1.43 – 2.84)
RRT
0.805 (0.716 – 0.895)
292.4
2.45 (1.90 – 3.17)
90-day mortality
0.430 (0.204 – 0.532)
39.3
Not valid
U-NGAL in prediction of
AKI, RRT and 90-day mortality
Independent predictive value of
U-NGAL for RRT
RRT
OR
95% CI
p
SAPS II – age (per 1 point)
1.043
1.020 – 1.070
<0.001
Patients with no sepsis at admission (N=562)
•
AKI 189 (33.6%)
•
RRT 37 (6.6%)
•
90-day mortality 88 (15.7%)
U-NGAL
(all)
median (IQR)
p
U-NGAL
(highest first 24h)
median (IQR)
p
No AKI
22.6 (10.0 – 55.9)
< 0.001
40.8 (15.4 – 109.3)
< 0.001
AKI
56.4 (17.1 - 195.8)
126.1 (33.6 – 538.4 )
No RRT
27.7 (10.0 – 72.3)
< 0.001
48.1 (17.6 – 160.8)
< 0.001
RRT
284.8 (67.9 – 1000.0)
602.5 (129.7 – 1000.0)
90-day survivor
29.3 (10.0 – 83.4)
< 0.001
49.9 (17.5 – 172.3)
0.010
90-day non-survivor
42.7 (15.3 – 125.7)
96.0 (33.4 – 293.6)
U-NGAL in patients with no sepsis
AUC= 0.674 (0.627 – 0.722)
AUC= 0.790 (0.708 – 0.872)
AKI
RRT
Highest U-NGAL during first 24 hours (N=561)
AUC= 0.586 (0.524 – 0.648)
90-day mortality
Highest U-NGAL during first 24 hours (N=561)
Urine NGAL predicted
• AKI adequately (AUC 0.699)
• RRT well (AUC 0.794)
• 90-day mortality inadequately (AUC 0.603)
• No better in patients with no sepsis
Conclusions
Central Finland Central Hospital: Raili Laru-Sompa, Anni Pulkkinen, Minna Saarelainen, Mikko Reilama, Sinikka Tolmunen, Ulla Rantalainen, Marja Miettinen
East Savo Central Hospital: Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa Kauppinen
Helsinki University Central Hospital: Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara, Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen, Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman
Jorvi Central Hospital: Tero Varpula, Päivi Porkka, Mirka Sivula Mira Rahkonen, Anne Tsurkka, Taina Nieminen, Niina Prittinen.
Kanta-Häme Central hospital: Ari Alaspää, Hanna Juntunen, Teija Sanisalo
Kuopio University Hospital: Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång, Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija Vaskelainen
Lapland Central Hospital: Meri Poukkanen, Esa Lintula, Sirpa Suominen
Länsi Pohja Central Hospital: Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi,
Middle Ostrobothnia Central Hospital: Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane Roiko
North Karelia Central Hospital: Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck, Jaana Kallinen
Satakunta Hospital district: Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu Johansson
South Karelia Central Hospital: Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne Toropainen
Tampere University Hospital: Anne Kuitunen, Jyrki Tenhunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo Varila
Turku University Hospital: Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu Laine
Oulu University Hospital: Tero Ala-Kokko, Jouko Laurila, Sinikka Sälkiö
Vaasa Central Hospital: Simo-Pekka Koivisto, Raku Hautamäki, Maria Skinnar
Study Group
Thank you!