1. ©2013 MFMER | slide-1 Biomarkers of AKI: Kidney Troponin Kianoush Kashani, MD Assistant Professor in Internal Medicine Consultant Division of Nephrology and Hypertension Consultant Division of Pulmonary and Critical Care Program Director – Critical Care Fellowship Mayo Clinic Multidisciplinary Simulation Center (MCMSC) kashani.kianoush@mayo.edu

2. ©2013 MFMER | slide-2 Therapeutic Window Himmelfarb et al: Clin J Am Soc Nephrol 3:962, 2008 High Risk Volume Responsive AKI Volume Unresponsive AKI Therapeutic Window Kidney Function Mortality Biomarkers SensitiveTraditional Hypervolemia Euvolemia Hypovolemia

3. ©2013 MFMER | slide-3 Kidney Troponin PeriodACSAKI 1960s LDHSerum creatinine 1970sCPK, myoglobinSerum creatinine 1980sCK-MBSerum creatinine 1990sTroponin TSerum creatinine 2000sTroponin ISerum creatinine Developed multiple therapies Developed multiple therapies  mortality  mortality Supportive therapy Supportive therapy High mortality High mortality

4. ©2013 MFMER | slide-4 Serum and urinary cystatin C 13KDa protein Synthesized and released into plasma by all nucleated cells Still dependent on lean body mass (MacDonald, AJKD, 48(5) 712-719, 2006) Serum cystatin C freely filtered (small and non-ionic) More sensitive than Scr as marker of GFR Cystatin C catabolized in PT Tubular damage  appearance in urine Won K et al, Curr Opin Crit Care, 10:476-482, 2004

5. ©2013 MFMER | slide-5 Cystatin C Obesity and Waste circumference Hyperthyroid Glucocorticoid use Smoker Non-Hispanic White Male Increased CRP Madero, et al; CO Neph HTN. 18:258–263. 2009

6. ©2013 MFMER | slide-6 Cystatin C and mortality N = 845 ICU patients Based on RIFLE criteria 271  AKI; 562  non-AKI Cystatin C and mortality related in both cohorts Stronger in patients without AKI Bell et al. Nephrol Dial Transplant (2009) 1 of 7

7. ©2013 MFMER | slide-7 Cystatin C and mortality Bell et al. Nephrol Dial Transplant (2009) 1 of 7

8. ©2013 MFMER | slide-8 Neutrophil Gelatinase-Associated Lipocalin (NGAL) Won K: Curr Opin Crit Care 10:476, 2004 Mishra J et al: JASN 14:534, 2003 Lipocalin superfamily Markedly up-regulated in early post-ischemic kidney in proliferating PT cells NGAL in plasma and urine Marker of AKI Appears in urine within 3 hours of ischemic injury and cisplatin exposure

9. ©2013 MFMER | slide-9 NGAL 2-3 Hours After CPB as the Predictor of AKI Haase-Fielitz et al: NDT, May 27, 2009 Timing of NGALAUC-ROC to PatientsCreatinineTiming of postopmeasurementpredict AKI Reference(no.)Settingincreasecreatinine increase(after end of CPB)(plasma/urine) Mishra et al 71Paediatric>50%Within 5 daysAt 2 h0.91/0.99 Dent et al120Paediatric>50%Within 5 daysAt 2 h0.96/– Bennett et al196Paediatric>50%Within 5 daysAt 2 h–/0.95 Wagener et al 81Adult>50%Within 5 daysAt 3 h–/0.74 Wagener et al426Adult>50% orWithin 2 daysAt 3 h–/0.60 >0.3 mg/dL Koyner et al 72Adult>25% or needWithin 3 daysAt ~2 h*0.53/0.70 for RRT Haase-Fielitz et al100Adult>50%Within 5 daysAt ~2 h*0.80/– AKI definition

10. ©2013 MFMER | slide-10 NGAL and Cystatin C after CPB Haase et al; Ann Thorac Surg 2009;88:124 –30. 2009

11. ©2013 MFMER | slide-11 NGAL predictive value Nickolas et al; Ann Intern Med. 2008;148:810-819

12. ©2013 MFMER | slide-12 Angiopoietin 2: A prognostic marker? Angiopoietin-2 (Ang-2) Circulating antagonistic ligand of the endothelial-specific Tie2 receptor Increases capillary leak Is not removed during dialysis n= 117 AKI at the time of initiation of RRT Circulating Ang-2 correlated with: Impaired oxygenation low mean arterial pressure vasopressor dose SOFA score Ang-2 significantly higher in non-survivors at day 0 and day 14 after initiation of RRT Kumpers et al. Intensive Care Med (2010) 36:462–470

13. ©2013 MFMER | slide-13 Angiopoietin 2: A prognostic marker?

14. ©2013 MFMER | slide-14 Kidney injury molecule-1 (KIM-1) Transmembrane protein Not detectable in normal kidney tissue Very high in dedifferentiated PT cells after ischemic or toxic injury Protein and mRNA up-regulated in 48-hr post ischemic Won et al, KI, 62: 237-244, 2002

15. ©2013 MFMER | slide-15 Rena-Stick Human Rena-Stick Vaidya et al, Kidney International (2009) 76, 108–114

16. ©2013 MFMER | slide-16 Multi-bead assay Vaidya et al, 2008 Clin. Trans Sci.

17. ©2013 MFMER | slide-17 Urinary and Serum Biomarkers for the Diagnosis Of AKI: An In-depth Review of the Literature Vanmassenhove et al. Nephrol Dial Transplant (2012) 0: 1–20

18. ©2013 MFMER | slide-18 Discovery Cohort in Search for New Kidney Troponins

19. ©2013 MFMER | slide-19 Vienna Cohort Age  18 ICU + sepsis n=134 Vienna Cohort Age  18 ICU + sepsis n=134 Duke Cohort Age  18 At least 1 risk factor n=123 Duke Cohort Age  18 At least 1 risk factor n=123 Mayo Cohort Age  18 At least 1 risk factor n=265 Mayo Cohort Age  18 At least 1 risk factor n=265 Sapphire Study 35 sites (20 North American, 15 Europe) Age >21, critically ill 3, no AKI (stage 2 or 3) 4 n=744 Sapphire Study 35 sites (20 North American, 15 Europe) Age >21, critically ill 3, no AKI (stage 2 or 3) 4 n=744 No stage 1 n=211 No stage 1 n=211 No stage 2 n=83 No stage 2 n=83 AKI stage 3 n=18 AKI stage 3 n=18 No AKI n=416 No AKI n=416 n=728 5 16 patients excluded (2 withdrew consent, 7 lost to follow-up, 7 with invalid or missing test results) Within 12 hr Validation Discovery Best 2 markers Pilot studies

20. ©2013 MFMER | slide-20 ROC-AUC – Comparison of Novel Markers [TIMP-2]  [IGFBP7] Urine TIMP-2 Urine IGFBP7 Urine NGAL Serum creatinine Plasma NGAL Plasma cystatin C AUC (with 95% CI) 0.40.90.80.70.60.5

21. ©2013 MFMER | slide-21 Sapphire Trial

22. ©2013 MFMER | slide-22 Vienna Cohort Age  18 ICU + sepsis n=134 Vienna Cohort Age  18 ICU + sepsis n=134 Duke Cohort Age  18 At least 1 risk factor 1 n=123 Duke Cohort Age  18 At least 1 risk factor 1 n=123 Mayo Cohort Age  18 At least 1 risk factor 2 n=265 Mayo Cohort Age  18 At least 1 risk factor 2 n=265 Sapphire Study 35 sites (20 North American, 15 Europe) Age >21, critically ill, no AKI (stage 2 or 3) n=744 Sapphire Study 35 sites (20 North American, 15 Europe) Age >21, critically ill, no AKI (stage 2 or 3) n=744 AKI stage 1 n=211 AKI stage 1 n=211 AKI stage 2 n=83 AKI stage 2 n=83 AKI stage 3 n=18 AKI stage 3 n=18 No AKI n=416 No AKI n=416 n=728 16 patients excluded (2 withdrew consent, 7 lost to follow-up, 7 with invalid or missing test results) Within 12 hr Validation Discovery Best 2 markers Sapphire Trial

23. ©2013 MFMER | slide-23 Urine KIM-1 Sapphire Study Concentration (ng/mL) ICU admission Cardiovascular Cerebrovascular Sepsis Respiratory Surgery Diabetes CHF CADCKD COPD Emphysema Chronic bronchitis Respiratory other No RIFLE RIFLE R RIFLE I RIFLE F Subjects without AKIAKI subjects stratified by RIFLE

24. ©2013 MFMER | slide-24 Urine NGAL Sapphire Study Concentration (ng/mL) ICU admission Cardiovascular Cerebrovascular Sepsis Respiratory Surgery Diabetes CHF CADCKD COPD Emphysema Chronic bronchitis Respiratory other No RIFLE RIFLE R RIFLE I RIFLE F Subjects without AKIAKI subjects stratified by RIFLE

25. ©2013 MFMER | slide-25 Sapphire Study ICU admission Cardiovascular Cerebrovascular Sepsis Respiratory Surgery Diabetes CHF CADCKD COPD Emphysema Chronic bronchitis Respiratory other No RIFLE RIFLE R RIFLE I RIFLE F Subjects without AKIAKI subjects stratified by RIFLE [TIMP2]  [IGFBP7]

26. ©2013 MFMER | slide-26 Sapphire Study P=0.00008 P<0.00003 Relative risk of RIFLE-I/F

27. ©2013 MFMER | slide-27 MAKE 30 Composite score Major adverse kidney events truncated in 30 days 1.Death 2.Need for RRT 3.Double Scr at 30 day or d/c [TIMP2]  [IGFBP7] ((ng/mL) 2 /1000) Risk of MAKE 30 Risk for AKI (KDIGO stage 2-3) Sensitivity threshold  0.3 Specificity threshold  2

28. ©2013 MFMER | slide-28 Kidney Troponin: where are we? PeriodACSAKI 1960s LDHSerum creatinine 1970sCPK, myoglobinSerum creatinine 1980sCK-MBSerum creatinine 1990sTroponin TSerum creatinine 2000sTroponin ISerum creatinine

29. ©2013 MFMER | slide-29 شكراً “The best interest of the patient is the only interest to be considered”

30. ©2013 MFMER | slide-30 Questions & Discussion