1、DamageNormal EpitheliumToxic/ischemic InjuryApoptosisNecrosisCell deathDeathComplicationsNormalIncreasedriskKidneyfailureDamage GFR Kidney Injury Molecule-1(KIM-1)Neutrophil Gelatinase Associated Lipocalin(NGAL)N-acetyl-D-glucosaminidase(NAG)Cystatin C Interleukin-18(L-18),microalbuminuria Serum Cre
2、atinine Blood Urea NitrogenPotential biomarkers for early diagnosis of AKIAKIN Scheme,2006 GFRDelayed biomarkers for kidney injuryFABP,2 microglobulin,a a1-microglobulin n DeathComplicationsNormalIncreasedriskKidneyfailureDamage GFRSeverity ofIllness scoresBiomarkersBiomarkersRIFLEAKINDialysisTimeIn
3、tervention TrialsSerumCreatinine(mg/dl)A Goal for Biomarker UsePapillaCortexMedullaUreterPelvisProxim al T ubulesDistal Tubules sCollecting DuctLoop of HenleGlomerulusKIM-1L-FABPAlbuminClusterinLipocalin(NGAL)GSTa2-microglobulina1-microglobulinNAGOsteopontinCystatin CNetrin-1IL-18Retinol binding pro
4、tHGF,NHE-3Cyr61Exosomal Fetuin-ACreatinineCystatin CProtein,albuminPodocalyxin2-microglobulinWT-1 in exosomesosteopontinCalbindin-D28OsteopontinClusterinLipocalin(NGAL)GST-NAGEGFOsteopontinCystatin CIL-18Calbindin-D28Candidate Biomarkers for Kidney InjuryBonventre et al.Nature Biotech 2010Sensitivit
5、y and Specificity of Kim-1,NAG,BUN,SCrHistopathology Grade SubsetSensitivityALL0 to 30 to 20 and 1Kim-1SCrBUNNAG0.70.80.91.00.6ALL0 to 30 to 20 and 1AUC from ROC0.70.80.91.0NAGBUNKim-1SCrVaidya et al.Nature Biotechnology,May,2010Predictive SafetyTesting ConsortiumRat Toxicity StudiesFDA and European
6、 Medicines Agency Will Consider New Biomarker Test Results When Assessing Kidney Toxicity of Experimental Drugshttp:/ the first use of a framework allowing submission of a single application to the 2 agencies,the U.S.Food and Drug Administration(FDA)and the European Medicines Agency(EMEA)will allow
7、drug companies to submit the results of 7 new tests that evaluate kidney toxicity,(FDA news release,6/17/2008).The tests measure levels of 7 key biomarker proteins found in urine that can provide information about drug-induced damage to kidney cells(renal toxicity).The new biomarkers are:KIM-1 Album
8、in Clusterin Trefoil factor-3 Cystatin C Total protein Beta-2 microglobulinTubular Injury BiomarkersGlomerular changes or impaired tubular reabsorption biomarkersDieterle et al.Nature Biotech 28:455-62,2010European InnoMed Predictive Toxicology ConsortiumROC curves for(a)biomarker gene expression an
9、d(b)urinary concentrationsHoffmann D et alToxicol.Sci.2010;116:8-22Urine KIM-1 in Different Strains of Mice Exposed to DB287Harrill et al.Toxicological Sciences 130:416-26,2012DB283 is the first oral effective drug for treatment of African trypanosomiasisClinical studystopped becauseof unexpectednep
10、hrotoxicitySerum BUN andcreatinine did not increasein any mousestrain.Genome wide association mapping of DB289-induced elevations in KIM-1.The network map of GWA significant genes.Harrill et al.Toxicological SciencesIn PressTubular DamageKIM-1,L-FABP,a-GST(albumin and NGAL)GFRCreat,Cystatin CKDIGO S
11、tageInflammationNGAL,IL-18 GFRCreat,Cystatin CKDIGO Stage+/-Inflammation GFRCreatinine,KDIGO StageInjury MarkerInflammation MarkerGFR Marker?Kidney Injury +/-+/-+-+/-+-(prerenal)+-+-+-+/-Tubular DamagePotential Context of Interpretation of AKI MarkersDiagnostic performance of the first postoperative
12、 value of urine IL-18,urine NGAL,and plasma NGAL for the detection of AKI Parikh C R et al.JASN 2011;22:1748-17572011 by American Society of NephrologyUrine IL-18 AUC 0.74Urine NGAL AUC 0.67Plasma NGAL AUC 0.70402060801001-Specificity020806010040SensitivityBiomarkers at 4 hr to predict AKI(AKIN)in c
13、hildrenZheng et al.PedCardiol.2013Plasma NGAL as a Predictor of AKI and Clinical OutcomesCruzRonco Intensive Care Med.36:444-451,2010 301 ICU patients;133(44%)developed AKI during ICU stay0246810121416C1D1C1D1POSTC1D2C1D3C1D4C1D5C2D1C2D1POSTC2D2C2D3C2D4C2D5C3D1C3D1POSTC3D2C3D3C3D4C3D5C4D1C4D1POSTC4D
14、2C4D3C4D4C4D5Cycle and DayNormalized biomarker valueKIM-1/creatNAG/creatMean Urinary KIM-1 and NAG Levels During Cisplatin TreatmentsIn Patients with Testicular CancerSCr did not changeUrinary KIM-1 Levels in Chinese Factory Workers Exposed to TrichloroethyleneVermeulen et al.Carcinogenesis 33:1538-
15、41,2012OSHA:100 ppm/8 hr100000100001000100101KIM-1(pg/mL)CCENCutoff for AKI vs.non-AKIPatients with or at risk of Endemic(Balkan)Nephropathycaused by Aristolochic Acid Three weekly subcut doses of a PCSK9 antisense(to lower LDL-cholesterol)oligonucleotide in 56 yr old otherwise healthy female volunt
16、eer.Recommendation“We conclude that measurement of KIM-1 suits many purposes and is therefore an appropriate choice.It allows for early detection of proximal tubule injury,differentiation between glomerular and tubular damage and assessment of reversibility and regeneration provided this occurs.KIM-
17、1 can be used to detect sub-chronic and chronic kidney injury.”Van Meer et al.Brit J Clin Pharm 77:947-57,2014Example of use of KIM-1 and RecommendationKIM-1Plasma KIM-1pg/mlPlasma Creatininemg/dLAbsolute Urinary KIM-1Normalized Urinary KIM-1ng/mg uCrng/mlPlasma KIM-1 is elevated in I/R mice*P0.001I
18、schemia,37 CT=3-144 hBiomarker measurementT=30 minReperfusionBALB/C,malePlasma KIM-1Plasma CreatinineNormalized Urinary KIM-1mg/dLpg/mlng/mg uCrTime(hr)Time(hr)Time(hr)*P0.001(daBiomarker measurementSprague Dawley ratGentamicin(50&200 mg/kgdaily for 10 days)day 11(*p0.001,#p0.05)Necrosis scoremg/dLP
19、lasma Creatininepg/mlPlasma KIM-1ng/mg uCrUrinary KIM-1050200050200Plasma KIM-1 is elevated in gentamicin induced kidney injury in ratsGentamicin(mg/kg)050200Tubular necrosis*Plasma and urinary KIM-1 is not elevated in mice treated with CCl4 LiverKidneyBiomarker measurementBALB/C,male10%CCl4(0.5 ml/
20、kg)T=48 hPlasma CreatinineUrine KIM-1Plasma KIM-1mg/dlpg/mg uCrpg/mlElevation of Plasma KIM-1 in patients who developed AKI after CPBPre-opEnd of CPB4hDay 1Day 2Day 3Day 4Day 501234No-AKIAKIPlasma Creatininemg/dLPre-opEnd of CPB4hDay 1Day 2Day 3Day 4Day50250500750No-AKIAKIPlasma KIM-1pg/ml*#*#*#Norm
21、alized urinary KIM-1ng/mg uCrPre-opEnd of CPB4h12hDay 1Day 2Day 3Day 4Day5No-AKIAKI 1.02.03.04.05.06.00.0*#*#*#Pre-opEnd of CPB4h12hDay 1Day 2Day 3Day 4Day5050100150200No-AKIAKIAlbuminuriamg/g uCr*#p0.05,significant difference from baseline*p0.05,significant difference between AKI and non-AKI group(
22、N=9)Plasma KIM-1 is elevated in patients who had developed AKI(*p0.001,#p 2 ng/mg Ucr as gold standard)AUC-ROC=0.55Very good Very good biomarkerbiomarkerSerum Serum CreatinineCreatinineEffect of Specificity of Gold Standard on Apparent Performance of“Perfect”Biomarker0.50 0.60 0.70 0.80 0.90 1.00 0
23、0.2 0.4 0.6 0.8 1 Area under the ROC curve Sensitivity or specificity 100 variable 99 variable 97 variable 95 variable 93 variable variable 95 Spec Sens Admission-to-discharge percentage change in GFR grouped by presence or absence of hemoconcentration.Testani J M et al.Circulation 2010;122:265-272C
24、opyright American Heart AssociationSurvival curves grouped by presence or absence of hemoconcentration after adjustment for baseline characteristics.Testani J M et al.Circulation 2010;122:265-272Copyright American Heart AssociationNoYesStatus of HemoconcentrationWhat is holding back the use of kidne
25、y injury biomarkers?The Gold Standard ProblemUnknown thresholds to mark injuryUnknown thresholds to mark“functionally important injury”What is“functionally important injury”“Normal”values.What is“normal”population?Undue conservatism in not believing that preclinical studies inform the use and interpretation of biomarkers in manCompany timidness in aggressively evaluating biomarkers Expectations for study results in humans are unrealistic Impacts harmonization of biomarker test values
