title: Post cardiac surgery acute kidney injury: a woebegone status rejuvenated by the novel biomarkers.
abstract: BACKGROUND
  Acute kidney injury (AKI) is common after cardiac surgery, the incidence varying between 7.7% and 28.1%. It significantly increases morbidity and mortality. Creatinine considerably delays the diagnosis with its own attended demerits. Novel urinary biomarkers are emerging which help in rapid diagnosis thus reducing the morbidity and mortality. Biomarkers of our study were neutrophil gelatinase-associated lipocalin (NGAL) and Interleukin-18 (IL-18).
  
  
  OBJECTIVE
  To find out the incidence of AKI in post-cardiac surgery patients in our hospital, the ability of the two biomarkers in early diagnosis in predicting the severity of AKI based on RIFLE's criteria and their ability to discriminate pre-renal from intrinsic AKI.
  
  
  METHODS
  One-hundred patients who underwent cardiac surgery were selected. Midstream urine samples were collected at 3 time intervals (baseline before surgery, 24 hours and 7 days after surgery). Biomarkers were measured by ELISA using BIORAD processors. Fractional excretion of sodium and urea were used to discriminate pre-renal from intrinsic AKI.
  
  
  RESULTS
  Out of 100 patients, 31 had AKI, 11 being pre-renal and 20 intrinsic AKI. Four patients required renal replacement therapy (12.9% among AKI cases and 4% in the overall study cohort). Four among 31 expired in intensive care unit. Identifiable risk factors for AKI included insulin requiring diabetes mellitus, chronic obstructive pulmonary disease, increased cardio-pulmonary bypass time, combined valvular surgery and coronary artery bypass grafting, employment of intra-aortic balloon counter pulsation, left main coronary artery occlusion and an ejection fraction of < 40%. NGAL was extremely sensitive (area under curve-0.96) in detecting intrinsic AKI at 24 hours followed by IL-18 ratio with an area under curve of 0.89. Creatinine at 24 hours was able to detect only 31.6% of intrinsic AKI. None of the pre-renal cases showed rise in the urinary biomarker levels. Patients with higher stages of AKI had higher levels of both biomarkers than those at lower stages.
  
  
  CONCLUSIONS
  NGAL and IL-18 obviated the disadvantages of creatinine. They were efficient in early detection of AKI, in differentiating pre-renal from intrinsic AKI and in predicting the severity of AKI reliably in post-cardiac surgery patients.
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Rajesh
authors: R
authors: Jayaraman
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Sham
authors: S
authors: Sunder
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Satyanand
authors: S
authors: Sathi
authors: Department of Cardio Thoracic and Vascular Surgery, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Vijay Kumar
authors: VK
authors: Gupta
authors: Department of Biochemistry, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Neera
authors: N
authors: Sharma
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Prabhu
authors: P
authors: Kanchi
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Anurag
authors: A
authors: Gupta
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Sunil Kumar
authors: SK
authors: Daksh
authors: Department of Nephrology, Dr. Ram Manohar Lohia Hospital, Indraprastha University, New Delhi, India.
authors: Pranith
authors: P
authors: Ram
authors: Prof. Brien Holden Eye Research Centre, LV Prasad Eye Institute, Hyderabad, India.
authors: Ashik
authors: A
authors: Mohamed
keywords: Acute Kidney Injury; Interleukin-18; NGAL Protein