ADULT CARDIAC
Neutrophil Gelatinase-Associated Lipocalin as Early
Predictor of Acute Kidney Injury After Cardiac
Surgery in Adults With Chronic Kidney Failure
Andrea Perrotti, MD, Guillaume Miltgen, MD, Albin Chevet-Noel, MD,
Camille Durst, MD, Dewi Vernerey, MS, Karine Bardonnet, MD,
Siamak Davani, MD, PhD, and Sidney Chocron, MD, PhD
Departments of Thoracic and Cardio-Vascular Surgery, Biochemistry, and Pharmacology, and Methodology and Quality of Life in
Oncology Unit, University Hospital Jean Minjoz, Besançon, France
Background. To assess the utility of neutrophil
gelatinase-associated lipocalin (NGAL) as an early
marker of acute kidney injury (AKI) occurring after
cardiac surgery in patients with prior chronic kidney
failure.
Methods. Patients with preoperative creatinine clear-
ance 60 mL
minL1
1.73 mL2 or less according to the
Cockcroft-Gault formula and scheduled to undergo car-
diac surgery were eligible for inclusion. The AKI was
defined as an increase in plasma creatinine greater than
50% over preoperative values. Threshold values of NGAL
predictive of AKI were determined using receiver oper-
ating characteristic curve analysis, and predictive value of
NGAL for AKI was evaluated by logistic regression.
Results. Over a 1-year inclusion period, 166 patients
were included. At 6 hours post-surgery, hypertension,
occurrence of at least 1 postoperative complication, and
A cute kidney injury (AKI) is one of the most frequent
complications after cardiac surgery [1]. The incidence
of postoperative AKI in cardiac surgery ranges from 5% to
50% depending on preoperative renal status, and the
criteria used to define AKI [2, 3]. Regardless of whether
renal function was normal before surgery or whether there
is a deterioration of previous chronic renal failure, AKI
after surgery is associated with increased morbidity and
perioperative mortality in-hospital [4]. In routine practice,
renal function is monitored by regular assessment of
plasma creatinine levels. However, there is a time delay
between the onset of renal impairment and the resulting
telltale increase in blood creatinine levels. Thus, by the
time creatinine levels are found to be elevated, renal
function has already been impaired for several days [5].
Recent studies have underlined the promising prop-
erties of neutrophil gelatinase-associated lipocalin
(NGAL), a protein normally expressed at very low plasma
levels, as an early predictor of AKI after cardiac surgery
Accepted for publication Oct 3, 2014.
Address correspondence to Dr Chocron, Department of Thoracic and
Cardio-Vascular Surgery, EA3920, University Hospital Jean Minjoz, Blvd
Fleming, 25000 Besançon, France; e-mail: sidney.chocron@univ-fcomte.fr.
Ó 2015 by The Society of Thoracic Surgeons
Published by Elsevier
NGAL greater than 155ng/mL were shown to be inde-
pendent predictors of AKI. NGAL greater than 155 ng/mL
at 6 hours was associated with an odds ratio for risk of
postoperative AKI of 7.1 [2.7 to 18]. On average, diagnosis
of postoperative AKI was made 20 hours earlier using
NGAL at 6 hours post-surgery as compared with a diag-
nosis based on a 50% increase in creatinine over baseline.
The threshold for NGAL of 155 ng/mL at 6 hours had a
sensitivity of 79% and specificity of 58% for the diagnosis
of AKI.
Conclusions. Earlier diagnosis of AKI post-surgery
based on NGAL assessment makes it possible to initiate
appropriate therapy at an earlier stage in this high-risk
patient population.
(Ann Thorac Surg 2015;99:864–9)
Ó 2015 by The Society of Thoracic Surgeons
in children [6] and adults [7, 8]. NGAL is released
in response to ischemia of the proximal tubules of the
kidney, and NGAL values early after surgery could pre-
dict the duration and severity of AKI. In addition, NGAL
can independently predict deteriorating renal function
and could therefore be useful even in the context of
preexisting renal failure. A novel marker that could
identify AKI after surgery at an earlier stage than
currently possible with monitoring of creatinine plasma
levels would make it possible to initiate appropriate
therapy more quickly in these patients.
To the best of our knowledge, no study to date has
investigated the utility of early NGAL assessment to
predict the occurrence of AKI post-cardiac surgery in
patients suffering from chronic renal failure prior to
surgery. Therefore, we aimed to assess the predictive
ability of plasma NGAL levels to identify deteriorations
in renal function after cardiac surgery in patients with
preexisting renal failure.
Material and Methods
We performed this prospective study in a single univer-
sity teaching hospital that is a referral center for a pop-
ulation basin of approximately 1.2 million inhabitants
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2014.10.011
Ann Thorac Surg
2015;99:864–9
(region of Franche-Comte in eastern France). This study
was approved by the local ethics committee (CPP EST II,
registered under the number 10/544) and was registered
with the ClinicalTrials.gov database under the number
NCT01227122. All participants provided written informed
consent.
The inclusion criteria for the study were adult
(age >18 years) patients with preoperative creatinine
clearance 60 mL
min1
1.73 m2 or less according
to the Cockcroft Gault formula scheduled to undergo
cardiac surgery, and who provided written informed
consent. Exclusion criteria were the following: emergency
surgery; injection of contrast medium in the 3 days pre-
ceding surgery or intravenous iodinated contrast medium
injection within the first 24 hours post-surgery; patients
with preoperative blood creatinine levels greater than
300 mmol/L; patients undergoing hemodialysis; patients
with ongoing inflammation, infection or cancer; preg-
nancy; patient refusal; adults under legal protection.
Neutrophil Gelatinase-Associated Lipocalin Assessments
NGAL was assessed from blood samples taken at 5 time
points: namely at induction of general anesthesia (base-
line NGAL); at 15 minutes after interruption of extracor-
poreal circulation; and at 6, 12, and 24 hours after the end
of surgery. Blood samples were centrifuged at 2,250  250
g for 13  2 minutes at room temperature (18 to 25
Celsius), aliquoted in 0.5 mL tubes (Eppendorf, Le Pecq,
France), and frozen at 20 C for later analysis. Tests were
performed using a specific kit, namely Triage NGAL
test (Biosite Inverness Medical, San Diego, CA). The
measurable range is from 15 to 1,300 ng/mL.
Serum creatinine and creatinine clearance according to
the Cockcroft-Gault formula were assessed at 6 and
12 hours after surgery, and then once daily until the third
postoperative day.
Definition of Acute Kidney Injury
Acute kidney injury was defined as an increase in blood
creatinine levels of at least 50% over preoperative values.
Patients were classified into the following 2 groups
accordingly: group 1, patients with a postoperative in-
crease in creatinine less than 50% over baseline (no-AKI
group); and group 2, patients with a postoperative
increase in creatinine ( 50%) over baseline (AKI group).
Correlations
The correlation between baseline NGAL and baseline
creatinine clearance value and to serum creatinine level
was tested. In the AKI group, the correlation between
the ratio of preoperative NGAL to NGAL at 6 hours
and the severity of the subsequent AKI—defined as the
ratio of the lowest postoperative creatinine clearance
during follow-up (considered as nil for patients who had
hemofiltration)—to preoperative creatinine clearance was
also tested.
Statistical Analysis
Quantitative data are described as mean  standard
deviation or median interquartile range for non-normally
PERROTTI ET AL 865
NGAL AND AKI
ADULT CARDIAC
distributed variables. Qualitative data are described as
number (percentage). Preoperative, perioperative, and
postoperative characteristics were compared using the
Mann-Whitney and c2 or Fisher exact test, as appropriate.
Correlations were evaluated by the Pearson correlation
coefficient. We considered the strength of a correlation as
weak for correlation coefficients ranging from 0.1 to 0.3,
moderate for 0.3 to 0.6, and strong for correlation
coefficients greater than 0.6.
To identify a threshold value of NGAL predictive of
AKI, receiver operating characteristic (ROC) curve anal-
ysis was used, and the sensitivity and specificity of the
cutoff values were calculated. Independent predictors of
postoperative AKI were identified by logistic regression.
All variables with a p value less than 0.10 by univariate
analysis were included in the model. All analyses were
performed using SAS version 9.2 (SAS Institute Inc, Cary,
NC). A p value of less than 0.05 was considered statisti-
cally significant.
Results
Between November 1, 2012 and November 27, 2013, 819
patients underwent cardiac surgery in our institution.
Among the 213 patients who met inclusion criteria,
8 refused to participate and 39 had too many missing
values to be analyzed. Therefore 166 patients were
included in the study. Preoperative renal failure was
moderate (creatinine clearance from 30 to 60 mL
min1

1.73 m2) in most patients (149, 90%), and severe
(creatinine clearance from 15 to 29 mL
min1
1.73 m2)
in 17 patients (10%). The baseline characteristics of the
study population are shown in Table 1. There was no
significant difference between groups at baseline except
for hypertension and preoperative creatinine clearance.
There was a borderline significant difference in the
duration of cardiopulmonary bypass (CPB) between
groups (p ¼ 0.05). In the AKI group, average time to 50%
increase in creatinine was 25.6  21.7 hours.
Although statistically significant (p < 0.01) the correla-
tion between preoperative NGAL values and (1) pre-
operative creatinine clearance and (2) preoperative
creatinine values was only moderate (r ¼ 0.34 and 0.42,
respectively). In the AKI group, the ratio of preoperative
NGAL to NGAL at 6 hours was not correlated with the
severity of subsequent AKI (r ¼ 0.02, p ¼ 0.9).
Table 2 details the postoperative complications in both
groups. There was a higher overall rate of complications
in the AKI group. There were 6 postoperative deaths (4%),
1 in the no AKI group from acute respiratory distress
syndrome, and 5 in the AKI group; namely, 1 from acute
respiratory distress syndrome, 3 from mesenteric
ischemia, and 1 from heart failure.
The threshold NGAL values at each time point, as
determined by ROC curve analysis, are indicated in
Figure 1. At 15 minutes, sensitivity was 54% and speci-
ficity was 71%; at 6 hours, these values were 79% and
58%, respectively.
By multivariate analysis (Table 3) at 6 hours a history
of hypertension (odds ratio [OR] ¼ 3.2 [1.2 to 8.9]),
 866 PERROTTI ET AL Ann Thorac Surg
NGAL AND AKI 2015;99:864–9
ADULT CARDIAC

Table 1. Baseline Characteristics of the Study Population

All No AKI AKI
Patient Characteristics n ¼ 166 n ¼ 114 n ¼ 52 p Value

Preoperative
Age (years) 77  6 77  6 78  5 0.2
Male sex (%) 88 (53) 62 (54) 26 (50) 0.6
BMI (kg/m2) 26  5 26  4 27  5 0.4
Diabetes (%) 49 (30) 33 (29) 16 (31) 0.8
Dyslipidemia (%) 85 (51) 60 (53) 25 (50) 0.6
History of hypertension (%) 118 (71) 75 (66) 43 (82) 0.03a
Family history of CAD (%) 24 (15) 20 (18) 4 (8) 0.09
PAD (%) 38 (23) 23 (20) 15 (29) 0.2
LVEF 0.58  0.14 0.58  0.14 0.60  0.13 0.5
Diuretics presurgery (%) 87 (52) 56 (49) 31 (59) 0.2
Mean preoperative creatinine clearance 45  11 47  10 41  10 0.01
Perioperative data
CABG on-pump (%) 41 (25) 32 (28) 9 (17) 0.6
CABG off-pump (%) 18 (11) 15 (13) 3 (6)
Isolated aortic valve replacement (%) 50 (30) 32 (28) 18 (35) 0.4
Other surgeryb (%) 57 (34) 35 (31) 22 (42) 0.1
CPB duration (minutes) 99  105 98  125 101  43 0.05
Duration of aortic clamping (minutes) 75  29 71  23 84  37 0.09
Postoperative data
Need of vasopressive medications (%) 60 (36) 39 (34) 21 (40) 0.4
Antihypertensive agents (%) 68 (41) 50 (44) 18 (35) 0.3
Time to extubation (hours) 7  15 63 11  27 0.07
Blood loss at 24 hours (mL) 513  328 505  275 530  422 0.92
a
p Value <0.05. b
Other surgery includes combined operations and mitral valve surgery.
AKI ¼ acute kidney injury; BMI ¼ body mass index; CABG ¼ coronary artery bypass grafting; CAD ¼ coronary artery disease; CPB ¼
cardiopulmonary bypass; LVEF ¼ left ventricular ejection fraction; PAD ¼ peripheral artery disease.

occurrence of at least 1 postoperative complication colleagues [9] showed, using the RIFLE [risk, injury,
(OR ¼ 4.5 [1.3 to 15]), and an NGAL value above 155 ng/ failure, loss of kidney function, and end-stage kidney
mL (OR ¼ 7.1 [2.7 to 18]) were shown to be independent disease] classification that the risk of death increased with
predictors of the occurrence of postoperative AKI. the severity of renal dysfunction post-cardiac surgery.
Chronic renal failure is also well established as a
predictor of death and complications in the context of
Comment
cardiac surgery [2, 10, 11]. In these particularly vulnerable
The occurrence of AKI after cardiac surgery is a known patients, early detection of any aggravation of renal
risk factor for complications and death. Kuitunen and dysfunction is therefore important. Monitoring creatinine
levels often makes it possible to follow the course of
Table 2. Postoperative Complications worsening renal function, but not to anticipate it.
In our study we investigated the utility of NGAL to
All No AKI AKI
Complication n ¼ 166 n ¼ 114 n ¼ 52 p Value predict occurrence of postoperative AKI in patients who
had preoperative creatinine clearance 60 mL
min1

Death (%) 6 (4) 1 (1) 5 (10) <0.01a 1.73 m2 or less, as estimated by the Cockcroft-Gault
Hemofiltration 4 (2) 0 (0) 4 (8) <0.01a formula, and plasma creatinine less than 300 mmol/L.
Pulmonary edema 2 (1) 0 (0) 2 (4) 0.04a We used an increase in serum creatinine of more than
Mesenteric ischemia 3 (2) 1 (1) 2 (4) 0.2 50% over preoperative values to define AKI as this
Reintubation 9 (5) 1 (1) 8 (15) <0.01a criterion is widely used in the literature [6–8]. Patients
Infection 12 (7) 6 (5) 6 (12) 0.2 undergoing emergency surgery were excluded because
Early reintervention 13 (8) 9 (8) 4 (8) 0.9 they were likely to have had administration of contrast
1 complication 22 (13) 8 (7) 14 (27) <0.01a medium immediately prior to the operation (eg, during
catheterization), and were also likely to be hemodynam-
a
p Value <0.05. ically unstable, both factors that could be potential
AKI ¼ acute kidney injury. confounders.
Ann Thorac Surg PERROTTI ET AL 867
2015;99:864–9 NGAL AND AKI

ADULT CARDIAC
Fig 1. Receiver operating characteristic
curves at (A) 15 minutes, (B) 6, (C) 12, and
(D) 24 hours after surgery. (AUC ¼ area
under the curve; NPV ¼ negative predictive
value; PPV ¼ positive predictive value.)

Our results indicate that as early as 15 minutes after the
end of surgery, an NGAL value greater than 178 ng/mL
can correctly identify 54% of patients who will go on to
present AKI. At 6 hours, an NGAL value greater than
155 ng/mL detects 79% of patients who will subsequently
develop AKI. The time gained in the diagnosis of AKI by
using the NGAL level at 6 hours was on average 20 hours,
and 25 hours if NGAL values at 15 minutes were used.
Indeed, creatinine values take on average 25.6 hours to
achieve a 50% increase over preoperative levels. This
considerable time gain in the diagnostic procedure can be
put to good use to initiate appropriate therapy. Unlike the
findings of Bennett and colleagues [12] and Haase and
colleagues [7], NGAL at 6 hours was not predictive of the
severity of the subsequent AKI in our study.
The NGAL threshold at 6 hours identified in our study
has a low specificity, at 58%. Plasma NGAL measure-
ments may be influenced by a number of coexisting
variables, including chronic hypertension, systemic in-
fections, inflammatory conditions, anemia, hypoxia, and
malignancies [1]. However, in their study, Haase and
colleagues [13] showed that there was an increase in
subsequent renal replacement therapy initiation when
comparing patients with normal NGAL level plus normal
creatinine level to patients with increased NGAL plus
normal creatinine level (OR ¼ 16.4 [3.6–76.9]). These
authors concluded that in the absence of diagnostic
increases in serum creatinine, NGAL detects patients
with likely subclinical AKI who have an increased risk of
worse outcome.

Table 3. Predictors of Postoperative Occurrence of Acute Kidney Injury (Multivariate Analysis)

NGAL at NGAL at NGAL at NGAL at
Variables 15 Minutes 6 Hours 12 Hours 24 Hours

History of hypertension 2.9 [1.1–7.4]a 3.2 [1.2–8.9]a 2.3 [0.8–6.3] 2.9 [1.0–8.1]a
Family history of 0.4 [0.1–1.4] 0.3 [0.1–1.3] 0.3 [0.1–1.2] 0.3 [0.1–1.6]
cardiovascular disease
Occurrence of  1 3.2 [1.05–9.55]a 4.5 [1.3–15]a 3.7 [1.0–12]a 2.7 [0.7–9.7]
postoperative complication
Clearance preoperative 1 [0.98–1.06] 1.1 [0.99–2.0] 1 [0.99–1.09] 1.04 [0.99–1.1]
Duration of CPB (minutes) 1 [0.98–1.01] 1 [0.96–1.02] 1 [0.97–1.01] 1 [0.97–1.01]
Duration of aortic 1 [0.99–1.04] 1 [0.99–1.05] 1 [0.99–1.04] 1 [0.99–1.04]
clamping (minutes)
Time to extubation (hours) 1.1 [0.96–1.2] 1.1 [0.96–1.2] 1 [0.96–1.08] 1 [0.95–1.15]
NGAL > threshold 2.1 [0.96–4.7] 7.1 [2.7–18]a 8.3 [3.0–23]a 5.1 [2.1–13]a
Cutoff: 178 ng/mL Cutoff: 155 ng/mL Cutoff: 173 ng/mL Cutoff: 258 ng/mL
a
Significant predictors in multivariate analysis.
CPB ¼ cardiopulmonary bypass; NGAL ¼ neutrophil gelatinase-associated lipocalin.
 868 PERROTTI ET AL
NGAL AND AKI
ADULT CARDIAC
To date, no study has demonstrated the utility of
assessing plasma NGAL values in patients with preex-
isting chronic renal failure. The patients in our study had
a high mean age and many comorbidities, in addition to
impaired renal function. This type of patient profile is
increasingly frequent in cardiac surgery, and for these
high-risk patients early diagnosis, and corresponding
early initiation of appropriate treatment, could help to
limit renal damage and reduce mortality.
Predicting the occurrence of postoperative AKI early
after the operation may be of clinical value as it makes it
possible to initiate treatment earlier. Monitoring of car-
diac and renal function can be intensified by searching for
organic causes using renal Doppler echography to iden-
tify any potential obstacle in the urinary tract or any
morphologic anomalies, and can also study renal vascular
resistance. Renal perfusion can be optimized by several
approaches: (1) by investigating the presence of occult
low cardiac output, either invasively using a Swann-Ganz
catheter, or by ultrasound; (2) by shifting the range of
hemodynamic targets to a higher mean arterial pressure
or cardiac output; (3) by investigating possible venous
congestion; (4) it is also necessary to screen for right
ventricular dysfunction or pericardial effusion; (5) fluid
balance must be optimized, if necessary using diuretics.
In addition, earlier intervention with renal replacement
therapy may be considered for patients with markedly
elevated biomarker levels in whom fluid overload is
developing but who have not yet displayed increased
serum creatinine owing to hemodilution, and the time
required to reestablish a steady state in creatinine con-
centration according to glomerular filtration rate [7]; and
(6) avoiding or deferring the use of drugs that may be
potentially nephrotoxic, such as nonsteroidal anti-
inflammatory drugs, angiotensin-converting enzyme
inhibitors, angiotensin-II receptor blockers, and iodinated
contrast medium. Only a specific study can conclude as to
whether early treatment based on NGAL values at
6 hours reduces the severity of, or the rate of, occurrence
of subsequent AKI.
Our findings are in line with those of Haase and
colleagues [7], who performed a similar study in 100 pa-
tients, of whom 40% had preoperative renal failure, but
do not concord with those of Perry and colleagues [8],
who reported that NGAL had limited predictive value at
2 hours post-surgery in their study of 879 patients.
We did not find the duration of CPB or aortic clamping
to be predictors of postoperative AKI occurrence. This
could be explained by the mean duration of CPB of
98 minutes in our study, which was somewhat lower
than the average of 115 minutes reported by Salis and
colleagues [14] to be associated with an increased risk of
renal complications in their study of over 5,000 patients.
In the context of both adult and pediatric cardiac sur-
gery, urinary NGAL has been shown to be a predictive
biomarker for postoperative AKI [15], with a sensitivity of
82% at 2 hours in 1 report [12]. Contrary to urinary NGAL,
plasma NGAL results from both reduced renal reab-
sorption during renal failure [3], and from extra-renal
synthesis of NGAL [16], which is compounded in the
Ann Thorac Surg
2015;99:864–9
inflammatory context of CPB during cardiac surgery [17].
In these studies, urinary NGAL is shown to be a better
marker of renal injury because the increase in urinary
NGAL occurs as a consequence of lesions in the renal
tubules and is not seen in functional renal failure [17–19].
In patients with chronic renal insufficiency, results of
studies evaluating urinary NGAL have been somewhat
disappointing as urinary NGAL does not appear to have
any predictive value for the identification of patients who
will go on to develop AKI [3, 20, 21]. Several factors may
explain these observations; difficulty amplifying the
NGAL “signal” in the injured renal tubules, or difficulties
obtaining urine samples in this context, possibly com-
pounded by hydration disorders in patients who are
likely receiving diuretics. Based on these data, it would
seem that in patients with chronic renal failure, plasma
NGAL is a better marker of postoperative AKI than
urinary NGAL.
Plasma NGAL is a marker of subsequent occurrence of
AKI after cardiac surgery in patients who have chronic
renal failure prior to surgery. A plasma NGAL level
greater than 155 ng/mL at 6 hours after surgery is asso-
ciated with a 7.1-fold increase in the risk of postoperative
AKI. Compared with diagnosis based on plasma creati-
nine levels the time gained by using NGAL at 6 hours to
diagnose likely AKI is, on average, 20 hours. This time
gain makes it possible to initiate preventive or therapeutic
measures likely to avoid or reduce the severity of subse-
quent AKI.
The authors thank Fiona Ecarnot (EA3920, University Hospital
Besancon, France) for translation and editorial assistance.
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INVITED COMMENTARY
This report by Perrotti and colleagues [1] describes a
series of 166 patients with prior chronic kidney failure
undergoing cardiac operations and tracks the elevations
in neutrophil gelatinase-associated lipocalin (NGAL) as a
predictor of subsequent acute kidney injury (AKI). The
report is of considerable interest because this issue is yet
unresolved in contemporary clinical practice, and AKI
after cardiac surgery is an increasingly frequent problem
in the current population of patients.
The authors have shown that plasma NGAL is an early
marker of AKI after surgery and that the diagnosis can be
made about 20 hours earlier as compared with a 50%
increase in creatinine values. NGAL above 155 ng/mL at
6 hours after operation was shown to be an independent
predictor of AKI, with an odds ratio of 7.1, a sensitivity of
79%, and a specificity of 58%. This finding could poten-
tially improve clinical practice in the postoperative
treatment of patients with chronic renal failure, allowing
early corrective interventions that might prevent or
reduce the onset of AKI.
Although plasma NGAL remains a useful marker of
AKI, it would be also interesting to evaluate the urinary
NGAL, highlighting any correlations with plasma values
and comparing the degree of specificity. Furthermore, it
might be useful to add another marker, such as cystatin
C, with the aim of increasing the low specificity of NGAL.
Concerning the potential usefulness of NGAL mea-
surements in clinical practice, the authors have properly
pointed out that the monitoring of patients at risk may be
intensified and that the renal perfusion can be optimized
Ó 2015 by The Society of Thoracic Surgeons
Published by Elsevier
PERROTTI ET AL 869
NGAL AND AKI
ADULT CARDIAC
16. Xu S, Venge P. Lipocalins as biochemical markers of disease.
Biochim Biophys Acta 2000;1482:298–307.
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Mariat C. NGAL, biomarker of acute kidney injury in 2012
[Article in French]. Nephrol Ther 2012;8:508–15.
18. Nejat M, Pickering JW, Devarajan P, et al. Some biomarkers
of acute kidney injury are increased in pre-renal acute injury.
Kidney Int 2012;81:1254–62.
19. Nickolas TL, O’Rourke MJ, Yang J, et al. Sensitivity and spec-
ificity of a single emergency department measurement of
urinary neutrophil gelatinase-associated lipocalin for diag-
nosing acute kidney injury. Ann Intern Med 2008;148:810–9.
20. Koyner JL, Vaidya VS, Bennett MR, et al. Urinary biomarkers
in the clinical prognosis and early detection of acute kidney
injury. Clin J Am Soc Nephrol 2010;5:2154–65.
21. Wagener G, Gubitosa G, Wang S, Borregaard N, Kim M,
Lee HT. Urinary neutrophil gelatinase-associated lipocalin
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by several approaches. They have identified several
possible interventions that could prevent the onset of AKI
or reduce its severity: close monitoring of low cardiac
output, venous congestion, right ventricular dysfunction,
or pericardial effusion; optimization of fluid balance and
hemodynamic targets; and avoiding renal drug toxicity.
Unfortunately, to date, none of these approaches has
been proved effective in preventing AKI after cardiac
surgery. Therefore, in this perspective, the article by
Perrotti and colleagues should be considered as a starting
point and a scientific basis for future clinical trials eval-
uating the effectiveness of preventive treatments based
on NGAL values, inasmuch as the exact detrimental
physiologic effect of AKI remains unclear, although these
patients experience increased mortality.
Nicola Vistarini, MD
Louis P. Perrault, MD, PhD
Department of Surgery of the Montreal Heart Institute
Research Center, Montreal Heart Institute
5000 Belanger St E
Montreal, Quebec H1T 1C8, Canada
e-mail: louis.perrault@icm-mhi.org
Reference
1. Perrotti A, Miltgen G, Chevet-Noel A, et al. Neutrophil
gelatinase-associated lipocalin as early predictor of acute
kidney injury after cardiac surgery in adults with chronic
kidney failure. Ann Thorac Surg 2015;99:864–9.
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2014.10.053