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Clin. Lab. 2019;65:XXX-XXX

©Copyright

LETTER TO THE EDITOR

High Urinary Kidney Injury Molecule-1 and

Neutrophil Gelatinase-Associated Lipocalin are Associated with
Increased Risk of Chronic Kidney Disease in
Patients with Type 2 Diabetes
Carolina S. Stein1, 2, José A. M. de Carvalho1, 3, Marta M. M. F. Duarte4, Fabio V. Comim5,
Melissa O. Premaor5, Maria B. Moretto2, Rafael N. Moresco1, 2
1 Laboratory of Clinical Biochemistry, Department of Clinical and Toxicological Analysis, Federal University of Santa Maria, Santa Maria, RS, Brazil
2 Pharmaceutical Sciences Postgraduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
3 University Hospital, Federal University of Santa Maria, Santa Maria, RS, Brazil
4Department of Health Sciences, Lutheran University of Brazil, Santa Maria, RS, Brazil
5 Department of Clinical Medicine, Federal University of Santa Maria, Santa Maria, RS, Brazil

(Clin. Lab. 2019;65:xx-xx. DOI: 10.7754/Clin.Lab.2019.190107)

Correspondence: KEY WORDS

Prof. Rafael Noal Moresco
Universidade Federal de Santa Maria
chronic kidney disease, tubular biomarkers, type 2 dia-
Centro de Ciências da Saúde
betes
Departamento de Análises Clínicas e Toxicológicas
Avenida Roraima 1000
Prédio 26, Sala 1401
97105-900, Santa Maria, RS LETTER TO THE EDITOR
Brazil
Phone: +55 55 32208941 Chronic kidney disease (CKD) is defined as a renal in-
Fax: +55 55 32208018 jury that lasts for over 3 months, and its global preva-
Email: rnmoresco@ufsm.br lence was estimated around 13% [1,2]. It is assessed as
an increase in albuminuria and a decrease in the glomer-
ular filtration rate (GFR) [1]. The Kidney Disease: Im-
proving Global Outcomes (KDIGO) provides recom-
mendations for the evaluation of CKD, including the
 classification of risk for CKD development based on the
albuminuria and estimated GFR [1], that stratifies the
risk in four categories (low, moderately increased, high,
and very high risk) according to GFR and albuminuria
values. While the glomerular markers are traditionally
used for the evaluation of kidney diseases, the use of tu-
bular markers gained visibility because of the high spec-
ificity and sensitivity that some of them present. Kidney
injury molecule-1 (KIM-1) and neutrophil gelatinase-
associated lipocalin (NGAL) are molecules produced by
the tubular epithelium in response to damage [3,4] and
were evaluated in CKD. Both biomarkers increased in
the CKD cases in a community study [5] and predicted
____________________________________________ CKD progression and mortality [6]. However, none of
Letter to the Editor accepted January 25, 2019
these studies evaluated the risk of CKD development

Clin. Lab. 8/2019 1

Page 2

C. S. Stein et al.

Table 1. Baseline characteristics and biochemical param- tion, malignancy, acute or chronic inflammatory dis-
eters of the study participants. eases, infectious diseases, and liver diseases. All par-
ticipants provided written consent, and the Institutional
Parameters Values Ethics Committee (12303113.0.0000.5346) approved
Age (years) 59.0 ± 12.6 the study protocol.
Blood samples were collected after an overnight fast pe-
Male (%) 33.3
riod of at least 8 hours. Fasting glucose, lipid profile,
BMI (kg/m²) 29.9 (26.8 - 36.1) and serum creatinine were measured via the Dimension
Hypertension (%) 75.0 RxL Max® automated analyzer (Siemens Healthcare Di-
Smokers (%) 11.1 agnostics Inc., Malvern, PA, USA). The serum insulin
measurement was performed via the Cobas 6000® auto-
Oral hypoglycemic use (%) 94.2
mated analyzer (Roche Diagnostics, Mannheim, Germa-
Insulin use (%) 33.3
ny). The glycated hemoglobin (HbA1c) was measured in
Antihypertensive use (%) 75.4 EDTA containing whole blood samples via the D-10®
Statins use (%) 69.6 automated analyzer (Bio-Rad, CA, USA). First-morning
urine samples were used for the measurement of urinary
Fasting glucose (mmol/L) 6.5 (5.7 - 8.8)
albumin and creatinine via the RxL Max® automated
HbA1c (mmol/mol) 50.0 (39.5 - 66.5)
analyzer. The urinary KIM-1 and NGAL levels were
HbA1c (%) 6.9 (5.9 - 8.3) measured using commercial ELISA kits (KIM-1: R&D
Fasting insulin (pmol/L) 83.3 (55.9 - 122.3) Systems Inc., Minneapolis, MN, USA; NGAL: HYB-
Total cholesterol (mmol/L) 4.5 (3.9 - 5.2) 211-05, Antibody Shop, Gentofte, Denmark). The GFR
was estimated using the creatinine equation from the
HDL cholesterol (mmol/L) 1.2 (1.0 - 1.5)
Chronic Kidney Disease Epidemiology Collaboration
LDL cholesterol (mmol/L) 2.5 ± 0.7 (CKD-EPI) [7]. The data were analyzed using the
Triglycerides (mmol/L) 1.5 (1.0 - 2.2) GraphPad Prism® software v. 6.00 for Windows® (La
Serum creatinine (μmol/L) 79.6 (70.7 - 97.2) Jolla, CA, USA), using the Kruskal-Wallis test. A
p < 0.05 was considered statistically significant. The pa-
GFR (mL/min/1.73 m2) 77.2 ± 20.7
rametric variables are expressed as the mean ± standard
UACR (mg/g creatinine) 9.8 (5.7 - 23.1) deviation, and the non-parametric variables are present-
ed as the median and interquartile range.
Data are expressed as mean ± standard deviation or median and
interquartile range. BMI - body mass index, HbA1c - glycated
The baseline characteristics of the study participants are
hemoglobin, GFR - glomerular filtration rate, UACR - urinary shown in Table 1. The urinary levels of KIM-1 and
albumin to creatinine ratio. NGAL were significantly increased in patients with
moderately increased risk and high or very high risk
compared to the group with a lower risk of development
of CKD (Figure 1). The KIM-1 values in Groups 2 and
3 were approximately twice as high as in Group 1
according to the KDIGO guidelines. Thus, the aim of [Group 1: 76.0 (58.0 - 94.5); Group 2: 168.5 (108.3
 this study was to investigate the association of urinary
KIM-1 and NGAL and the risk of CKD development
according to the KDIGO guidelines.
Overall, 69 patients with type 2 diabetes were enrolled
at the University Hospital of Santa Maria (Santa Maria,
RS, Brazil) and stratified according to KDIGO recom-
mendations for CKD risk assessment [1], as follows:
Group 1 - Low risk (GFR > 60 mL/min/1.73 m² and al-
buminuria < 30 mg/g of creatinine; n = 48), Group 2
- Moderately increased risk (GFR 45 - 59 mL/min/1.73
m² and albuminuria < 30 mg/g of creatinine or GFR
> 60 mL/min/1.73 m² and albuminuria 30 - 300 mg/g of
creatinine; n = 12), and Group 3 - High or very high risk
(GFR < 45 mL/min/1.73 m² and albuminuria < 30 mg/g
of creatinine, GFR < 60 mL/min/1.73 m² and albumin-
uria 30 - 300 mg/g of creatinine, or albuminuria > 300
mg/g of creatinine independently of GFR value; n = 9).
In the present study, patients with high and very high
risk were combined in the same group. The exclusion
criteria included pregnancy, urinary tract infections,
chronic renal failure, renal surgery, renal transplanta-
2 Clin. Lab. 8/2019
Page 3
Urinary KIM-1 and NGAL Indicate Early CKD Risk
- 186.5); Group 3: 156.0 (141.0 - 182.5) pg/mL]. Also,
the NGAL values in Groups 2 and 3 were about 78%
higher than Group 1 [Group 1: 37.0 (29.0 - 46.5); Group
2: 66.0 (57.5 - 75.2); Group 3: 69.0 (60.0 - 77.5)
ng/mL].
GFR is usually calculated from the creatinine measure-
ment in serum, which is commonly measured by the
colorimetric method based on the Jaffe reaction. How-
ever, this reaction can be affected by pseudochromo-
gens like glucose, proteins, and some medicines [8].
Furthermore, albuminuria measurement has some limi-
tations [9]. Besides, some patients who already present
renal damage, assessed by KIM-1 and NGAL, still have
normal albumin levels in urine [10]. Therefore, the pres-
ent study showed that high urinary levels of KIM-1 and
NGAL were associated with the risk of CKD according
to the KDIGO classification. Thus, we can infer that
evaluation of tubular markers such as NGAL and KIM-
1 may contribute significantly to the early detection of
renal damage and to the risk assessment of CKD, espe-
cially in those patients who have not yet shown signifi-
 Figure 1. Box-and-whisker plots showing the urinary concentrations of (A) KIM-1 and (B) NGAL according to the risk
categories of CKD based on the KDIGO criteria.

The box contained 50% of all values (from the 25th to 75th percentile) and was divided by the horizontal bar representing the median value
(50th percentile).

cant changes in albuminuria and GFR. Hence, we spec- Declaration of Interest:

ulate that the use of tubular markers such as KIM-1 and
NGAL combined with albuminuria and GFR may im-
prove the risk assessment of CKD, and it may be rele-
vant to consider the addition of tubular biomarkers in
the diagrams for risk assessment of CKD, especially in
patients with type 2 diabetes.
Funding:
The authors declare no conflict of interest.
References:
1. Kidney Disease: Improving Global Outcomes (KDIGO): Clinical
Practice Guideline for the Evaluation and Management of Chron-
ic Kidney Disease. Kidney Int. Suppl. 2013;3:1–150.
(https://www.sciencedirect.com/journal/kidney-international-
supplements/vol/3/issue/1).

This study was supported by the Conselho Nacional de

Desenvolvimento Científico e Tecnológico (CNPq, Bra-
zil, number 428321/2016-0) and Coordenação de Aper-
feiçoamento de Pessoal de Nível Superior (CAPES,
Brazil, finance code 001). R. N. Moresco, M. B. Mo-
retto and M. O. Premaor are recipients of the research
productivity scholarships from the CNPq/Brazil.
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ease. Clin Chim Acta 2018;487:15-21 (PMID: 30201372).

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4 Clin. Lab. 8/2019