NGAL in trans-catheter aortic valve implantation on and off RenalGuard

Introduction: Acute kidney injury (AKI) is a well-known complication post invasive cardiac procedures. RenalGuard system has been shown to reduce the risk of AKI in high-risk patients by evacuating iodine-based contrast material rapidly. Neutrophil gelatinase-associated lipocalin (NGAL) is a glycoprotein stored in granules of mature neutrophils and is released to the blood stream due to acute tubular damage. This report examined the biomarker as a sub study of the randomized sham control study REDUCE-AKI in the setting of Trans-Aortic Valve Implantation (TAVI).

Methods: Venous blood was drawn from 27 patients. Blood was drawn at designated time intervals: before the procedure, after 12 hours and after 24 hours. Patients were randomly allocated to active versus sham RenalGuard activity.

Results: There was no difference between baseline and 24 hours levels in NGAL values (ng/mL) in the sham group (median 70.3 IQ 21.5, 176.6) versus the active group (median 46.9, IQR 1.3, 127.7) (P = 0.259). There was also no association between NGAL and clinical complications.

Conclusion: Forced diuresis with matched hydration does not prevent AKI in patients undergoing TAVI and measuring NGAL correlates with these findings.

TAVI; TAVR; AKI; NGAL; RenalGuard

[1] Kliuk-Ben Bassat O, Finkelstein A, Bazan S, Halkin A, Herz I, Salzer Gotler D, et al. Acute kidney injury after transcatheter aortic valve implantation and mortality risk-long-term follow-up. Nephrology Dialysis Transplantation. 2020; 35: 433-438.

[2] Lo K, Penalver J, Mostafavi Toroghi H, Jeon H, Habib N, Hung Pinto W, et al. Invasive hemodynamic predictors of renal outcomes after percutaneous coronary interventions. Cardiorenal Medicine. 2019; 9: 382-390.

[3] Arbel Y, Ben-Assa E, Puzhevsky D, Litmanowicz B, Galli N, Chorin E, et al. Forced diuresis with matched hydration during transcatheter aortic valve implantation for reducing acute kidney injury: a randomized, sham-controlled study (REDUCE-AKI). European Heart Journal. 2019; 40: 3169-3178.

[4] Bagur R, Webb JG, Nietlispach F, Dumont E, De Larochelliere R, Doyle D, et al. Acute kidney injury following transcatheter aortic valve implantation: predictive factors, prognostic value, and comparison with surgical aortic valve replacement. European Heart Journal. 2010; 31: 865-874.

[5] Attard S, Buttigieg J, Galea S, Mintoff M, Farrugia E, Cassar A. The incidence, predictors, and prognosis of acute kidney injury after transcatheter aortic valve implantation. Clinical Nephrology. 2018; 90: 373-379.

[6] Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, et al. Renal insufficiency after contrast media administration trial II (REMEDIAL II): RenalGuard system in high-risk patients for contrast-induced acute kidney injury. Circulation. 2011; 124: 1260-1269.

[7] Banai A, Rozenfeld K-L, Lewit D, Merdler I, Loewenstein I, Banai S, et al. Neutrophil gelatinase-associated lipocalin (NGAL) for the prediction of acute kidney injury in chronic kidney disease patients treated with primary percutaneous coronary intervention. IJC Heart and Vessels. 2021; 32: 100695.

[8] Shah R, Wood SJ, Khan SA, Chaudhry A, Rehan Khan M, Morsy MS. High-volume forced diuresis with matched hydration using the RenalGuard System to prevent contrast-induced nephropathy: a meta-analysis of randomized trials. Clinical Cardiology. 2017; 40: 1242-1246.

[9] Merdler I, Rozenfeld K, Zahler D, Shtark M, Goldiner I, Loewenstein I, et al. Neutrophil gelatinase-associated lipocalin for the early prediction of acute kidney injury in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Car-diorenal Medicine. 2020; 10: 154-161.

[10] Rozenfeld K, Zahler D, Shtark M, Goldiner I, Keren G, Banai S, et al. Elevated neutrophil gelatinase-associated lipocalin for the assessment of structural versus functional renal damage among ST-segment elevation myocardial infarction patients. Blood Purification. 2020; 49: 560-566.

[11] Rozenfeld K, Zahler D, Shtark M, Goldiner I, Keren G, Shacham Y. Elevated neutrophil gelatinase-associated lipocalin levels before contrast media administration among ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Coro-nary Artery Disease. 2020; 31: 118-123.

[12] Rodriguez R, Hasoon M, Eng M, Michalek J, Liu Q, Hernandez B, Bansal S, Bailey SR, Prasad A. Incidence and predictors of acute kidney injury following transcatheter aortic valve replacement: role of changing definitions of renal function and injury. Journal of Invasive Cardiology. 2020; 32: 138-141.

[13] Musso CG, Álvarez-Gregori J, Jauregui J, Macías-Núñez JF. Glomerular filtration rate equations: a comprehensive review. International Urology and Nephrology. 2016; 48: 1105-1110.

[14] Ma M, Gao W, Gu Y, Wang Y, Zhu Y, He Y. Clinical effects of acute kidney injury after transcatheter aortic valve implantation: a systematic review and meta-analysis. Internal and Emergency Medicine. 2019; 14: 161-175.

[15] Barbanti M, Gargiulo G, Tamburino C. Renal dysfunction and tran-scatheter aortic valve implantation outcomes. Expert Review of Cardio-vascular Therapy. 2016; 14: 1315-1323.

[16] Cao W, Cui S, Yang L, Wu C, Liu J, Yang F, et al. Contrast-enhanced ultrasound for assessing renal perfusion impairment and predicting acute kidney injury to chronic kidney disease progression. Antioxidants & Redox Signaling. 2017; 27: 1397-1411.

[17] Kashani K, Cheungpasitporn W, Ronco C. Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption. Clinical Chemistry and Laboratory Medicine. 2017; 55: 1074-1089.

[18] Schrezenmeier EV, Barasch J, Budde K, Westhoff T, Schmidt-Ott KM. Biomarkers in acute kidney injury-pathophysiological basis and clinical performance. Acta Physiologica. 2017; 219: 556-574.

[19] Shang W, Wang Z. The update of NGAL in acute kidney injury. Current Protein & Peptide Science. 2017; 18: 1211-1217.

[20] Soni SS, Cruz D, Bobek I, Chionh CY, Nalesso F, Lentini P, et al. NGAL: a biomarker of acute kidney injury and other systemic conditions. International Urology and Nephrology. 2010; 42: 141-150.

[21] de Geus HRH, Ronco C, Haase M, Jacob L, Lewington A, Vincent J. The cardiac surgery-associated neutrophil gelatinase-associated lipocalin (CSA-NGAL) score: a potential tool to monitor acute tubular damage. The Journal of Thoracic and Cardiovascular Surgery. 2016; 151: 1476-1481.