Predictive Value of Plasma NGAL:Hepcidin-25 for Major Adverse Kidney Events After Cardiac Surgery with Cardiopulmonary Bypass: A Pilot Study

Background@#Neutrophil gelatinase-associated lipocalin (NGAL) and hepcidin-25 are involved in catalytic iron-related kidney injury after cardiac surgery with cardiopulmonary bypass. We explored the predictive value of plasma NGAL, plasma hepcidin-25, and the plasma NGAL:hepcidin-25 ratio for major adverse kidney events (MAKE) after cardiac surgery. @*Methods@#We compared the predictive value of plasma NGAL, hepcidin-25, and plasma NGAL:hepcidin-25 with that of serum creatinine (Cr) and urinary output and protein for primary-endpoint MAKE (acute kidney injury [AKI] stages 2 and 3, persistent AKI > 48 hours, acute dialysis, and in-hospital mortality) and secondary-endpoint AKI in 100 cardiac surgery patients at intensive care unit (ICU) admission. We performed ROC curve, logistic regression, and reclassification analyses. @*Results@#At ICU admission, plasma NGAL, plasma NGAL:hepcidin-25, plasma interleukin-6, and Cr predicted MAKE (area under the ROC curve [AUC]: 0.77, 0.79, 0.74, and 0.74, respectively) and AKI (0.73, 0.89, 0.70, and 0.69). For AKI prediction, plasma NGAL:hepcidin-25 had a higher discriminatory power than Cr (AUC difference 0.26 [95% CI 0.00–0.53]). Urinary output and protein, plasma lactate, C-reactive protein, creatine kinase myocardial band, and brain natriuretic peptide did not predict MAKE or AKI (AUC < 0.70). Only plasma NGAL:hepcidin-25 correctly reclassified patients according to their MAKE and AKI status (category-free net reclassification improvement: 0.82 [95% CI 0.12–1.52], 1.03 [0.29–1.77]). After adjustment to the Cleveland risk score, plasma NGAL:hepcidin-25 ≥ 0.9 independently predicted MAKE (adjusted odds ratio 16.34 [95% CI 1.77–150.49], P = 0.014). @*Conclusions@#Plasma NGAL:hepcidin-25 is a promising marker for predicting postoperative MAKE.

Urinary Biomarkers may Complement the Cleveland Score for Prediction of Adverse Kidney Events After Cardiac Surgery: A Pilot Study

BACKGROUND: The ability of urinary biomarkers to complement established clinical risk prediction models for postoperative adverse kidney events is unclear. We assessed the effect of urinary biomarkers linked to suspected pathogenesis of cardiac surgery-induced acute kidney injury (AKI) on the performance of the Cleveland Score, a risk assessment model for postoperative adverse kidney events. METHODS: This pilot study included 100 patients who underwent open-heart surgery. We determined improvements to the Cleveland Score when adding urinary biomarkers measured using clinical laboratory platforms (neutrophil gelatinase-associated lipocalin [NGAL], interleukin-6) and those in the preclinical stage (hepcidin-25, midkine, alpha-1 microglobulin), all sampled immediately post-surgery. The primary endpoint was major adverse kidney events (MAKE), and the secondary endpoint was AKI. We performed ROC curve analysis, assessed baseline model performance (odds ratios [OR], 95% CI), and carried out statistical reclassification analyses to assess model improvement. RESULTS: NGAL (OR [95% CI] per 20 concentration-units wherever applicable): (1.07 [1.01–1.14]), Interleukin-6 (1.51 [1.01–2.26]), midkine (1.01 [1.00–1.02]), 1-hepcidin-25 (1.08 [1.00–1.17]), and NGAL/hepcidin-ratio (2.91 [1.30–6.49]) were independent predictors of MAKE and AKI (1.38 [1.03–1.85], 1.08 [1.01–1.15], 1.01 [1.00–1.02], 1.09 [1.01–1.18], and 3.45 [1.54–7.72]). Category-free net reclassification improvement identified interleukin-6 as a model-improving biomarker for MAKE and NGAL for AKI. However, only NGAL/hepcidin-25 improved model performance for event- and event-free patients for MAKE and AKI. CONCLUSIONS: NGAL and interleukin-6 measured immediately post cardiac surgery may complement the Cleveland Score. The combination of biomarkers with hepcidin-25 may further improve diagnostic discrimination.

Extrusao ortodôntica com finalidade restauradora / Orthodontic extrusion for restrorative purposes

A extrusäo ortodôntica é um tratamento conservador que visa a recuperaçäo de elementos dentais com defeitos subgengivais ou infra-ósseos. A realizaçäo de procedimentos cirúrgicos destinados a expor a área envolvida seria outra opçäo de tratamento nestes casos, todavia podem comprometer a estética dental e promover reaçöes periodontais adversas. Várias säo as indicaçöes para o emprego desta técnica, porém este trabalho enfoca seu emprego mais frequente, ou seja, a recuperaçäo de dentes anteriores com finalidade restauradoura. Conclui-se, entre outars coisas, que, mais importante do que a metodologia empregada para a extrusäo ortodôntica é a observância e o cumprimento dos princípios biomecânicos que a regem. Além disso, a direçäo do movimento extrusivo deve ser puramente no sentido do longo eixo do dente, e, para tal, o sistema de ancoragem que emprega dentes adjacentes é o mais indicado. A quantidade de força empregada para a extrusäo de dentes monorradiculares deve ser de 20 a 40 gramas. Os aparelhos fixos que utilizaram fio ortodôntico retangular deveräo ser os acessórios ortodônticos de escolha, sempre que possível, pois permitem um melhor controle do movimento extrusivo e independem da colaboraçäo do paciente. A migraçäo concomitante das estruturas de inserçäo é inversamente proporcional à velocidade e à quantidade de força empregadas. É imprescindível um longo período de contençäo do dente extruído, até que a observaçäo radiográfica da lâmina dura seja possível. Apesar de aparentemente simples e amplamente utilizado, o movimento ortodôntico extrusivo segue alguns princípios básicos e exige acompanhamento periódico do profissional que realiza. Assim sendo, esta revisäo objetivou abordar aspectos como vantagens e desvantagens; indicaçöes e contra-indicaçöes; diferentes sistemas de ancoragem e dispositivos ortodônticos utilizados; velocidade, controle do movimento e contençäo, a fim de enfatizar a revelância do estrito cumprimento do protocolo para a realizaçäo desta técnica