Acute kidney injury: Early detection thanks to biomarker
Acute kidney injury: Early detection thanks to biomarker
Interview with Dr. Tobias Bergler, Head of the Department of Nephrology, University Hospital Regensburg
Major surgeries in the abdominal region often result in kidney injury in patients. Meanwhile, the clinical manifestations don't present until one or two days after the procedure. This causes physicians to lose valuable time to treat patients. The University Hospital Regensburg has researched a new concept for the treatment of kidney injuries for several years.
Dr. Tobias Bergler, Head of the Department of Nephrology, UKR
In this interview with MEDICA-tradefair.com, Dr. Tobias Bergler talks about the consequences of acute kidney injuries and explains how they were detected early and quickly in a study with the help of a biomarker – before patients exhibited pain.
Dr. Bergler, how common are acute kidney injuries after major surgeries? Which patients are particularly at risk?
Dr. Tobias Bergler: The probability of an acute kidney injury in major visceral surgery is between 13 and 50 percent. Fortunately, the percentage of patients who need postoperative dialysis is significantly lower. The incidence rate ranges between two and seven percent in this case. Needless to say, this also depends on the patient’s comorbidities. All patients who already demonstrate risk factors for acute renal failure are particularly at risk. Those are patients who at the time of surgery exhibit arterial hypertension, diabetes mellitus or a preoperative compromised renal function but also patients who exhibit protein loss related to the kidneys, that being albuminuria or proteinuria.
What are the consequences of acute kidney injury?
Bergler: There is a relatively wide range of consequences of acute kidney failure. On the one hand, patients may exhibit a temporary loss of renal function. However, even minor changes in renal function or slightly elevated creatinine levels have prognostic relevance for patients, also in terms of mortality. The consequences range from a temporary loss of renal function, a severe permanent limitation all the way to a permanent need for dialysis. It is always difficult to identify those patients with a real dramatic increase in risk presurgery. That being said, the actual risk is always there and patients should be aware of it prior to the surgery.
Surgeons of the UKR at work
You have now developed a new concept for the diagnosis of acute kidney injuries. How does it work?What are the advantages?
Bergler: Until now, the fundamental problem with these types of surgical procedures was that we had to wait until we could detect clinical manifestations of impending acute kidney injury. These manifestations- such as elevated levels of creatinine or loss of renal function or urinary excretion rate - are usually considerably time delayed between 24 and 48 hours. This is a window of time that could previously not be used for therapeutic interventions. For the first time ever, our new approach involves the use of an established and validated biomarker (TIMP2 x IGFBP7) as the starting point for patients requiring visceral surgery – at a very early stage. After major visceral surgical procedures, patients are placed in the surgical intensive care unit. The biomarker is immediately non-invasively obtained via urine test. The result of the biomarker test is available in less than 70 minutes. A biomarker response is an indicator of onset kidney damage. The major advantage is that we obtain information about an impending kidney injury very early on before its clinical manifestations actually become evident. This gives us time for therapeutic intervention, especially during the vulnerable phase where renal failure can be most successfully controlled in my opinion. The patient can be treated before the clinical symptoms can be seen and before he/she potentially enters a higher phase of kidney injury.
In addition to Dr. Bergler, Dr. Ivan Göcze, Head of the Department of the surgical intensive care unit at the clinic and polyclinic for surgery, was also involved in the study "Biomarker-guided intervention to prevent acute kidney injury after major surgery: the prospective randomized BigpAK Study".
In what way is your research interdisciplinary?
Bergler: An interdisciplinary approach is extremely important in this concept and we have deliberately opted in favor of it. Patients who face a major minimum four-hour visceral surgical procedure with an additive risk factor for renal insufficiency are treated by surgeons and anesthesiologists. As nephrologists, we enter the scene in the immediate postoperative setting once the result of the biomarker testing is available to make the necessary recommendations based on the KDIGO guidelines. When it comes to complex clinical pictures such as these, I believe it is vitally important to simply team up the involved disciplines of nephrology, surgery, and anesthesia. We consider the care of patients to be an interdisciplinary task intended to achieve the maximum benefit and prevent them from going through the severe stages of renal failure.
What are your future goals?
Bergler: Together with our colleagues in anesthesia and surgery, we want be able to offer this biomarker test outside of the clinical trial setting and have it become a part of routine intensive care. We also want to combine it with an electronic alert system. Once the biomarker responds, all involved parties can communicate and be aware that they are dealing with a patient at increased risk for acute kidney injury. This ensures optical care for the patient. In other words, this is not supposed to be a purely academic pilot project but is intended to be applied in the general patient care process early next year, thus making the test also available to patients outside the clinical trial.
The interview was conducted by Elena Blume and translated from German by Elena O'Meara. MEDICA-tradefair.com