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October 17, 2012
10:00:00 AM - 11:30:00 AM
Room 101
Urinary NGAL as Marker of Hepato-Renal Syndrome
Gebhard Wagener, M.D., Moury Minhaz, B.S., Andrew Young, M.D.
Columbia University, New York, New York, United States

Hepatorenal syndrome (HRS) is a serious complication of advanced liver disease. Type I HRS is rapidly progressive and often fatal whereas type II is slower with a slightly better prognosis. Clinically, HRS can be difficult to distinguish from other forms of acute kidney injury (AKI) but differentiation is important as HRS type II completely recovers after liver transplantation and dose not require a combined liver-kidney transplant. There is currently no simple test to diagnose HRS. Urinary NGAL has previously been confirmed as a fast, sensitive and specific marker of renal injury in many scenarios of AKI 1-3. This study aims to investigate neutrophil gelatinase-associated lipocalin (NGAL), a novel renal biomarker, as a diagnostic marker of HRS.


We measured urinary NGAL (ELISA) prior to liver transplantation. HRS type II was defined by the International Ascites Club definition 4: presence of ascites, S-creatinine > 1.5 mg/dL, no infection (WBC < 11k), proteinuria < 500 mg/dL and no other explanation for kidney failure such as diabetes or artherosclerotic disease. Urinary NGAL levels of patients with and without HRS were compared and receiver-operator curves were created to determine the ability of urinary NGAL to detect HRS.


90 patients were enrolled. Of these 9 patients had HRS type II ad defined above (10 %). Preoperative S-Creatinine in the HRS group was 1.74 +/- 0.34 mg/dL and 0.82 +/- 0.22 mg/dL in the non HRS group (p < 0.0001). Preoperative urinary NGAL levels were 67.71 +/- 79.98 ng/mL for patients with HRS and 17.48 +/- 35.87 ng/mL for those without (p = 0.0011) (Figure 1). The area under the curve of the receiver-operator characteristic (ROC) curve for the ability of urinary NGAL to detect HRS was 0.802 (CI [95%]: 0.67 to 0.93, p = 0.003). The best cutoff value for NGAL (defined as the point on the ROC curve closest to sensitivity=specificity = 1) was 13.25 ng/mL with a sensitivity of 66.67% [CI (95 %): 55.08% to 76.94%] and a specificity of 88.89% [CI (95 %): 51.75% to 99.72%].


Urinary NGAL was able to detect HRS type II with good sensitivity and specificity as indicated by the high AUC of the ROC curve. Future studies will have to determine if preoperative urinary NGAL can be used as an indicator for post-liver transplant renal recovery and therefore aid in the decision if a patient requires a liver- or a combined liver-kidney transplant.


1. McIlroy DR, Wagener G, Lee HT. Biomarkers of acute kidney injury: an evolving domain. Anesthesiology 2010;112:998-1004.

2. Wagener G, Jan M, Kim M, et al. Association between increases in urinary neutrophil gelatinase-associated lipocalin and acute renal dysfunction after adult cardiac surgery. Anesthesiology 2006;105:485-91.

3. Wagener G, Minhaz M, Mattis FA, Kim M, Emond JC, Lee HT. Urinary neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury after orthotopic liver transplantation. Nephrol Dial Transplant 2011;26:1717-23.

4. Moore KP, Wong F, Gines P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003;38:258-66.

Figure 1

Copyright © 2012 American Society of Anesthesiologists