BIOMARKER COMBINATION FOR IDENTIFICATION OF "AT-RISK" SUBJECTS FOR AKI

Abstract

A method for determining predisposition of a subject to developing renal dysfunction (AKI), and to a kit for use in making such a determination is provided. Suitably at least one marker selected from Midkine (MK) or H-FABP present in a blood or urine sample is used in the method.

Claims

1. A method to determine a predisposition of a subject to developing AKI, the method comprising the step of: determining the level of at least one marker selected from Midkine (MK) or H-FABP present in a blood or urine sample taken from the subject within 48 hours following surgery, physical trauma, hypotension, sepsis and/or septic shock syndrome, in particular cardiac surgery or a fracture trauma; wherein when the level of the Midkine or H-FABP is higher than a normal level of Midkine or H-FABP in a blood or urine sample from a control it is indicative the subject has a greater than normal predisposition for developing AKI following surgery, physical trauma, hypotension, sepsis and/or septic shock syndrome, in particular cardiac surgery or a fracture trauma.

2. A method to determine a predisposition of a subject to developing AKI, the method comprising the step of: determining the level of at least one marker selected from H-FABP or Midkine (MK) present in a blood or urine sample taken from the subject prior to surgery, physical trauma, hypotension, sepsis and/or septic shock syndrome, in particular cardiac surgery or a fracture trauma; wherein when the level of the H-FABP or Midkine marker is higher than a normal level of H-FABP or Midkine in a blood or urine sample from a control it is indicative the subject has a greater than normal predisposition for developing AKI following surgery, physical trauma, hypotension, sepsis and/or septic shock syndrome, in particular cardiac surgery or a fracture trauma.

3. The method of claim 1 or 2 wherein the step of determining the level of at least one marker selected from H-FABP or Midkine is undertaken on serum from the subject.

4. The method of any previous claim wherein the determining step comprises determining the level of at least two markers wherein a first marker is selected from at least one of Midkine (MK) and H-FABP and at least a second marker is selected from at least one of TNFRII and TNFRI wherein when the detected level of TNFRII and/or TNFRI is higher than a normal level of TNFRII and/or TNFRI respectively in a control it is indicative the subject has a greater than normal predisposition for developing AKI following cardiac surgery or fracture trauma.

5. The method of any previous claim wherein the determining step comprises determining the level of at least three markers selected from TNFRI, TNFRII and Midkine.

6. The method of any of claims 1 to 4 wherein the determining step comprises determining the level of at least three markers selected from TNFRI, TNFRII and H-FABP.

7. The method of any of claims 1 to 4 wherein the determining step comprises determining the level of at least three markers selected from TNFRI, H-FABP and Midkine.

8. The method of any previous claim wherein the method further comprises detecting at least one marker selected from IL-1a, IL-5, IL-6, IL-8, IL-10, IL-15, MIP1-alpha, VEGF, INF-gamma, TNF-alpha, MCP, NGAL, IL12P40, IP10 or IL1Ra.

9. The method of claim 8 wherein at least one of IL-1a, IL-5, IL-6, IL-8, IL-10, IL-15, MIP1-alpha VEGF, INF-gamma, TNF-alpha, MCP and NGAL is detected from plasma from the subject.

10. The method of claim 8 wherein IL12P40 is detected from serum or urine of a subject.

11. The method of claim 8 wherein IP10 or IL1Ra are detected in urine.

12. The method of any of claims 2 to 11 wherein the sample is obtained from a subject within 24 hours of a proposed surgery.

13. The method of any of claims 1 and 3 to 11 wherein the sample is obtained from a subject within 24 hours post surgery.

14. The method of any preceding claims wherein the sample is plasma or serum or urine.

15. The method of any of the previous claims wherein a ratio of urinary TNFsr1/HFABP (serum) is determined wherein TNFsr1 (UB)/HFABP (SB) is lower in AKI subjects than non AKI subjects.

16. The method of any of the previous claims wherein the ratio of urinary TNFsr2/HFABP(serum) is determined wherein TNFsr2 (UB)/HFABP(SB) is lower in AKI subjects than non AKI subjects.

17. The method of any of claims 1 to 14 wherein the method comprises determining AKI risk on post-operative ratios selected from uTNFsr1/sMidkine, uTNFsr2/sMidkine or ulL1ra/sMidkine wherein the urinary anti-inflammatory/blood pro-inflammatory ratios are lower in those who develop renal dysfunction.

18. The method of any of claims 1 to 14 wherein the method comprises determining pre-operative uTNFSR1/blood pro-inflammatory or uTNFsr2/blood pro-inflammatory ratios wherein urinary anti-inflammatory/blood pro-inflammatory ratios were lower in those who later developed renal dysfunction.

19. A kit for use in the method of any preceding claim, wherein the kit comprises:- one or more reagents to detect at least one of TN FI, TNFII, Midkine and H-FABP or a combination thereof instructions for determining whether the at least one of TNFRI, TNFRII, Midkine and H-FABP is higher than a normal level as observed in a subject according to the first or second aspect.

20. A method of treating renal dysfunction induced by surgery, physical trauma, hypotension, sepsis and/or septic shock syndrome, in particular cardiac surgery or a fracture trauma; wherein the method includes the steps of: (i) prognosing renal dysfunction according to any of the methods of claims 1 to 19; and (ii) when the subject is identified to be at increased risk of developing renal dysfunction, applying therapeutic measures to treat or obviate the impending renal dysfunction.

21. The method of claim 20 wherein the therapeutic measures applied in step (ii) are selected from: maintaining a supra-normal blood pressure; ensuring adequate tissue oxygen delivery; administration of steroids; renal replacement therapy; dialysis; or any combination thereof, administration of erythropoietin, minimizing the duration of cardiopulmonary bypass, early renal replacement therapy.

Description

[0099] Embodiments of the present invention will now be described, by way of example, with reference to the accompanying figures, in which:-

[0100] FIG. 1 shows pre-surgery ROC of TNFRI, TNFRII and Midkine model;

[0101] FIG. 2 shows a pre-surgery TNFRI, TNFRII and Midkine model;

[0102] FIG. 3 shows a pre-surgery TNFRI, TNFRII and Midkine model;

[0103] FIG. 4 shows a patient scores using Serum Pre-surgery TNFRI, TNFRII and Midkine model;

[0104] FIG. 5 shows ROC for a serum post surgery TNFRI, TNFRII and Midkine model;

[0105] FIG. 6 shows a serum post surgery TNFRI, TNFRII and Midkine model;

[0106] FIG. 7 shows a serum post surgery TNFRI, TNFRII and Midkine model;

[0107] FIG. 8 shows a serum post surgery TNFRI, TNFRII and Midkine model;

[0108] FIG. 9 shows patient scores for a serum post surgery TNFRI, TNFRII and Midkine model;

[0109] FIG. 10 shows patient scores for a serum post surgery TNFRI, TNFRII and Midkine model;

[0110] FIG. 11 shows patient scores for a serum post surgery TNFRI, TNFRII and Midkine model;

[0111] FIG. 12 shows ROC for serum pre-surgery TNFRI and TNFRII;

[0112] FIG. 13 shows serum pre-surgery TNFRI and Midkine;

[0113] FIG. 14 shows serum pre-surgery TNFRII and Midkine;

[0114] FIG. 15 shows serum post surgery TNFRI and TNFRII;

[0115] FIG. 16 shows serum post-surgery TNFRI and Midkine;

[0116] FIG. 17 shows serum post-surgery TNFRII and Midkine;

[0117] FIG. 18 shows serum pre-surgery TNFRI;

[0118] FIG. 19 shows serum pre-surgery TNFRII;

[0119] FIG. 20 shows serum pre-surgery Midkine;

[0120] FIG. 21 shows serum post-surgery TNFRI;

[0121] FIG. 22 shows serum post-surgery TNFRII;

[0122] FIG. 23 shows serum post-surgery Midkine;

[0123] FIGS. 24 A and B show serum pre-fracture repair surgery;

[0124] FIGS. 25 A and B show serum post fracture repair surgery;

[0125] FIG. 26 illustrates Serum pre-surgery predictive model H-FABP and TNFRI;

[0126] FIG. 27 illustrates Serum pre-surgery predictive model H-FABP, TNFRI and Midkine;

[0127] FIG. 28 illustrates Serum post-surgery model H-FABP and TNFRI;

[0128] FIG. 29 illustrates Serum post-surgery H-FABP, TNFRI and Midkine biomarker model;

[0129] FIG. 30 illustrates biomarker results;

[0130] FIG. 31 illustrates biomarker results;

[0131] FIG. 32 illustrates biomarker results;

[0132] FIG. 33 illustrates biomarker results;

[0133] FIG. 34 illustrates biomarker results;

[0134] FIG. 35 illustrates biomarker results;

[0135] FIG. 36 illustrates biomarker results;

[0136] FIG. 37 illustrates biomarker results;

[0137] FIG. 38 illustrates biomarker results;

[0138] FIG. 39 illustrates biomarker results;

[0139] FIG. 40 illustrates biomarker results;

[0140] FIG. 41 illustrates biomarker results;

[0141] FIG. 42 illustrates biomarker results;

[0142] FIG. 43 illustrates biomarker results;

[0143] FIG. 44 illustrates biomarker results; and

[0144] FIG. 45 illustrates biomarker results.

EXPERIMENTAL METHODS

[0145] Ethical approval was granted from the Research Ethics Committee and the Royal Research Office research governance committee.

[0146] Cardiac surgery patients were consecutively scheduled for elective and emergency cardiac surgery within the Cardiac Surgical Unit of the Royal Victoria Hospital Belfast while the orthopaedic trauma patients were consecutively scheduled for open reduction internal fixation of their fracture within the fracture unit of the Belfast Trust. Exclusion criteria for all patients was pre-operative or pre-trauma dialysis dependent renal failure or known significant renal disease prior to entrance into the study (known eGFR <30).

Sampling Protocol

[0147] Urinalysis (Sample A) (20 ml) was performed on admission (for fracture patients) or for cardiac patients following catheterisation on induction of anaesthesia and (Sample B) (20 ml) on day 1 post-operatively.

[0148] Blood Sample A (20 ml) was performed on admission for fracture patients together with their routine pre-operative blood sample work-up such that participation in this study did not involve additional venepuncture. Blood sample A for cardiac patients followed routine arterial line insertion pre-operatively. Day 1 post-operative Sample B (20 ml) for fracture patients was taken at the time of routine analyses, hence not requiring further venepuncture. If, for a fracture patient, a blood sample was inadvertently missed during the time that routine bloods are being taken, it was not pursued to avoid additional discomfort of venepuncture beyond what was required for routine care, unless that patient, in intensive care or HDU had a routinely placed arterial catheter in situ. Unlike many fracture patients who do not have a routinely placed arterial line, all cardiac surgery patients have an arterial line inserted pre-operatively, remaining in situ for 48 hours such that obtaining the post-operative day 1 blood Sample B will be painless.

[0149] Blood and urine samples were immediately centrifuged in the clinical area and the

TABLE-US-00001 TABLE 1 AKI is defined as a drop of eGFR >25% from baseline. The number of patients in each group is shown for each of the AKI time points. Non-AKI patients AKI patients AKI Day 2 220 50 AKI Day 5 246 18 AKI Any Day 210 58
resulting supernatants stored in fridges. Each week these samples were transported to Randox Laboratories Ltd for storage and analysis.

EXAMPLE 1

Cardiac Surgery

[0150] Acute Kidney Injury (AKI) was defined as a drop of baseline eGFR of >25%. A drop in eGFR was recorded on day 1, day 2 and day 5 following surgery. To increase the number of patients in the population, the analyses are based upon an AKI any-day definition. Patients were included in this category if eGFR dropped to less than 75% of baseline, at any day following cardiac surgery. Based on this criteria, a population was described.

[0151] The levels of biomarkers were then determined from the AKI and non-subjects for for plasma, serum and urinary samples. Biomarkers were highlighted as significant at p<0.05 between the AKI and non-AKI groups using a Mann-Whitney U test. The predictive ability of individual biomarkers, identified as significant by Mann-Whitney U test, was investigated by ROC analyses.

[0152] Results for plasma, serum and urinary biomarkers are shown in Tables 2, 3 and 4, respectively.

TABLE-US-00002 TABLE 2 Plasma biomarkers identified as showing a significant difference between AKI and non-AKI. Marker Pre/Post surgery Sig. AUC IL-6 Pre 0.001 0.630 IL-1a Pre 0.040 0.628 VEGF Pre 0.002 0.628 INFy Pre 0.030 0.550 TNF Pre and Post <0.001, <0.001 0.645 MCP Pre and Post 0.010, 0.001 0.604 MIP1 Pre and Post 0.001, <0.001 0.639 NGAL Pre and Post 0.001, <0.001 0.632 IL-8 Post 0.005 0.614 IL-10 Post 0.009 0.604

TABLE-US-00003 TABLE 3 Serum biomarkers identified as showing a significant difference between AKI and non-AKI. Marker Pre/Post surgery Sig. AUC IL12P40 Pre and Post <0.001, <0.001 0.682, 0.714 IL1RA Pre and Post 0.005, <0.001 0.542, 0.687 IP10 Pre and Post 0.012, 0.046 0.601, 0.580 TNFRI Pre and Post <0.001, <0.001 0.748, 0.748 TNFRII Pre and Post <0.001, <0.001 0.715, 0.763 H-FABP Pre and Post 0.001, 0.001 0.637, 0.637 Midkine Post <0.001 0.695

TABLE-US-00004 TABLE 4 Urine biomarkers identified as showing a significant difference between AKI and non-AKI. Pre/Post Marker Surgery Sig. AUC TNFRI Pre and Post 0.044, 0.020 0.581, 0.593 TNFRII Pre and Post 0.018, 0.018 0.595, 0.595 IL12P40 Pre and Post 0.035, <0.001 0.580, 0.667 IL10 Post 0.001 0.637, 0.637 IL1Ra Post 0.024 0.591 NGAL Post <0.001 0.651

[0153] Biomarker combinations were then considered which provided the greatest ability to predict AKI from non-AKI subject groups.

EXAMPLE 2

Fracture Surgery

[0154] AKI could not be defined using the same definition as applied in the cardiac population, namely a drop of >25% in eGFR from baseline, as patients may already have AKI, as a result of their fracture injury, before surgery. The Classification of AKI in the fracture population was based on the RIFLE system. Patients were assumed to have a baseline GFR of at least 60m1/min/1.73m.sup.2 therefore, a value of less than 45m1/min/1.73m.sup.2 was used to define a patient as AKI positive.

[0155] The levels of biomarkers were then determined from the AKI and non-subjects for for plasma, serum and urinary samples. Biomarkers were highlighted as significant at p<0.05 between the AKI and non-AKI groups using a Mann-Whitney U test. The predictive ability of individual biomarkers, identified as significant by Mann-Whitney U test, was investigated by ROC analyses.

[0156] Results for plasma, serum and urinary biomarkers are shown in Tables 5, 6 and 7, respectively.

TABLE-US-00005 TABLE 5 Plasma biomarkers identified as showing a significant difference between AKI and non-AKI group. indicates data missing or illegible when filed

TABLE-US-00006 TABLE 6 Serum biomarkers identified as showing a statistically significant difference between AKI and non-AKI groups. Marker Pre/Post Surgery Sig. AUC IL12P40 Pre and Post-surgery 0.004, 0.021 0.637, 0.619 IL1RA Post-surgery 0.003 0.653 TNFRI Pre and Post-surgery <0.001 0.729, 0.795 TNFRII Pre and Post-surgery 0.004, <0.001 0.634, 0.734 IL2Ra Post-surgery 0.040 0.606 H-FABP Pre and Post-surgery <0.001 0.712, 0.829 Midkine Pre and Post-surgery 0.035, 0.001 0.615, 0.678 IL-6 Post-surgery 0.001 0.661 TNF Pre and Post-surgery 0.02, 0.002 0.607, 0.653 MCP Pre and Post-surgery 0.035, 0.003 0.597, 0.646 IL-5 Pre-surgery 0.039 0.594 IL-15 Post-surgery 0.001 0.523, 0.663 MIP1 Pre and Post-surgery 0.009, 0.003 0.619, 0.644 NGAL Pre and Post-surgery <0.001, <0.001 0.752, 0.812

TABLE-US-00007 TABLE 7 Urinary biomarkers identified as significant between AKI and non-AKI groups. Marker Pre/Post Surgery Sig. AUC TNFRI Pre and Post-Surgery 0.004, 0.001 0.638, 0.656 NGAL Post-surgery 0.008 0.631

[0157] Biomarker combinations were then considered which providing the greatest ability to predict AKI from non-AKI subject groups.

[0158] Further, analysis of biomarkers was undertaken wherein ratios between biomarkers were considered. Ratios of urinary anti- and pro-inflammatory mediators were determined. Further ratios of anti- and pro-inflammatory mediators in the blood (in particular the serum) were considered. Additionally, ratios of anti- and pro-inflammatory mediators in the urine and blood were considered.

[0159] Based on this work it was considered that the ratio or balance of anti- and pro-inflammatory mediators in blood and urine will be lower in those subjects that develop renal dysfunction post operatively that those subjects retaining normal post-operative renal function.

[0160] Without wishing to be bound by theory, it is considered that in blood and urine of those subjects who develop renal dysfunction (AKI) there would either be no correlation or a negative correlation between anti- and pro-inflammatory mediators. Further it is considered that hypoperfusion in combination with a further insult of an imbalanced inflammatory response can be more injurious to the kidney than either insult occurring alone. Since hypoperfusion is an important contributing factor to perioperative AKI, suitably markers such as HFABP and VEGF can be measured and used to assess AKI risk.

[0161] Based on the results shown in FIGS. 30 to 45 (wherein no shading indicates no differences in the Number of subjects (n) between SPSS and PRISM results/no differences or small differences in Ratios and p-values between SPSS and PRISM results and shading indicates differences in the Number of subjects (n) between SPSS and PRISM results/Greater differences in Ratios and p-values between SPSS and PRISM results, particular ratios were found to be predictive.

[0162] It was determined that the ratio of postoperative urinary TNFsr2/serum HFABP fell in AKI patients, suggesting that organ hypoperfusion as indicated by increased serum HFABP was particularly injurious to those patients who did not develop an adequate anti-inflammatory urinary TNFsr2 response. Without wishing to be bound by theory it is considered that an inadequate protective urinary anti-inflammatory response becomes significant in those patients who endure the double insults of proinflammation (as evidenced by urinary proinflammatory mediators) as well as hypoperfusion (as evidenced by increased serum HFABP). It is further considered that inadequate protective urinary anti-inflammatory response becomes significant in those patients who endure the double insults of proinflammation (as evidenced by blood and urinary proinflammatory mediators)as well as hypoperfusion as evidenced by increased serum HFABP and VEGF.

[0163] Preoperative VEGF has been determined to be higher in the AKI group for all endpoints including D5 renal dysfunction(P<0.001). VEGF is considered to be a direct hypoperfusion/hypoxia marker.

[0164] Without wishing to be bound by theory, it is considered that post operatively, after cardiac surgery, when the heart is fixed, overall perfusion and oxygenation is typically improved. HFABP post op does not typically indicate overall oxygenation and perfusion post op. Post op HFABP may be considered to be more indicative of the magnitude of the intraoperative insult and in turn be predictive of AKI.

[0165] Post op hypoperfusion/hypoxia is typically less of a problem in the majority of straightforward low risk cases because following cardiac surgery the heart is revascularised and the subject is typically mechanically ventilated with oxygen supplementation giving them a supra physiological pO2. VEGF as a marker of hypoperfusion and hypoxia at the moment of measurement, may those be indicative of artificially supplemented oxygenation. However, a rise in VEGF post op may be particularly significant.

[0166] Pre op VEGF thus is considered predictive of vulnerability to perioperative hypoperfusion on CPB with heightened AKI risk stretching as far as D5.

[0167] In fracture subjects it was determined that peri-operative increases were observed in almost all blood pro- and anti-inflammatory mediators measured, with some pro-inflammatory mediators (pre and post op) and some anti-inflammatory mediators showing significantly greater increases in the renal dysfunction group compared with the normal renal function subjects.

[0168] It is considered results determined in relation to cardiac surgery with respect to pre and post operative blood and urinary cytokines and anti/pro inflammatory cytokine ratios are similarly observed in post trauma orthopaedic surgery patients with the difference that base line post trauma pre operative samples will have undergone some increase in response to the fracture trauma.

[0169] For fracture subjects, it is considered the ratio of

urinary TNFsr1/HFABP (serum) [0170] TNFsr1(UA)/HFABP (SA) (Do AKI) (was lower in AKI) [0171] TNFsr1 (UB)/HFABP (SB) (D0,D1, D5) (was lower in AKI)
urinary TNFsr2/HFABP(serum)

[0172] TNFsr2(UA)/HFABP (SA) (Do AKI) (was lower in AKI) [0173] TNFsr2 (UB)/HFABP(SB) (D0, D1,D2,D5) (was lower in AKI)

[0174] UA refers to pre urine samples and UB refers to post urine samples. The same applies for serum.

[0175] For the fracture patientsD0=before the operation (this can still be 3-4 days after the initial trauma) [0176] D1 =24 hours after the operation [0177] D5 =5 days after the operation and [0178] TNFsr2UB/TNFSR2 (SB) (D5AKI) (was lower in AKI) are particularly significant.

[0179] This has also been considered in cardiac patients wherein the ratio of postoperative urinary TNFsr2/serum HFABP fell in AKI patients, suggesting that organ hypoperfusion as indicated by increased serum HFABP was particularly injurious to those patients who did not develop an adequate anti-inflammatory urinary TNFsr2 response.

[0180] Post-operative ratios of urinary anti-inflammatory mediators/blood pro-inflammatory mediators were generally lower in renal dysfunction patients than the normal renal patients.

[0181] Further it is considered increased TNFa in blood correlates weakly but significantly with TNFsr2 in urine in non-AKI patients. This may suggest that in AKI patients the post operative compensatory rise in urinary TNFsr2 is compromised: and there may be a tendency to this deficiency pre-operatively even when renal function is normal

TABLE-US-00008 TABLE 8 Plasma TNF vs urinary TNFsr2 - cardiac TNFSR2 UB/HFABP SB AKI AKI Normal Normal N Median N Median P Value D1 25 0.1484 286 0.3978 0.0016 D2 56 0.1821 271 0.4061 <0.001 DS 22 0.1962 295 0.3949 0.0102 Any time 65 0.1959 247 0.4395 <0.0001

TABLE-US-00009 TABLE 10 Timepoint P-Value r-Value n (XY pairs) A AKI Anytime 75% 0.6016 0.0665 64 Non-AKI 0.0045 0.1834 239 B AKI Anytime 75% 0.6387 0.05933 65 Non-AKI <0.0001 0.2553 242 Correlations between plasma TNF and urinary TNFsr2

TABLE-US-00010 TABLE 11 TNFSR2 UA/HFABP SA AKI Non AKI N Mean N Mean P Value Any Time AKI 63 0.1441 250 0.1384 0.5313 Day 1 AKI 24 0.1403 288 0.1482 0.6467 Day 2 AKI 54 0.1597 274 0.1395 0.3645 Day 5 AKI 22 0.1478 296 0.1442 0.9358

TABLE-US-00011 TABLE 12 TNFSR2 UB/HFABP SB SB AKI AKI Normal Normal N Median N Median P Value D1 25 0.1484 286 0.3978 0.0016 D2 56 0.1821 271 0.4061 <0.001 D5 22 0.1962 295 0.3949 0.0102 Anytime 65 0.1959 247 0.4395 <0.0001

[0182] In the cardiac study it was determined that there were peri-operative increases in almost all blood pro- and anti-inflammatory mediators measured, with both pro-inflammatory mediators (pre and post op TNFalpha, IP10, IL12p40, MIP1alpha, MCP1 and NGAL; post op IL8 and Midkine; pre op IL6) and anti-inflammatory mediators (pre and post op TNFsr1, TNFsr2 and IL1ra; post op IL10) showing significantly greater increases in the anytime renal dysfunction group compared with the normal renal function patients. This study shows that in comparison with those patients who retained normal renal function, those who developed renal dysfunction post operatively had a higher baseline preoperative blood concentration of a range of pro-inflammatory markers (eg TNFa, IP10, IL12p40, MIP1alpha, MCP1, NGAL and 1L6) as well as a greater postoperative proinflammatory response in blood (eg TNFa, IP10, IL12p40, MIP1alpha, MCP1, NGAL, IL8, and Midkine).

[0183] Determination of ratios of blood anti-inflammatory mediators/blood pro-inflammatory mediators consistently showed higher anti-inflammatory/pro-inflammatory ratios in the renal dysfunction group(these differences being significant in pre and post op sTNFsr1/plasma TNF, sTNFsr1/plasmaMCP1, sTNFsr2/plasma TNFalpha, sTNFsr2/plasma IL8, sTNFsr2/sIP10, sTNFsr2/plasmaMCP1; pre-op sTNFsr1/plasma IL8, sTNFsr1/sIP10, sTNFsr1/plasma MIP1alpha, sTNFsr1/plasma NGAL, sTNFsr2/plasma MIP1alpha, sTNFsr2/sMidkine, sTNFsr2/plasmaNGAL; post op sTNFsr1/plasma IL6, sTNFsr2/plasma IL6, sIL1ra/plasma TNFalpha, sIL1ra/plasma IL8, sIL1ra/plasma IL6, sIL1ra/sIP10, sIL1ra/plasma MCP1, sIL1ra/plasma NGAL).

[0184] In cardiac and fracture studies, in contrast to blood, in the urine, the anti-/pro-inflammatory ratios were consistently lower in the renal dysfunction patients than the normal renal function patients. In the cardiac study, these differences were significant with respect to any time renal dysfunction in the following ratios: post- operative uTNFsr1/uIP10; post-op uTNFsr1/uNGAL; post-operative uTNFsr2/uIP10; post-operative uTNFsr2/uNGAL; post-operative uIL1ra/uI1P10; post-operative ulL1ra/uIL12p40; post-operative uIL1ra/uNGAL. These differences were also significant with respect to D5 renal dysfunction patients in the following ratios: post- operative uTNFsr2/uIL12p40; post-operative uIL1ra/uIP10; post-operative uIL1ra/uIL12p40; post-operative uIL1ra/uNGAL.

[0185] Post-operative ratios of urinary anti-inflammatory mediators/blood pro-inflammatory mediators were generally lower in the renal dysfunction patients than the normal renal function patients. Differences considered to be significant with respect to any time renal dysfunction were the following post-operative ratios: uTNFsr1/sIL12p40, uTNFsr1/sMidkine, uTNFsr2/sIL12p40, uTNFsr2/pMIP1alpha, uTNFsr2/sMidkine, uTNFsr2/pNGAL, uIL1ra/pTNFalpha, uIL1ra/pIL8, uIL1ra/pIL6, uIL1ra/sIP10, uIL1ra/sIL12p40, uIL1ra/pMIP1alpha, uIL1ra/pMCP1, uIL1ra/sMidkine, uIL1ra/pNGAL.

[0186] Although no pre-operative uTNFSR1/blood pro-inflammatory or uTNFsr2/blood pro-inflammatory ratios were different between normal renal function and renal dysfunction groups, some pre-operative uIL1ra/blood pro-inflammatory ratios were also significantly lower in those who later developed renal dysfunction namely preoperative uIL1ra/pIL6, uIL1ra/sIL12p40, uIL1ra/pMIP1alpha, uIL1ra/pNGAL. Of particular interest to clinicians, these differences were also significant with respect to D5 renal dysfunction patients in the following post operative ratios: post op uTNFsr2/plL8, uTNFsr2/sIL12p40, uTNFsr2/pMIP1alpha, uTNFsr2/pNGAL, uIL1ra/pTNFalpha, uIL1ra/pIL8, uIL1ra/sIL12p40, uIL1ra/pMIP1alpha, uIL1ra/pMCP1, uIL1ra/sMidkine, uIL1ra/pNGAL and of note with respect to the pre-operative ratio of pre-operative uIL1ra/pIL6, uIL1ra/sIL12p40, uIL1ra/pMIP1alpha, uIL1ra/pNGAL.

[0187] If urinary anti-inflammatory/blood pro-inflammatory ratios (in contrast to blood anti-inflammatory/blood pro-inflammatory ratios), are lower in the renal dysfunction groups than in the normal renal function subjects, it may be inferred that filtered blood pro-inflammatory mediators are less well counterbalanced by a compensatory intrarenal anti-inflammatory response in the renal dysfunction patients than the normal renal function patients. This is further corroborated by the demonstration of negative correlations between blood pro- and urinary anti-inflammatory mediators in the renal dysfunction groups.

Ratio of Urinary TNFsr2/Serum HFABP

[0188] Finally, in cardiac patients, the ratio of postoperative urinary TNFsr2/serum HFABP fell in AKI patients, suggesting that organ hypoperfusion as indicated by increased serum HFABP was particularly injurious to those patients who did not develop an adequate anti-inflammatory urinary TNFsr2 response.

[0189] Each document, reference, patent application or patent cited in this text is expressly incorporated herein in their entirety by reference, which means it should be read and considered by the reader as part of this text. That the document, reference, patent application or patent cited in the text is not repeated in this text is merely for reasons of conciseness.

[0190] Reference to cited material or information contained in the text should not be understood as a concession that the material or information was part of the common general knowledge or was known in any country.

[0191] Although the invention has been particularly shown and described with reference to particular examples, it will be understood by those skilled in the art that various changes in the form and details may be made therein without departing from the scope of the present invention.