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Neutrophil gelatinase-associated lipocalin is a biomarker of acute-on-chronic liver failure and prognosis in cirrhosis

  • Author Footnotes
    † These authors contributed equally as joint first authors.
    X. Ariza
    Footnotes
    † These authors contributed equally as joint first authors.
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • Author Footnotes
    † These authors contributed equally as joint first authors.
    I. Graupera
    Footnotes
    † These authors contributed equally as joint first authors.
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • M. Coll
    Affiliations
    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • E. Solà
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • R. Barreto
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • E. García
    Affiliations
    Data Management Centre, EASL-CLIF Consortium, Barcelona, Spain
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  • R. Moreira
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • C. Elia
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • M. Morales-Ruiz
    Affiliations
    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain

    Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Spain
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  • M. Llopis
    Affiliations
    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • P. Huelin
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • C. Solé
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • N. Fabrellas
    Affiliations
    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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  • E. Weiss
    Affiliations
    Inserm, U1149, Centre de Recherche sur l’Inflammation (CRI), Clichy and Paris, France

    UMRS1149, Université Paris Diderot, Paris, France

    Département Hospitalo-Universitaire (DHU) UNITY, Service d’Hépatologie, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France

    Laboratoire d’Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
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  • F. Nevens
    Affiliations
    Division of Liver and Biliopancreatic Disorders, University Hospitals of Leuven, KU Leuven, University of Leuven, Belgium
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  • A. Gerbes
    Affiliations
    Liver Center Munich, Department of Internal Medicine II, University Hospital LMU Munich, Grosshadern, Munich, Germany
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  • J. Trebicka
    Affiliations
    Department of Internal Medicine I, University of Bonn, Bonn, Germany
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  • F. Saliba
    Affiliations
    Hôpital Paul Brousse, Villejuif, France
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  • C. Fondevila
    Affiliations
    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain

    Hepatobiliary Surgery & Liver Transplant, Hospital Clínic de Barcelona, Barcelona, Spain
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  • V. Hernández-Gea
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain

    Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
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  • J. Fernández
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • M. Bernardi
    Affiliations
    Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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  • V. Arroyo
    Affiliations
    EASL-CLIF Consortium, Barcelona, Spain
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  • W. Jiménez
    Affiliations
    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain

    Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Spain
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  • C. Deulofeu
    Affiliations
    Data Management Centre, EASL-CLIF Consortium, Barcelona, Spain
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  • M. Pavesi
    Affiliations
    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain

    Data Management Centre, EASL-CLIF Consortium, Barcelona, Spain
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  • P. Angeli
    Affiliations
    Unit of Hepatic Emergencies and Liver Transplantation, Department of Surgery, University of Padova, Padova, Italy
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  • R. Jalan
    Affiliations
    Liver Failure Group, University College London Institute for Liver and Digestive Health, University College London Medical School, Royal Free Hospital, London, United Kingdom
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  • R. Moreau
    Affiliations
    Inserm, U1149, Centre de Recherche sur l’Inflammation (CRI), Clichy and Paris, France

    UMRS1149, Université Paris Diderot, Paris, France

    Département Hospitalo-Universitaire (DHU) UNITY, Service d’Hépatologie, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France

    Laboratoire d’Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
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  • P. Sancho-Bru
    Affiliations
    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • P. Ginès
    Correspondence
    Corresponding author. Address: Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain. Tel.: +34 932271713; fax: +34 93 2271779.
    Affiliations
    Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain

    University of Barcelona, Barcelona, Spain

    Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
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  • on behalf of theCANONIC Investigators, EASL CLIF Consortium
  • Author Footnotes
    † These authors contributed equally as joint first authors.
Published:March 14, 2016DOI:https://doi.org/10.1016/j.jhep.2016.03.002

      Background & Aims

      Acute-on-chronic liver failure (ACLF) is a syndrome that occurs in cirrhosis characterized by organ failure(s) and high mortality rate. There are no biomarkers of ACLF. The LCN2 gene and its product, neutrophil gelatinase-associated lipocalin (NGAL), are upregulated in experimental models of liver injury and cultured hepatocytes as a result of injury by toxins or proinflammatory cytokines, particularly Interleukin-6. The aim of this study was to investigate whether NGAL could be a biomarker of ACLF and whether LCN2 gene may be upregulated in the liver in ACLF.

      Methods

      We analyzed urine and plasma NGAL levels in 716 patients hospitalized for complications of cirrhosis, 148 with ACLF. LCN2 expression was assessed in liver biopsies from 29 additional patients with decompensated cirrhosis with and without ACLF.

      Results

      Urine NGAL was markedly increased in ACLF vs. no ACLF patients (108(35–400) vs. 29(12–73) μg/g creatinine; p <0.001) and was an independent predictive factor of ACLF; the independent association persisted after adjustment for kidney function or exclusion of variables present in ACLF definition. Urine NGAL was also an independent predictive factor of 28 day transplant-free mortality together with MELD score and leukocyte count (AUROC 0.88(0.83–0.92)). Urine NGAL improved significantly the accuracy of MELD in predicting prognosis. The LCN2 gene was markedly upregulated in the liver of patients with ACLF. Gene expression correlated directly with serum bilirubin and INR (r = 0.79; p <0.001 and r = 0.67; p <0.001), MELD (r = 0.68; p <0.001) and Interleukin-6 (r = 0.65; p <0.001).

      Conclusions

      NGAL is a biomarker of ACLF and prognosis and correlates with liver failure and systemic inflammation. There is remarkable overexpression of LCN2 gene in the liver in ACLF syndrome.

      Lay summary

      Urine NGAL is a biomarker of acute-on-chronic liver failure (ACLF). NGAL is a protein that may be expressed in several tissues in response to injury. The protein is filtered by the kidneys due to its small size and can be measured in the urine. Ariza, Graupera and colleagues found in a series of 716 patients with cirrhosis that urine NGAL was markedly increased in patients with ACLF and correlated with prognosis. Moreover, gene coding NGAL was markedly overexpressed in the liver tissue in ACLF.

      Graphical abstract

      Abbreviations:

      NGAL (neutrophil gelatinase-associated lipocalin), LCN2 (lipocalin-2), AKI (acute kidney injury), uNGAL (urine NGAL), ACLF (acute-on-chronic liver failure), IL-6 (interleukin 6), KIM-1 (kidney injury molecule-1), qPCR (quantitative real-time PCR), MELD (model of end-stage liver disease), pNGAL (plasma NGAL), TLRs (toll-like receptors), GFR (glomerular filtration rate)

      Keywords

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      References

      Author names in bold designate shared co-first authorship

        • Chakraborty S.
        • Kaur S.
        • Guha S.
        • Batra S.K.
        The multifaceted roles of neutrophil gelatinase associated lipocalin (NGAL) in inflammation and cancer.
        Biochim Biophys Acta. 2012; 1826: 129-169
        • Cowland J.B.
        • Borregaard N.
        Molecular characterization and pattern of tissue expression of the gene for neutrophil gelatinase-associated lipocalin from humans.
        Genomics. 1997; 45: 17-23
        • Goetz D.H.
        • Holmes M.A.
        • Borregaard N.
        • Bluhm M.E.
        • Raymond K.N.
        • Strong R.K.
        The neutrophil lipocalin NGAL is a bacteriostatic agent that interferes with siderophore-mediated iron acquisition.
        Mol Cell. 2002; 10: 1033-1043
        • Flo T.H.
        • Smith K.D.
        • Sato S.
        • Rodriguez D.J.
        • Holmes M.A.
        • Strong R.K.
        • et al.
        Lipocalin 2 mediates an innate immune response to bacterial infection by sequestrating iron.
        Nature. 2004; 432: 917-921
        • Schmidt-Ott K.M.
        • Mori K.
        • Li J.Y.
        • Kalandadze A.
        • Cohen D.J.
        • Devarajan P.
        • et al.
        Dual action of neutrophil gelatinase-associated lipocalin.
        J Am Soc Nephrol. 2007; 18: 407-413
        • Mishra J.
        • Ma Q.
        • Prada A.
        • Mitsnefes M.
        • Zahedi K.
        • Yang J.
        • et al.
        Identification of neutrophil gelatinase-associated lipocalin as a novel early urinary biomarker for ischemic renal injury.
        J Am Soc Nephrol. 2003; 14: 2534-2543
        • Supavekin S.
        • Zhang W.
        • Kucherlapati R.
        • Kaskel F.J.
        • Moore L.C.
        • Devarajan P.
        Differential gene expression following early renal ischemia/reperfusion.
        Kidney Int. 2003; 63: 1714-1724
        • Paragas N.
        • Qiu A.
        • Zhang Q.
        • Samstein B.
        • Deng S.X.
        • Schmidt-Ott K.M.
        • et al.
        The Ngal reporter mouse detects the response of the kidney to injury in real time.
        Nat Med. 2011; 17: 216-222
        • Alge J.L.
        • Arthur J.M.
        Biomarkers of AKI: a review of mechanistic relevance and potential therapeutic implications.
        Clin J Am Soc Nephrol. 2015; 10: 147-155
        • Nickolas T.L.
        • O’Rourke M.J.
        • Yang J.
        • Sise M.E.
        • Canetta P.A.
        • Barasch N.
        • et al.
        Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury.
        Ann Intern Med. 2008; 148: 810-819
        • Nickolas T.L.
        • Schmidt-Ott K.M.
        • Canetta P.
        • Forster C.
        • Singer E.
        • Sise M.
        • et al.
        Diagnostic and prognostic stratification in the emergency department using urinary biomarkers of nephron damage: a multicenter prospective cohort study.
        J Am Coll Cardiol. 2012; 59: 246-255
        • Koyner J.L.
        • Parikh C.R.
        Clinical utility of biomarkers of AKI in cardiac surgery and critical illness.
        Clin J Am Soc Nephrol. 2013; 8: 1034-1042
        • Borkham-Kamphorst E.
        • Drews F.
        • Weiskirchen R.
        Induction of lipocalin-2 expression in acute and chronic experimental liver injury moderated by pro-inflammatory cytokines interleukin-1β through nuclear factor-κB activation.
        Liver Int. 2011; 31: 656-665
        • Borkham-Kamphorst E.
        • van de Leur E.
        • Zimmermann H.W.
        • Karlmark K.R.
        • Tihaa L.
        • Haas U.
        • et al.
        Protective effects of lipocalin-2 (LCN2) in acute liver injury suggest a novel function in liver homeostasis.
        Biochim Biophys Acta. 2013; 1832: 660-673
        • Labbus K.
        • Henning M.
        • Borkham-Kamphorst E.
        • Geisler C.
        • Berger T.
        • Mak T.W.
        • et al.
        Proteomic profiling in Lipocalin 2 deficient mice under normal and inflammatory conditions.
        J Proteomics. 2013; 78: 188-196
        • Xu M.J.
        • Feng D.
        • Wu H.
        • Wang H.
        • Chan Y.
        • Kolls J.
        • et al.
        Liver is the major source of elevated serum lipocalin-2 levels after bacterial infection or partial hepatectomy: a critical role for IL-6/STAT3.
        Hepatology. 2015; 61: 692-702
        • Auguet T.
        • Terra X.
        • Quintero Y.
        • Martínez S.
        • Manresa N.
        • Porras J.A.
        • et al.
        Liver lipocalin 2 expression in severely obese women with non alcoholic fatty liver disease.
        Exp Clin Endocrinol Diabetes. 2013; 121: 119-124
        • Moreau R.
        • Jalan R.
        • Ginès P.
        • Pavesi M.
        • Angeli P.
        • Cordoba J.
        • et al.
        • CANONIC Study Investigators of the EASL–CLIF Consortium
        Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis.
        Gastroenterology. 2013; 144: 1426-1437
        • Arroyo V.
        • Moreau R.
        • Jalan R.
        • Ginès P.
        • EASL-CLIF Consortium CANONIC Study
        Acute-on-chronic liver failure: A new syndrome that will re-classify cirrhosis.
        J Hepatol. 2015; 62: S131-S143
        • Decavele A.S.
        • Dhondt L.
        • De Buyzere M.L.
        • Delanghe J.R.
        Increased urinary neutrophil gelatinase associated lipocalin in urinary tract infections and leukocyturia.
        Clin Chem Lab Med. 2011; 49: 999-1003
        • Bosch J.
        • Garcia-Pagán J.C.
        • Berzigotti A.
        • Abraldes J.G.
        Measurement of portal pressure and its role in the management of chronic liver disease.
        Semin Liver Dis. 2006; 26: 348-362
        • Jalan R.
        • Saliba F.
        • Pavesi M.
        • Amorós A.
        • Moreau R.
        • Ginès P.
        • et al.
        • CANONIC study investigators of the EASL-CLIF Consortium
        Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure.
        J Hepatol. 2014; 61: 1038-1047
        • Kamath P.S.
        • Kim W.R.
        Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD).
        Hepatology. 2007; 45: 797-805
        • Whitmore M.M.
        • Iparraguirre A.
        • Kubelka L.
        • Weninger W.
        • Hai T.
        • Williams B.R.
        • et al.
        Negative regulation of TLR-signaling pathways by activating transcription factor-3.
        J Immunol. 2007; 179: 3622-3630
        • Tilg H.
        • Wilmer A.
        • Vogel W.
        • Herold M.
        • Nölchen B.
        • Judmaier G.
        • et al.
        Serum levels of cytokines in chronic liver diseases.
        Gastroenterology. 1992; 103: 264-274
        • López-Talavera J.C.
        • Levitzki A.
        • Martínez M.
        • Gazit A.
        • Esteban R.
        • Guardia J.
        • et al.
        Tyrosine kinase inhibition ameliorates the hyperdynamic state and decreases nitric oxide production in cirrhotic rats with portal hypertension and ascites.
        J Clin Invest. 1997; 100: 664-670
        • Navasa M.
        • Follo A.
        • Filella X.
        • Jiménez W.
        • Francitorra A.
        • Planas R.
        • et al.
        Tumor necrosis factor and interleukin-6 in spontaneous bacterial peritonitis in cirrhosis: relationship with the development of renal impairment and mortality.
        Hepatology. 1998; 27: 1227-1232
        • Genescà J.
        • Martí R.
        • Rojo F.
        • Campos F.
        • Peribáñez V.
        • Gónzalez A.
        • et al.
        Increased tumour necrosis factor alpha production in mesenteric lymph nodes of cirrhotic patients with ascites.
        Gut. 2003; 52: 1054-1059
        • Zapater P.
        • Francés R.
        • González-Navajas J.M.
        • de la Hoz M.A.
        • Moreu R.
        • Pascual S.
        • et al.
        Serum and ascitic fluid bacterial DNA: a new independent prognostic factor in noninfected patients with cirrhosis.
        Hepatology. 2008; 48: 1924-1931
        • Bagshaw S.M.
        • Bennett M.
        • Haase M.
        • Haase-Fielitz A.
        • Egi M.
        • Morimatsu H.
        • et al.
        Plasma and urine neutrophil gelatinase-associated lipocalin in septic versus non-septic acute kidney injury in critical illness.
        Intensive Care Med. 2010; 36: 452-461
        • Wang M.
        • Zhang Q.
        • Zhao X.
        • Dong G.
        • Li C.
        Diagnostic and prognostic value of neutrophil gelatinase-associated lipocalin, matrix metalloproteinase-9, and tissue inhibitor of matrix metalloproteinases-1 for sepsis in the Emergency Department: an observational study.
        Crit Care. 2014; 18: 634
        • Berger T.
        • Togawa A.
        • Duncan G.S.
        • Elia A.J.
        • You-Ten A.
        • Wakeham A.
        • et al.
        Lipocalin 2-deficient mice exhibit increased sensitivity to Escherichia coli infection but not to ischemia-reperfusion injury.
        Proc Natl Acad Sci U S A. 2006; 103: 1834-1839
        • Liu Z.
        • Petersen R.
        • Devireddy L.
        Impaired neutrophil function in 24p3 null mice contributes to enhanced susceptibility to bacterial infections.
        J Immunol. 2013; 190: 4692-4706
        • Fernández J.
        • Acevedo J.
        • Castro M.
        • Garcia O.
        • de Lope C.R.
        • Roca D.
        • et al.
        Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study.
        Hepatology. 2012; 55: 1551-1561
        • Jalan R.
        • Fernández J.
        • Wiest R.
        • Schnabl B.
        • Moreau R.
        • Angeli P.
        • et al.
        Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013.
        J Hepatol. 2014; 60: 1310-1324