Earlier and more reliable detection of drug-induced kidney injury would improve clinical care and help to streamline drug-development. As the current standards to monitor renal function, such as blood urea nitrogen (BUN) or serum creatinine (SCr), are late indicators of kidney injury, we conducted ten nonclinical studies to rigorously assess the potential of four previously described nephrotoxicity markers to detect drug-induced kidney and liver injury. Whereas urinary clusterin outperformed BUN and SCr for detecting proximal tubular injury, urinary total protein, cystatin C and β2-microglobulin showed a better diagnostic performance than BUN and SCr for detecting glomerular injury. Gene and protein expression analysis, in-situ hybridization and immunohistochemistry provide mechanistic evidence to support the use of these four markers for detecting kidney injury to guide regulatory decision making in drug development. The recognition of the qualification of these biomarkers by the EMEA and FDA will significantly enhance renal safety monitoring.
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Vaidya, V.S. et al. Next-generation biomarkers for detecting kidney toxicity. Nat. Biotechnol. 28, 436–440 (2010).
Chertow, G.M., Burdick, E., Honour, M., Bonventre, J.V. & Bates, D.W. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J. Am. Soc. Nephrol. 16, 3365–3370 (2005).
Dieterle, F. et al. Monitoring kidney safety in drug development: emerging technologies and their implications. Curr. Opin. Drug Discov. Devel. 11, 60–71 (2008).
Parikh, C.R. & Devarajan, P. New biomarkers of acute kidney injury. Crit. Care Med. 36 Suppl, S159–S165 (2008).
Endre, Z.H. & Westhuyzen, J. Early detection of acute kidney injury: emerging new biomarkers. Nephrology 13, 91–98 (2008).
Ferguson, M.A., Vaidya, V.S. & Bonventre, J.V. Biomarkers of nephrotoxic acute kidney injury. Toxicology 245, 182–193 (2008).
Mattes, W.B. & Walker, E.G. Translational toxicology and the work of the predictive safety testing consortium. Clin. Pharmacol. Ther. 85, 327–330 (2009).
Rosenberg, M.E. & Silkensen, J. Clusterin and the kidney. Exp. Nephrol. 3, 9–14 (1995).
Kharasch, E.D., Schroeder, J.L., Bammler, T., Beyer, R. & Srinouanprachanh, S. Gene expression profiling of nephrotoxicity from the sevoflurane degradation product fluoromethyl-2,2-difluoro-1-(trifluoromethyl)vinyl ether (“compound A”) in rats. Toxicol. Sci. 90, 419–431 (2006).
Rached, E. et al. Evaluation of putative biomarkers of nephrotoxicity after exposure to ochratoxin a in vivo and in vitro. Toxicol. Sci. 103, 371–381 (2008).
Correa-Rotter, R. et al. Induction of clusterin in tubules of nephrotic rats. J. Am. Soc. Nephrol. 9, 33–37 (1998).
Tsuchiya, Y. et al. Investigation on urinary proteins and renal mRNA expression in canine renal papillary necrosis induced by nefiracetam. Arch. Toxicol. 79, 500–507 (2005).
Yoshida, T. et al. Monitoring changes in gene expression in renal ischemia-reperfusion in the rat. Kidney Int. 61, 1646–1654 (2002).
Correa-Rotter, R., Hostetter, T.H., Manivel, J.C., Eddy, A.A. & Rosenberg, M.E. Intrarenal distribution of clusterin following reduction of renal mass. Kidney Int. 41, 938–950 (1992).
Ishii, A., Sakai, Y. & Nakamura, A. Molecular pathological evaluation of clusterin in a rat model of unilateral ureteral obstruction as a possible biomarker of nephrotoxicity. Toxicol. Pathol. 35, 376–382 (2007).
Hidaka, S., Kränzlin, B., Gretz, N. & Witzgall, R. Urinary clusterin levels in the rat correlate with the severity of tubular damage and may help to differentiate between glomerular and tubular injuries. Cell Tissue Res. 310, 289–296 (2002).
Rosenberg, M.E. & Silkensen, J. Clusterin: physiologic and pathophysiologic considerations. Int. J. Biochem. Cell Biol. 27, 633–645 (1995).
Ghiggeri, G.M. et al. Depletion of clusterin in renal diseases causing nephrotic syndrome. Kidney Int. 62, 2184–2194 (2002).
D'Amico, G. & Bazzi, C. Pathophysiology of proteinuria. Kidney Int. 63, 809–825 (2003).
Shankland, S.J. The podocyte's response to injury: role in proteinuria and glomerulosclerosis. Kidney Int. 69, 2131–2147 (2006).
Thielemans, N., Lauwerys, R. & Bernard, A. Competition between Albumin and low-molecular-weight proteins for renal tubular uptake in experimental nephropathies. Nephron 66, 453–458 (1994).
Gatanaga, H. et al. Urinary beta2-microglobulin as a possible sensitive marker for renal injury caused by tenofovir disoproxil fumarate. AIDS Res. Hum. Retroviruses 22, 744–748 (2006).
Mussap, M. & Plebani, M. Biochemistry and clinical role of human cystatin C. Crit. Rev. Clin. Lab. Sci. 41, 467–550 (2004).
Madero, M., Sarnak, M.J. & Stevens, L.A. Serum cystatin C as a marker of glomerular filtration rate. Curr. Opin. Nephrol. Hypertens. 15, 610–616 (2006).
Dharnidharka, V.R., Kwond, C. & Stevens, G. Serum cystatin C is superior to serum creatinine as a marker of kidney function: a meta-analysis. Am. J. Kidney Dis. 40, 221–226 (2002).
Shlipak, M.G., Praught, M.L. & Sarnak, M.J. Update on cystatin C: new insights into the importance of mild kidney dysfunction. Curr. Opin. Nephrol. Hypertens. 15, 270–275 (2006).
Herget-Rosenthal, S. et al. Early detection of acute renal failure by serum Cystatin C. Kidney Int. 66, 1115–1122 (2004).
Tenstad, O., Roald, A.B., Grubb, A. & Aukland, K. Renal handling of radiolabelled human cystatin C in the rat. Scand. J. Clin. Lab. Invest. 56, 409–414 (1996).
Collé, A., Tavera, C., Laurent, P., Leung-Tack, J. & Girolami, J.P. Direct radioimmunoassay of rat cystatin C: increased urinary excretion of this cysteine proteases inhibitor during chromate nephropathy. J. Immunoassay 11, 199–214 (1990).
Herget-Rosenthal, S., van Wikj, J. & Bröcker-Preuss, M. Increased urinary cystatin C reflects structural and functional renal tubular impairment independent of glomerular filtration rate. Clin. Biochem. 40, 946–951 (2007).
Conti, M. et al. Urinary cystatin C as a specific marker of tubular dysfunction. Clin. Chem. Lab. Med. 44, 288–291 (2006).
Sistare, F.D. et al. Towards consensus practices to qualify safety biomarkers for use in early drug development. Nat. Biotechnol. 28, 446–454 (2010).
Bernard, A., Viau, C., Ouled, A., Tulkens, P. & Lauwerys, R. Effects of gentamicin on the renal uptake of endogenous and exogenous protein in conscious rats. Toxicol. Appl. Pharmacol. 84, 431–438 (1986).
Rybak, M.J., Frankowski, J.J., Edwards, D.J. & Albrecht, L.M. Alanine aminopeptidase and beta 2-microglobulin excretion in patients receiving vancomycin and gentamicin. Antimicrob. Agents Chemother. 31, 1461–1464 (1987).
Trollfors, B., Bergmark, J., Hiesche, K. & Jagenburg, R. Urinary alanine aminopepticase and β2-microglobulin as measurements of aminoglycoside-associated renal impairment. Infection 12, 20–22 (1984).
Kaye, W.A. et al. The significance of beta-2 microglobulinuria associated with gentamicin therapy. Ann. Clin. Lab. Sci. 11, 530–537 (1981).
Biomarker Website, E.M.E.A. <http://www.emea.europa.eu/htms/human/mes/biomarkers.htm>.
Gerhold, D.L. et al. Urinary biomarkers trefoil factor 3 and albumin enable early detection of kidney tubular injury. Nat. Biotechnol. 28, 470–477 (2010).
Vaidya, V.S. et al. Kidney injury molecule-1 outperforms traditional biomarkers of kidney injury in preclinical biomarker qualification studies. Nat. Biotechnol. 28, 478–485 (2010).
Sing, T., Sander, O., Beerenwinkel, N. & Lengauer, T. ROCR: visualizing classifier performance in R. Bioinformatics 21, 3940–3941 (2005).
Hanley, J.A. & McNeil, B.J. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143, 29–36 (1982).
DeLong, E.R., DeLong, D.M. & Clarke-Pearson, D.L. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44, 837–845 (1988).
Harrell, F . ERegression Modeling Strategies (Springer, New York, 2001).
S. Leuillet and B. Palate from CIT are acknowledged for performing the in-life studies and the histopathology assessment. J. Mapes and D. Eisinger from Rules-Based Medicine are acknowledged for the development of the luminex assays. We thank the D. Moor and P. Brodmann from Biolytix for the validation and measurements of the RT-PCR assays.
All authors are employees of Novartis.
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Dieterle, F., Perentes, E., Cordier, A. et al. Urinary clusterin, cystatin C, β2-microglobulin and total protein as markers to detect drug-induced kidney injury. Nat Biotechnol 28, 463–469 (2010). https://doi.org/10.1038/nbt.1622
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