Acute kidney disease and acute kidney injury biomarkers in coronary care unit patients.

BACKGROUND: Acute kidney disease (AKD) describes acute or subacute damage and/or loss of kidney function for a duration of between 7 and 90 days after exposure to an acute kidney injury (AKI) initiating event. This study investigated the predictive ability of AKI biomarkers in predicting AKD in coronary care unit (CCU) patients. METHODS: A total of 269 (mean age: 64 years; 202 (75%) men and 67 (25%) women) patients admitted to the CCU of a tertiary care teaching hospital from November 2009 to September 2014 were enrolled. Information considered necessary to evaluate 31 demographic, clinical and laboratory variables (including AKI biomarkers) was prospectively recorded on the first day of CCU admission for post hoc analysis as predictors of AKD. Blood and urinary samples of the enrolled patients were tested for neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (CysC) and interleukin-18 (IL-18). RESULTS: The overall hospital mortality rate was 4.8%. Of the 269 patients, 128 (47.6%) had AKD. Multivariate logistic regression analysis revealed that age, hemoglobin, ejection fraction and serum IL-18 were independent predictors of AKD. Cumulative survival rates at 5 years of follow-up after hospital discharge differed significantly (p < 0.001) between subgroups of patients diagnosed with AKD (stage 0A, 0C, 1, 2 and 3). The overall 5-year survival rate was 81.8% (220/269). Multivariate Cox proportional hazard analysis revealed that urine NGAL, body weight and hemoglobin level were independent risk factors for 5-year mortality. CONCLUSIONS: This investigation confirmed that AKI biomarkers can predict AKD in CCU patients. Age, hemoglobin, ejection fraction and serum IL-18 were independently associated with developing AKD in the CCU patients, and urine NGAL, body weight and hemoglobin level could predict 5-year survival in these patients.

Effect of clofibrate on the chiral inversion of ibuprofen in healthy volunteers.

OBJECTIVES: To determine the influence of the hypolipidemic drug clofibrate on the stereoselective metabolism of ibuprofen in humans. METHODS: Healthy male subjects (n = 12) ingested a dose of 400 mg pseudoracemic ibuprofen (200 mg R-ibuprofen, 160 mg S-ibuprofen, and 40 mg 13C-S-ibuprofen) on two occasions after either pretreatment with clofibrate (2 gm/day over 1 week) or no pretreatment in a randomized order. RESULTS: When subjects were pretreated with clofibrate, clearances of R-ibuprofen and 13C-S-ibuprofen increased significantly from 55.0 and 66.4 ml/min to 186.2 and 106.7 ml/min (p < 0.01), respectively. This increase was similarly reflected in the clearance by inversion of R-ibuprofen (control, 36.0 ml/min; treated, 118.8 ml/min; p < 0.01), as well as in the clearance by noninversion (control, 19.0 ml/min; treated, 67.4 ml/min; p < 0.01). Unbound clearance values significantly increased for R-ibuprofen (control, 19.5 L/min; treated, 38.7 L/min) but not for 13C-S-ibuprofen (11.8 versus 10.6 L/min, respectively). The fractional inversion of ibuprofen calculated from the urinary metabolite data was increased after clofibrate pretreatment (clofibrate group, 66.4%; control, 53.5%; p < 0.01). However, this was not evident when fractional inversion was calculated from the plasma concentration-time data for the unmetabolized drug. CONCLUSIONS: Clofibrate altered the stereoselective disposition of ibuprofen in healthy volunteers by increased formation of R-ibuprofenoyl-coenzyme A rather than by an effect on oxidative metabolism of ibuprofen. This interaction has potential therapeutic implications.

Electrophilic reactions of acyl-linked glucuronides. Formation of clofibrate mercapturate in humans.

An acyl-linked mercapturic acid metabolite of clofibrate has been identified in human urine. The identification is based on comparison of fast-atom bombardment mass spectra and high-pressure liquid chromatograms with those of synthesized material. This represents the first acyl-linked mercapturate found in man. The mechanism proposed for its formation involves transacylation of clofibrate acyl glucuronide by glutathione, hydrolysis, and acetylation to produce clofibryl mercapturic acid. Synthetic clofibrate glucuronide is shown to be electrophilic; it reacts covalently with ethanethiol and p-nitro-benzylpyridine. We propose that clofibrate acyl glucuronide is an electrophilic metabolite which reacts with sulfhydryl groups and therefore may be responsible for the human hepatotoxicity of clofibrate.

Determination of tibric acid and clofibrate in animal feed, wastewater and hunan urine.

Analytical chemical procedures are described to determine residues of the drugs clofibrate and tibric acid in animal feed, wastewater, and human urine. Clofibrate was extracted from animal feed and human urine with hexane, whereas residues from wastewater were collected on a Sep-PakTM then eluted with methanol for analysis. Clofibrate residues from the feed, wastewater, and urine were analyzed by high-pressure liquid chromatography (HPLC) with minimum detectable levels (MDL) of about 40, 0.5 and 1.0 ppb, respectively. Tibric acid was extracted from animal feed with 90% methanol and 10% 0.1 N NaOH, whereas wastewater and human urine were acidified with 12 N HCl and then extracted with benzene. The MDL for tibric acid in feed by electron capture/gas chromatography (EC/GC) and HPLC were about 40 ppb and 2.0 ppm, respectively. Residues from these extracts that contained more than 5 ppm of tibric acid were analyzed by HPLC, whereas GC was required for levels below 5 ppm. The GC procedures, which required that tibric acid be derivatized (methylated) prior to analysis, had MDL of 0.1 and 1.0 ppb for wastewater and human urine, respectively. Data are also presented concerning partition values, stability of the compounds in animal feed, and recoveries of the compounds from the three substrates.

Formation of 2-(4-chlorophenoxy)-2- methylpropanamide from a clofibrate metabolite during extraction of urine.

Drug isolation from urine by solvent extraction after alkalinization suffers the potential disadvantage of chemically altering desired isolates by hydrolytic reactions. This paper reports a reaction which results in the formation of an amide substance when urine from individuals ingesting clofibrate is treated with ammonium hydroxide or sodium hydroxide and ammonium ion. The amide formed in urine has been compared to synthetically prepared 2-(4-chlorophenoxy)-2-methylpropanamide by gas chromatography, thin layer chromatography, ultraviolet spectrophotometry, infrared spectrophotometry, and mass spectrometry with complete correspondence of chemical properties. Conditions under which this amide, the major clofibrate-related entity, formed in urine are those routinely employed in analytical toxicology.

Measurement of clofibric acid (CPIB) metabolites in plasma of patients on clofibrate therapy.

1. The metabolites of clofibric acid [CPIB;2-(chlorophenoxy)-2-methylpropionic acid] are present in the plasma of patients on clofibrate therapy. The highest plasma concentrations of CPIB in metabolite form (up to 51 micrograms/ml) were generally found in patients with renal disease. Negligible concentrations (less than or equal to 2 micrograms/ml) were found in only seven patients out of thirty-six studied. 2. The two conjugates of CPIB found in urine were present in plasma. 3. When measuring conjugated CPIB in plasma it is essential to take care in the handling and storage of specimens, and to select an assay method known to be specific for unmetabolized CPIB.

Separation of two conjugates of clofibric acid (CPIB) found in the urine of subjects taking clofibrate.

1. Two main conjugates of CPIB (2-[chlorophenoxy]-2-methylpropionic acid) are present in the urine of subjects taking clofibrate. The metabolites can be separated by thin-layer chromatography (TLC). 2. Both conjugates are hydrolysed by dilute alkali, but only one is hydrolysed by the enzyme beta-glucuronidase. In eighty-five urine specimens this conjugate accounted for an average of 54.5% (range 25-70%) of the total CPIB, while 2.6-12.45% (mean 5.1%) was present as free CPIB.

High-pressure liquid chromatographic analysis of drugs in biological fluids. IV. Determination of clofibrinic acid.

A rapid, sensitive and specific high-pressure liquid chromatographic method is described for the quantitative analysis of clofibrinic acid in plasma, saliva and urine. In contrast to previously reported gas-liquid chromatographic methods, which require derivatization of clofibrinic acid before chromatography, the present method involves a simple two-step extraction procedure and chromatographic determination of the underivatized clofibrinic acid. Concentrations between 1.0 and 25.0 microgram per sample can be measured with a coefficient of variation from 1 to 6%.

A rapid gas chromatographic method for the determination of chlorophenoxyisobutyric acid in plasma and urine.

A rapid gas chromatographic method is described for the determination of chlorophenoxyisobutyric acid (the active metabolite of clofibrate) in plasma and urine. The assay involves an extraction into toluene and back-extraction of the chlorophenoxyisobutyric acid and the internal standard (2-naphthoic acid) into the methylating reagent (trimethylanilinium hydroxide). Concentrations of 1 mug/ml in plasma and urine can easily be measured; the precision of the method is 3.3 +/- 0.7% for plasma and 2.7 +/- 0.4% for urine. There is no interference from endogenous compounds or from drugs commonly prescribed together with clofibrate.

Pharmacokinetics of drugs in patients with the nephrotic syndrome.

Since the binding of drugs to plasma proteins can significantly after the intensity of pharmacological and toxicological effects of drugs, we studied the pharmacokinetics of three drugs in patients with hypoalbuminemia secondary to the nephrotic syndrome, but with relatively normal renal function. No significant differences were seen in the pharmacokinetic parameters observed for antipyrine, a drug which is less than 10% bound to plasms proteins. The percentage of unbound diphenylhydantoin, a highly plasms protein-bound drug, was found in patients with the nephrotic syndrome to be twice that of healthy individuals (19,2 vs. 10.1%, P smaller than 0.001). However, there was also a lower steady-state plasma concentration of diphenylhydantoin (2.9 plus or minus 0.6 vs. 6.8 plus or minus 0.6 mug/ml, P smaller than 0.001) secondary to an increase in the plasms clearance (0.048 plus or minus 0.019 vs. 0.022 plus or minus 0.006 liter/kg.h, P smaller than 0.001) in the nephrotic patients. The net effect is no difference in the absolute concentration of unbound diphenylhydantoin in healthy individuals (0.69 plus or minus 0.05 mug/ml) and patients with the nephrotic syndrome (0.59 plus or minus 0.06 mug/ml). Qualitatively, similar differences were observed with clofibrate. The dose of these drugs need not be routinely reduced in patients with the nephrotic syndrome as long as they have reasonably normal renal function (creatinine clearance greater than 50 ml/min). With all highly bound acidic drugs, knowledge of the concentration of unbound drug is essential to the proper interpretation of total blood levels and subsequent treatment of the patient.

Determination of clofibrate in biological fluids by thin-layer and gas-liquid chromatography.

A specific and sensitive method is described for the detection of clofibrate in biological fluids. The drug is separated from associated fatty acids by thin-layer chromatography and the methyl ester is quantified by gas-liquid chromatography. Recovery is excellent, and any small losses are corrected with an internal recovery standard. Although more time-consuming than other available techniques, the method offers advantages for accurate studies of clofibrate metabolism.