Serum Levels of Neutrophil Gelatinase Associated Lipocalin (NGAL) Predicts Hemodialysis After Coronary Angiography in High Risk Patients with Acute Coronary Syndrome.

Serum Levels of Neutrophil Gelatinase Associated Lipocalin (NGAL) Predicts Hemodialysis After Coronary Angiography in High Risk Patients with Acute Coronary Syndrome. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Serum Levels of Neutrophil Gelatinase Associated Lipocalin (NGAL) Predicts Hemodialysis After Coronary Angiography in High Risk Patients with Acute Coronary Syndrome. Luis Felipe Reyes, Diego Fernando Severiche-Bueno, Carlos A. Bustamante, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.17874/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Apr, 2020 Read the published version in BMC Nephrology → Version 3 posted 7 You are reading this latest preprint version Show more versions Abstract Background: Contrast-induced nephropathy (CIN) following a percutaneous coronary intervention (PCI) is the third most common cause of acute kidney injury (AKI) worldwide. Patients who require hemodialysis secondary to CIN have an elevated mortality rate as high as 55%. The current definition of CIN is based on an elevation of creatinine and decrease in urinary output. Creatinine typically increases 48 hours after the contrast exposure, which delays the diagnosis and treatment of CIN. The neutrophil gelatinase associated lipocalin (NGAL) has emerged as a sensitive and specific biomarker of renal injury. Limited data exists about the effectiveness of NGAL to predict CIN in high-risk patients with acute coronary syndrome (ACS) that underwent PCI. The primary aim of this study was to determine the association of serum NGAL levels and the need for hemodialysis after PCI. Methods: This is a prospective, observational study. NGAL levels were measured using ELISA. Blood samples were obtained within the first 6 hours of hospital admission, and 12 and 24 hours after contrast exposure from angiography. The primary outcome was the requirement of hemodialysis. The non-parametric Mann-Whitney U test was used to test for differences in median serum levels of NGAL. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL to predict the need for hemodialysis after PCI. Results: A total of 2,875 were screened; however, 45 patients with ACS that underwent PCI were included. All patients were at high risk of developing CIN defined by Mehran score >11 points. The median (IQR) serum concentration of NGAL was significantly higher in patients that required versus did not require hemodialysis (340 [83-384] vs. 169 [100-210], p=0.01). Elevated serum levels of NGAL with a cut-off at 6 hours post PCI of 281 mg/dL predicted the need for hemodialysis with an area under the curve of 0.86 (95% CI: 0.66-1.00). Conclusions: In patients with ACS undergoing PCI; and high risk of developing CIN, an elevated serum level of NGAL 6 hours after contrast exposure predicts the development of acute kidney injury requiring hemodialysis. Urology & Nephrology Contrast-induced Nephropathy hemodialysis biomarkers. Figures Figure 1 Figure 2 Figure 3 1. Background The incidence of contrast-induced nephropathy (CIN) is low in patients without risk factors (< 5%) [1], but increases among patients with chronic kidney disease (CKD) [2], particularly in patients with diabetes mellitus (DM), congestive heart failure (CHF), and advanced age [3]. Additionally, the risk of developing CIN is even higher among patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI) [4]. Incidence of CIN after a PCI is < 3% in patients without renal dysfunction but can rise to 40% in patients with chronic kidney disease besides being associated with higher in-hospital mortality [5, 6]. CIN is defined as an acute decrease in renal function after the administration of intravenous contrast without an alternative cause [7]. The most frequently used definition of CIN is based on the elevation of serum creatinine (SCr) [8]. It is important to note that SCr does not begin to rise until 50% or more of the kidney glomeruli have been affected [9]. Serum creatinine is neither sensitive nor specific because several conditions can alter its serum concentration [10, 11]. Several scoring systems have been devised to identify patients at high risk of developing CIN after a cardiac intervention [12-16]. Mehran et al created a scoring system that incorporates 8 clinical and procedural variables (hypotension, congestive heart failure, serum creatinine, DM, age >75 years, anemia, the volume of contrast, and use of an intra-aortic balloon pump) that have been widely used and validated in different cohorts [17-20]. Given the limitations of SCr to detect patients with subclinical CIN, isolation of a biomarker for acute kidney injury after a PCI would be clinically useful. Neutrophil gelatinase associated-lipocalin (NGAL), also known as lipocalin-2 (LCN2), is a small (25-kDa) glycoprotein covalently stored in granules of mature neutrophils [21]. It is normally expressed at very low levels in a variety of human tissues, including bone marrow, uterus, prostate, salivary gland, stomach, colon, trachea, lung, liver, and kidney [22, 23]. It is rapidly released in distal tubular cells in response to inflammation or injury of nephrons [24]. It can be easily detected in the blood and urine soon after acute kidney injury [25, 26]. NGAL is emerging as a promising renal biomarker to detect patients with acute kidney injury [27]. Recent studies have shown that NGAL can be used as a diagnostic tool to detect CIN in patients that undergo an elective PCI with similar performance between urinary and serum NGAL. However, most of the studies in this group of patients used serum NGAL[25, 28-30]. However, limited data are available on the utility of NGAL to predict CIN and the need for hemodialysis in high-risk patients with ACS and this study will attempt to solve this gap in the literature. Therefore, we hypothesized that serum levels of NGAL could predict the development of CIN requiring hemodialysis after PCI in patients with ACS and high risk of developing CIN. The objective of this study is to determine whether NGAL measured 6 hours post PCI can identify patients that will develop CIN and require hemodialysis. Moreover, we will assess whether NGAL levels are associated with a longer length of hospital stay and hospital mortality. 2. Methods A prospective observational study of consecutively admitted patients with ACS that underwent PCI was performed during two consecutive years at Shaio Clinic, a high-volume cardiovascular referral center in Bogota, Colombia. The local institutional ethics committee approved the study. Informed consent was obtained from all study subjects prior to enrollment. Not study procedures were performed before patient enrollment, and official inform consent was obtained. PCI was performed using a standard protocol via either the radial or femoral artery approach by an attending interventional cardiologist. All procedures were performed using a standard dose (3–5 ml/kg) of non-ionic, low-osmolality contrast media in doses adjusted for body weight and type of cardiovascular angiogram. Patients’ interventions were performed according to local and international guidelines, not per protocol. It is essential to highlight that all patients were monitored during PCI by a certified anesthesiologist to prevent cardiovascular complications; none of the subjects included in the study developed hypotension nor cardiovascular instability during the procedure. The decision to begin hemodialysis therapy was determined by the nephrology team taking into account the following life-threatening indications for renal replacement therapy: acidosis unresponsive to medical treatment, acute severe refractory hyperkalemia, pulmonary edema and uremic complications (e.g., encephalopathy and uremic pericarditis) [31]. The nephrology team did not have access to the NGAL values during the study. 2.1 Subjects The study inclusion criteria were age >18 years, ACS per standard definition [32], and high risk for CIN determined by a Mehran score >11 points ( Table 1 ). Exclusion criteria were end-stage renal disease requiring chronic hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD); suspected infection, sepsis or septic shock; exposure to nephrotoxic drugs or intravenous contrast medium 48 hours prior to the study period; terminal disease (malignant cancer of any type or end-stage liver disease); and pregnancy. 2.2 Definition of contrast-induced nephropathy (CIN) CIN was defined according to criteria by the Acute Kidney Injury Network (AKIN) as an increase in SCr by ≥ 0.3 mg/dl (≥26.4 μmol/L) or ≥1.5 times baseline creatinine level within 48 hours of the procedure [33]. Urine volume criteria for AKI were not applied in this study because of potential changes in urinary volume induced by diuretics in the ICU. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease-4 (MDRD) formula [34]. 2.3 Enrollment and Follow-Up After screening all patients for eligibility at the time of ICU admission, patients with high risk for CIN were treated prophylactically according to the institutional protocol for renal protection: normal saline at a rate of 1 mL/Kg/h IV; N-acetylcysteine 1,200 mg IV BID on the day before and 12 hours after the procedure, and sodium bicarbonate started at least 1 hour before the procedure and up to 6 hours after administration of contrast. All patients were followed daily until hospital discharge, and data were gathered daily using an electronic case report form for each patient. 2.4 Clinical Outcomes Our primary aim was to determine the association of serum NGAL levels 6 hours after contrast media exposure and the need for hemodialysis after PCI in patients with ACS. Our secondary outcome was to determine the association of serum NGAL levels and hospital length of stay (LOS) or hospital mortality. 2.5 Biomarker assay Venous blood samples measured serum creatinine (SCr) and blood urea nitrogen (BUN) every 24 hours after ICU admission. Blood was drawn prior to PCI and 6, 24, and 48 hours after the procedure to determine levels of SCr, BUN, and NGAL. Serum NGAL was measured using a commercially available kit (Alere™ Triage® NGAL immunoassay), immediately after blood sample collection according to the manufacturer’s instructions. 2.6 Statistical Analysis We used Fisher’s exact test to compare categorical variables and the non-parametric test (Man-Whitney U Test) to evaluate continuous variables. Values are expressed as medians (IQR). Statistical significance was defined as a p-value < 0.05. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL levels to -index to identify the best cut-off at 6 hours post PCI of NGAL. All statistical analyses were performed with IBM SPSS, Statistics for Mac, version 22.0. Armonk, NY: IBM Corp. 3. Results A total of 2,875 PCIs were performed during the study period. We identified 617 patients as potential study subjects; however, only 45 patients met the inclusion/exclusion criteria and were enrolled as study subjects ( Figure 1 ). A majority of the subjects were men (60%) and older than 70 years old. During the median 12.2 days of follow-up of all study subjects, 8 patients required hemodialysis therapy, and 3 patients died. None of the patients develop cardiogenic shock nor required cardiac surgery. The baseline characteristics of study subjects are presented in Table 2, and the serial measurements of NGAL, creatinine, and BUN at baseline, 6, 24, and 48 hours are shown in Figure 2 . Among the patients that required versus did not require hemodialysis, there were no differences in hemoglobin levels or platelets counts. However, subjects in the hemodialysis group had higher albumin levels, lower glomerular filtration rates at admission determined per MDRD-4 formula, and lower left ventricular ejection fraction. These subjects also had a longer hospital LOS, and one subject continued to requiring hemodialysis at hospital discharge. Finally, among subjects that required hemodialysis, 3 died. Serum concentrations of NGAL at 6 hours were higher in patients whom died during hospital admission (341.0 mg/mL [311-350] vs. 171.5 mg/mL [100-230], p= 0.007). However, serum concentrations of NGAL were not different in patients with CIN who died (340.0 mg/ml [220-392] vs. 341.0 mg/mL [311-341], p= 0.1). As expected, patients that required hemodialysis had a longer hospital LOS (17 days [+/-5] vs. 10 days [+/-7], p= 0.008). Regarding serum biomarker levels at 6 hours, the median (IQR) for serum concentration of NGAL was significantly higher in subjects that required hemodialysis versus those that did not require hemodialysis (340.5 mg/mL [235-384] vs. 169 mg/mL [100-210], p= 0.001) ( Figure 3 ). BUN was also higher in the hemodialysis group versus those subjects not requiring hemodialysis, but the difference was not statistically significant. The median serum concentration of creatinine at 6 hours was similar between subjects that required hemodialysis versus those that did not require hemodialysis (1.55 [1.22-2.07] vs. 1.40 [1.20-1.70], p =0.37). These data demonstrated that elevated serum levels of NGAL at 6 hours predicted the need for hemodialysis with an area under the curve (AUC) of 0.858. Using the Youden index, we identified that the best cut-off at 6 hours post PCI of NGAL is 281mg/dL. With this cut-off, the sensitivity and specificity were 0.75 and 0.95, respectively, to predict the requirement for hemodialysis. 4. Discussion To the best of our knowledge, this is the first study available in medical literature to assess the role of serum NGAL as an early biomarker of CIN after PCI in high-risk patients. The main finding of our study is that serum levels of creatinine and BUN, traditional biomarkers of renal injury, could not detect early development of CIN. In contrast, serum concentrations of NGAL at 6 hours post-PCI could detect patients that are at high risk of developing CIN requiring hemodialysis during hospitalization. Moreover, we also found that NGAL levels were higher in patients who developed CIN and died during hospital admission. This finding is clinically relevant because using serum NGAL concentration, physicians could identify patients at risk of developing CIN that will require hemodialysis early and may benefit from prompt renal specialist consultation and medical interventions, such as optimization of intravascular volume status and avoidance of nephrotoxic medications. Although our study is the first to use serum NGAL for early detection of CIN in high-risk patients with ACS undergoing PCI; our findings build on prior knowledge that has shown that NGAL is superior to serum creatinine or BUN for early diagnosis of acute kidney injury and CIN. A recent meta-analysis showed that NGAL had an excellent predictive utility for CIN with AUCs of 0.91 for serum NGAL and 0.94 for urinary NGAL [35]. However, in this meta-analysis, authors only included 4 studies that used serum NGAL in adults, and all 4 studies had small sample sizes [35]. Additionally, these studies were in patients who underwent elective PCI, and only one study used the same definition of CIN as our study. Besides this, regarding renal protection protocols, in two of them, patients received normal intravenous saline at a rate of 1 mL/kg per hour previous to the procedure and in only one study patients also received oral N-acetylcysteine (NAC) 600 mg twice daily for 3 days [28, 30, 36]. A more recent study by Nguyen et al. with unselected patients with ST-elevation myocardial infarction treated by PCI and were all patient receive only 1000 mL of physiological saline given at a rate of 0.6 mL/kg per hour for 24 hours except in those patients in Killip class III or IV; plasmatic NGAL did not provide additional value regarding CIN prediction compared with other risk [37]. In contrast, all of our study subjects received per-protocol treatment for renal protection to prevent CIN that included normal saline at a rate of 1 ml/Kg/h IV; N-acetylcysteine 1,200 mg IV BID 24 hours before and 12 hours after the procedure, and sodium bicarbonate started at least 1-hour pre-procedure and continued up to 6 hours post-procedure. Moreover, our study included only high-risk patients identified by Mehran score >11 points, whereas other studies included lower-risk patients, which constitutes the strength and novelty of our results. The importance of early detection of CIN is that several observational studies have demonstrated that in-hospital mortality is five times higher in patients with CIN that patients who do not have CIN. Added to the above, observational studies have shown that as many as 20% of patients who develop CIN suffer a persistent worsening of renal function [5, 38, 39]. Therefore, early detection of CIN could mean an early consultation to a renal specialist because it has been demonstrated that a delay in nephrology consultation contributes to higher mortality in acute kidney injury [40]. Several urinary and serum biomarkers have been proposed to identify patients at risk of dying due to CIN. However, the results are controversial and not conclusive. In our study, we found that patients with higher concentrations of serum NGAL had higher mortality. Even though this is an exciting finding, our study was not powered nor designed to predict mortality; thus, this finding should be interpreted with caution. However, this might open the possibility to design more prominent, multicentric, prospective studies to evaluate whether NGAL may be used as a prognosis biomarker in patients with CIN and, more specifically, in patients with AKI due to CIN. Our study has important strengths and limitations that need to be recognized. One of the strengths of our study is that the setting was a highly specialized cardiovascular hospital with established protocols to identify and intervene on patients at risk of CIN. Another strength of our study is the inclusion of only high-risk patients, an important group of patients frequently excluded from other studies. However, it is essential to recognize that the small sample size limits our study due to the recruitment of a specific high-risk patient population. This also limits our ability to the performance of all statistical tests to assess the performance of NGAL as a diagnostic marker in the early detection of patients with CIN requiring hemodialysis. Moreover, only three patients died in our study; thus, we cannot conclude, nor hypothesize the role of NGAL in this regard. It is important to mention that NGAL has been recently associated with heart failure and coronary artery disease possible as a manifestation of inflammation [41]; and essential aspect that needs to be kept in mind because this condition could develop a false positive scenario. Besides this, some patients that required hemodialysis had higher baseline sCr, which could imply some undiagnosed cases of the chronic kidney, which could have an impact on the initial value of NGAL. Nevertheless, the discriminatory power of NGAL at 6 hours superior to creatinine levels at 6 hours to predict the need for hemodialysis. Acute kidney injury is a widely used and accepted definition. However, there are several definitions, and there is controversy about which is the most representative classification. Thus, we did not asses AKI in patients that did not require hemodialysis. Readers should be aware that the data presented in this study only represent patients with severe CIN requiring hemodialysis, and these data should not be extrapolated to other patients. Finally, not all hospitals can ensure nephroprotection in high-risk patients within the first 6 hours of hospital admission. Therefore, the results presented in this study might not be generalizable for all hospitals . 5. Conclusion In summary, our study has demonstrated that in patients with ACS undergoing PCI that are at high risk of developing CIN, an elevated serum level of NGAL 6 hours after contrast exposure predicts the development of acute renal failure requiring hemodialysis. Early detection of acute kidney injury may prompt clinicians to seek early renal consultation and initiate aggressive therapies to reduce the risk of progression of renal failure. Additional studies are needed to confirm our findings and identify potential therapeutic interventions that may delay the progression of CIN in high-risk patients. Abbreviations Intensive care unit (ICU) Neutrophil Gelatinase Associated Lipocalin (NGAL) Contrast-induced nephropathy (CIN) Acute coronary syndrome (ACS) Percutaneous coronary intervention (PCI) Kidney disease (CKD) Diabetes mellitus (DM) Congestive heart failure (CHF) Serum creatinine (SCr) Hemodialysis (HD) Continuous ambulatory peritoneal dialysis (CAPD) Estimated glomerular filtration rate (eGFR) Modification of Diet in Renal Disease-4 (MDRD) Length of stay (LOS) Declarations Conflict of interest: All authors have no conflict of interest Ethics approval and consent to participate: This study was approved by the Committee of the Research Ethics of the Fundacion Clinica Shaio and Universidad de La Sabana. The purpose of the study was explained and written informed consent was obtained from each study participant or his or her caregivers. The patient’s privacy and the availability of services were guaranteed by the investigator team even if the patients decided to leave the study. This study did not involve any potentially harmful intervention for the patient. The confidentiality of the data was preserved until the writing of the manuscript for publication. Consent for publication: Not applicable. Competing interests : The authors declare that they have no competing interests. Availability of data and materials: Not applicable Funding: Not applicable Author contribution : LFR, DFSB, CAB, SM, NJS, MP, EG, RB and AR contributed to the planning, writing and, correction of each section of the manuscript. All authors have read and approved the manuscript. Acknowledgements : Special thanks to all patients who agreed to participate in the study References Rihal CS, Textor SC, Grill DE et al . 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The Mehran risk score for the prediction of CIN Mehran score periprocedural CIN risk factor Score Hypotension (SBP < 80 mmHg or <1 hour of inotropic support) 5 Intra-arterial balloon pump therapy 5 Chronic heart failure (NYHA III/IV or recent pulmonary edema 5 Age < 75 years 4 diabetes mellitus 3 Anemia (male: HCT < 0.39, female: HCT 1.5 mg/dL 4 OR Estimated glomerular filtration rate < 20 mL/min 6 Estimated glomerular filtration rate 20-40 mL/min 4 Estimated glomerular filtration rate 40-60 mL/min 2 Contrast media volume (cc) 1 point for each 100 CIN, contrast induce nephropathy; SBP, systolic blood pressure; NYHA, New York heart association functional classification; HCT, hematocrit. *Only patients with a score > 11 were included in the study Table 2. Baseline characteristics of patients with acute coronary syndrome (ACS) stratified according to the requirement of hemodialysis during hospital admission Characteristic No Hemodialysis (n=37) Hemodialysis (n=8) p Value Demographic Male 19 (51) 8 (100) 0.01 Age, median (IQR) 76 (69, 80) 71 (63, 79) 0.41 Comorbid conditions , n (%) Obesity 7 (19) 1 (12) 0.66 Hypertension 30 (81) 7 (87) 0.66 Active cancer 2 (5) 0 (0) 0.31 Atrial fibrillation 4 (10) 2 (22) 0.28 Chronic heart failure 15 (40) 6 (75) 0.07 COPD 4 (10) 0 (0) 0.37 Chronic kidney disease 3 (8) 1 (12) 0.30 Diabetes mellitus 16 (43) 5 (62) 0.32 Hyperlipidemia 27 (73) 6 (75) 0.90 Hypothyroidism 10 (27) 3 (37) 0.55 Tobacco use 12 (32) 4 (50) 0.34 At admission , median (IQR*) Left ventricular ejection fraction 45 (21, 55) 32 (30, 53) 0.89 MDRD4 46 (40, 47) 36 (31, 46) 0.14 Creatinine 1.15 (1.2, 1.6) 1.75 (1.2, 2.1) 0.27 BUN 21 (15, 35) 37 (19, 57) 0.09 Hemoglobin 14.10 (12.6, 15.9) 12.55 (11.5, 14.1) 0.09 Platelets 219 (193, 282) 261 (200, 281) 0.63 Admission diagnosis, n (%) NSTEMI 24 (65) 7 (87) 0.21 STEMI 3 (8) 1 (12) 0.69 Unstable angina 10 (27) 0 (0) 0.95 Clinical outcomes, n (%) Discharge hemodialysis 0 (0) 1 (12) 0.03 In-hospital mortality 0 (0) 3 (37) <0.01 NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction IQR, Interquartile ratio; COPD chronic obstructive lung disease; BUN, Blood urea nitrogen; MDRD4, 4-variable Modification of Diet in Renal Disease Study Group formula Cite Share Download PDF Status: Published Journal Publication published 22 Apr, 2020 Read the published version in BMC Nephrology → Version 3 posted Editorial decision: Accept 07 Apr, 2020 Review # 1 received at journal 02 Apr, 2020 Editor assigned by journal 23 Mar, 2020 Reviewers invited by journal 23 Mar, 2020 Reviewer # 1 agreed at journal 23 Mar, 2020 Submission checks completed at journal 22 Mar, 2020 Editor invited by journal 22 Mar, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8505","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":438353,"identity":"77caa9aa-5b81-426b-966b-de53350d7a16","order_by":1,"name":"Luis Felipe Reyes","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-1172-6539","institution":"Universidad de La Sabana","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Felipe","lastName":"Reyes","suffix":""},{"id":438354,"identity":"05ea1abd-2840-4c11-9d1d-1c67edd7c538","order_by":2,"name":"Diego Fernando Severiche-Bueno","email":"","orcid":"","institution":"Universidad de La Sabana","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Diego","middleName":"Fernando","lastName":"Severiche-Bueno","suffix":""},{"id":438355,"identity":"0546db8d-e0c7-4b65-8e6f-c59265969dfb","order_by":3,"name":"Carlos A. Bustamante","email":"","orcid":"","institution":"Universidad de La Sabana","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"A.","lastName":"Bustamante","suffix":""},{"id":438356,"identity":"89d69165-5654-47c0-8cea-b0cab1562bbf","order_by":4,"name":"Sixta Murillo","email":"","orcid":"","institution":"Universidad de La Sabana","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sixta","middleName":"","lastName":"Murillo","suffix":""},{"id":438357,"identity":"efd70fe0-cd8d-4644-96f7-c5eb96b87e59","order_by":5,"name":"Nilam J. Soni","email":"","orcid":"","institution":"University of Texas Health Science Center at San Antonio","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nilam","middleName":"J.","lastName":"Soni","suffix":""},{"id":438358,"identity":"11fae44d-5a45-4226-9d2f-4576449b7ee4","order_by":6,"name":"Marcela Poveda","email":"","orcid":"","institution":"Fundacion Clinica Abood Shaio","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marcela","middleName":"","lastName":"Poveda","suffix":""},{"id":438359,"identity":"33a51008-399c-4544-864b-0b40a0cec653","order_by":7,"name":"Efrain Gomez","email":"","orcid":"","institution":"Universidad de La Sabana","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Efrain","middleName":"","lastName":"Gomez","suffix":""},{"id":438360,"identity":"2455d376-7d04-4039-ae03-cce81660e262","order_by":8,"name":"Ricardo Buitrago","email":"","orcid":"","institution":"Universidad de La Sabana","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ricardo","middleName":"","lastName":"Buitrago","suffix":""},{"id":438361,"identity":"963764f0-079b-4877-b30e-ab4235e657a5","order_by":9,"name":"Alejandro Rodriguez","email":"","orcid":"","institution":"Hospital Universitari de Tarragona Joan XXIII","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alejandro","middleName":"","lastName":"Rodriguez","suffix":""}],"badges":[],"createdAt":"2019-11-25 13:32:46","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.2.17874/v3","doiUrl":"https://doi.org/10.21203/rs.2.17874/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-020-01799-5","type":"published","date":"2020-04-22T21:06:39+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":722125,"identity":"38ed6c9a-0078-4270-8dbe-a650dcf521ce","added_by":"auto","created_at":"2020-03-27 13:52:12","extension":"tiff","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72269,"visible":true,"origin":"","legend":"Study flow chart. Flow diagram of the patients with the acute coronary syndrome (ACS) that underwent PCI that entered the study.","description":"","filename":"Figure1.tiff","url":"https://assets-eu.researchsquare.com/files/rs-8505/v3/Figure 1.tiff"},{"id":722126,"identity":"5e3670e2-fee1-4e04-8d6d-db1e141ed960","added_by":"auto","created_at":"2020-03-27 13:52:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":714876,"visible":true,"origin":"","legend":"Serial measurements of NGAL, creatinine, and BUN at baseline, 6, 24, and 48 hours. Box plots of serum NGAL, creatinine, and BUN at baseline, 6 hours, 24 hours and 48 hours. A. NGAL levels started to rise at 6 hours and then decreased at 24 and 48 hours. B. Creatinine values did not rise at any interval. C. BUN levels also did not rise at any time interval. NS: Not significant; P: \u003c0.05.","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8505/v3/Figure 2.png"},{"id":722127,"identity":"21a2c719-dc75-4c15-9a86-724b7a3e0aa6","added_by":"auto","created_at":"2020-03-27 13:52:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":302762,"visible":true,"origin":"","legend":"Serial measurements of NGAL, creatinine, and BUN at baseline, 6, 24, and 48 hours in hemodialysis patients versus those who did not require hemodialysis. Box plots of serum NGAL, creatinine and BUN at baseline, 6 hours, 24 hours, and 48 hours in the patients who required hemodialysis and those who did not. A. NGAL levels started to rise at 6 hours with higher values in those patients who require hemodialysis. B. Creatinine values only started to rise at 48 hours in those patients who require hemodialysis. C. BUN levels did not show a rising pattern in either group. NS: Not significant; p: \u003c0.05.","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8505/v3/Figure 3.png"},{"id":13495828,"identity":"7b223c75-f564-4892-8f0e-0e08ef3e44ec","added_by":"auto","created_at":"2021-09-16 22:46:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":686501,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8505/v3/f4fc6926-1f81-4504-a943-50f29edbf9df.pdf"}],"financialInterests":"","formattedTitle":"Serum Levels of Neutrophil Gelatinase Associated Lipocalin (NGAL) Predicts Hemodialysis After Coronary Angiography in High Risk Patients with Acute Coronary Syndrome.","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe incidence of contrast-induced nephropathy (CIN) is low in patients without risk factors (\u0026lt; 5%) [1], but increases among patients with chronic kidney disease (CKD) [2], particularly in patients with diabetes mellitus (DM), congestive heart failure (CHF), and advanced age [3]. Additionally, the risk of developing CIN is even higher among patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI) [4]. Incidence of CIN after a PCI is \u0026lt; 3% in patients without renal dysfunction but can rise to 40% in patients with chronic kidney disease besides being associated with higher in-hospital mortality [5, 6].\u003c/p\u003e\n\u003cp\u003eCIN is defined as an acute decrease in renal function after the administration of intravenous contrast without an alternative cause [7]. The most frequently used definition of CIN is based on the elevation of serum creatinine (SCr) [8]. It is important to note that SCr does not begin to rise until 50% or more of the kidney glomeruli have been affected [9]. Serum creatinine is neither sensitive nor specific because several conditions can alter its serum concentration [10, 11].\u003c/p\u003e\n\u003cp\u003eSeveral scoring systems have been devised to identify patients at high risk of developing CIN after a cardiac intervention [12-16]. Mehran \u003cem\u003eet al\u003c/em\u003e created a scoring system that incorporates 8 clinical and procedural variables (hypotension, congestive heart failure, serum creatinine, DM, age \u0026gt;75 years, anemia, the volume of contrast, and use of an intra-aortic balloon pump) that have been widely used and validated in different cohorts [17-20].\u003c/p\u003e\n\u003cp\u003eGiven the limitations of SCr to detect patients with subclinical CIN, isolation of a biomarker for acute kidney injury after a PCI would be clinically useful. Neutrophil gelatinase associated-lipocalin (NGAL), also known as lipocalin-2 (LCN2), is a small (25-kDa) glycoprotein covalently stored in granules of mature neutrophils [21]. It is normally expressed at very low levels in a variety of human tissues, including bone marrow, uterus, prostate, salivary gland, stomach, colon, trachea, lung, liver, and kidney [22, 23]. It is rapidly released in distal tubular cells in response to inflammation or injury of nephrons [24]. It can be easily detected in the blood and urine soon after acute kidney injury [25, 26]. NGAL is emerging as a promising renal biomarker to detect patients with acute kidney injury [27]. Recent studies have shown that NGAL can be used as a diagnostic tool to detect CIN in patients that undergo an elective PCI with similar performance between urinary and serum NGAL. However, most of the studies in this group of patients used serum NGAL[25, 28-30].\u003c/p\u003e\n\u003cp\u003eHowever, limited data are available on the utility of NGAL to predict CIN and the need for hemodialysis in high-risk patients with ACS and this study will attempt to solve this gap in the literature. Therefore, we hypothesized that serum levels of NGAL could predict the development of CIN requiring hemodialysis after PCI in patients with ACS and high risk of developing CIN. The objective of this study is to determine whether NGAL measured 6 hours post PCI can identify patients that will develop CIN and require hemodialysis.\u0026nbsp; Moreover, we will assess whether NGAL levels are associated with a longer length of hospital stay and hospital mortality.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eA prospective observational study of consecutively admitted patients with ACS that underwent PCI was performed during two consecutive years at Shaio Clinic, a high-volume cardiovascular referral center in Bogota, Colombia. The local institutional ethics committee approved the study. Informed consent was obtained from all study subjects prior to enrollment. Not study procedures were performed before patient enrollment, and official inform consent was obtained.\u003c/p\u003e\n\u003cp\u003ePCI was performed using a standard protocol via either the radial or femoral artery approach by an attending interventional cardiologist. All procedures were performed using a standard dose (3\u0026ndash;5 ml/kg) of non-ionic, low-osmolality contrast media in doses adjusted for body weight and type of cardiovascular angiogram. Patients\u0026rsquo; interventions were performed according to local and international guidelines, not per protocol. It is essential to highlight that all patients were monitored during PCI by a certified anesthesiologist to prevent cardiovascular complications; none of the subjects included in the study developed hypotension nor cardiovascular instability during the procedure. The decision to begin hemodialysis therapy was determined by the nephrology team taking into account the following life-threatening indications for renal replacement therapy: acidosis unresponsive to medical treatment, acute severe refractory hyperkalemia, pulmonary edema and uremic complications (e.g., encephalopathy and uremic pericarditis) [31]. The nephrology team did not have access to the NGAL values during the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1 Subjects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study \u003cem\u003einclusion criteria\u003c/em\u003e were age \u0026gt;18 years, ACS per standard definition [32], and high risk for CIN determined by a Mehran score \u0026gt;11 points (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExclusion criteria\u003c/em\u003e were end-stage renal disease requiring chronic hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD); suspected infection, sepsis or septic shock; exposure to nephrotoxic drugs or intravenous contrast medium 48 hours prior to the study period; terminal disease (malignant cancer of any type or end-stage liver disease); and pregnancy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.2 Definition of contrast-induced nephropathy (CIN)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCIN was defined according to criteria by the Acute Kidney Injury Network (AKIN) as an increase in SCr by \u0026ge; 0.3 mg/dl (\u0026ge;26.4 \u0026mu;mol/L) or \u0026ge;1.5 times baseline creatinine level within 48 hours of the procedure [33]. Urine volume criteria for AKI were not applied in this study because of potential changes in urinary volume induced by diuretics in the ICU. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease-4 (MDRD) formula [34].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3 Enrollment and Follow-Up\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter screening all patients for eligibility at the time of ICU admission, patients with high risk for CIN were treated prophylactically according to the institutional protocol for renal protection: normal saline at a rate of 1 mL/Kg/h IV; N-acetylcysteine 1,200 mg IV BID on the day before and 12 hours after the procedure, and sodium bicarbonate started at least 1 hour before the procedure and up to 6 hours after administration of contrast. All patients were followed daily until hospital discharge, and data were gathered daily using an electronic case report form for each patient.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4\u0026nbsp;Clinical Outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOur primary aim was to determine the association of serum NGAL levels 6 hours after contrast media exposure and the need for hemodialysis after PCI in patients with ACS. Our secondary outcome was to determine the association of serum NGAL levels and hospital length of stay (LOS) or hospital mortality.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5\u0026nbsp;\u003c/em\u003e\u003cem\u003eBiomarker assay\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVenous blood samples measured serum creatinine (SCr) and blood urea nitrogen (BUN) every 24 hours after ICU admission. Blood was drawn prior to PCI and 6, 24, and 48 hours after the procedure to determine levels of SCr, BUN, and NGAL. Serum NGAL was measured using a commercially available kit (Alere\u0026trade; Triage\u0026reg; NGAL immunoassay), immediately after blood sample collection according to the manufacturer\u0026rsquo;s instructions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.6\u0026nbsp;\u003c/em\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe used Fisher\u0026rsquo;s exact test to compare categorical variables and the non-parametric test (Man-Whitney U Test) to evaluate continuous variables. Values are expressed as medians (IQR). Statistical significance was defined as a p-value \u003cu\u003e\u0026lt;\u003c/u\u003e0.05. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL levels to -index to identify the best cut-off at 6 hours post PCI of NGAL. All statistical analyses were performed with IBM SPSS, Statistics for Mac, version 22.0. Armonk, NY: IBM Corp.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 2,875 PCIs were performed during the study period. We identified 617 patients as potential study subjects; however, only 45 patients met the inclusion/exclusion criteria and were enrolled as study subjects (\u003cstrong\u003eFigure 1\u003c/strong\u003e). A majority of the subjects were men (60%) and older than 70 years old. During the median 12.2 days of follow-up of all study subjects, 8 patients required hemodialysis therapy, and 3 patients died. None of the patients develop cardiogenic shock nor required cardiac surgery. The baseline characteristics of study subjects are presented in \u003cstrong\u003eTable 2, \u003c/strong\u003eand the serial measurements of NGAL, creatinine, and BUN at baseline, 6, 24, and 48 hours are shown in\u003cstrong\u003e Figure 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eAmong the patients that required versus did not require hemodialysis, there were no differences in hemoglobin levels or platelets counts. However, subjects in the hemodialysis group had higher albumin levels, lower glomerular filtration rates at admission determined per MDRD-4 formula, and lower left ventricular ejection fraction. These subjects also had a longer hospital LOS, and one subject continued to requiring hemodialysis at hospital discharge. Finally, among subjects that required hemodialysis, 3 died. Serum concentrations of NGAL at 6 hours were higher in patients whom died during hospital admission (341.0 mg/mL [311-350] vs. 171.5 mg/mL [100-230], \u003cem\u003ep=\u003c/em\u003e0.007). However, serum concentrations of NGAL were not different in patients with CIN who died (340.0 mg/ml [220-392] vs. 341.0 mg/mL [311-341], \u003cem\u003ep=\u003c/em\u003e0.1). As expected, patients that required hemodialysis had a longer hospital LOS (17 days [+/-5] vs. 10 days [+/-7], \u003cem\u003ep=\u003c/em\u003e0.008).\u003c/p\u003e\n\u003cp\u003eRegarding serum biomarker levels at 6 hours, the median (IQR) for serum concentration of NGAL was significantly higher in subjects that required hemodialysis versus those that did not require hemodialysis (340.5 mg/mL [235-384] vs. 169 mg/mL [100-210], \u003cem\u003ep=\u003c/em\u003e0.001) (\u003cstrong\u003eFigure 3\u003c/strong\u003e). BUN was also higher in the hemodialysis group versus those subjects not requiring hemodialysis, but the difference was not statistically significant. The median serum concentration of creatinine at 6 hours was similar between subjects that required hemodialysis versus those that did not require hemodialysis (1.55 [1.22-2.07] vs. 1.40 [1.20-1.70], \u003cem\u003ep\u003c/em\u003e=0.37). These data demonstrated that elevated serum levels of NGAL at 6 hours predicted the need for hemodialysis with an area under the curve (AUC) of 0.858. Using the Youden index, we identified that the best cut-off at 6 hours post PCI of NGAL is 281mg/dL. With this cut-off, the sensitivity and specificity were 0.75 and 0.95, respectively, to predict the requirement for hemodialysis.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study available in medical literature to assess the role of serum NGAL as an early biomarker of CIN after PCI in high-risk patients. The main finding of our study is that serum levels of creatinine and BUN, traditional biomarkers of renal injury, could not detect early development of CIN. In contrast, serum concentrations of NGAL at 6 hours post-PCI could detect patients that are at high risk of developing CIN requiring hemodialysis during hospitalization. Moreover, we also found that NGAL levels were higher in patients who developed CIN and died during hospital admission. This finding is clinically relevant because using serum NGAL concentration, physicians could identify patients at risk of developing CIN that will require hemodialysis early and may benefit from prompt renal specialist consultation and medical interventions, such as optimization of intravascular volume status and avoidance of nephrotoxic medications.\u003c/p\u003e\n\u003cp\u003eAlthough our study is the first to use serum NGAL for early detection of CIN in high-risk patients with ACS undergoing PCI; our findings build on prior knowledge that has shown that NGAL is superior to serum creatinine or BUN for early diagnosis of acute kidney injury and CIN. A recent meta-analysis showed that NGAL had an excellent predictive utility for CIN with AUCs of 0.91 for serum NGAL and 0.94 for urinary NGAL [35]. However, in this meta-analysis, authors only included 4 studies that used serum NGAL in adults, and all 4 studies had small sample sizes [35]. Additionally, these studies were in patients who underwent elective PCI, and only one study used the same definition of CIN as our study. Besides this, regarding renal protection protocols, in two of them, patients received normal intravenous saline at a rate of 1 mL/kg per hour previous to the procedure and in only one study patients also received oral N-acetylcysteine (NAC) 600 mg twice daily for 3 days [28, 30, 36]. A more recent study by Nguyen et al. with unselected patients with ST-elevation myocardial infarction treated by PCI and were all patient receive only 1000 mL of physiological saline given at a rate of 0.6 mL/kg per hour for 24 hours except in those patients in Killip class III or IV; plasmatic NGAL did not provide additional value regarding CIN prediction compared with other risk [37].\u003c/p\u003e\n\u003cp\u003eIn contrast, all of our study subjects received per-protocol treatment for renal protection to prevent CIN that included normal saline at a rate of 1 ml/Kg/h IV; N-acetylcysteine 1,200 mg IV BID 24 hours before and 12 hours after the procedure, and sodium bicarbonate started at least 1-hour pre-procedure and continued up to 6 hours post-procedure. Moreover, our study included only high-risk patients identified by Mehran score \u0026gt;11 points, whereas other studies included lower-risk patients, which constitutes the strength and novelty of our results.\u003c/p\u003e\n\u003cp\u003eThe importance of early detection of CIN is that several observational studies have demonstrated that in-hospital mortality is five times higher in patients with CIN that patients who do not have CIN. Added to the above, observational studies have shown that as many as 20% of patients who develop CIN suffer a persistent worsening of renal function [5, 38, 39]. Therefore, early detection of CIN could mean an early consultation to a renal specialist because it has been demonstrated that a delay in nephrology consultation\u0026nbsp; contributes to higher mortality in acute kidney injury [40].\u003c/p\u003e\n\u003cp\u003eSeveral urinary and serum biomarkers have been proposed to identify patients at risk of dying due to CIN. However, the results are controversial and not conclusive. In our study, we found that patients with higher concentrations of serum NGAL had higher mortality. Even though this is an exciting finding, our study was not powered nor designed to predict mortality; thus, this finding should be interpreted with caution. However, this might open the possibility to design more prominent, multicentric, prospective studies to evaluate whether NGAL may be used as a prognosis biomarker in patients with CIN and, more specifically, in patients with AKI due to CIN.\u003c/p\u003e\n\u003cp\u003eOur study has important strengths and limitations that need to be recognized. One of the strengths of our study is that the setting was a highly specialized cardiovascular hospital with established protocols to identify and intervene on patients at risk of CIN. Another strength of our study is the inclusion of only high-risk patients, an important group of patients frequently excluded from other studies. However, it is essential to recognize that the small sample size limits our study due to the recruitment of a specific high-risk patient population. This also limits our ability to the performance of all statistical tests to assess the performance of NGAL as a diagnostic marker in the early detection of patients with CIN requiring hemodialysis. Moreover, only three patients died in our study; thus, we cannot conclude, nor hypothesize the role of NGAL in this regard. It is important to mention that NGAL has been recently associated with heart failure and coronary artery disease possible as a manifestation of inflammation [41]; and essential aspect that needs to be kept in mind because this condition could develop a false positive scenario. Besides this, some patients that required hemodialysis had higher baseline sCr, which could imply some undiagnosed cases of the chronic kidney, which could have an impact on the initial value of NGAL. Nevertheless, the discriminatory power of NGAL at 6 hours superior to creatinine levels at 6 hours to predict the need for hemodialysis. \u003cem\u003eAcute kidney injury is a widely used and accepted definition. However, there are several definitions, and there is controversy about which is the most representative classification. Thus, we did not asses AKI in patients that did not require hemodialysis. Readers should be aware that the data presented in this study only represent patients with severe CIN requiring hemodialysis, and these data should not be extrapolated to other patients. \u003c/em\u003eFinally, \u003cem\u003enot all hospitals can ensure nephroprotection in high-risk patients within the first 6 hours of hospital admission. Therefore, the results presented in this study might not be generalizable for all hospitals\u003c/em\u003e.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn summary, our study has demonstrated that in patients with ACS undergoing PCI that are at high risk of developing CIN, an elevated serum level of NGAL 6 hours after contrast exposure predicts the development of acute renal failure requiring hemodialysis. Early detection of acute kidney injury may prompt clinicians to seek early renal consultation and initiate aggressive therapies to reduce the risk of progression of renal failure. Additional studies are needed to confirm our findings and identify potential therapeutic interventions that may delay the progression of CIN in high-risk patients.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIntensive care unit (ICU)\u003c/p\u003e\n\u003cp\u003eNeutrophil Gelatinase Associated\u0026nbsp;Lipocalin (NGAL)\u003c/p\u003e\n\u003cp\u003eContrast-induced nephropathy (CIN)\u003c/p\u003e\n\u003cp\u003eAcute coronary syndrome (ACS)\u003c/p\u003e\n\u003cp\u003ePercutaneous coronary intervention (PCI)\u003c/p\u003e\n\u003cp\u003eKidney disease (CKD)\u003c/p\u003e\n\u003cp\u003eDiabetes mellitus (DM)\u003c/p\u003e\n\u003cp\u003eCongestive heart failure (CHF)\u003c/p\u003e\n\u003cp\u003eSerum creatinine (SCr)\u003c/p\u003e\n\u003cp\u003eHemodialysis (HD)\u003c/p\u003e\n\u003cp\u003eContinuous ambulatory peritoneal dialysis (CAPD)\u003c/p\u003e\n\u003cp\u003eEstimated glomerular filtration rate (eGFR)\u003c/p\u003e\n\u003cp\u003eModification of Diet in Renal Disease-4 (MDRD)\u003c/p\u003e\n\u003cp\u003eLength of stay (LOS)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest: \u003c/strong\u003eAll authors have no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study was approved by the Committee of the Research Ethics of the Fundacion Clinica Shaio and Universidad de La Sabana. The purpose of the study was explained and written informed consent was obtained from each study participant or his or her caregivers. The patient\u0026rsquo;s privacy and the availability of services were guaranteed by the investigator team even if the patients decided to leave the study. This study did not involve any potentially harmful intervention for the patient. The confidentiality of the data was preserved until the writing of the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e: LFR, DFSB, CAB, SM, NJS, MP, EG, RB and AR contributed to the planning, writing and, correction of each section of the manuscript. All authors have read and approved the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Special thanks to all patients who agreed to participate in the study\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRihal CS, Textor SC, Grill DE\u003cem\u003e et al\u003c/em\u003e. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention\u003cem\u003e.\u003c/em\u003e \u003cem\u003eCirculation \u003c/em\u003e105(19), 2259-2264 (2002).\u003c/li\u003e\n\u003cli\u003eDangas G, [email protected], Iakovou I\u003cem\u003e et al\u003c/em\u003e. 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Estimating the prevalence of elevated plasma neutrophil gelatinase associated lipocalin level in patients with acute coronary syndromes and its association with outcomes\u003cem\u003e.\u003c/em\u003e \u003cem\u003eIndian Heart J \u003c/em\u003e70(2), 220-224 (2018).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cspan style=\"color: rgb(0, 0, 0); font-size: 12px; font-family: Helvetica;\"\u003eTable 1.\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eThe Mehran risk score for the prediction of CIN\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"width:6.0in;border-collapse:collapse;border:none;\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eMehran score periprocedural CIN risk factor\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid rgb(127, 127, 127);padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eHypotension (SBP \u0026lt; 80 mmHg or \u0026lt;1 hour of inotropic support)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid rgb(127, 127, 127);padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eIntra-arterial balloon pump therapy\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eChronic heart failure (NYHA III/IV or recent pulmonary edema\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAge \u0026lt; 75 years\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;height: 13.25pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003ediabetes mellitus\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;height: 13.25pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAnemia (male: HCT \u0026lt; 0.39, female: HCT \u0026lt; 0.36\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eCreatinin\u003c/strong\u003ee \u003cstrong\u003e\u0026gt; 1.5 mg/dL\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eEstimated glomerular filtration rate \u0026lt; 20 mL/min\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eEstimated glomerular filtration rate 20-40 mL/min\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eEstimated glomerular filtration rate 40-60 mL/min\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"75%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eContrast media volume (cc)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 point for each 100\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 6in;border-top: 1pt solid rgb(127, 127, 127);border-left: none;border-bottom: 1pt solid rgb(127, 127, 127);border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eCIN, contrast induce nephropathy; SBP, systolic blood pressure; NYHA, New York heart association functional classification; HCT, hematocrit.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e*Only patients with a score \u0026gt; 11 were included in the study\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\n \u003cbr\u003e\u0026nbsp;\n \u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eBaseline characteristics of patients with acute coronary syndrome (ACS) stratified according to the requirement of hemodialysis during hospital admission\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\" width=\"570\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 427.5pt;border-top: 2.25pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cdiv style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;border:none;border-top:solid windowtext 1.0pt;padding:1.0pt 0in 0in 0in;\"\u003e\n \u003cp style=\"border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cdiv style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;border:none;border-top:solid windowtext 1.0pt;padding:1.0pt 0in 0in 0in;\"\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cdiv style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;border:none;border-top:solid windowtext 1.0pt;padding:1.0pt 0in 0in 0in;\"\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eNo Hemodialysis\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e(n=37)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cdiv style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;border:none;border-top:solid windowtext 1.0pt;padding:1.0pt 0in 0in 0in;\"\u003e\n \u003cp style=\"margin-left:21.25pt;text-align:center;text-indent:-21.25pt;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-left:21.25pt;text-align:center;text-indent:-21.25pt;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eHemodialysis\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e(n=8)\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cdiv style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;border:none;border-top:solid windowtext 1.0pt;padding:1.0pt 0in 0in 0in;\"\u003e\n \u003cp style=\"border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;border:none;padding:0in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 427.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eDemographic\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:13.5pt;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eMale\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e19 (51)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e8 (100)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:13.5pt;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAge, median (IQR)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e76 (69, 80)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e71 (63, 79)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.41\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 427.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eComorbid conditions\u003cem\u003e,\u0026nbsp;\u003c/em\u003en (%)\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eObesity\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e7 (19)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (12)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.66\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eHypertension\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e30 (81)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e7 (87)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.66\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eActive cancer\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2 (5)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.31\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAtrial fibrillation\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4 (10)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2 (22)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.28\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eChronic heart failure\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e15 (40)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e6 (75)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.07\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eCOPD\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4 (10)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.37\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eChronic kidney disease\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3 (8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (12)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.30\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eDiabetes mellitus\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e16 (43)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5 (62)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.32\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eHyperlipidemia\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e27 (73)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e6 (75)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.90\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eHypothyroidism\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e10 (27)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3 (37)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.55\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eTobacco use\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e12 (32)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4 (50)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.34\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eAt admission\u003cem\u003e, median (IQR*)\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eLeft ventricular ejection fraction \u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e45 (21, 55)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e32 (30, 53)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.89\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eMDRD4\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e46 (40, 47)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e36 (31, 46)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.14\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eCreatinine\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1.15 (1.2, 1.6)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1.75 (1.2, 2.1)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.27\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eBUN\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e21 (15, 35)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e37 (19, 57)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.09\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eHemoglobin \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e14.10 (12.6, 15.9)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e12.55 (11.5, 14.1)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.09\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"text-indent:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003ePlatelets \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e219 (193, 282)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e261 (200, 281)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.63\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eAdmission diagnosis, n (%)\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eNSTEMI\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e24 (65)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e7 (87)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.21\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eSTEMI\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3 (8)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (12)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.69\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eUnstable angina\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e10 (27)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.95\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003eClinical outcomes, n (%)\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eDischarge hemodialysis \u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (12)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border: none;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2.75in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"46.31578947368421%\"\u003e\n \u003cp style=\"margin-left:.25in;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eIn-hospital mortality\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"23.157894736842106%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0 (0)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"20%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3 (37)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;vertical-align: top;\" valign=\"top\" width=\"10.526315789473685%\"\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"text-align:center;\"\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 427.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.75pt;height: 3.5pt;vertical-align: top;\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cspan style=\"font-family: \n Helvetica;\"\u003e\u003cspan style=\"font-size: \n 12px;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eNSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction IQR, Interquartile ratio; COPD chronic obstructive lung disease; BUN, Blood urea nitrogen; MDRD4, 4-variable Modification of Diet in Renal Disease Study Group formula\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0); font-size: 12px; font-family: Helvetica;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Contrast-induced Nephropathy, hemodialysis, biomarkers. ","lastPublishedDoi":"10.21203/rs.2.17874/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.17874/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Contrast-induced nephropathy (CIN) following a percutaneous coronary intervention (PCI) is the third most common cause of acute kidney injury (AKI) worldwide. Patients who require hemodialysis secondary to CIN have an elevated mortality rate as high as 55%. The current definition of CIN is based on an elevation of creatinine and decrease in urinary output. Creatinine typically increases 48 hours after the contrast exposure, which delays the diagnosis and treatment of CIN. The neutrophil gelatinase associated\u0026nbsp;lipocalin (NGAL) has emerged as a sensitive and specific biomarker of renal injury. Limited data exists about the effectiveness of NGAL to predict CIN in high-risk patients with acute coronary syndrome (ACS) that underwent PCI. The primary aim of this study was to determine the association of serum NGAL levels and the need for hemodialysis after PCI. Methods:\u0026nbsp;This is a prospective, observational study. NGAL levels were measured using ELISA. Blood samples were obtained within the first 6 hours of hospital admission, and 12 and 24 hours after contrast exposure from angiography. The primary outcome was the requirement of hemodialysis. The non-parametric Mann-Whitney U test was used to test for differences in median serum levels of NGAL. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL to predict the need for hemodialysis after PCI. Results: A total of 2,875 were screened; however, 45 patients with ACS that underwent PCI were included. All patients were at high risk of developing CIN defined by Mehran score \u0026gt;11 points. The median (IQR) serum concentration of NGAL was significantly higher in patients that required versus did not require hemodialysis (340 [83-384] vs. 169 [100-210],\u0026nbsp;p=0.01).\u0026nbsp;Elevated serum levels of NGAL with a cut-off at 6 hours post PCI of 281 mg/dL predicted the need for hemodialysis with an area under the curve of 0.86 (95% CI: 0.66-1.00). Conclusions:\u0026nbsp;In patients with ACS undergoing PCI; and high risk of developing CIN, an elevated serum level of NGAL 6 hours after contrast exposure predicts the development of acute kidney injury requiring hemodialysis.\u003c/p\u003e","manuscriptTitle":"Serum Levels of Neutrophil Gelatinase Associated Lipocalin (NGAL) Predicts Hemodialysis After Coronary Angiography in High Risk Patients with Acute Coronary Syndrome.","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-03-27 13:52:12","doi":"10.21203/rs.2.17874/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-04-07T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-04-02T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nNo further comments.* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **N/A**\n* Are you able to assess the statistics?: ** I have been able to assess all of the statistics in this manuscript (please refer to checklist above)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Acceptable**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests' below**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorAssigned","content":"","date":"2020-03-23T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-03-23T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-03-23T12:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-03-22T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-03-22T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-02-26 18:52:19","doi":"10.21203/rs.2.17874/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-03-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-03-08T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe paper is highly improved after revisions and is now suitable for publication.\nI have only one comment about point 4. It is true that AKI had several definition but, as author correctly pointed out this is also true for CIN, I think that could be useful to choose a classification for AKI (e.g. AKIN Criteria) to explore predictive role of nGAL even in AKI without dialysis need. Otherwise, authors should specify more clearly why that aspect was not evaluated (e.g. lack of data, paucity of cases or other).\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **N/A**\n* Are you able to assess the statistics?: ** I have been able to assess all of the statistics in this manuscript (please refer to checklist above)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Acceptable**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-03-07T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe revised manuscript is now more clear and the authors has taken the comments into consideration.\n\nI have a few comments\n\nAbstract: The cut -off level after 6 hours should be included\n\nStatistical analysis: Youden index is not mentioned, ought to be\n\nResults: It is described that there was no increase i s-creatinine before 48 hours after contrast infuaion in the hemodialysis group. What was the time-window until the first dialysis? Was it \u003e 48 hours?\n\nTable 1: to help the reader it could be included in the legend that only patient with a score \u003e 11 are inclued in the study\n\nFigure 3: The X-axis legend should include NGAL (A), Creatinin (b) and BUN (C)* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **N/A**\n* Are you able to assess the statistics?: ** I have been able to assess all of the statistics in this manuscript (please refer to checklist above)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Acceptable**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-03-01T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-02-25T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-02-25T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-02-24T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-23T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-23T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-11-27 21:31:51","doi":"10.21203/rs.2.17874/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-01-03T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-02T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **N/A**\n* Are you able to assess the statistics?: ** I have been able to assess all of the statistics in this manuscript (please refer to checklist above)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Needs some language corrections before being published**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nThe topic of the study is really important and interesting; however, the numerosity is lacking mainly due to criteria exclusion.\nMajor comments\n- Even taking into account the importance of population homogeneity, it should be underlined that in real life it is likely not success to perform nephroprotection protocol before PCI due to urgency. Therefore, it should be ascertained if nGAL level at 6 hours is yet able to predict haemodialysis need even in the absence of nephroprotection in a separate analysis.\n- Was nGAL level available for nephrologist team during the study? If yes it could have influenced physician choice to underwent dialysis treatment in patients under study? Please further clarify dialysis initiation criteria in population under study.\n- Other characteristics could influence AKI development and dialysis need such as number of coronaries with pathologic lesion, procedure duration or mean arterial pressure during and after procedure and should be mentioned in table 2.\n- nGAL is also related to development of CIN without dialysis need? A separate analysis on this topic should be provided.\nMinor\n- There was necessity of cardiac surgery after PCI in any of patient under study?\n- In haemodialysis group, sCr mean value at admission was higher so that there could be a number of undiagnosed cases of chronic Kidney disease among them. This data should be at least partially related itself to higher nGAL level in combination with acute damage.\n- Mean time of dialysis initiation after PCI should be mentioned.\n- Graphic quality of figures should be improved.\n- In the introduction should be included a brief discussion on the diagnostic and prognostic similarities/differences between urinary and serum nGAL. As mentioned in discussion there are recent evidences of a similar usefulness of serum and urinary nGAL in CIN context, why authors have chosen to focus on serum levels?\n- There are some spelling mistakes along the text; a careful English language control should be performed.\n"},{"type":"editorInvitedReview","content":"","date":"2019-12-21T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **No**\n* Are you able to assess the statistics?: ** There are statistical tests that I am unable to assess and recommend seeking additional advice (please specify which tests these are in the ‘Comments to Editor’ box)**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Quality of written English: **Not suitable for publication unless extensively edited**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nA biomarker for detection of AKI as early as possible is absolutely wanted. The study design was prospective observational of consecutively admitted patients with acute coronary syndrome who underwent PCI. In this study they looked wether p-NGAL level could predict the need for hemodialysis. Further they looked into need for longer length of hospital stay and hospital mortality. The inclusion criteria are clear and based of that, only few patients are included - n=45.\n\nThe results focus on p-NGAL level. The authors make a ROC analysis and demonstrate that in 86 % p-NGAL was able to predict hemodialysis - an acceptable level. ROC analysis does not tell anything about how to use the analysis in daily clinic. The \"cut-off\" level of p-NGAL to be used for the clinician is not presented. The data are few - but it could be useful to present a 2x2 table for specificty and sensitivity. The curve is very chopped. What will happen if data are correted for eg gender and age? The number of patients are very few to do that\n\nThere are in the literatur several studies who demonstrate that p-NGAL increase in cardiac surgery patients who develop AKI. None of the studies could demonstrate that NGAL was better than other biomarkers - eg p-creatinin - to predict AKI.\nThis is nor demonstrated in the present study. So the clinicians are not better helped after the present study. In this study the group of patients are narrowed to patients who develop need for hemodialysis and not only AKI.\n\nThe value of the present data could be enhanced if a cut-off level for p-NGAL was calculated and the usefullness of NGAL compared to other basic labatory values - cretinin, GFR, albumin.\n\nIn the present form the paper is not suitable for publication in BMJ\n"},{"type":"reviewerAgreed","content":"","date":"2019-12-14T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2019-12-10T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-12-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-11-17T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-11-16T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-11-16T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-11-14T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1f9c6cc8-b43f-4a42-a57e-40594b20b637","owner":[],"postedDate":"March 27th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":62833,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2021-07-27T21:06:39+00:00","versionOfRecord":{"articleIdentity":"rs-8505","link":"https://doi.org/10.1186/s12882-020-01799-5","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2020-04-22 21:06:39","publishedOnDateReadable":"April 22nd, 2020"},"versionCreatedAt":"2020-03-27 13:52:12","video":"","vorDoi":"10.1186/s12882-020-01799-5","vorDoiUrl":"https://doi.org/10.1186/s12882-020-01799-5","workflowStages":[]},"version":"v3","identity":"rs-8505","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-8505","version":["v3"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}