Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 174
  • Home
  • Print this page
  • Email this page
Cover page of the Journal of Health Sciences


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 34-40

Assessment of plasma homocysteine as a marker of acute renal injury in patients undergoing extracorporeal shock wave lithotripsy for renal stone disease - 1-year cross-sectional study


1 Department of General Surgery, Jawaharlal Nehru Medical College, KLE'S Dr. Prabhakar Kore Hospital and MRC, KLE University, Belagavi, Karnataka, India
2 Department of Urology, Jawaharlal Nehru Medical College, KLE'S Dr. Prabhakar Kore Hospital and MRC, KLE University, Belagavi, Karnataka, India

Date of Web Publication18-Jan-2017

Correspondence Address:
Dr. Shruti G Raikar
Department of General Surgery, Jawaharlal Nehru Medical College, KLE'S Dr. Prabhakar Kore Hospital and MRC, KLE University, Belagavi - 590 010, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.198581

Rights and Permissions
  Abstract 

Context: Extracorporeal shock wave lithotripsy (ESWL) commonly used procedure for treating upper urinary tract stones may result in acute kidney injury (AKI) with release of biomarkers. Association of plasma total homocysteine (tHCy), serum high-sensitivity C-reactive protein (hs-CRP), and serum creatinine with renal dysfunction and their role as acute renal injury markers is to be assessed.
Aim: The study aims to assess plasma tHCy as a marker of AKI in patients undergoing ESWL for renal stone disease and compare the same with other markers, i.e., serum creatinine and serum hs-CRP.
Setting and Design: One-year cross-sectional study at a tertiary care teaching hospital.
Subjects and Methods: Sixty-four patients undergoing ESWL for renal stone disease were investigated for plasma tHCy, serum creatinine, and serum hs-CRP 24 h before and after ESWL procedure. Patients were divided into AKI and non-AKI group.
Statistical Analysis: SPSS statistical software, rates, ratios, percentages, and mean ± standard deviation. A P ͳ 0.05 at 95% confidence interval was considered as statistically significant.
Results: Following ESWL, AKI developed in 56.25% of the patients. Post-ESWL mean plasma tHCy levels were significantly high in patients with AKI (21.01 ± 7.67 vs. 16.93 ± 7.44 μmol/L; P = 0.036) compared to those who did not develop AKI. The post-ESWL mean serum creatinine levels and mean change were significantly high in patients with AKI. The post-ESWL mean serum hs-CRP levels were comparable in patients with AKI and those who did not develop AKI. However, 72.22% of the patients with AKI had significant rise of serum hs-CRP (≥2-fold of baseline) level following ESWL which was the only insult on kidney in 24 h.
Conclusion: Plasma tHcy, Serum hs-CRP, and Serum creatinine can be used as acute renal injury markers following ESWL in patients with renal stone disease.

Keywords: Acute kidney injury, extracorporeal shock wave lithotripsy, plasma total homocysteine, renal stone disease, serum creatinine, serum high sensitivity C-reactive protein


How to cite this article:
Raikar SG, Neeli SI, Uppin VM, Uppin SM. Assessment of plasma homocysteine as a marker of acute renal injury in patients undergoing extracorporeal shock wave lithotripsy for renal stone disease - 1-year cross-sectional study. Indian J Health Sci Biomed Res 2017;10:34-40

How to cite this URL:
Raikar SG, Neeli SI, Uppin VM, Uppin SM. Assessment of plasma homocysteine as a marker of acute renal injury in patients undergoing extracorporeal shock wave lithotripsy for renal stone disease - 1-year cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2019 Jul 16];10:34-40. Available from: http://www.ijournalhs.org/text.asp?2017/10/1/34/198581


  Introduction Top


The increased prevalence of renal stone disease is pandemic[1],[2] with a lifetime risk of kidney stones currently at 6%-12% in the general U.S. population.[1] Since its introduction in early 1980s, extracorporeal shock wave lithotripsy (ESWL) is accepted as the first-line treatment modality for renal and upper ureteric stones. It is a noninvasive procedure which is simple, safe, and effective and can be performed with and without anesthesia on outpatient basis. Dornier HM3 lithotripter was the first lithotripter to be introduced.[3] Siemens Modularis Vario lithotripter is a newer generation lithotripter. ESWL continues to be the treatment of choice for uncomplicated kidney stones of <2 cm in diameter, 25 years after its introduction into the USA. ESWL is well tolerated by patients and has a low morbidity and high success rate.[4] However, it has been known since 1985 that a clinical dose of sound waves induces acute renal injury that extends from the papilla to the outer cortex, with a change in renal function in most, if not all patients.[5] This focal and predictable injury has two components; a traumatic vascular injury thought to be induced by the physical forces of the shock wave and an ischemic/hypoxic response linked to the severely damaged renal vessels. In addition, an inflammatory response, termed "lithotripsy nephritis" quickly ensues at the sites of endothelial injury.[5] This oxidant stress renal injury is followed by release of markers. The impact of ESWL on renal function has been evaluated in many studies. Recently, it is suggested that plasma homocysteine levels increase in patients with renal dysfunction. Numerous studies have demonstrated that kidney function is one of the most important determinants of plasma total homocysteine (tHcy) concentration.[6]

Homocysteine is a sulfur-containing amino acid with a reactive sulfhydryl group (-SH) and like most thiols (RSH) can undergo oxidation to disulfide (RSSR) at physiological pH in the presence of O2 . It is formed by demethylation of methionine and can be reversibly converted back to methionine and irreversibly to cysteine. These reactions are catalyzed by transition metals, Vitamin B6, B12, and folic acid. Homocysteine can cyclize to give homocysteine thiolactone, a five-membered heterocycle. Because of this "self-looping" reaction, homocysteine - containing peptides tend to cleave themselves by reactions generating oxidative stress. Homocysteine is cleared from the body by renal and extrarenal metabolism. Renal metabolism includes urinary excretion after glomerular filtration just like creatinine. Elevated tHcy levels have been associated with atherothrombotic vascular disease and numerous other diseases including Alzheimer's disease, osteoporosis, deep vein thrombosis, and pulmonary embolism in the general population.[7],[8] Furthermore, serum creatinine is raised in any kidney disease either acute or chronic. It is excreted by glomerular filtration and is one of the well-known renal injury marker. Serum high-sensitivity C-reactive protein (hs-CRP) is a nonspecific marker of any injury and inflammatory process. Acute kidney injury (AKI) is defined based on RIFLE criteria as two-fold rise in serum creatinine from the baseline value after ESWL.

The aim of this study was to assess plasma homocysteine as a marker of acute renal injury in patients undergoing ESWL for renal stone disease and compare the same with other markers, i.e., serum creatinine and serum hs-CRP.


  Subjects and Methods Top


The 1 year study design was a cross-sectional study done from January 2015 to December 2015. It was carried out in the Department of General Surgery and Department of Urology of a Tertiary Care Teaching Hospital. Sixty-four patients undergoing ESWL for renal stones fulfilling the selection criteria were included in the study. Patients aged between 24 and 61 years and undergoing ESWL in a first sitting which was used as the only modality of treatment were included in the study. Pregnant patients, patients with baseline renal impairment who developed post-ESWL complications such as ureteric obstruction or sepsis that required further intervention, calculi >2 cm, patients with chronic kidney disease or acute renal failure and patients with blood coagulation disorders were excluded from the study. Before the commencement, the Ethical Clearance was obtained from the Institutional Ethics Committee, Jawaharlal Nehru Medical College, Belagavi.

Patients fulfilling selection criteria were briefed about the nature of the study and a written informed consent was obtained. The demographic data such as age and sex, presenting complaints were noted. The patients were subjected to clinical examination, and vitals were noted. The systemic examination was done. These findings were recorded on a predesigned pro forma. Patients were subjected to the following routine investigations pre-ESWL-Complete blood count, mini renal test, liver function test, urine routine, and microscopy and coagulation profile. The position of the calculi and stone diameter was measured by either X-ray kidney, ureter, bladder (KUB), ultrasonography (USG) KUB or plain computed tomography KUB.

Patient demographics are summarized in [Table 1]. In our study, out of 64 patients, the majority of the patients were males 46 (71.88%) and 18 (28.13%) females. The male to female ratio was 2.55:1. In this study, most of the patients were aged between 31-40 years and 41-50 years (31.25% each). The mean (standard deviation [SD]) age was 40.88 (10.46) years with median age of 41 years and range 24 being minimum and 61 years being maximum. In the present study, most of the patients had pain (96.87%) followed by hematuria (2.08%) and nausea (1.04%). Thirty-four (53.13%) patients were diagnosed with left renal calculi while right renal calculi were noted in 30 (46.88%) patients. Overall 41 (64.06%), 20 (31.25%), and 3 (4.68%) patients had one, two, and three calculi, respectively. The calculi were located in the renal pelvis in 35 patients (54.68%), in upper calyx in 11 (17.18%), in mid calyx in 10 (15.63%), and in lower calyx in 8 patients (12.5%). The mean (SD) size of the renal calculus was 1.41 (0.58) mm. Seven patients (10.93%), 32 patients (50%), and 25 patients (39%) had calculus size in between 5 and 10 mm, 11 and 15 mm, and 16 and 19 mm, respectively. The maximum stone size considered was <2 cm [Table 1].
Table 1: Patients' demographics


Click here to view


Patients were hydrated thoroughly before, during, and after ESWL. All the ESWL were carried out using Siemens modularis lithotripter either under local anesthesia using gel or under intravenous sedation (fentanyl/propofol/morphine/ketamine). The procedure was done in supine position. In most cases, a combination of USG and fluoroscopy was used to target the calculi. According to the department's protocol, therapy was commenced at low power and gradually increased during lithotripsy based on the stone fragmentation. The shock rate was set at 60/min. Maximum shocks delivered were adjusted to 3000 per sitting. Total number of shocks used per sitting was adjusted to achieve satisfactory fragmentation of calculus. The procedure was terminated if maximum shocks delivered reached 3000 without satisfactory fragmentation.

Plasma tHCy, serum hs-CRP and Serum creatinine levels were measured pre- and post-ESWL, i.e., 24 h before (baseline value) and 24 h after ESWL and noted for rise in levels. Fasting samples were obtained. EDTA anticoagulated blood was used for measuring plasma tHCy. It was estimated by automated architect immunoassay analyzer and levels between 5.9 and 16 μmol/L was regarded as normal.[9] Serum hs-CRP levels were estimated on Automated DADE Dimension RXL Analyser and levels between 0 and 3 mg/dL was regarded as normal.[10] Plain blood was used for measurement. Serum creatinine levels were estimated on Automated DADE Dimension RXL Analyser. Levels between 0.5 and 1.4 mg/dL were regarded as normal.[11]

Outcome variables

Patients were monitored for the development of acute renal injury which was considered based on RIFLE criteria as two-fold rise in serum creatinine from the baseline value after ESWL and risk was considered as 1.5 fold rise in serum creatinine from the baseline value after ESWL.[12]

Statistical analysis

The data were analyzed using SPSS statistical software version 20.0. The categorical data were expressed as rates, ratios, and percentages and continuous data were expressed as mean ± SD. Probability (P ≤ 0.05) at 95% confidence interval was considered as statistically significant.


  Results Top


The mean number of shock waves per session was 2457 ± 207.95. Most of the patients underwent 2500 total number of shocks per session (85.94%). The total energy delivered per session averaged 78.88 ± 13.79 J and the average intensity used was 3.59 ± 0.60 W. The mean duration of ESWL per session averaged 55.30 ± 8.23 min.

Considering RIFLE criteria for AKI as two-fold rise in serum creatinine from the baseline value after ESWL, AKI was seen to develop in 36 (56.25%) patients. Hence, patients were divided into two groups - AKI group and non-AKI group. Considering two-fold rise of plasma tHCy and serum hs-CRP following ESWL from the baseline value pre-ESWL as significant rise, post-ESWL plasma tHCy levels was significantly raised in 67.19% of the patients while 32.81% of the patients had no significant rise and post-ESWL serum hs-CRP levels was significantly raised in 59.38% of the patients while 40.63% of the patients had no significant rise.

Pre-ESWL mean plasma tHCy levels were comparable in patients who developed AKI and who did not develop (P = 0.971). However, post-ESWL mean plasma homocysteine levels were significantly high in patients with AKI (21.01 ± 7.67 μmol/L) compared to those who did not develop AKI (16.93 ± 7.44 μmol/L) (P = 0.036). Similarly, the mean change in plasma homocysteine levels in patients with AKI was significantly high (10.90 ± 4.87 μmol/L) compared to those who did not develop AKI (6.85 ± 6.06 μmol/L) (P = 0.004) [Graph 1]. The post-ESWL mean serum creatinine levels were significantly high in patients with AKI (1.59 ± 0.44 mg/dL) compared to those who did not develop AKI (1.32 ± 0.29 mg/dL) (P = 0.006). Similarly, the mean change in serum creatinine levels in patients with AKI was significantly high (0.90 ± 0.25 mg/dL) compared to those who did not develop AKI (0.28 ± 0.24 mg/dL) (P < 0.001) [Graph 2]. The pre-ESWL mean serum hs-CRP levels were comparable in patients who did not develop AKI and who developed AKI (P = 0.314). Similarly, the post-ESWL mean serum hs-CRP levels were also comparable in patients with AKI and those who did not develop AKI (P = 0.120) [Graph 3]. Furthermore, the mean change in hs-CRP levels in patients with AKI and those who did not develop AKI was almost similar statistically (P < 0.107). But when the percentage is considered in patients with AKI, 72.22% of the patients had a significant rise in serum hs-CRP levels, and all patients had raised serum hs-CRP levels compared to the baseline values following ESWL, which is the only cause of insult on kidney in 24 h following ESWL.



Considering, RIFLE's criteria for AKI as two-fold rise in serum creatinine from the baseline value after ESWL and risk of developing ARI as one and half fold rise in serum creatinine from the baseline value after ESWL and two-fold rise in plasma tHCy and serum hs-CRP following ESWL from the baseline value pre-ESWL as significant rise, following results were obtained: In patients with AKI, 83.33% of the patients had significant rise in serum tHcy levels and 72.22% of the patients had significant rise in serum hs-CRP levels 24 h following ESWL. In patients with risk of developing ARI, 57.14% of the patients had significant rise in serum tHcy levels and 57.14% of the patients had significant rise in serum hs-CRP levels.


  Discussion Top


ESWL is a commonly used procedure for treating upper urinary tract stones in patients who require treatment. It is a noninvasive approach that can be performed as an outpatient procedure.[13] Despite its proven safety and efficacy, there are many studies on the complications occurring after ESWL.[14],[15] ESWL does cause a predictable pattern of acute renal injury by causing rupture of blood vessels in the medulla and cortex which is accompanied by intraparenchymal bleeding, oxidative stress, inflammation, and an impairment of renal hemodynamics.[5] Resolution of the acute injury may result in scar formation with loss of functional renal tissue.[5] The risk of developing irreversible changes following SWL is influenced by the number of shock waves and rate at which it is administered, the energy and the number of SWL treatment sessions. Yet, the relationship between these risk factors is not understood.[13] There is a need for identification of new renal injury markers to prevent the progression of the renal injury and for early initiation of treatment.

Homocysteine is a sulfur-containing amino acid with a reactive sulfhydryl group (-SH) can undergo oxidation to disulfide (RSSR) in the presence of O2 and at physiological pH. It is formed by demethylation of methionine and can be reversibly converted back to methionine and irreversibly to cysteine. These reactions are catalyzed by transition metals, Vitamin B6, B12, and folic acid. Homocysteine can cyclize to provide homocysteine thiolactone, a five-membered heterocycle. Due to this "self-looping" reaction, peptides containing homocysteine tend to cleave themselves by reactions generating oxidative stress. Homocysteine is cleared in the body by renal and extrarenal metabolism. Renal metabolism includes urinary excretion after glomerular filtration just like creatinine. Elevated tHcy levels have an association with atherothrombotic vascular disease[7],[8] and numerous other diseases including Alzheimers disease, deep vein thrombosis, osteoporosis, and pulmonary embolism in the general population.

Recently, it is suggested that plasma homocysteine levels increase in patients with renal dysfunction. Several studies have demonstrated that renal function is the most important determinant of plasma tHcy concentration.[16],[17],[18] In this study, we aimed to evaluate the relationship between plasma tHCy levels and ESWL in patients with renal stone. Furthermore, serum creatinine is raised in any kidney disease either acute or chronic.[19] It is excreted by glomerular fitration and is one of the well-known renal injury marker. Serum hs-CRP is a nonspecific marker of any injury and inflammatory process.[20],[21] This prompted us to assess plasma homocysteine as a marker of acute renal injury marker in patients undergoing ESWL for renal stone disease and compare the same with other markers, i.e., serum creatinine and serum hs-CRP.

AKI was defined based on RIFLE criteria as two-fold rise in serum creatinine from the baseline value after ESWL and risk was considered as 1.5 fold rise in serum creatinine from the baseline value after ESWL. Two-fold rise in plasma tHCy and serum hs-CRP from the baseline value after ESWL was considered significant.

In a study done by Demir et al.[6] the aim was to evaluate the relationship between tHcy levels and ESWL for patients with kidney stones and to see if the change in homocysteine levels continued on the improvement of renal dysfunction. In their study, tHcy levels showed a statistically significant increase from 9.4 ± 1.4 to 18 ± 4.8 and 11.2 ± 2.1 at 2 days and at 3 months, respectively. Serum creatinine also showed a statistically significant increase compared to baseline at 2 days and at 3 months after ESWL.

In a study done by Modi et al.[21] mean hs-CRP value increased in all three groups, i.e., Group A (no antioxidant), Group B (Vitamin E), and Group C (Vitamin C) after 48 h of lithotripsy but then gradually it came down. The mean hs-CRP levels were significantly lower in Group B (Vitamin E) and Group C(Vitamin C); (Student's t-test, P < 0.05) compared to Group A (no antioxidant) on day 2, 7 and 28 after the lithotripsy. In Group C (Vitamin C) mean hs-CRP value was lower than Group B (Vitamin E) but was not statistically significant (Student's t-test, P > 0.05). Lowest mean hs-CRP value achieved in Group C (Vitamin C) patients at day 28 (1.52).

Considering RIFLE criteria for AKI as two-fold rise in serum creatinine from the baseline value after ESWL, AKI was seen to develop in 36 (56.25%) patients in this study. Hence, patients were divided into two groups - AKI group and non-AKI group. To the best of our knowledge, we did not find any other studies with such division after ESWL for comparison. In one study done by Moriyama et al.[22] based on AKI criteria (KDIGO criteria), fifty patients who underwent cardiac surgery with cardiopulmonary bypass were divided into two groups: AKI group (n = 11) and non-AKI group (n = 39), with respect to postoperative serum creatinine (Cr) levels, i.e., 11 patients developed AKI postoperatively.

We considered two-fold rise in plasma tHCy post-ESWL from the baseline value pre-ESWL as significant rise. Furthermore, we considered two-fold rise in serum hs-CRP post-ESWL from the baseline value pre-ESWL as significant rise. In the present study, post-ESWL plasma tHCy levels were significantly raised in 67.19% of the patients while 32.81% of the patients had no significant rise. Furthermore, in this study, post-ESWL serum hs-CRP levels were significantly raised in 59.38% of the patients while 40.63% of the patients had no significant rise.

In this study, pre-ESWL mean plasma tHCy levels were comparable in patients who developed AKI and who did not develop (P = 0.971). However, post-ESWL mean plasma homocysteine levels were significantly high in patients with AKI (21.01 ± 7.67 μmol/L) compared to those who did not develop AKI (16.93 ± 7.44 μmol/L) (P = 0.036). Similarly, the mean change in plasma homocysteine levels in patients with AKI was significantly high (10.90 ± 4.87 μmol/L) compared to those who did not develop AKI (6.85 ± 6.06 μmol/L) (P = 0.004). Considering the significant rise of plasma tHCy post-ESWL it can be concluded that plasma tHcy can be considered an acute renal injury marker following ESWL. In a study done by Demir et al.[6] tHcy levels showed a statistically significant increase from 9.4 ± 1.4-18 ± 4.8 and 11.2 ± 2.1 at 2 days and at 3 months, respectively post-ESWL for renal stones.

In the present study, the post-ESWL mean serum creatinine levels were significantly high in patients with AKI (1.59 ± 0.44 mg/dL) compared to those who did not develop AKI (1.32 ± 0.29 mg/dL) (P = 0.006). Similarly, the mean change in serum creatinine levels in patients with AKI was significantly high (0.90 ± 0.25 mg/dL) compared to those who did not develop AKI (0.28 ± 0.24 mg/dL) (P < 0.001) confirming creatinine as an acute renal injury marker post-ESWL. This was in accordance to the study done by Demir et al.[6] where serum creatinine showed a statistically significant increase compared to baseline at 2 days and at 3 months after ESWL.

In this study, pre-ESWL mean serum hs-CRP levels were comparable in patients who did not develop AKI and who developed AKI (P = 0.314). Similarly, the post-ESWL mean serum hs-CRP levels were also comparable in patients with AKI and those who did not develop AKI (P = 0.120). Furthermore, the mean change in hs-CRP levels in patients with AKI and those who did not develop AKI was almost similar statistically (P < 0.107). However, when percentage is considered in patients with AKI, 72.22% of the patients had significant rise in serum hs-CRP levels and all patients had raised serum hs-CRP levels compared to the baseline values following ESWL, which is the only cause of insult on kidney in 24 h suggesting the role of serum hs-CRP as an acute renal injury marker whose significance could not be proved due to small sample size of this study. Similar result was shown in a study done by Modi et al.[21] in which mean hs-CRP value increased in all three groups - Group A (no antioxidant), Group B (Vitamin E), and Group C (Vitamin C) after 48 h of lithotripsy but then gradually it came down.

Considering RIFLE's criteria for AKI as two-fold rise in serum creatinine from the baseline value after ESWL and risk of developing ARI as one and half fold rise in serum creatinine from the baseline value after ESWL and two-fold rise in plasma tHCy and serum hs-CRP post-ESWL from the baseline value pre-ESWL as significant rise following results were obtained: In patients with AKI, 83.33% of the patients had significant rise in serum tHcy levels and 72.22% of the patients had significant rise in serum hs-CRP levels 24 h post-ESWL. In patients with risk of developing ARI, 57.14% of the patients had significant rise in serumtHcy levels and 57.14% of the patients had significant rise in serum hs-CRP levels.

Overall the findings of this study suggest that plasma tHcy and serum creatinine can be considered as acute renal injury markers. With aforementioned explanation serum, hs-CRP can also be considered as renal injury marker but needs to be further evaluated.

An important limitation of this study was long-term recovery of these markers and kidney function could not be assessed and a smaller sample size of the study population.


  Conclusion Top


Although ESWL is considered a safe and effective procedure in the treatment of renal stone disease yet it may cause acute renal injury. In this study plasma, total homocysteine and serum hs-CRP rise significantly in addition to serum Creatinine following acute renal injury caused by ESWL. Hence, plasma total homocysteine, serum hs-CRP and serum creatinine can be used as acute renal injury markers following ESWL in patients with renal stone disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

 
  References Top

1.
Sakhaee K, Maalouf NM, Sinnott B. Clinical review. Kidney stones 2012: Pathogenesis, diagnosis, and management. J Clin Endocrinol Metab 2012;97:1847-60.  Back to cited text no. 1
    
2.
Romero V, Akpinar H, Assimos DG. Kidney stones: A global picture of prevalence, incidence, and associated risk factors. Rev Urol 2010;12:e86-96.  Back to cited text no. 2
    
3.
Srisubat A, Potisat S, Lojanapiwat B, Setthawong V, Laopaiboon M. Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones. Cochrane Database Syst Rev 2009;4:CD007044.  Back to cited text no. 3
    
4.
Joshi HN, Karmacharya RM, Shrestha R, Shrestha B, de Jong IJ, Shrestha RK. Outcomes of extra corporeal shock wave lithotripsy in renal and ureteral calculi. Kathmandu Univ Med J 2014;12:51-4.  Back to cited text no. 4
    
5.
Evan AP, Willis LR, Lingeman JE, McAteer JA. Renal trauma and the risk of long-term complications in shock wave lithotripsy. Nephron 1998;78:1-8.  Back to cited text no. 5
    
6.
Demir E, Izol V, Aridogan IA, Paydas S, Tansug Z, Erken U. Immediate and long-term high levels of plasma homocysteine after extracorporeal shock wave lithotripsy in patients with renal stone disease. Clin Exp Nephrol 2014;18:623-5.  Back to cited text no. 6
    
7.
Boushey CJ, Beresford SA, Omenn GS, Motulsky AG. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease. Probable benefits of increasing folic acid intakes. JAMA 1995;274:1049-57.  Back to cited text no. 7
    
8.
Homocysteine Studies Collaboration. Homocysteine and risk of ischemic heart disease and stroke: A meta-analysis. JAMA 2002;288:2015-22.  Back to cited text no. 8
    
9.
Cobas HCYS Homocysteine Enzymatic Assay. 2015-12 V 3.0 English. Indianapolis: Roche Diagnostics; 2015.  Back to cited text no. 9
    
10.
Cobas CRPHS Cardiac C-reactive Protein (Latex) High Sensitive 2015-04 V 9.0 English. Indianapolis: Roche Diagnostics; 2015.  Back to cited text no. 10
    
11.
Cobas CREP 2 Creatinine Plus Ver. 2. Indianapolis: Roche Diagnostics; 2015.  Back to cited text no. 11
    
12.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative Workgroup. Acute renal failure-definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R204-12.  Back to cited text no. 12
    
13.
Kardakos IS, Volanis DI, Kalikaki A, Tzortzis VP, Serafetinides EN, Melekos MD, et al. Evaluation of neutrophil gelatinase-associated lipocalin, interleukin-18, and cystatin C as molecular markers before and after unilateral shock wave lithotripsy. Urology 2014;84:783-8.  Back to cited text no. 13
    
14.
Willis LR, Evan AP, Connors BA, Reed G, Fineberg NS, Lingeman JA. Effects of extracorporeal shock wave lithotripsy to one kidney on bilateral glomerular filtration rate and PAH clearance in minipigs. J Urol 1996;156:1502-6.  Back to cited text no. 14
    
15.
Vlajkovic M, Slavkovic A, Radovanovic M, Siric Z, Stefanovic V, Perovic S. Long-term functional outcome of kidneys in children with urolithiasis after ESWL treatment. Eur J Pediatr Surg 2002;12:118-23.  Back to cited text no. 15
    
16.
Arnadottir M, Hultberg B, Nilsson-Ehle P, Thysell H. The effect of reduced glomerular filtration rate on plasma total homocysteine concentration. Scand J Clin Lab Invest 1996;56:41-6.  Back to cited text no. 16
    
17.
Vanizor Kural B, Orem A, Cimsit G, Uydu HA, Yandi YE, Alver A. Plasma homocysteine and its relationships with atherothrombotic markers in psoriatic patients. Clin Chim Acta 2003;332:23-30.  Back to cited text no. 17
    
18.
Wollesen F, Brattström L, Refsum H, Ueland PM, Berglund L, Berne C. Plasma total homocysteine and cysteine in relation to glomerular filtration rate in diabetes mellitus. Kidney Int 1999;55:1028-35.  Back to cited text no. 18
    
19.
Waikar SS, Bonventre JV. Creatinine kinetics and the definition of acute kidney injury. J Am Soc Nephrol 2009;20:672-9.  Back to cited text no. 19
    
20.
Rakshitha Gowda BH, Meera KS, Mahesh E. Serum levels of high sensitivity C reactive protein and malondialdehyde in chronic kidney disease. Int J Med Res Health Sci 2015;4:608-15.  Back to cited text no. 20
    
21.
Modi J, Modi P, Pal B, Bansal J, Kumar S, Nagarajan R, et al. Role of Vitamin C and E supplementation in reduction of serum level of renal injury marker following shock wave lithotripsy: Prospective single centre experience. Urol Ann 2015;7:350-4.  Back to cited text no. 21
[PUBMED]  Medknow Journal  
22.
Moriyama T, Hagihara S, Shiramomo T, Nagaoka M, Iwakawa S, Kanmura Y. Comparison of three early biomarkers for acute kidney injury after cardiac surgery under cardiopulmonary bypass. J Intensive Care 2016;4:41.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Subjects and Methods
  Results
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed1047    
    Printed30    
    Emailed0    
    PDF Downloaded130    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]