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Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies Case Solution & Answer

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The case tells the story of Rodamas group, owned by the Tan Chinese family in Indonesia. The company started as a trading company in 1951 and eventually became a joint venture partner in the business of manufacturing a wide range of partners, mainly Japanese after Indonesia began to embark on a program of industrialization in the 1960s. In the 1980s, the company was gradually transferred to the second generation leader, and has continued to grow and prosper to become part of the top 20 business groups in Indonesia. Companies included the manufacture of glass (Asahi), personal care products (Kao), containers (with Dai Nippon) and the production of monosodium glutamate. The role of these associations is Rodamas in dealing with local, hire local staff and distribute products in Indonesia. When former President Suharto was toppled in the 1998 Asian crisis, Indonesia has undergone several drastic changes, including the transition to democracy. Its economy has become more open, and foreign companies are allowed to operate in the country without a local partner. In addition, several developments of global companies, including multinationals tend to rely on lawyers and consultants rather than partners of local actions threatened the business model Rodamas. In this perspective, the current leader, Mucki Tan, is reconsidering the future of their business and weighing a few options. The case ends with the strategic choices: 1) internationalization with existing partners, and 2) the development of specific low-technology companies, such as property, 3) buy existing manufacturing companies, 4) the emphasis on distribution products for foreign multinationals 5) development of the traditional role of partnership with a new wave of foreign direct investment (FDI) to develop the multinational market, especially in China. It asked students to analyze the business and its environment, decide on strategic direction and think about the consequences. by Marleen Dieleman, Shawkat Kamal Source: Ivey Publishing 16 pages. Release: June 23, 2009. Prod #: 909M49-PDF-ENG Rodamas Group: designing strategies to the changing realities of emerging settlement of cases

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RODAMAS CASE STUDY

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Hasif Farhan Harith

wrote this case solely to provide material for class discussion. The authors do not intend to illustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identifying information to protect confidentiality. Ivey Management Services prohibits any form of reproduction, storage or transmittal without its written permission. Mucki Tan, deputy chairman and main shareholder of the Rodamas Group, was thinking about the future of his group of companies. It was a hot and humid afternoon and clouds were building up on the horizon in Jakarta, the capital of Indonesia. Tan wondered whether the traditional local partnership role his company had played with different foreign multinationals was losing its advantage. The roles a local partner fulfills for multinational players in emerging economies can also be outsourced, and Tan had noticed the rapid growth of service firms in Jakarta that employed consultants, lobbyists and lawyers working for multinationals. Also, starting from 1994, the Indonesian government allowed multinational companies to operate in the country with 100 per cent foreign ownership in certain sectors. In 2008, the world economy was about to enter into a crisis, which was likely to bring problems, but also to offer opportunities. Did the business model developed by Tan's entrepreneurial father need a major overhaul? What were the alternatives? After Tan had reorganized and streamlined the company, selling off some of its smaller businesses, it was time to choose a new course of action. He knew he had to be very careful in selecting the right option. INDONESIA: A PROMISING EMERGING ECONOMY Indonesia is a vast archipelago with a population of around 240 million, and has, over the years, experienced significant growth. The country became independent from Dutch colonial rule after the Second World War, and has since transformed from a mostly agricultural society to an emerging industrial economy. The period in which Suharto was president, from 1966 to 1998, was one of especially rapid economic growth. This came with inflows of foreign direct investment, for example in manufacturing for the large local market or in the extraction of Indonesia's many natural resources. Economic prosperity translated into declining poverty rates, but was also accompanied by a system of cronyism in which Suharto nurtured relations and distributed business opportunities to a limited group of business families. The larger business families developed sprawling conglomerates that spanned several sectors of the economy. Often they were owned by families descended from Chinese migrants.

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Rodamas Case Study

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1.0 CASE SUMMARY The case tells the story of the Rodamas Group, where Rodamas means “golden wheel”. Rodamas Group owne

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1.0 CASE SUMMARY The case tells the story of the Rodamas Group, where Rodamas means “golden wheel”. Rodamas Group owned by the ethnic Chinese Tan family in Indonesia. Rodamas was engaged in variety of businesses. These included food, healthcare, personal care and hygiene, chemicals, glass, diamond coated tools, building parts and components, printing and packaging and consumer product distributions. Rodamas was started By Mucki Tan’s father Tan Siong Kie in 1951. The company started as a trading firm and, over time, became a joint venture partner in manufacturing businesses with a range of mainly Japanese partners after Indonesia started to embark an industrialization program in the late 1960s. In the 1980s the company continued to grow and prosper until it became part of the top business groups in Indonesia. The Rodamas was done a lots of partnership with others company such as Japan and a few in United State. The role of Rodamas in these partnerships was to deal with local regulations, hire local personnel and distribute the products in Indonesia. When the then President Suharto was toppled in the Asian Crisis in 1998, Indonesia underwent several drastic changes, including the transition to democracy. This changes has huge impact on Rodamas businesses. Its economy became more open, and foreign firms were allowed to operate in the country without having a local partner. In addition, several global business developments, including the tendency of multinationals to rely on lawyers and consultants rather than local equity partners, threatened the Rodamas business model. On the other hand, with the increasing standardization of product worldwide, it make Rodamas difficult to convince Rodamas’s partners to adapt a product to fit local market demand. Lower demand for various products was predicted which would impact Rodamas’s cash flow. In view of this, the current leader, Mucki Tan, is reconsidering the future of his company and weighing a few strategic options to which are internationalize with existing partners, develop own businesses that need little technology, such as property, buy existing manufacturing firms, focus on distribution of products for foreign multinationals, focus on a traditional partnership role with a new wave of foreign direct investment (FDI) from developing market multinationals, more specifically, China. 1 2.0 PROBLEM STATEMENT 2.1 What are the core competencies of Rodamas? Are they sources of sustainable advantages? Some of the core competencies of Rodamas group in my opinion are High Management competency of the management relative to other business professional in Indonesia which enabled them to understand international business and form partnerships. This is because mostly Rodamad was involved with partnership with company outside the Indonesia. Rodamas has a strong knowledge in terms of the regulation, markets, and also the standard of the international businesses. By having these advantages, Rodamas was able to get the opportunity to expand their businesses outside Indonesia. On the other hand with the conservative management style which enabled the company to grow steadily without any financial risks and also stay under the radar of bureaucracy. Mucki Tan and his father have a same style when it comes to the management. Both of them appeared to be more conservative and risk-averse and had a preference for slow and steady growth rather than applying a high risk high return strategy. Rodamas also has strategic connections to foreign companies across the globe as well as with the local government and businesses which helped smooth obtaining of licenses land and other requirements. This can be prove by having a partnership with the Japanese firm. These Japanese partners of Rodamas played the most significant role in the success of the company. while the Japanese were in charge of technology and production, they tended to involve the Rodamas management in making decision and they tried to avoid potential conflict. 2 2.2 What are the main characteristics of the business environment before and after the 2008 Asia Financial crisis? 2.2.1 Before The business environment was thriving in Indonesia before the crisis with strong growth and in terms of value of the Indonesian currency with respect to the US dollar. Post crisis, most companies went bankrupt as the value of the Indonesian currency plummeted and the cost of their loans which they had converted to US dollar had sky rocketed. This crisis led to the closure of several players and created opportunity for Rodamas in the market in terms of expansion and acquisitions. The crisis also marked the end of Suharto which led to establishment of a new anticorruption regime. It also moved the country towards a more open economy in which tariffs and trade barriers had come down. This made the business landscape for Rodamas more competitive than before. Many of the protective measures were removed. 100% FDI was allowed into most sectors which allowed foreign players to directly enter the market! giving rise to competition as well as eliminating the need for a local partner if the company chose to. This policy had a direct impact on business strategy of Rodamas of forming ventures and could potentially alter the competitive landscape and market opportunities. 2.2.2 After There were noticeable changes in the governance practices in multinationals. There were tightening laws on corporate governance and stricter accounting rules which made multinationals to use lawyers and consultants for rectifying local issues rather than using local partners. Thus, the role and say of companies like Rodamas was reducing in their ventures Additionally, the crisis created a shift in the companies towards consolidation and standardisation. This meant that it became difficult for partners like Rodamas to convince their venture partners to adapt a product to fit the local demand. This often led to friction between the partners as well and led to termination of several key alliances although the business was performing well in the market. 3 The crisis also led to the rise of multinationals from emerging economies like China and India. This created a window of opportunity for Rodamas to form new alliances on favorable terms with the potential new parties interested in Indonesia. 2.3 How do such changes affect Rodamas core competencies? Despite of the above changes, Rodamas still remains an efficient and trustworthy partner. Although, direct FDI eliminates the need of any foreign partner the existing corruption and bureaucracy coupled with the need for deep market penetration still keeps the need for partners like Rodamas still alive. On the other hand, the source of temporary competitive advantage is now even easier to break into. The opening of FDI creates the need for Rodamas to create new competencies as the previous competencies may soon become irrelevant. The group needs to focus towards building its owned expertise in terms of design and manufacturing so that they can become self-reliant. The company was also facing high attrition in its middle management due to the above changes in the business environment which would make them loose vital human capital which is one of the key reasons for its success in the local Indonesian market. The company may also need to consolidate some of its businesses due to expected competition and thus would loose out on its edge of having a foot hold in a breadth of businesses. 4 3.0 ALTERNATIVE STRATEGIES 3.1 Internationalization with existing partners. By having internalization with existing partners, Rodamas can establishing and managing successful collaborations and partnerships. However, to be success with this strategies Rodamas should have a strategic planning. It should be based on a careful planning process that clarifies international goals and objectives, particularly with respect to final outcomes which is the business goals. International collaborations should align with overall institutional mission and priorities, and should take into account availability of financial and personnel resources. 3.2 Develop own businesses that need little technology. There's a fine line between too much and not enough. Spend too much on technology it will consume your time and budget, leaving you ill prepared to do anything else on your business. Rodamas should select a few of technology that will bring advantages to their businesses. A little technology will help Rodamas to seethe real benefit, prevent the worst disasters, and not miss out on any major opportunities, while not spending more than Rodamans can handle. Rodamas need to hire a good consultant to help them use as much quality free software in their business as possible. 3.3 Buy existing manufacturing firms. By buying an existing manufacturing firms, there may be established customers, a reliable income, a reputation to capitalise and build on and a useful network of contacts. Rodamas does not have to worried about the future income however Rodamas need to make some improvement on the manufacturing to add value on it. On the other hand, by buying an existing manufacturing firms, a business plan and marketing method should already be in place. Rodamas would cut the budget on this section and focus how to enhance and attract potential buyers. Existing manufacturing firms must have existing employees for sure. Therefore, Rodmas does not have to hired and train a new employees as there are existing employees that should have experience that Rodamas can draw on. 3.4 Focus on distribution of products for foreign multinationals. Due to economic crisis its created world wide opportunities that could be captured by Rodamas. By focusing distribution for foreign multinational there is no need for doing 5 research and development and innovation required. On the other hand, Rodamas has a good record on previous foreign ventures. 3.5 Focus on a traditional partnership specifically China. This strategy was in line with the company philosophy from the beginning. Rodamas was known with their expertise with forming alliances with other company whether local or oversea country. 4.0 SWOT ANALYSIS At this point, it is vital to understand the strengths and weaknesses of the company and also critically analyse each opportunity and the threat as well. 4.1 I. Strength Strong and experienced management. Mucki Tan was the only son of Tan Senior. He obtained his degree in business at University of Portland in Oregon, United States. Mucki Tan joined the family business in 1980 as a manager. The management divided the company into food, chemical, construction materials and other businesses. The company had a process of training its future manager internally. This is because Tan, like his father believed in providing autonomy to the managers. Rodamas was proud of its management trainee program and most of the managers that the company had moved up through this program. II. High understanding of local market and distribution channels. Rodamas Group has a knowledge and understanding of the regulations and politics of local markets as well for business outside the Indonesia. This is important as to ensure that their businesses follow the standard to get know in-depth knowlwdge of the market, consumer , regulators, the regulations, the opportunities and local challenges. By knowing all of these matters it will helps Rodamas Group to strength their businesses. III. No specific competitors. The competitors of Rodamas were diverse and there was no specific competitors as the company was engaged in a variety of businesses. Rodamas engaged in numbers of sectors. These included food, healthcare, personal care and hygeine, chemicals, glass, diamond coated tools, building parts and components, printing and packaging and consumer product distribution. By involving in a lots of different sector it will 6 generate more income because it will attract a lot of potential customer in the different markets. 4.2 I. Weakness High dependence on partnership. Rodamas have done a lot of partnership contract. Partership is good to entering a new markets, however too much rely on partnership may have negative effect to the businesses. The possible of having an argument with the partner may arise if both parties have different view of how the business should be conducted. II. Conservative management style. Mucki Tan and his father have a same style when it comes to the management. Both of them appeared to be more conservative and risk-averse and had a preference for slow and steady growth rather than applying a high risk high return strategy. Mucki Tan was a very careful man and always made sure that his company abided by the regulations. Conservative management style will lead to slow process on making decision. The possibility that the manager may lose importance towards the employees as the manager is seen to be unable to make a decision for himself/ herself. III. Limited Research and Development. Research and development (R&D) is a valuable tool for growing and improving your business. R&D involves researching your market and customer needs and developing new and improved products and services to fit these needs. Businesses that have an R&D strategy have a greater chance of success than businesses that don't. However, Rodamas Group did not take any step to make R&D for their business. Rodamas put too much rely on the partnership. 4.3 I. Opportunity Emerging consumer market, expansion opportunities. Indonesia is a countries which have started to grow but have yet to reach a mature stage of development where there is significant potential for economic. From the case, Rodamas has found a lot of right local partner. Market entry strategy is crucial and companies should think carefully about working with local partners. On the other hand, Rodamas also have the strong knowledge about the market before entering into the pool. This is important to gain a deep understanding of the market is crucial. 7 This includes the education system, competitors, the operation environment, consumers and suppliers. II. Opportunity to acquire businesses due to the financial crisis. Financial crisis was happened of the late 1990s. Prior to the crisis, most companies had converted their loans to U.S Dollar loans since interest rates were more attractive. 4.4 I. Threat Exchange rate fluctuation. Exchange rates fluctuate due to many factors. Some may be strictly financial but political events can also affect the exchange rates. In the case of the Rodamas, it may have face this threat because of they do involve with foreign businesses. 8 5.0 PORTER’S FIVE FORCE MODEL Strategy Threat of Threat new of Bargaining substitute power entrants Enter the Low market of barriers, manufacturing brand simple the buyer High low switching of substitutes market the degree Large pool of local of inputs, limited scope probable high of sustainable product available differentiation of competition of for disadvantages, products Indonesian of availability of differentiation manufacturers, number local low Intensity supplier buyer Low leverage, equity, costs, cost products of power consumers entry Low Bargaining in market, concentration competitive of suppliers advantages low level of through perceived innovation differentiation Enter the High entry Low consumer barriers. product Difficult market moderate to threat Entering in a short type degree Low business the High cost Strategic estate barrier of bargaining of competition. bargaining power As through advantage, building leasing Labour Existing intensive alliances, high means players, differentiation opportunity of of inputs spatial differentiation High volatility Ease for may focusing others to form easily alliances, big by adopting a segment the similar imports degree Existing of perceived property traditional Relatively low Low of leverage niche manufacturing barrier mostly currently cost level office on be and new business may be there of model products would of location, high buyer entry, intensity moderate of time. business by to Low and form alliances depending on power products real to Low of Relatively low Low prevalent firms substitution, bargaining move low perceived power to level other of suppliers differentiation because advantageous between 9 expected competition of for this particular of model of manufacturing role of foreign partnership may with enter firms regions for partners directly higher profits scale of operations developing transnational corporation market like china Internalization with High entry Low existing barriers partners like other threat Low for from bargaining firms, substitute Asahi in other already power product consumers Asian markets establish like Thailand business Low moderate of bargaining power to Low intensity of competition expected of other in Asian suppliers regions Low Low bargaining competition and global presence of parent company Entering the Establish Low threat as Moderate consumer channel, deep company products penetration, distribution high business entry cost profitability bargaining offers a deep power of knowledge consumer and and channels of power suppliers of expected from middle small to scale for companies in distribution need of services 10 6.0 RECOMMENDATION After doing with all the analysis there a several recommendation that Rodamas can get it done. The first recommendation is Rodamas should focus its core strength and vast experience in distribution to act as a distribution and logistic provider to business. Through the various alliances, the company already has a good understanding foreign partners needs and can tie up with new firm entering Indonesia and increase the scale of this business. This can lead to the larger market for Rodamas itself. On the other hand, since the consumer purchasing trend is increasing, the company should consider relying on its second core strength by forming further alliances allow companies to enter Indonesia for various consumer products such as food and beverage and other industrial products like chemicals, construction material to cater to corporate demands as well. Divesting from its dependency should also be considered in the long term. Next recommendation is it is vital to establish a competitive advantages. Although, the very nature of competitive advantages makes it prone to attack by other rivals in the industry and it may disappear over time. However, in my opinion the company should consider adopting the following measures. Which are: i. Exploiting the niche in the markets by new strategic alliances. This would require a re-alignment of SBU’S and promotion of positive collaborative environment SBU’s to leverage on each other strengths. ii. The company should consider using IPO’s to finance ventures mentioned above. This will free finances to jumpstart the integration projects mentioned above and allow the group to have cash reserves in time of critical need. iii. The company should convert its core distribution compentency into a strength by spinning off a supply logisctic and distribution company to better manage the entire process. iv. Rodamas can also consider “technology transfer” in their allliances thereby increasing their competence over time. 11 7.0 CONCLUSION For 
 people
 like
 Tan senior,
 it
 was 
 a 
 difficult
 and
 hostile
 setting
 in 
 which
 one
 had
 to
 navigate
 carefully.
But
 it
 was
 the opportunities,
since 
many 
existing
 foreign
 businesses
 closed
 and
 left
 a
 gap 
 that
 needed
 to
 be
 filled.
 
 In
 this
 context,
 with
 little
 industrial
 activity
 and
 no
 expertise
 to
 produce 
even 
basic
 products
domestically,
 
 many 
business 
leaders
 focused
 on 
trade,
mostly
 import 
 trade, 
 and 
 Rodamas 
 followed 
 this 
 pattern. 
 It 
 developed 
 partnerships 
 with 
 foreign 
 manufacturers
and
 became
 their
 agent 
in
 Indonesia
. Rodamas has been involved in consumer goods product, personal care and household product medicated plaster, liniment and others. The case was reflected on the strength of Rodamas’s core competence — a local partnership role in a difficult emerging market – Indonesia . 12 8.0 REFERENCES Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies Harvard Case Solution & Analysis retrieved from http://www.thecasesolutions.com/rodamas-group-designing-strategies-for-changingrealities-in-emerging-economies-5011 on 19.04.2016. Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies retrieved from https://hbr.org/product/rodamas-group-designing-strategies-for- changing-realities-in-emerging-economies/909M49-PDF-ENG on 20.04.2016. Rodamas Group: Designing the Portfolio Case Solution retrieved from http://casesolutionsprovider.blogspot.my/2015/08/rodamas-group-designing-portfoliocase.html on 23.04.2016. 13

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Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies Harvard Case Solution & Analysis

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The case narrates the story of the Rodamas Group, owned by the ethnic Chinese Tan family in Indonesia. After Indonesia started to set out on an industrialization plan in the late 1960s the company started in 1951 as a trading business and, over time, became a joint venture partner in manufacturing businesses with a range of largely Japanese associates. In the 1980s, the corporation was slowly transferred to the second generation organizer, and constantly grew and prospered until it became part of the top-20 business groups in Indonesia. The part of Rodamas in these partnerships was to handle local regulations, hire local employees and distribute the products in Indonesia. When the then President Suharto was toppled in the Asian Crisis in 1998, Indonesia experienced several radical changes, including the transition to democracy. Its market became more open, and foreign companies were permitted to operate in the state without having a local partner.

Moreover, several global business developments , including the tendency of multinationals to rely on consultants and lawyers rather than local equity partners, jeopardized the Rodamas business model . In view of this, Mucki Tan, the current leader, is reconsidering the future of his company and weighing a few alternatives. The case ends with these tactical options: 1) internationalize with existing associates; 2) develop own companies that need small technology, like property; 3) buy present manufacturing firms; 4) focus on distribution of products for foreign multinationals; 5) focus on a conventional partnership function with a new wave of foreign direct investment (FDI) from developing market multinationals, more specifically, China. Pupils are requested to examine its surroundings and the company, decide on a tactical direction and reflect on the results.

PUBLICATION DATE: June 23, 2009 PRODUCT #: 909M49-HCB-ENG

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Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies

Subjects Covered Change management Emerging markets Joint ventures Manufacturing Strategic planning Strategic thinking

by Marleen Dieleman, Shawkat Kamal

Source: Richard Ivey School of Business Foundation

16 pages. Publication Date: Jun 23, 2009. Prod. #: 909M49-PDF-ENG

Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies Harvard Case Study Solution and HBR and HBS Case Analysis

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Case Study Solutions

Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies

Subjects Covered Change management Emerging markets Joint ventures Manufacturing Strategic planning Strategic thinking

by Marleen Dieleman, Shawkat Kamal

Source: Richard Ivey School of Business Foundation

16 pages. Publication Date: Jun 23, 2009. Prod. #: 909M49-PDF-ENG

Rodamas Group: Designing Strategies for Changing Realities in Emerging Economies Harvard Case Study Solution and HBR and HBS Case Analysis

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What is Harvard Business School (HBS) Case Method

Harvard Business School (HBS) Case Method, a renowned approach to business education, using business case studies in the field of marketing, sales, leadership, technology, finance, enterpreneurship, human resources, and more .

Core Principles:

• Real-World Dilemmas: HBS cases delve into genuine business challenges faced by companies, exposing students to the complexities and uncertainties of real-world decision-making.
• Active Participation: Students are not passive recipients of knowledge. The case method emphasizes active participation through case discussions, fostering critical thinking and analysis.
• Developing Judgment: There are often no single “correct” answers in case studies. The focus is on developing sound judgment by weighing evidence, considering various perspectives, and making well-supported recommendations.
• Diversity and Collaboration: Diverse backgrounds and experiences enrich case discussions. Students learn from each other as they analyze the case from different viewpoints.

Structure and Implementation:

• Pre-Class Preparation: Effective case study learning hinges on thorough preparation. Students are expected to read and analyze the case beforehand, identifying key issues, conducting research, and formulating potential solutions.
• Case Discussion: The case discussion in class is the heart of the method. The instructor facilitates a dynamic discussion, encouraging active participation from all students.
• Open-Ended Questions: Instead of spoon-feeding answers, instructors pose open-ended questions that stimulate critical thinking and analysis.
• Cold Calling: The HBS method is known for its “cold calling” technique, where professors randomly call on students to respond, promoting active engagement and preparation.
• Socratic Dialogue: Instructors often employ the Socratic method, asking probing questions to challenge assumptions, encourage deeper analysis, and draw out student reasoning.

Benefits of the HBS Case Method:

• Develops Critical Thinking Skills: Grappling with complex business problems and analyzing diverse perspectives strengthens critical thinking abilities.
• Enhances Communication Skills: Active participation and clear articulation of ideas within case discussions hone communication skills.
• Sharpens Analytical Abilities: Students learn to dissect complex situations, identify key drivers, and weigh evidence effectively.
• Promotes Decision-Making Confidence: The case method fosters the ability to make well-reasoned decisions under uncertainty.
• Builds Leadership Skills: Active participation in discussions and persuasively advocating for solutions develops leadership potential.
• Prepares Students for Real-World Business: The case method equips students with the knowledge and skills to navigate the complexities of real-world business environments.

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How to Write a Great Case Study Solution | HBR Case Study Assignment Help

A top-tier Harvard Business School (HBS) case study solution comprises a thorough analysis, strategic insights, and actionable recommendations. The solution is not just an academic exercise but a practical approach to solving real-world business problems. Here’s an illustration of what the best Harvard case study solutions comprise, along with a detailed checklist to ensure excellence.

Key Components of a Harvard Case Study Solution

Comprehensive Understanding of the Case

• Summary of the Case : Provide a concise summary that outlines the key issues, stakeholders, and objectives. This sets the stage for deeper analysis.
• Problem Identification : Clearly define the main problem or decision point that the case presents. This includes understanding the underlying causes and the broader business context.

Detailed Analysis

• Qualitative Analysis : Evaluate qualitative factors such as organizational culture, leadership styles, and market conditions. This helps in understanding the non-quantifiable aspects that impact the business scenario.
• Quantitative Analysis : Use data and financial metrics to analyze the business performance. This includes profit margins, cost structures, revenue streams, and other relevant financial indicators.
• SWOT Analysis : Conduct a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis to provide a structured view of the internal and external factors affecting the business.

Strategic Alternatives

• Generation of Alternatives : Develop multiple strategic alternatives to address the identified problem. Each alternative should be feasible and align with the company’s goals and resources.
• Evaluation of Alternatives : Assess each alternative based on criteria such as cost, feasibility, impact, and alignment with the company’s strategic objectives. Use quantitative data where possible to support the evaluation.

Recommended Solution

• Selection of the Best Alternative : Choose the most viable solution from the generated alternatives. Justify the choice with clear, logical reasoning and supporting evidence.
• Implementation Plan : Develop a detailed implementation plan that includes steps, timelines, resources required, and potential risks. This ensures the recommended solution is actionable and practical.
• Contingency Plan : Outline a contingency plan to address potential challenges or risks that may arise during the implementation phase.

Reflection and Learning

• Lessons Learned : Reflect on the case study process and the key lessons learned. This includes insights into decision-making, strategic thinking, and the application of business concepts.
• Future Implications : Discuss the broader implications of the case study for the industry and future business scenarios.

Checklist for a Great Harvard Case Study Solution

Comprehensive Understanding

• Clearly summarized the case
• Identified the main problem and stakeholders
• Understood the broader business context
• Conducted qualitative analysis (organizational culture, market conditions, etc.)
• Performed quantitative analysis (financial metrics, data analysis)
• Completed a SWOT analysis
• Generated multiple feasible alternatives
• Evaluated alternatives based on relevant criteria
• Supported evaluations with data and logical reasoning
• Selected the most viable alternative with a strong justification
• Developed a detailed and practical implementation plan
• Created a contingency plan to manage potential risks
• Reflected on the case study process
• Identified key lessons learned
• Discussed future implications for the industry and business practices

At Fern Fort University creating a top-tier Harvard case study solution involves a methodical approach to understanding the case, performing detailed analysis, generating and evaluating strategic alternatives, and providing actionable recommendations. By following this structured process, our case solution writing experts deliver solutions that are best in class.

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Hiring Fern Fort University to write your case studies solutions is a strategic investment that delivers exceptional results. Our combination of expertise, efficiency, comprehensive analysis, and tailored solutions ensures that your case studies solutions will be of the highest quality, providing valuable insights and a competitive edge. Focus on your core activities and leave the complex task of case study analysis to the experts at Fern Fort University, ensuring academic excellence and business success.

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Importance of Each Step in the Process

Filling the form and uploading guidelines.

This initial step is critical as it sets the direction for the entire project. Clear and detailed guidelines ensure that the writer understands the scope, objectives, and specific requirements, reducing the risk of misalignment and ensuring a focused approach.

Uploading the Case Study PDF

Providing the case study in its original format ensures that the writer has all the necessary context and background information. This step is crucial for a thorough understanding of the problem and accurate analysis.

Communication with the Writer

Direct communication allows for clarification of any doubts and ensures that both the client and the writer have a mutual understanding of the project deliverables. This interaction is essential for tailoring the solution to meet the client’s specific needs.

Delivery of the Solution

Delivering a comprehensive and well-structured case study solution provides the client with actionable insights and recommendations. This step showcases the writer’s expertise and ensures that the client receives a valuable product that addresses the case study’s challenges effectively.

Requesting Improvements

The opportunity for revisions ensures that the final product meets the client’s expectations and adheres to all requirements. This step adds a layer of quality assurance, ensuring client satisfaction.

The case study writing service process at Fern Fort University is designed to deliver high-quality, tailored solutions through a structured and client-focused approach. Each step in the process is carefully crafted to ensure clarity, thorough analysis, and client satisfaction. By following this comprehensive process, Fern Fort University guarantees that clients receive insightful and actionable case study solutions that meet their specific needs and contribute to their academic or business success.

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Fern Fort University’s professional case study solution writers have the following attributes that can help you to boost your academic and professional growth --

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Fern Fort University’s professional case study solution writers deliver comprehensive, insightful, and actionable case study solutions that meet the highest academic and professional standards.

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• Published: 28 August 2024

Predictive value of perioperative NT-proBNP levels for acute kidney injury in patients with compromised renal function undergoing cardiac surgery: a case control study

• Yiting Ma 1   na1 ,
• Jili Zheng 1   na1 ,
• Wanting Zhou 1 ,
• Zhe Luo 2 &
• Wuhua Jiang 3  

BMC Anesthesiology volume  24 , Article number:  298 ( 2024 ) Cite this article

Metrics details

Acute kidney injury (AKI) significantly increases morbidity and mortality following cardiac surgery, especially in patients with pre-existing renal impairments. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a marker of cardiac stress and dysfunction, conditions often exacerbated during cardiac surgery and prevalent in chronic kidney disease (CKD) patients. Elevated NT-proBNP levels can indicate underlying cardiac strain, hemodynamic instability and volume overload. This study evaluated the association between perioperative changes in NT-proBNP levels and the incidence of AKI in this particular patient group.

This retrospective study involved patients with impaired renal function (eGFR 15–60 ml/min/1.73 m²) who underwent cardiac surgery from July to December 2022. It analyzed the association between the ratio of preoperative and ICU admittance post-surgery NT-proBNP levels and the development of AKI and AKI stage 2–3, based on KDIGO criteria, using multivariate logistic regression models. Restricted cubic spline analysis assessed non-linear associations between NT-proBNP and endpoints. Subgroup analysis was performed to assess the heterogeneity of the association between NT-proBNP and endpoints in subgroups.

Among the 199 participants, 116 developed postoperative AKI and 16 required renal replacement therapy. Patients with AKI showed significantly higher postoperative NT-proBNP levels compared to those without AKI. Decreased baseline eGFR and increased post/preoperative NT-proBNP ratios were associated with higher AKI risk. Specifically, the highest quantile post/preoperative NT-proBNP ratio indicated an approximately seven-fold increase in AKI risk and a ninefold increase in AKI stage 2–3 risk compared to the lowest quantile. The area under the receiver operating characteristic curve for predicting AKI and AKI stage 2–3 using NT-proBNP were 0.63 and 0.71, respectively, demonstrating moderate accuracy. Subgroup analysis demonstrated that the positive association between endpoints and logarithmic transformed post/preoperative NT-proBNP levels was consistently robust in subgroup analyses stratified by age, sex, surgery, CPB application, hypertension, diabetes status and fluid balance.

Perioperative NT-proBNP level changes are predictive of postoperative AKI in patients with pre-existing renal deficiencies undergoing cardiac surgery, aiding in risk assessment and patient management.

Peer Review reports

Introduction

Acute kidney injury (AKI) following cardiac surgery represents a significant complication that escalates morbidity and mortality among patients [ 1 , 2 ]. Despite advancements in surgical techniques and patient care, the incidence of AKI remains high, particularly among individuals with pre-existing renal impairment [ 3 ]. The capability to precisely predict postoperative AKI and its severity could guide preventive strategies and patient management, potentially improving outcomes [ 4 , 5 ].

Recent research has underscored the significance of biomarkers in the early prediction of AKI. Among these, N-terminal pro-B-type natriuretic peptide (NT-proBNP) has emerged as a promising indicator.

NT-proBNP is a fragment of the prohormone BNP (B-type natriuretic peptide), which is released by the heart in response to cardiac stress and dysfunction. Both NT-proBNP and BNP are used clinically to diagnose and manage heart failure, as they reflect similar pathophysiological processes. However, NT-proBNP has a longer half-life and is more stable in the bloodstream, making it a more reliable marker for assessing cardiac function [ 6 ]. Traditionally associated with cardiac function, NT-proBNP’s elevation has been correlated with renal outcomes as well. Elevated preoperative NT-proBNP levels have been linked with an increased risk of developing postoperative AKI. This correlation between NT-proBNP concentrations and the risk of any-stage AKI, as well as severe AKI following cardiac procedures, supports its utility as a predictive marker [ 7 , 8 ].

In another study, Patel et al. demonstrated that higher preoperative brain natriuretic peptide (BNP) levels significantly predict the risk of AKI after cardiac surgery. The study suggested that incorporating BNP levels into preoperative evaluations could improve risk stratification and outcomes for patients undergoing cardiac surgery [ 9 ]. Fiorentino et al. demonstrated that while NT-proBNP alone may not significantly predict AKI recovery, its combination with other biomarkers like plasma neutrophil gelatinase-associated lipocalin (NGAL) improves predictive accuracy [ 10 ].

While existing research predominantly focuses on the relationship between preoperative levels of BNP and postoperative AKI, the dynamics of postoperative BNP elevations remain critically underexplored. In addition, patients with impaired kidney function tend to have elevated preoperative BNP [ 11 ]. Therefore, in this specific population, it is difficult to draw effective conclusions only by measuring BNP before surgery. An increase in BNP levels following cardiac surgery may reflect augmented cardiac volume stress [ 12 ], which could indirectly impact renal function and promote the onset of AKI. Furthermore, monitoring perioperative BNP elevation could offer a novel approach for early identification of patients at elevated risk, enabling timely interventions aimed at mitigating the incidence and severity of AKI. In view of the stability of the prediction effect of NT-proBNP on cardiac function, investigating the association between perioperative elevations in NT-proBNP and the development of AKI holds significant promise for enhancing patient management and outcomes following cardiac procedures.

This study seek to bridge this knowledge gap by evaluating the association between postoperative increases in NT-proBNP and the emergence of AKI in a specific patient cohort - those with impaired preoperative renal function, for developing AKI and more severe stages of the condition following cardiac surgery.

Patients and inclusion/exclusion criteria

This research focused on adult individuals who had reduced preoperative kidney function (eGFR between 15 and 60 ml/min/1.73 m²) and who underwent valve, coronary artery bypass, or combined procedures at our facility from July to December 2022. Excluded were those previously on renal replacement therapy (RRT) or with a transplant, those meeting the KDIGO criteria [ 13 ] for preoperative acute kidney injury, those with incomplete health records, those who died within 48 h post-ICU, and those undergoing urgent surgery. The study received approval from the Ethics Committee of Shanghai Zhongshan Hospital (Approval Number B2021–873R), and all participants provided written consent.

This retrospective analysis involved gathering clinical information from electronic health records, covering (1) demographic information: age, gender, body mass index (BMI), and comorbidities such as hypertension and diabetes mellitus. (2) laboratory results: including preoperative and postoperative levels of NT-proBNP, (3) surgical details: type of surgery (valve, CABG, or combined), duration of cardiopulmonary bypass (CPB), and other intraoperative variables. (4) postoperative outcomes: central venous pressure (CVP) upon admission of intensive care unit (ICU), fluid balance, incidence and severity of AKI based on KDIGO criteria, RRT, length of hospital stay, and in-hospital mortality.

Rationale of perioperative care

We used an electronic ICU medical record system that dynamically monitored and followed up on renal function and urine output. This system included automated tracking and alerts for changes in key indicators such as serum creatinine levels and urine output.

Following surgery, SCr was tracked daily in the ICU, with kidney function assessments performed for the first three days after leaving the ICU and then every other day until hospital discharge.

At our institution, NT-proBNP measurement is routinely performed for all hospitalized patients, regardless of their department. This standard practice ensures that comprehensive cardiac monitoring is maintained across all patient populations. Consequently, the perioperative NT-proBNP measurements used in this study were part of the routine clinical care, reinforcing the retrospective nature of the study. The rationale for the blood tests is that blood samples were collected upon ICU admittance and every 24 h postoperatively until the patients were discharged from the ICU. The consistent monitoring typically continued for 3 to 7 days, depending on the patient’s clinical condition and recovery progress.

Definitions

The primary outcome of the study was the incidence of post-surgery AKI, defined by the KDIGO guidelines [ 13 ], which include both serum creatinine and urine output measurements. Participants were divided into two groups according to whether they developed AKI after their operation.

The primary exposure of interest in this study was the perioperative change in NT-proBNP levels, defined as the ratio of the last NT-proBNP level before surgery (usually the morning of the surgery day) to the NT-proBNP level upon admission to the ICU after surgery. This ratio was calculated for each patient and used to assess the association between perioperative NT-proBNP changes and the incidence of postoperative AKI. The NT-proBNP ratio was logarithmically transformed for statistical analysis to normalize its distribution.

The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula [ 14 ] based on the last serum creatinine (SCr) level measured before surgery.

Fluid Balance (FB) was based on detailed records of fluid intake and output were collected for the first 48 h postoperatively or until the diagnosis of AKI, whichever came first. This included intraoperative fluid administration, postoperative fluid management, and daily fluid balance.

In the subgroup analysis, we categorized patients into volume overload (≥ 5%) and non-overload (< 5%) groups based on fluid balance (FB). This classification was derived from previous study [ 15 ].

Statistical analysis

Data analysis utilized R software, version 4.3.0. Data following a normal distribution were presented as mean ± standard deviation, while those not normally distributed were shown as medians with interquartile ranges. Categorical data were expressed as frequencies and percentages. The Kolmogorov-Smirnov test checked for normality and homogeneity of variances. Continuous data differences were assessed using the Student’s t-test or nonparametric equivalents, and categorical data differences were analyzed using Fisher’s exact or chi-square tests. For data not normally distributed, logarithmic (lg) transformed was applied before analysis. To explore the nonlinear association between perioperative change of NT-proBNP and postoperative AKI using restricted cubic splines (RCS) in the context of a clinical study, while adjusting for age, gender, CPB time, surgical type, pre-existing hypertension/diabetes mellitus, preoperative hemoglobin and albumin. Univariate logistic regression identified potential risk factors for postoperative AKI, calculating odds ratios and 95% confidence intervals. Multivariate analysis, employing stepwise forward selection, was applied to variables with P-values less than 0.05, considered predictive of postoperative AKI. To ensure the reliability of our regression analysis, we assessed multicollinearity among the explanatory variables. We calculated the variance inflation factors (VIFs) for each variable included in the model. A VIF value greater than 10 was considered indicative of significant multicollinearity and the variable was excluded from the regression [ 16 ]. Additionally, we performed trend analysis to evaluate the trending association between NT-proBNP quartiles and the endpoints. The optimal cutoff values for biomarkers in predicting the primary outcome were determined by maximizing the Youden index. Subgroup analyses were conducted to explore the associations between NT-proBNP classified with the optimal cut-off and outcomes among individuals of different sexes, ages, surgery, diabetes status, and hypertension status. Interaction tests determine the consistency of these associations across the various subgroups. A P-value of less than 0.05 was set as the threshold for statistical significance.

Basic characteristics

A total of 199 eligible patients were enrolled to this study (Fig.  1 ) and 116 patients (58.3%) developed AKI after cardiac surgery. RRT was performed in 16 patients. The AKI group had higher postoperative NT-proBNP levels (2973.00 vs. 1110.00 pg/mL, P  < 0.001), lower albumin levels (38.84 ± 3.33 vs. 40.92 ± 4.03 g/L, P  < 0.001), higher serum creatinine levels (142.54 ± 44.04 vs. 126.54 ± 37.46 µmol/L, P  = 0.006), and lower eGFR (45.39 ± 10.85vs. 50.04 ± 10.13 ml/min/1.73 m², P  = 0.003). Additionally, postoperative cTnT and CK-MB levels were higher in the AKI group (0.73 vs. 0.31 µg/L, P  < 0.001 and 29.50 vs. 20.00 U/L, P  = 0.001, respectively), and the length of hospital stay was longer (16.50 vs. 15.00 days, P  = 0.017) (Table  1 ).

Flowchart of the patients enrollment

Nonlinear association analysis

The RCS curve analysis was applied to identify potential nonlinear association between logarithmic transformed NT-proBNP and AKI (Fig.  2 A)/AKI stages 2–3 (Fig.  2 B). However, the statistical test for nonlinearity did not reach significance ( P for nonlinear = 0.272 and 0.121), indicating that the relationship between LgNT-proBNP and AKI/AKI stages 2–3 can be adequately described by logistic models in this study.

Potential nonlinear relationship between logarithmic transformed NT-proBNP and AKI

Association between perioperative NT-proBNP change and AKI

Because NT-proBNP in our study was not normally distributed, we performed logarithmic transformations of NT-proBNP and classified them according to their logarithmic quartiles: Q1[-0.701,0.0176), Q2[0.0176,0.282), Q3[0.282,0.629) and Q4[0.629,2.14]. In the logistic regression analysis for risk factors of AKI (Table  2 ), significant predictors in the multivariate analysis included baseline albumin (OR: 0.84, p  = 0.018) and logarithmic transformed Post/Preoperative NT-proBNP levels in the highest quantile (OR: 6.68, p  = 0.017). Trend analysis indicated that the risk of AKI increased with higher NT-proBNP levels (P for trend = 0.007). Gender, age, fluid balance, and other comorbidities like hypertension and diabetes mellitus were not statistically significant risk factors. Notably, elevated levels of logarithmic transformed Post/Preoperative cTnT and CK-MB were associated with an increased risk of AKI in univariate analysis but did not retain significance in the multivariate model. Figure  3  A showed that logarithmic transformed Post/Preoperative NT-proBNP levels significantly excelled with an AUROC of 0.63 (95%CI 0.552–0.708) for prediction of all stages AKI, indicating moderate predictive accuracy. The optimal cut-off point was determined to be 0.31, with a sensitivity of 57.8% and a specificity of 67.5%.

Receiver Operating Characteristic curves for the prediction of all stage AKI and AKI Stage 2–3 based on perioperative NT-proBNP ratio

For AKI stages 2–3, baseline albumin levels (OR:0.83, p  < 0.001), the third (OR:7.70, p  = 0.003) and highest quantiles of logarithmic transformed post/preoperative NT-proBNP (OR:9.38, p  = 0.001) were significant risk factors in the multivariate analysis (Table  3 ). Trend analysis indicated that the risk of AKI increased with higher NT-proBNP levels ( P for trend < 0.001). Other factors like age, gender, hypertension, diabetes mellitus, and CPB duration did not show significant associations. This highlighted the importance of monitoring preoperative albumin and perioperative NT-proBNP levels in predicting severe AKI post-operation. Figure 3B demonstrated the predictive accuracy for AKI stage 2–3, with logarithmic transformed Post/Preoperative NT-proBNP achieving an AUROC of 0.714 (95%CI 0.63–0.798), showcasing good predictive ability. Logarithmic transformed Post/Preoperative NT-proBNP = 0.365 was the best cut-off point, with a sensitivity of 75%, a specificity of 65.2%.

Subgroup analysis

Subgroup analysis was performed to elucidate the heterogeneity of the association between NT-proBNP and endpoints in subgroups. No significant differences were observed between endpoints and logarithmic transformed Post/Preoperative NT-proBNP levels classified with optimal cut-off points (P for interaction > 0.05, Tables  4 and 5 ). Specifically, the results demonstrated that the positive association between endpoints and logarithmic transformed Post/Preoperative NT-proBNP levels was consistently robust in subgroup analyses stratified by age, sex, surgery, CPB application, hypertension, diabetes status and fluid balance.

Advancements in cardiac surgical techniques have enabled an increasing number of patients with pre-existing renal insufficiency to undergo cardiac operations. However, this patient cohort is at heightened risk for developing AKI postoperatively [ 17 ], underscoring the imperative for early prediction of AKI risk among these high-risk individuals. In this study, we identified that changes in NT-proBNP levels during the perioperative period can predict the occurrence of AKI and severe AKI. Moreover, we found the optimal cut-off point for prediction of AKI and AKI stage 2–3, and subgroup analysis showed consistency of the association among subgroups. To the best of our knowledge, this is the first study addressing the predictive value of the perioperative change of NT-proBNP for cardiac surgery associated AKI .

While prior investigations in general populations have established a correlation between preoperative BNP levels and the incidence of postoperative AKI [ 7 , 8 , 9 ], the predictive value of preoperative BNP is compromised in patients with pre-existing renal insufficiency due to inherently elevated BNP levels [ 18 ]. Consequently, relying solely on preoperative BNP levels to predict postoperative AKI risk in this specific patient subset presents considerable challenges. The results of the present study underlined the significant role of elevated perioperative NT-proBNP levels in predicting AKI post-cardiac surgery, specifically in patients with compromised preoperative renal function.

In our study, NT-proBNP was not normally distributed; therefore, we performed a base-10 logarithmic transformation and grouped it according to its quartiles. Multivariate regression analysis showed that the highest quartile group, Q4 [0.629, 2.14], was associated with AKI, meaning that when postoperative NT-proBNP increased to 4.26 times the preoperative level, the risk of AKI was 5.68 times higher compared to patients in Q1, whose postoperative NT-proBNP increased to less than 1.04 times the preoperative level or decreased. Simultaneously, Q3 and Q4 were associated with AKI stages 2–3, meaning that when postoperative NT-proBNP increased to 1.91–4.26 times the preoperative level, the risk of AKI stages 2–3 was 6.7 times higher compared to patients in Q1, and when postoperative NT-proBNP increased to 4.26 times the preoperative level, the risk of AKI stages 2–3 was 8.38 times higher compared to patients in Q1.

Our findings showed that the sensitivity and specificity of NT-proBNP for predicting AKI (AUROC 0.63) and AKI stage 2–3 (AUROC 0.714) are moderate. Despite this, NT-proBNP remains valuable in clinical practice for several reasons: Firstly, even with moderate accuracy, NT-proBNP provides significant predictive information, especially in high-risk populations such as those with preoperative renal impairment.

Secondly, our subgroup analysis showed consistent associations between NT-proBNP levels and AKI risk across different patient groups, supporting its reliability as a predictive biomarker. In addition, NT-proBNP should be used alongside other biomarkers and clinical indicators to enhance overall predictive accuracy and provide a comprehensive assessment of AKI risk.

The utility of NT-proBNP measured at ICU admission is supported by its ability to reflect the immediate postoperative state of cardiac stress. For patients who developed AKI shortly after surgery, elevated NT-proBNP levels at ICU admission likely indicate early signs of cardiac stress and dysfunction. For those who developed AKI a few days later, NT-proBNP levels at admission may still serve as a indicative reference and provide valuable predictive information, indicating an ongoing risk due to increased cardiac stress and reduced renal clearance capacity [ 18 ].

While NT-proBNP is traditionally considered a marker of cardiac stress, it is important to note that elevated NT-proBNP levels can also result from impaired renal clearance due to AKI or CKD [ 18 ]. This suggested that NT-proBNP may serve more as an indicator of existing renal dysfunction rather than a direct cause of AKI or solely a marker of increased cardiac stress.

While NT-proBNP is typically associated with volume status, our study found no significant differences in fluid balance and CVP between the AKI and non-AKI groups. This suggested that the predictive value of NT-proBNP for AKI in our cohort may not be solely related to alteration in volume status.

Additionally, subgroup analyses showed that the association between NT-proBNP levels and AKI remained consistent across various subgroups, including those classified by fluid balance. This indicates that BNP’s predictive value for AKI is robust and not significantly influenced by volume status as measured by fluid balance or CVP.

However, while the predictive value of NT-proBNP is clear, our findings also echo the complexity of AKI as a multifactorial condition, particularly within the setting of cardiac surgery. This complexity mandates a multifactorial approach to risk assessment, highlighting the limitations of relying solely on NT-proBNP or any single biomarker for predicting postoperative renal outcomes. This perspective was bolstered by recent discussions in the literature which advocated for the use of multi-biomarker strategies for improving the accuracy and reliability of AKI predictions [ 19 ].

Nevertheless, while our study offers significant insights, it is not without limitations. The retrospective design limits our ability to infer causality between elevated NT-proBNP levels and the incidence of AKI. Prospective studies are needed to confirm our findings and establish a temporal relationship between NT-proBNP levels and AKI development. Additionally, our study population, derived from a single center, may limit the generalizability of our findings. The demographic and clinical characteristics specific to our institution may not be representative of other settings, highlighting the need for multicenter studies to validate our results across different populations and healthcare settings.

Additionally, the timing of NT-proBNP measurements in our retrospective study were based on routine clinical practice rather than a predefined protocol. In our hospital, the first postoperative NT-proBNP was measured at the admission to the ICU. This may mainly reflect the intraoperative cardiac function or fluid overload.

Moreover, our study did not account for all possible confounders that could influence NT-proBNP levels, such as intraoperative hemodynamic changes. The impact of these factors on NT-proBNP levels warrants further investigation to elucidate the multifaceted dynamics at play.

Other biomarkers such as serum and urine neutrophil gelatinase-associated lipocalin (NGAL), urinary kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) are known to have predictive value for AKI [ 20 ]. Unfortunately, these biomarkers were not included in our routine diagnostic panel due to national health insurance policies. As these biomarkers are classified as out-of-pocket expenses, not all patients were willing or able to bear these additional costs, limiting their use in our study. As a result, we were unable to compare the predictive value of NT-proBNP with these other biomarkers.

Conclusions

This study highlighted the predictive value of perioperative changes in NT-proBNP levels for AKI and severe AKI in cardiac surgery patients with preoperative renal impairment. NT-proBNP levels, routinely available and indicative of both cardiac stress and renal function, can aid in early identification of high-risk patients.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Acute Kidney Injury

Brain Natriuretic Peptide

Chronic Kidney Disease

Cardiopulmonary Bypass

Cardiac Troponin T

Estimated Glomerular Filtration Rate

Intensive Care Unit

Kidney Disease: Improving Global Outcomes

N-terminal pro-B-type Natriuretic Peptide

Restricted Cubic Spline

Serum Creatinine

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Acknowledgements

We are grateful for the contribution of the study personnel from the department of nephrology, cardiac surgery and critical care for persistent contribution to the maintenance of the cardiac surgery database.

This work was supported by National Nature Science Foundation of China, No. 82102289; Shanghai Federation of Nephrology Project supported by Shanghai ShenKang Hospital Development Center, No. SHDC2202230; Shanghai “science and technology innovation plan " Yangtze River Delta scientific and technological Innovation Community project, No. 21002411500.

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Yiting Ma and Jili Zheng contributed equally to this work.

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Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China

Yiting Ma, Jili Zheng & Wanting Zhou

Department of Cardiac Surgery Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China

Department of Nephrology, Zhongshan Hospital, Fudan University, No 180 Fenglin Rd, Shanghai, China

Wuhua Jiang

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JZ, ZL and WJ designed and directed the study, YM and WZ participated in data collection and maintenance, YM, WZ and JZ analyzed the data, YM, WZ and WJ interpreted the results and writing. WJ and ZL participated in reviewing the manuscript, the maintenance of dataset and facilitating the acquisition of data. All authors read and approved the final manuscript.

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Correspondence to Wuhua Jiang .

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This study was approved by the ethical board from Zhongshan Hospital, Fudan University (Approval Number B2021–873R). All participants provided written consent. The study was conducted in accordance with the Helsinki Declaration (WMA Declaration of Helsinki, 2013).

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Ma, Y., Zheng, J., Zhou, W. et al. Predictive value of perioperative NT-proBNP levels for acute kidney injury in patients with compromised renal function undergoing cardiac surgery: a case control study. BMC Anesthesiol 24 , 298 (2024). https://doi.org/10.1186/s12871-024-02672-w

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DOI : https://doi.org/10.1186/s12871-024-02672-w

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Proteomic analysis identifies dysregulated proteins in albuminuria: a south african pilot study.

Simple Summary

1. introduction, 2. materials and methods, 2.1. ethics statement, 2.2. the study population, 2.3. clinical laboratory tests, 2.4. urine protein extraction, 2.5. retrospective power analysis, 2.6. data analysis and pathway analysis, 3.1. clinical and demographic characteristics of patients, 3.2. performance of study-specific system suitability-quality control, 3.3. differentially abundant proteins between cases and controls, 3.4. potential markers for albuminuria and normoalbuminuria classification, 3.5. functional enrichment analysis of differentially abundant proteins, 4. discussion, 5. conclusions, supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Khoza, S.; George, J.A.; Naicker, P.; Stoychev, S.H.; Fabian, J.; Govender, I.S. Proteomic Analysis Identifies Dysregulated Proteins in Albuminuria: A South African Pilot Study. Biology 2024 , 13 , 680. https://doi.org/10.3390/biology13090680

Khoza S, George JA, Naicker P, Stoychev SH, Fabian J, Govender IS. Proteomic Analysis Identifies Dysregulated Proteins in Albuminuria: A South African Pilot Study. Biology . 2024; 13(9):680. https://doi.org/10.3390/biology13090680

Khoza, Siyabonga, Jaya A. George, Previn Naicker, Stoyan H. Stoychev, June Fabian, and Ireshyn S. Govender. 2024. "Proteomic Analysis Identifies Dysregulated Proteins in Albuminuria: A South African Pilot Study" Biology 13, no. 9: 680. https://doi.org/10.3390/biology13090680

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