The NEPHROCHECK Test System Training Program The NEPHROCHECK Training Program US: Astute Medical, Inc. 2014 PN 700001 Rev D 2014/09/16
Learning Objectives At the conclusion of this training, participants will be able to: 1. Evaluate the importance of risk assessment for Acute Kidney Injury (AKI). 2. Identify the NEPHROCHECK Test System components. 3. Summarize how to run the NEPHROCHECK Test. 4. Interpret the NEPHROCHECK Test results in the context of the NEPHROCHECK Test s performance. 5. Recognize the NEPHROCHECK Test limitations and their implications in the use of the test. 6. Identify the components of the NEPHROCHECK Test training program and related support services. 7. Understand how to request additional training and how to access training materials. 2
Table of Contents I. Importance of Risk Assessment for AKI II. The NEPHROCHECK Test System III. Clinical Performance IV. Interpreting the NEPHROCHECK Test Results V. Limitations of the NEPHROCHECK Test VI. Training Program Materials and Support 3
I. Importance of Risk Assessment for AKI 4
Identification of Patients at Risk for Acute Kidney Injury Is an Unmet Clinical Need Acute kidney injury (AKI) is prevalent in critically ill patients and has serious consequences. 1 High incidence (2.1/1000 population) 2,3 similar to that of acute myocardial infarction Increased risk of death or end-stage renal disease developing within at least one year following the index event 3,4 1. Uchino S, Kellum JA, Bellomo R et al. J Am Med Assoc. 2005;294(7):813-8. 2. Ali T, Khan I, Simpson W et al. J Am Soc Nephrol. 2007;18(4):1292-8. 3. Kellum JA, Bellomo R, Ronco C. J Am Med Assoc. 2012;307(21)2265-6. 4. Amdur RL, Chawla LS, Amodeo S et al. Kidney Int. 2009;76(10):1089-97. 5
Identification of Patients at Risk for Acute Kidney Injury Is an Unmet Clinical Need Early recognition and management of patients at risk for AKI is paramount since there are no specific therapies to reverse established AKI. 1 As compared to myocardial infarction, AKI may not provide early signs and symptoms sufficient to guide risk assessment. 2 Current methods for risk assessment are insufficient, placing substantial numbers of patients at serious risk of death and morbidity. 1,2 1. KDIGO Clinical Practice Guideline. Kidney Inter. Suppl. 2012;2:1 138. 2. MacLeod A. Lancet. 2009;374:1405-6. 6
II. The NEPHROCHECK Test System 7
The NEPHROCHECK Test The NEPHROCHECK Test should not be used as a standalone test and results have only been validated in patients who currently have or have had within the past 24 hours acute cardiovascular and or respiratory compromise and are ICU patients. Test results should be evaluated in the context of all clinical and laboratory data available. In those instances where the NEPHROCHECK Test results do not agree with the clinical evaluation, clinical judgment and additional tests should be used accordingly. 8
The NEPHROCHECK Test System Components 9
The NEPHROCHECK Test System Components Materials Provided The NEPHROCHECK Test Kit contains all the reagents needed for the generation of NEPHROCHECK Test results in human adult urine specimens. The NEPHROCHECK Test Kit (Part Number 500011) contains: NEPHROCHECK Test... 25 NEPHROCHECK Test Conjugate Vial... 25 NEPHROCHECK Test RFID Card... 1 NEPHROCHECK Test Buffer (2 x 5 ml)... 1 NEPHROCHECK Test Kit Package Insert... 1 Materials Required But Not Provided ASTUTE140 Meter Kit (PN 500017) NEPHROCHECK Liquid Control Kit (PN 500013) NEPHROCHECK Calibration Verification Kit (PN 500009) NEPHROCHECK Electronic Quality Control (PN 400016) Calibrated precision pipette, capable of dispensing 100 µl 10
The NEPHROCHECK Test Warnings and Precautions The NEPHROCHECK Test is not for Point-of-Care Use 11
Principle of the NEPHROCHECK Test: Fluorometric Sandwich Immunoassay Single-use cartridge consists of a membrane test strip with proprietary reagents enclosed in a plastic housing that is precisely molded for reproducible and accurate results Membrane test strip has capture antibodies immobilized in discreet zones for quantitative detection of urinary biomarkers TIMP-2 and IGFBP-7, and for checking Test integrity Fluorescent antibody reagents are mixed with a patient s urine sample and are applied to the single-use cartridge 12
Performing the NEPHROCHECK Test Buffer Vial Step 1 Pipette 100 µl of buffer into conjugate vial Step 3 Pipette 100 µl of mixed sample into cartridge Step 4 Place cartridge in meter Step 5 20 minutes to results Conjugate Vial Step 2 Pipette 100 µl of centrifuged urine into conjugate vial Urine Specimen Cup Each lot of the NEPHROCHECK Test cartridges and the ASTUTE140 Meter is calibrated at the factory no need for user calibration Lot-specific information such as assay calibration curves and expiration date are loaded into the ASTUTE140 Meter from the RFID card. 13
Quality Control Considerations The NEPHROCHECK Test System incorporates several methods for Quality Control, including the NEPHROCHECK Test Liquid Controls, the NEPHROCHECK Test Calibration Verification (Cal Vers) Materials and the ASTUTE140 Electronic Quality Control (EQC Device). Good Laboratory Practice suggests: NEPHROCHECK Test Liquid Controls should be tested: Every 30 days With each new lot number of NEPHROCHECK Test Kits With each new shipment of the NEPHROCHECK Test Kits After ASTUTE140 Meter maintenance or servicing In accordance with your local, state, and/or federal regulations or accreditation requirements and standard quality control procedures NEPHROCHECK Test Calibration Verification Materials should be tested: At least once every 6 months After ASTUTE140 Meter maintenance or servicing In accordance with local, state, and/or federal regulations or accreditation requirements. ASTUTE140 Electronic Quality Control (EQC) Device be tested: Daily After ASTUTE140 Meter maintenance or servicing In accordance with your local, state, and/or federal regulations or accreditation requirements 14
The NEPHROCHECK Test Results The ASTUTE140 Meter automatically calculates and displays a single numerical test result (AKIRISK Score) derived from the measurement of TIMP-2 and IGFBP-7. The AKIRISK Score is displayed on the ASTUTE140 Meter screen without units after the NEPHROCHECK Test procedure is completed. Results for the individual markers are not displayed. The numerical AKIRISK Score is calculated by multiplying the concentrations of the two biomarkers, and then dividing by 1000: The NEPHROCHECK Test Result (AKIRISK Score) = [TIMP-2]*[IGFBP-7] (units = (ng/ml) 2 /1000) 1000 15
III. Clinical Performance 16
The NEPHROCHECK Test Was Validated in Two Clinical Studies in the Intended Use Population 23 sites in the US Age 21, Intended Use population*, Within ± 24 hrs of ICU admission N = 408 Urine sample collected at enrollment No AKI N = 337 Study A Diagnosis of AKI or No AKI within 12 hours after enrollment as determined by an adjudication committee AKI N = 71 * Intended Use Population: patients who currently have or have had within the past 24 hours acute cardiovascular and or respiratory compromise and are ICU patients Patient status within the 12 hours after enrollment Study B 6 sites in the US Age 21Intended Use population*, Within ± 24 hrs of ICU admission N = 126 Urine sample collected at enrollment Diagnosis of AKI or No AKI within 12 hours after enrollment as determined by an adjudication committee Patient status within the 12 hours after enrollment No AKI AKI N = 97 N = 29 NEPHROCHECK Test measurement of urine samples NEPHROCHECK Test measurement of urine samples 17
The 408 Intended Use Patients Were Stratified into Two Groups by AKIRisk Score (Study A) Negative AKIRisk Score ( 0.3) 163 Intended Use Patients Positive AKIRisk Score (> 0.3) 245 Intended Use Patients 6 patients had AKI 157 patients didn t have AKI = AKI = No AKI Patient status within the 12 hours after enrollment 65 patients had AKI 180 patients didn t have AKI 18
The 126 Intended Use Patients Were Stratified into Two Groups by AKIRISK Score (Study B) Negative AKIRisk Score ( 0.3) 56 Intended Use Patients Positive AKIRisk Score (> 0.3) 70 Intended Use Patients k 7 patients had AKI 49 patients didn t have AKI 22 patients had AKI 48 patients didn t have AKI = AKI = No AKI Patient status within the 12 hours after enrollment 19
How Do NEPHROCHECK Test Results Relate to Negative and Positive Predictive Values (NPV and PPV) for the Cutoff > 0.3 in Intended Use Patients? (Study A) Negative AKIRisk Score ( 0.3) 163 Intended Use Patients Positive AKIRisk Score (> 0.3) 245 Intended Use Patients NPV: proportion of Intended Use patients with Negative AKIRISK Score 0.3 who did not have AKI PPV: proportion of Intended Use patients with Positive AKIRISK Score > 0.3 who had AKI NPV = 157 ( No AKI patients with AKIRISK Score 0.3) 163 (all patients with AKIRISK Score 0.3) NPV = 96% X 100% 96% of Intended Use patients with a Negative AKIRisk Score ( 0.3) did not manifest moderate to severe AKI within 12h. PPV = 65 ( AKI patients with AKIRISK Score > 0.3) 245 (all patients with AKIRISK Score > 0.3) PPV = 27% 27% (1 out of 4) of Intended Use patients with a Positive AKIRisk Score (> 0.3) manifested moderate to severe AKI within 12h. 20 X 100
How Do NEPHROCHECK Test Results Relate to Negative and Positive Predictive Values (NPV and PPV) for the Cutoff > 0.3 in Intended Use Patients? (Study B) Negative AKIRisk Score ( 0.3) 56 Intended Use Patients Positive AKIRisk Score (> 0.3) 70 Intended Use Patients k NPV: proportion of Intended Use patients with a Negative AKIRISK Score 0.3 who did not have AKI PPV: proportion of Intended Use patients with a Positive AKIRISK Score > 0.3 who had AKI NPV = 49( No AKI patients with AKIRISK Score 0.3) 56 (all patients with AKIRISK Score 0.3) NPV = 88% X 100% 88% of Intended Use patients with a Negative AKIRisk Score ( 0.3) did not manifest moderate to severe AKI within 12h. PPV = 22 ( AKI patients with AKIRISK Score > 0.3) 70 (all patients with AKIRISK Score > 0.3) PPV = 31% X 100 31% (1 out of 3) of Intended Use patients with a positive AKIRisk Score (> 0.3) manifested moderate to severe AKI within 12h. 21
Clinical Performance was Evaluated in Two Studies: A and B 90 th Percentile 75 th Percentile Median 25 th Percentile 10 th Percentile The AKIRISK Score was not statistically different between studies A and B (p > 0.05 for No AKI subjects and for AKI subjects). For subjects with AKI, variability in the AKIRISK Score (indicated by the interquartile range (Central 95%)) in Study B was larger than in Study A and was associated with a lower sensitivity in Study B (0.76, 95% CI 0.60-0.91) compared with Study A (0.92, 95% CI 0.85-0.98). 22
Comparison of AKIRISK Score with Diagnosis of AKI or No AKI (Study A and B) Study A Laboratory 1 AKIRISK Score > 0.3 AKIRISK Score 0.3 Total Number of Test Results AKI 65 (16.0%) TP 6 (1.5%) FN No AKI 182 (44.7%) FP 154 (37.8%) TN Total Number of Test Results* 247 160 71 336 407 Study A Laboratory 2 AKIRISK Score > 0.3 AKIRISK Score 0.3 Total Number of Test Results AKI 64 (15.7%) TP 7 (1.7%) FN No AKI 172 (42.3%) FP 164 (40.3%) TN Total Number of Test Results* 236 171 71 336 407 Study A Laboratory 3 AKIRISK Score > 0.3 AKIRISK Score 0.3 Total Number of Test Results AKI 66 (16.2%) TP 5 (1.2%) FN No AKI 186 (45.7%) FP 150 (36.9%) TN Total Number of Test Results* 252 155 71 336 407 Study B AKI No AKI AKIRISK Score > 0.3 AKIRISK Score 0.3 Total Number of Test Results 22 (17.5%) TP 7 (5.6%) FN 48 (38.1%) FP 49 (38.9%) TN Total Number of Test Results 70 56 29 97 126 TP = True Positive, FP = False Positive, FN = False Negative, TN = True Negative AKI prevalence was 17% in Study A and 23% in Study B * In Study A, test results from 407 of 408 enrolled patients are reported from each laboratory, because each laboratory had one missing test result. The missing test result was from a different patient at each laboratory (altogether, 3 patients were missing a test result from one laboratory but had test results from the other two laboratories, and 405 patients had test results from all three laboratories). 23
IV. Interpreting the NEPHROCHECK Test Results 24
The NEPHROCHECK Test Intended Use and Indications The Astute Medical NEPHROCHECK Test System is intended to be used in conjunction with clinical evaluation in patients who currently have or have had within the past 24 hours acute cardiovascular and or respiratory compromise and are ICU patients as an aid in the risk assessment for moderate or severe acute kidney injury (AKI) within 12 hours of patient assessment. The NEPHROCHECK Test System is intended to be used in patients 21 years of age or older. 25
The NEPHROCHECK Test Reportable Range and Reference Ranges Result Reportable Range* AKIRISK Score 0.04-10.00* * AKIRISK Scores that are outside the above reportable range are reported as either < 0.04 or > 10.00 by the ASTUTE140 Meter. If the AKIRISK Score is > 10.00, the specimen should not be diluted for retesting. Cohort Gender Number of Subjects AKIRISK Score Range Apparently Healthy subjects Subjects with stable chronic morbidities Intended Use subjects with No AKI (Study A) Intended Use subjects with AKI (Study A) All 378 0.04-2.25 All 372 0.05-2.20 All 337 0.04-2.62 All 71 0.10-8.47 Based on central 95% 26
Distribution of the NEPHROCHECK Test Results by Cohort (Study A) 7 Laboratory 1 Laboratory 2 Laboratory 3 6 5 90 th Percentile AKIRISK Score 4 3 2 1 0 N = 378 N = 372 N = 336 N = 71 N = 336 N = 71 N = 336 N = 71 75 th Percentile Median 25 th Percentile 10 th Percentile Apparently healthy subjects Subjects with chronic stable morbidities No AKI AKI No AKI AKI No AKI Intended Use Subjects AKI AKIRISK Scores are not elevated (relative to results for apparently healthy subjects) for subjects with chronic comorbidities or for subjects representative of the intended use population without AKI. Conversely, AKIRISK Scores are substantially elevated for subjects representative of the intended use population with AKI. Because there is overlap between the distributions of the AKIRISK Scores for No AKI and AKI, NEPHROCHECK Test results cannot be used as standalone results, and, based on the low PPV, a result > 0.3 is not necessarily predictive of developing moderate to severe AKI within a specific time frame. 27
NEPHROCHECK Test Operating Characteristics for the Cutoff of > 0.3 for Moderate to Severe AKI Within 12 Hours of Patient Assessment for Risk of AKI (Studies A and B) Statistic Sensitivity (TPR) Study A N = 408 (95% CI) 0.92 (0.85, 0.98) Study B N = 126 (95% CI) 0.76 (0.60, 0.91) FNR (1- Sensitivity) 0.08 (0.02, 0.15) 0.24 (0.09, 0.40) Sensitivity (equivalent to true positive rate or TPR): the AKIRISK Score was positive (> 0.3) for 76-92% of the patients of the intended use population who manifested moderate to severe AKI within 12 hours of patient assessment for risk of moderate to severe AKI. Thus, the NEPHROCHECK Test captured the majority (76-92%) of the AKI cases. False negative rate (FNR; equivalent to 1-sensitivity): the AKIRISK Score was negative ( 0.3) for 8-24% of the patients who manifested moderate to severe AKI within 12 hours of patient assessment for risk of moderate to severe AKI. Thus, for a negative AKIRISK Score ( 0.3), the clinician should consider all clinical information and manage the patient according to standard of care. 28
NEPHROCHECK Test Operating Characteristics for the Cutoff of > 0.3 for Moderate to Severe AKI Within 12 Hours of Patient Assessment for Risk of AKI (Studies A and B) Statistic Specificity (TNR) Study A N = 408 (95% CI) 0.46 (0.41, 0.52) Study B N = 126 (95% CI) 0.51 (0.41, 0.60) FPR (1- Specificity) 0.54 (0.48, 0.59) 0.49 (0.40, 0.59) Specificity (equivalent to true negative rate or TNR): the AKIRISK Score was negative (< 0.3) for 46%-51% of the patients in the intended use population who did not manifest moderate to severe AKI within 12 hours of patient assessment for risk of moderate to severe AKI. False positive rate (FPR; equivalent to 1 specificity): the AKIRISK Score was positive (> 0.3) for 49%-54% of the patients (approximately 1 out of every 2 patients) who did not manifest moderate to severe AKI within 12 hours of patient assessment for risk of moderate to severe AKI. Therefore a positive AKIRISK Score of (> 0.3) must be evaluated with other clinical and laboratory findings and may not be predictive of developing AKI within 12 hours of patient assessment. 29
Understanding the NEPHROCHECK Test Results In Intended Use Patients Based on the PPV of 27 (Study A) 31 (Study B)%, a positive AKIRISK Score (> 0.3) is not necessarily predictive of developing moderate to severe AKI within a specific time frame. The patient might not develop moderate to severe AKI within 12 hours of evaluation. NEPHROCHECK Test Result What It Means Positive AKIRISK Score (> 0.3) Patient could develop moderate to severe AKI within 12 hours of evaluation. Negative AKIRISK Score ( 0.3) Patient might not develop moderate to severe AKI within 12 hours of evaluation. Based upon results from clinical testing, patients in the intended use population with negative AKIRISK TM Scores (< 0.3) are at lower risk of developing moderate to severe AKI within 12 h of assessment than patients in the intended use population with positive AKIRISK TM Scores (> 0.3). 30
V. Limitations of the NEPHROCHECK Test 31
Limitations of the NEPHROCHECK Test Result The NEPHROCHECK Test should not be used as a standalone test. Results have only been validated in patients who currently have or have had within the past 24 hours acute cardiovascular and or respiratory compromise and are ICU patients. An AKIRISK Score > 0.3 may not be indicative of developing moderate to severe AKI within 12 hours of sampling. All NEPHROCHECK Test results should be evaluated in the context of all clinical and laboratory data available. In those instances where NEPHROCHECK Test results do not agree with clinical evaluation, clinical judgment and additional tests should be used accordingly. In addition, not all patients who manifest AKI will test positive on the NEPHROCHECK Test, and some patients who test positive will not manifest AKI. The AKIRISK Score is intended to be used in conjunction with clinical evaluation as an adjunct to standard of care. 32
Limitations of the NEPHROCHECK Test Result The following substances exhibited significant interference (exhibited a bias exceeding 10%) with the AKIRISK Score as described below: Urinary albumin at concentrations above 125 mg/dl interfere with the NEPHROCHECK Test results. Urinary albumin at concentrations above 3000 mg/dl cause an invalid test result. Urinary bilirubin at concentrations above 7.2 mg/dl interfere with the NEPHROCHECK Test results. Use caution in interpreting NEPHROCHECK Test results in patients with significant proteinuria or severe hyperbilirubinuria. Methylene blue at concentrations above 0.49 mg/l interferes with NEPHROCHECK Test results. 33
Limitations of the NEPHROCHECK Test Result Variability in the AKIRISK Score has been observed in normal populations and by race. A wide range in the values of AKIRISK Scores was observed in apparently healthy subjects and subjects with stable chronic morbidities and the range of observed values of AKIRISK Scores was wider for Caucasians than for non-caucasians for each cohort (apparently healthy subjects; subjects with stable chronic morbidities; and patients in the intended use population). Although greater variability in the AKIRISK Scores was observed with Caucasian subjects than for non-caucasians, logistic covariate analysis demonstrated that race (Caucasian, non-caucasian) did not have a statistically significant main effect, whereas the NEPHROCHECK Test was highly significant (p < 0.0001); therefore the NEPHROCHECK Test performance is robust with respect to race. 34
VI. Training Program and Support 35
The NEPHROCHECK Test System Training Program Materials NEPHROCHECK Test System Training Program PowerPoint slide presentation Supplemental training materials include copies of the: NEPHROCHECK Test Instructions for Use NEPHROCHECK Liquid Controls Kit Instructions for Use; NEPHROCHECK Calibration Verification (Cal Vers) Kit Instructions for Use ASTUTE140 Meter Manual, and NEPHROCHECK Proficiency Test. 36
Identification of Trainees Potential personnel to receive training: Potential Department(s) Role Possible Job Titles critical care physicians Intensive Care Unit(s) Personnel ordering the test interpreting/using the test results nephrologists intensivists residents cardio-thoracic surgeons Medical Floor Personnel Emergency Department Personnel ordering the test interpreting/using the test results ordering the test interpreting/using the test results anesthesiologists hospitalists physicians residents physicians residents Laboratory running the test laboratory professionals 37
How to Request Additional Training To request additional training for new employees or additional potential users of the Astute NEPHROCHECK Test System, please contact: Your Astute Medical Trainer, Your Astute Sales Representative, or Astute Medical s Customer Support Team Astute Medical, Inc. 3550 General Atomics Court Building 2 San Diego, CA 92121 USA Phone: +1 (855) 317-2788 Fax: +1 (858) 332-0690 Email: customerservice@astutemedical.com Email: technicalsupport@astutemedical.com 38
How to Access Training Materials To access the NEPHROCHECK Test Training Materials on the web, go to www.astutemedical.com/education Materials are password protected Password may be obtained by contacting your Astute Medical Trainer or Astute Medical s Customer Support Team Copies of Training Materials are also available by request through your Astute Medical Trainer, Astute Medical Sales Representative or Astute Medical s Customer Support Team Trainings may be scheduled during weekends and across shifts (e.g., evenings, nights and early mornings) On-site and web-conferenced based trainings are available 39
Customer Service and Technical Support For questions regarding the use or performance of the NEPHROCHECK Test Kit or any Astute Medical, Inc. product, please contact Astute Technical Support. Astute Medical, Inc. 3550 General Atomics Court Building 2 San Diego, CA 92121 USA Phone: +1 (855) 317-2788 Fax: +1 (858) 332-0690 Email: customerservice@astutemedical.com Email: technicalsupport@astutemedical.com Slides will be posted on the Astute Medical education page: www.astutemedical.com/education 40