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\begin{document}

\title{The Measurement of Neutrophil Gelatinase Associated Lipocalin In
Umbilical Cord Blood And The Assessment Of Its Relationship With
Neonatal Results}



\author[1]{Seckin ILTER}%
\author[2]{Sabahattin ERUGRUL}%
\author[2]{İbrahim DEGER}%
\author[2]{Sibel TANRIVERDİ YILMAZ}%
\author[3]{ilyas yolbaş}%
\affil[1]{Siverek State Hospital, Şanlıurfa}%
\affil[2]{Dicle University Medical Faculty}%
\affil[3]{Dicle Universitesi}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: The aim of this study was to investigate the relationship
between umbilical cord blood neutrophil gelatinase-associated lipocalin
and neonatal diseases, such as acute kidney injury. Materials and
Method: The neutrophil gelatinase-associated lipocalin levels were
measured in umbilical cord blood of 180 babies born in the department of
Obstetrics and Gynecology between 2015-2016. Patients were classified
according to maternal diseases, neonatal diseases, and demographic
features. The obtained data were compared with umbilical cord blood
neutrophil gelatinase-associated lipocalin levels. Results: There was a
statistically significant difference between umbilical cord blood NGAL
levels and premature rupture of membranes (p\textless{}0.05), ABO
incompatibility (p\textless{}0.05), meconium aspiration syndrome
(p\textless{}0.001), ventricular septal defect (p\textless{}0.001), and
breech presentation birth (p\textless{}0.001). Conclusion: neutrophil
gelatinase-associated lipocalin can be useful as a diagnostic biomarker
in the evaluation of maternal and neonatal diseases. However, further
studies on larger patient populations are needed.%
\end{abstract}%



\sloppy


\textbf{Abstract}

\textbf{Aim:} The aim of this study was to investigate the relationship
between umbilical cord blood neutrophil gelatinase-associated lipocalin
and neonatal diseases, such as acute kidney injury.

\textbf{Materials and Method:} The neutrophil gelatinase-associated
lipocalin levels were measured in umbilical cord blood of 180 babies
born in the department of Obstetrics and Gynecology between 2015-2016.
Patients were classified according to maternal diseases, neonatal
diseases, and demographic features. The obtained data were compared with
umbilical cord blood neutrophil gelatinase-associated lipocalin levels.

\textbf{Results:} There was a statistically significant difference
between umbilical cord blood NGAL levels and premature rupture of
membranes (p\textless{}0.05), ABO incompatibility (p\textless{}0.05),
meconium aspiration syndrome (p\textless{}0.001), ventricular septal
defect (p\textless{}0.001), and breech presentation birth
(p\textless{}0.001).

\textbf{Conclusion:} neutrophil gelatinase-associated lipocalin can be
useful as a diagnostic biomarker in the evaluation of maternal and
neonatal diseases. However, further studies on larger patient
populations are needed.

\textbf{What's already known about this topic?}

The studies, it has been observed that NGAL plays a critical role in the
transformation of the leading cells in the developing kidney into
epithelial and tubule cells. It has been shown that the concentration of
this protein in serum increases dramatically if epithelial organs are
damaged by ischemia-reperfusion or sepsis.

\textbf{What does this article add?}

The NGAL levels in umbilical cord blood, which may be a marker for the
diseases that occur in the neonatal period. Umbilical cord blood NGAL
levels may also be related to maternal diseases and perinatal and
neonatal morbidities.

\textbf{Introduction}

Neutrophil gelatinase-associated lipocalin (NGAL), also known as
Lipocalin 2, is a protein that belongs to the lipocalin protein family
and weighs 25 kDa. It is covalently bonded to gelatinase in neutrophils,
takes part in iron transport, and is released at very low levels from
many other tissues such as kidney, lung, stomach, colon as well as
neutrophils.\textsuperscript{(1)}

According to the experimental animal studies conducted recently, NGAL is
released in the kidneys in the early stages of ischemic injury. With
these studies, it has been observed that NGAL plays a critical role in
the transformation of the leading cells in the developing kidney into
epithelial and tubule cells. It has been shown that the concentration of
this protein in serum increases dramatically if epithelial organs are
damaged by ischemia-reperfusion or sepsis.

To date, elevated serum and urine NGAL levels in neonates have been
associated with intrauterine hypoxia, sepsis, bronchopulmonary
dysplasia, and acute kidney injury (AKI).
\textsuperscript{(2-6)}Although data on umbilical cord blood NGAL
concentrations are insufficient, it was demonstrated that NGAL
measurements could be predictive for certain diseases, such as neonatal
infections.\textsuperscript{(7)}

Until now, no accepted reference NGAL values have been determined for
neonates. Different serum and urine NGAL levels have been reported in
studies by different researchers.

In our study, we aimed to investigate NGAL levels in umbilical cord
blood, which may be a marker for the diseases that occur in the neonatal
period. Umbilical cord blood NGAL levels may also be related to maternal
diseases and perinatal and neonatal morbidities.

\section*{Material and Methods}

{\label{material-and-methods}}

We used the umbilical cord blood of 180 babies born in Gynecology and
Obstetrics Clinic in 2015-2016. This prospective study was approved by
the Dicle University medical school ethics committee.

Umbilical cord blood samples were collected from neonates who born in
Dicle University Obstetrics and Gynecology Clinic. The blood samples
were centrifuged for 10 minutes at 4000 rpm and were kept at -20 \selectlanguage{ngerman}°C.
Serum NGAL was studied on these 180 blood samples obtained. Serum NGAL
levels were measured by the enzyme-linked immunosorbent assay (ELISA)
technique via a commercial kit (SunRed\textsuperscript{®} Biotechnology
Company).

The gestational ages of the babies were determined according to the last
menstrual period or the New Ballard Score. Those with a gestational age
below 37 weeks were classified as preterm, those with a gestational age
between 37-42 weeks were classified as term, and those with a
gestational age over 42 weeks were classified as postterm. There were no
babies in our study older than 42 weeks. The babies were divided as 28
weeks below, 28-31 weeks, 32-37 weeks, and 37 weeks and over according
to their gestational ages. They were also divided as 750 grams and
below, 750-1200 grams, 1200-1800 grams, 1800-2500 grams, and 2500 grams
and over according to their birth weights.

Exclusion criteria:

1- Having chromosomal disorders (such as trisomy 13, 18, 21) 2- Having
major congenital malformations 3- Stillbirth 4- Preterm babies born at
\textless{}22 gestational week.

Statistical Analysis

In the statistical evaluation of our research data, IBM SPSS 21.0
statistical package program for Windows was used. Numeric variables were
presented with mean ± standard deviation (SD); categorical variables
were presented with numbers and percentages (\%). The compliance of the
data with normal distribution was examined. In the comparison of groups
with normal distribution and two measurements, dependent and independent
t-tests were used. In the comparison of groups with non-normal
distribution and two measurements, Mann Whitney U and Wilcoxon tests
were used. In the comparison of means in groups with normal distribution
and multiple measurements, the one-way analysis of variance was used. In
the comparison of groups with non-normal distribution and multiple
measurements, Kruskal Wallis H and Friedman tests were used. The
measured data were expressed as mean and standard deviation. Hypotheses
were two-sided; p\selectlanguage{english}[?]0.05 was considered as statistically significant,
p\selectlanguage{english}[?]0.01 highly significant, and p\selectlanguage{english}[?]0.001extremely significant.

\section*{Results}

{\label{results}}

In total, 180 babies were included in the study. 58.9\% of the babies
were boys, and 41.1\% were girls; 96.7\% were delivered via cesarean
section, and 3.3\% were delivered via normal birth. Of the babies
included in the study, 74.4\% were 2500 grams and over in birth weight,
60\% were born at 37 weeks gestation or later, and 26.1\% were born
between 32-36 weeks.

The mean NGAL value of the boys was 1283.99 ng/mL, and the mean NGAL
value of the girls was 1306.52 ng/mL. There was no statistically
significant difference between gender and umbilical cord blood NGAL
levels. There was also no statistically significant difference between
childbirth type, birth weight, and gestational age and umbilical cord
blood NGAL levels. The demographic characteristics of the babies
included in the study and the relationship between these characteristics
and umbilical cord blood NGAL levels are shown in table 1.

The most common postnatal disease of the babies included in the study
was respiratory distress syndrome (RDS)(15.6\%). Other common postnatal
diseases were~\emph{neural tube defects(} NTD)(4.4\%), congenital heart
diseases(CHD)(3.3\%), and blood incompatibility(2.2\%).

The mean NGAL value of 28 babies diagnosed with RDS was 1083.36 ng/mL,
and those without RDS had a mean NGAL value of 1331.92 ng/mL. There was
no statistically significant difference between RDS and umbilical cord
blood NGAL levels. There were statistically significant differences in
umbilical cord blood NGAL levels between babies diagnosed with meconium
aspiration syndrome or ventricular septal defect or ABO incompatibility
and babies who had not been diagnosed with these diseases. The
relationship between neonatal diseases and umbilical cord blood NGAL
levels is shown in table 2.

The most common maternal disease of the mothers of the babies included
in the study was oligohydramnios (8.9\%). Other common maternal diseases
were gestational diabetes mellitus (GDM) (6.1\%) and hypertension
(6.1\%). 39.4\% of the mothers were healthy.

There were no statistically significant differences in umbilical cord
blood NGAL levels between mothers diagnosed with preeclampsia or
placenta previa or GDM or oligohydramnios and mothers who had not been
diagnosed with these diseases. However, there was a statistically
significant difference between premature rupture of membranes (PROM) and
umbilical cord blood NGAL levels. The relationship between maternal
diseases and umbilical cord blood NGAL levels is shown in table 3.

There was no statistically significant difference between Apgar scores
and umbilical cord blood NGAL levels. The relationship between Apgar
scores and umbilical cord blood NGAL levels is shown in table 4.

\section*{Discussion}

{\label{discussion}}

High NGAL levels in body fluids have been associated with many diseases
especially acute kidney injury.\textsuperscript{(8,9,10)} The risk of
acute kidney injury (AKI) is higher in neonates than in other
groups.\textsuperscript{(11,12,13)} For this reason, early detection of
AKI in neonates is vital. Current biomarkers in use are too late to show
kidney injury. Studies have shown that NGAL can be used as a biomarker
for early detection of AKI.\textsuperscript{(14)} In addition, it was
found valuable in other cases with ischemia and related tissue damage.

In the study of Krawczeski et al.\textsuperscript{(15)},urine NGAL
levels of neonates were significantly increased at the second hour after
cardiopulmonary bypass surgery, while there were no changes in serum
creatinine levels. If the cutoff value was taken as 185 ng/ml, the
sensitivity and specificity of urine NGAL for AKI were 100\% and 93\%,
respectively. It was stated that urine NGAL was an early and reliable
marker in the diagnosis of neonatal AKI compared to serum creatinine. In
another study conducted in critically ill neonates, serum NGAL levels
increased earlier than serum creatinine in neonates who developed AKI.
It was shown that, with or without sepsis, NGAL could be used as an
early marker in neonatal AKI cases.\textsuperscript{(16)} However, in a
more recent study, Reiter et al.\textsuperscript{(17)} stated that
plasma and urine NGAL levels were not reliable markers for developing
AKI in neonates after cardiac surgery with cardiopulmonary bypass. In
our study, there was no patient diagnosed with AKI. They attributed
increased NGAL levels to inflammation following cardiac bypass. As
supported by these studies, NGAL increases in ischemic and inflammatory
events, and this is only noticed when organ functions are affected.
However, NGAL can be used in the early detection of organ damage. In our
study, there was no statistically significant difference, such as low
birth weight, prematurity and low Apgar score, and umbilical cord blood
NGAL levels.

Sepsis is one of the major causes of AKI in neonates. In a study
conducted by Pynn et al.\textsuperscript{(18)}, urine NGAL was pointed
out as a non-invasive biomarker with high negative predictive value at
the time of late-onset sepsis assessment in neonates. According to a
study conducted by Parravicini et al.\textsuperscript{(4)}, on 91 very
low birth weight infants, urine NGAL is a promising candidate as an
early biomarker for sepsis and it was also shown that urinary NGAL
levels was an early biomarker to detect sepsis. In our study, there was
no statistically significant difference between the risk factors of
sepsis, such as male gender, gestational age below 37 weeks and
umbilical cord blood NGAL levels; however, there was a statistically
significant difference between PROM, which is also a risk factor in
sepsis, and umbilical cord blood NGAL levels. \textsuperscript{(18)}

In a group of neonates with intrauterine hypoxia, Essajee et al.(20)
found that urine NGAL is a predictor of mortality and hypoxic
encephalopathy. Similar results were found in another study conducted by
Fiala et al. \textsuperscript{(21)}. According to this study, NGAL has
the potential to be a good marker for perinatal hypoxia and has high
sensitivity and specificity. In our study, there was no statistically
significant difference between the risk factors of asphyxia, such as
cesarean section, low birth weight and preterm labor, and umbilical cord
blood NGAL levels.

In a study conducted by Chen et al. \textsuperscript{(22)} on 24 preterm
and 38 term infants, it was found that there was no statistically
significant difference between gestational age and birth weight and
urine NGAL levels in preterm infants. The same study found that urine
NGAL values of the female term infants were higher compared to male term
infants. Another study reported that NGAL concentrations were higher in
preterm female infants and decreased with higher gestational
age.\textsuperscript{(23)} In our study, there was no statistically
significant difference between gestational age, gender, birth weight and
umbilical cord blood NGAL levels.

In clinical practice, there is always a need for markers that predict
complications and divide patients into risk categories so that they can
be diagnosed and treated early. If NGAL takes its place in routine use
as a diagnostic biomarker, it will contribute greatly to the development
of new treatment approaches. In our study, the desired number of
patients could not be reached in some groups. Also, the limited number
of similar studies on this biomarker reduces the comparability of our
study. In order to accurately determine the effects of specific
perinatal risk factors on umbilical cord blood NGAL levels, multivariate
analyses and comprehensive studies in large numbers of neonates with
specific risk factors isolated are required.

In this study, the relationship between umbilical cord blood NGAL levels
and neonatal diseases was examined. As there are only a few studies in
the literature on umbilical cord blood NGAL levels, this study was
compared with studies that examined urine and serum NGAL levels and
their relationship to certain diseases. However, further studies on
larger patient populations are needed.

\textbf{Table 1:} The relationship between demographic characteristics
and NGAL levels\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& & \textbf{NGAL (ng/mL)} & \textbf{NGAL (ng/mL)} &\tabularnewline
Demographic characteristics of the babies & Demographic characteristics
of the babies & \textbf{n(\%)} & \selectlanguage{ngerman}\textbf{Mean±SD} & p\tabularnewline
Childbirth types & Normal birth & 6\textbf{(}3.3\textbf{)} &
1345.77\selectlanguage{ngerman}±1740.08 & 0.931\tabularnewline
& Cesarean section & 174\textbf{(}96.7\textbf{)} & 1291.44\selectlanguage{ngerman}±1496.46
&\tabularnewline
Gender & Male & 106\textbf{(}58.9\textbf{)} & 1283.99\selectlanguage{ngerman}±1405.72 &
0.921\tabularnewline
& Female & 74\textbf{(}41.1\textbf{)} & 1306.52\selectlanguage{ngerman}±1634.65 &\tabularnewline
Birth weight (grams) & 750 grams below & 2\textbf{(}1.1\textbf{)} &
509.38\selectlanguage{ngerman}±189.08 & 0.616\tabularnewline
& 750-1199 g & 5\textbf{(}2.8\textbf{)} & 1342.53\selectlanguage{ngerman}±1512.00
&\tabularnewline
& 1200-1799 g & 9\textbf{(}5\textbf{)} & 1362.35\selectlanguage{ngerman}±1836.77
&\tabularnewline
& 1800-2499 g & 30\textbf{(}16.7\textbf{)} & 1657.33\selectlanguage{ngerman}±1884.25
&\tabularnewline
& 2500 g and over & 134\textbf{(}74.4\textbf{)} & 1216.96\selectlanguage{ngerman}±1391.15
&\tabularnewline
Gestational age at birth (weeks) & 28 weeks below &
5\textbf{(}2.8\textbf{)} & 1151.96\selectlanguage{ngerman}±1579.12 & 0.975\tabularnewline
& 28-31 w & 20\textbf{(}11.1\textbf{)} & 1348.89\selectlanguage{ngerman}±1395.73
&\tabularnewline
& 32-36 w & 47\textbf{(}26.1\textbf{)} & 1360.55\selectlanguage{ngerman}±1687.65
&\tabularnewline
& 37 w and over & 108\textbf{(}60\textbf{)} & 1260.20\selectlanguage{ngerman}±1447.10
&\tabularnewline
\bottomrule
\end{longtable}

\par\null

\textbf{Table 2:} The relationship between neonatal diseases and NGAL
levels\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& \textbf{NGAL (ng/mL)} & \textbf{NGAL (ng/mL)} & \textbf{NGAL
(ng/mL)}\tabularnewline
& \selectlanguage{ngerman}\textbf{With(mean±SD)} & \selectlanguage{ngerman}\textbf{Without(Mean±SD)} &
\textbf{p}\tabularnewline
\textbf{Preterm} & 1311.95\selectlanguage{ngerman}\textbf{±}1560.36 & 1280.79\selectlanguage{ngerman}\textbf{±}1465.05 &
0.892\tabularnewline
\textbf{Term- Neonates with any problems} & 1659.17\selectlanguage{ngerman}\textbf{±}1918.02 &
1228.68\selectlanguage{ngerman}\textbf{±}1411.11 & 0.170\tabularnewline
\textbf{Term- Neonates without any problems} & 1177.76\selectlanguage{ngerman}\textbf{±}1276.76
& 1383.59\selectlanguage{ngerman}\textbf{±}1653.91 & 0.362\tabularnewline
\textbf{Macrosomia (Over 4000 grams)} & 1205.85\selectlanguage{ngerman}\textbf{±}749.97 &
630.50\selectlanguage{ngerman}\textbf{±}370.03 & 0.907\tabularnewline
\textbf{RDS} & 1083.36\selectlanguage{ngerman}\textbf{±}1171.19 & 1331.92\selectlanguage{ngerman}\textbf{±}1552.76 &
0.422\tabularnewline
\textbf{NTD} & 1050.91\selectlanguage{ngerman}\textbf{±}1567.15 & 1304.52\selectlanguage{ngerman}\textbf{±}1500.26 &
0.641\tabularnewline
\textbf{Rh incompatibility} & 727.58\selectlanguage{ngerman}\textbf{±}618.33 &
1306.11\selectlanguage{ngerman}\textbf{±}1512.07 & 0.447\tabularnewline
\textbf{ABO incompatibility} & 3013.76\selectlanguage{ngerman}\textbf{±}2570.63 &
1264.09\selectlanguage{ngerman}\textbf{±}1470.01 & \textbf{0.045}\tabularnewline
\textbf{IUGR} & 1913.46\selectlanguage{ngerman}\textbf{±}2833.54 & 1275.53\selectlanguage{ngerman}\textbf{±}1455.22 &
0.350\tabularnewline
\textbf{Renal pathology} & 584.97\selectlanguage{ngerman}\textbf{±-}. & 1297.21\selectlanguage{ngerman}\textbf{±}1502.93
& -\tabularnewline
\textbf{Thrombocytopenia} & 607.64\selectlanguage{ngerman}\textbf{±}129.42 &
1304.87\selectlanguage{ngerman}\textbf{±}1509.63 & 0.426\tabularnewline
\textbf{MAS} & 762.97\selectlanguage{ngerman}\textbf{±}15.50 & 1299.21\selectlanguage{ngerman}\textbf{±}1507.05 &
\textbf{0.000}\tabularnewline
\textbf{VSD} & 598.45\selectlanguage{ngerman}\textbf{±}130.01 & 1305.03\selectlanguage{ngerman}\textbf{±}1509.56 &
\textbf{0.000}\tabularnewline
\textbf{ASD} & 1683.79\selectlanguage{ngerman}\textbf{±}1837.32 & 1286.63\selectlanguage{ngerman}\textbf{±}1498.77 &
0.650\tabularnewline
\textbf{Other CHDs} & 1468.02\selectlanguage{ngerman}\textbf{±}1184.73 &
1287.23\selectlanguage{ngerman}\textbf{±}1511.73 & 0.772\tabularnewline
\textbf{Breech birth} & 411.81\selectlanguage{ngerman}\textbf{±}177.45 &
1334.25\selectlanguage{ngerman}\textbf{±}1521.47 & \textbf{0.000}\tabularnewline
\textbf{Multiple birth} & 924.89\selectlanguage{ngerman}\textbf{±}583.49 &
1308.16\selectlanguage{ngerman}\textbf{±}1524.10 & 0.442\tabularnewline
\bottomrule
\end{longtable}

\emph{\textbf{ASD:} Atrial septal defect, \textbf{CHD:} Congenital heart
disease, \textbf{IUGR:} Intrauterine growth restriction,
\textbf{MAS:}Meconium aspiration syndrome, \textbf{NTD:} Neural tube
defect,\textbf{RDS:} Respiratory distress syndrome, \textbf{VSD:}
Ventricular septal defect.}

\textbf{Table 3:} The relationship between maternal diseases and NGAL
levels\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& & \textbf{NGAL (ng/mL)} & \textbf{NGAL (ng/mL)} & \textbf{NGAL
(ng/mL)}\tabularnewline
& \textbf{n(\%)} & \selectlanguage{ngerman}\textbf{With(mean±SD)} & \selectlanguage{ngerman}\textbf{Without(Mean±SD)} &
\textbf{p}\tabularnewline
Preeclampsia & 31\textbf{(}17.2\textbf{)} & 1635.97\selectlanguage{ngerman}±1856.55 &
1221.94\selectlanguage{ngerman}±1411.26 & 0.163\tabularnewline
Placenta previa & 27\textbf{(}15\textbf{)} & 882.43\selectlanguage{ngerman}±759.34 &
1365.75\selectlanguage{ngerman}±1585.74 & 0.123\tabularnewline
Oligohydramnios & 16\textbf{(}8.9\textbf{)} & 1470.87\selectlanguage{ngerman}±1496.03 &
1275.92\selectlanguage{ngerman}±1503.45 & 0.621\tabularnewline
Hypertension & 11\textbf{(}6.1\textbf{)} & 1056.62\selectlanguage{ngerman}±891.19 &
1308.65\selectlanguage{ngerman}±1531.36 & 0.591\tabularnewline
Gestational diabetes mellitus & 11\textbf{(}6.1\textbf{)} &
1289.74\selectlanguage{ngerman}±1133.50 & 1293.48\selectlanguage{ngerman}±1523.07 & 0.994\tabularnewline
Anhydramnios & 6\textbf{(}3.3\textbf{)} & 1706.05\selectlanguage{ngerman}±2589.66 &
1279.01\selectlanguage{ngerman}±1458.44 & 0.494\tabularnewline
Premature rupture of membranes & 6\textbf{(}3.3\textbf{)} &
2594.19\selectlanguage{ngerman}±2037.13 & 1248.39\selectlanguage{ngerman}±1465.03 & \textbf{0.034}\tabularnewline
Polihydramnios & 5\textbf{(}2.8\textbf{)} & 506.26\selectlanguage{ngerman}±119.33 &
1315.73\selectlanguage{ngerman}±1514.91 & 0.235\tabularnewline
HELLP syndrome & 4\textbf{(}2.2\textbf{)} & 1322.06\selectlanguage{ngerman}±1523.55 &
1292.59\selectlanguage{ngerman}±1503.52 & 0.969\tabularnewline
Hypothyroidism & 4\textbf{(}2.2\textbf{)} & 801.94\selectlanguage{ngerman}±375.49 &
1304.41\selectlanguage{ngerman}±1514.04 & 0.509\tabularnewline
Thrombocytopenia & 4\textbf{(}2.2\textbf{)} & 1134.94\selectlanguage{ngerman}±1139.88 &
1296.85\selectlanguage{ngerman}±1509.15 & 0.832\tabularnewline
Nephrolithiasis & 4\textbf{(}2.2\textbf{)} & 1224.54\selectlanguage{ngerman}±1024.30 &
1294.81\selectlanguage{ngerman}±1510.72 & 0.926\tabularnewline
Hepatitis B & 3\textbf{(}1.7\textbf{)} & 726.58\selectlanguage{ngerman}±416.31 & 1302.85\selectlanguage{ngerman}±1509.89
& 0.511\tabularnewline
Splenectomy & 3\textbf{(}1.7\textbf{)} & 605.39\selectlanguage{ngerman}±128.86 & 1304.91\selectlanguage{ngerman}±1509.61
& 0.425\tabularnewline
Heart disease & 2\textbf{(}1.1\textbf{)} & 531.01\selectlanguage{ngerman}±299.03 &
1301.81\selectlanguage{ngerman}±1505.74 & 0.471\tabularnewline
Chorioamnionitis & 2\textbf{(}1.1\textbf{)} & 3100.19\selectlanguage{ngerman}±3320.83 &
1272.95\selectlanguage{ngerman}±1474.71 & 0.087\tabularnewline
Renal ectasia & 1\textbf{(}0.6\textbf{)} & 495.46\selectlanguage{ngerman}±- & 1297.71\selectlanguage{ngerman}±1502.67 &
0.595\tabularnewline
Ventriculoperitoneal Shunt & 1\textbf{(}0.6\textbf{)} & 1592.64\selectlanguage{ngerman}±- &
1291.58\selectlanguage{ngerman}±1503.70 & 0.842\tabularnewline
Other diagnoses & 36\textbf{(}20\textbf{)} & 1139.14\selectlanguage{ngerman}±1233.31 &
1331.78\selectlanguage{ngerman}±1560.57 & 0.492\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4:} The relationship between Apgar scores and NGAL levels\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& \textbf{NGAL (ng/mL)} & \textbf{NGAL (ng/mL)} &
\textbf{p}\tabularnewline
& \selectlanguage{ngerman}\textbf{With (mean±SD)} & \selectlanguage{ngerman}\textbf{Without(Mean±SD)} &\tabularnewline
Apgar (1\textsuperscript{st}minute) \textless{}5 & 1608.03\selectlanguage{ngerman}±1744.42 &
1244.83\selectlanguage{ngerman}±1458.76 & 0.271\tabularnewline
Apgar (1\textsuperscript{st} minute) 5-7 & 1228.68\selectlanguage{ngerman}±1473.83 &
1361.05\selectlanguage{ngerman}±1538.45 & 0.562\tabularnewline
Apgar (1\textsuperscript{st} minute) 7\textgreater{} & 1269.98\selectlanguage{ngerman}±1431.04 &
1302.71\selectlanguage{ngerman}±1532.04 & 0.895\tabularnewline
Apgar (5\textsuperscript{th} minute) \textless{}5 & - & 1293.25\selectlanguage{ngerman}±1499.66
& -\tabularnewline
Apgar (5\textsuperscript{th} minute) 5-7 & 1327.73\selectlanguage{ngerman}±1537.66 &
1279.99\selectlanguage{ngerman}±1490.62 & 0.849\tabularnewline
Apgar (5\textsuperscript{th}minute) 7\textgreater{} & 1278.27\selectlanguage{ngerman}±1496.30 &
1331.14\selectlanguage{ngerman}±1522.40 & 0.832\tabularnewline
\bottomrule
\end{longtable}

\textbf{The captions to tables}

\textbf{Table 1.} The relationship between demographic characteristics
and NGAL levels

\textbf{Table 2.} The relationship between neonatal diseases and NGAL
levels

\textbf{Table 3.} The relationship between maternal diseases and NGAL
levels

\textbf{Table 4.} The relationship between Apgar scores and NGAL levels

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\selectlanguage{english}
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