Katsuya Inada

Influence of methylprednisolone on cytokine balance during cardiac surgery

OBJECTIVE To determine the influence of methylprednisolone on the cytokine balance during cardiac surgery. DESIGN Prospective, randomized, nonblinded study. SETTING University hospital. PATIENTS Twenty-one patients on cardiopulmonary bypass undergoing aortocoronary bypass surgery. INTERVENTIONS According to a randomized sequence, the patients either received methylprednisolone (30 mg/kg) [corrected] before cardiopulmonary bypass and before declamping of the aorta (MPS group, n = 11) or received nothing (control group, n = 10). MEASUREMENTS AND MAIN RESULTS Serum proinflammatory cytokines (interleukin [IL]-8, IL-6) and anti-inflammatory cytokines (IL-10, IL-1ra) were measured by enzyme-linked immunosorbent assays. Serum IL-6 and IL-8 concentrations in the control group (15.2 +/- 4.1 and 14.1 +/- 1.9 pg/mL, preoperatively) increased to 242 +/- 70.1 and 97.3 +/- 18.3 pg/mL at 60 mins after declamping of the aorta (p < .01, p < .01, respectively). The increases were greater than those from 2.5 +/- 0.6 and 2.5 +/- 0.5 pg/mL to 109.5 +/- 29.0 and 33 +/- 4.1 pg/mL in the MPS group for IL-6 and IL-8, respectively. Serum IL-10 concentrations increased significantly 60 mins after declamping of the aorta compared with its preoperative value in the two groups (the control group, from 1.0 +/- 0 to 537.9 +/- 61.7 pg/mL; the MPS group, from 0.3 +/- 0.2 to 654.9 +/- 24 pg/mL [p < .01, p < .01, respectively]). No difference was found between the two groups. Similarly, serum IL-1ra concentrations in the two groups increased the preoperative value in the control group from 304 +/- 120 to 44,374 +/- 14,631 pg/mL and in the MPS group from 616.5 +/- 109.6 to 35,598 +/- 9,074 pg/mL at 60 mins after declamping of the aorta (p < .01, p < .01, respectively). There was no difference between the two groups. CONCLUSIONS Methylprednisolone reduces the production of IL-6 and IL-8 but not that of IL-10 and IL-1ra. These results suggest that one of the mechanisms of the cytoprotective effect of methylprednisolone may be to make changes in the proinflammatory and anti-inflammatory cytokine balance.

Plasma cytokine levels in patients with severe burn injury-with reference to the relationship between infection and prognosis

Blood levels of various cytokines were determined in patients with burn injury immediately after the accident, and the relationship between cytokines and morbid condition was investigated. There was almost no marked elevation of cytokines in the early stage of burn injury. Throughout the entire course, tumour necrosis factor alpha, interleukin 6 and interleukin 8, as cytokines, showed high levels in patients with burn injury associated with sepsis and those who died. These levels well reflected the severity in the phase complicated with sepsis.

Establishment of a New Perchloric Acid Treatment Method to Allow Determination of the Total Endotoxin Content in Human Plasma by the Limulus Test and Clinical Application

We established a new method of plasma treatment for the removal of interfering factors in the plasma to allow detection of endotoxin by limulus test. The limulus test used was an endotoxin‐specific chromogenic test, the Endospecy test. Perchloric acid (PCA) treatment and centrifugation (PCA method) is usually used to remove interfering factors from plasma, with the precipitate being discarded and the supernatant used to detect endotoxin. As the solubilized precipitates of endotoxin‐spiked plasma and some patient plasma were found to contain the Endospecy activity, we have devised a new method assaying endotoxin in both the supernatant and precipitate. This study confirmed that the solubilized precipitate of endotoxin‐spiked plasma had Endospecy activity and found that the precipitate had other endotoxin activities, such as lethality in galactosamine‐sensitized mice and pyrogenicity in rabbits. We also confirmed that interfering factors were completely removed from plasma samples by this new method. The endotoxin level after the new PCA method was found to be about 8 times higher than that determined after PCA treatment and the new PCA method surpasses the conventional PCA method with regard to the positive rate of endotoxin contents in clinical samples. These results indicate that the new PCA method is superior to the PCA method as a plasma pretreatment method for limulus test.

Methylprednisolone inhibits increase of interleukin 8 and 6 during open heart surgery

It has been reported that interleukin 8 (IL-8) and interleukin 6 (IL-6) are two of the chemical mediators causing myocardial injury. It is not clear whether treatment with corticosteroids in vitro in these patients can prevent the production of interleukin 8 and 6. This prospective study was conducted to investigate whether methylprednisolone (MP) pretreatment (30 mg · kg−1 before CPB and before declamping of aorta) influenced the production of IL-8 and 6 in the peripheral circulation in 27 patients undergoing elective coronary artery bypass surgery. The IL-8 and IL-6 concentrations were measured by ELISA kit. We also studied the effect of MP pretreatment on postoperative cardiac Junction. Serum concentration of IL-8 in non-MP-treated patients (37 ± 44 pg · ml−1 preoperatively) increased to 169 ± 86 pg · ml−1 60 min after declamping of the aorta (P < 0.001). The increase was greater than the increase from 22 ± 8.9 pg · ml−1 to 52 ± 35 pg · ml−1 in the MP-treated patients (P < 0.01). Serum IL-6 concentration in non-MP-treated patients increased from the preoperative value of 59 ± 30 pg · ml−1 to 436 ± 143 pg · ml−1 60 min after declamping of the aorta (P < 0.001). The increase was greater than the increase from 36 ± 15 pg · ml−1 to 135 ± 55 pg · ml−1 in the MP-treated patients (P < 0.01). Furthermore, postoperative cardiac index in MP-treated patients (3.6 ± 1.1 L · min−1· m−2) was higher than 2.3 ± 0.8 L · min−1 · m−2 of non MP-treated patients (P < 0.05). The levels of IL-8 max during surgery correlated negatively with postoperative cardiac index (γ = −0.67). These results suggest that methylprednisolone suppresses production of IL-8 and 6.RésuméOn a rapporté que l’interleukine 8 (IL-8) et que l’interleukine 6 (IL-6) étaient deux des médiateurs chimiques de la lésion cardiaque. Toutefois, on ne sait pas encore si le traitement aux corticostéroïdes in vivo prévient la production des interleukines 8 et 6. Cette étude prospective vise à déterminer si le prétraitement à la méthylprednisolone (MP) (30 mg · kg−1 avant le CEC et avant le déclampage de l’aorte) influence la concentration de l’IL-8 de l’IL-6 du sang veineux périphérique de 27 patients soumis à une chirurgie réglée de revascularisation myocardique. Les concentrations de l’IL-8 de l’IL-6 sont mesurée avec une trousse Elisa. Nous étudions aussi les répercussions du traitement à la MP sur la fonction cardiaque postopératoire. La concentration sérique de l’IL-8 des patients non traités (37 ± 44 pg · ml−1 en préopératoire) augmente à 169 ± 86 pg · ml−1 60 minutes après le déclampage de l’aorte (P < 0,001). Cette augmentation est plus importante que l’augmentation de 22 ± 8,9 pg · ml−1 à 52 ± 55 pg · ml−1 notée chez les patients traité à la MP (P < 0,01). La concentration serique de l’IL-6 chez les patients non traités à la MP augmente de la valeur préopératoire de 59 ± 30 pg · ml−1 à 436 ± 143 pg · ml−1 60 min après le déclampage de l’aorte (P < 0,001). Cette augmentation est plus importante que celle de 36 ± 15 pg · ml−1 à 135 ± 55 pg · ml−1 survenue chez les patients traités à la MP (P < 0,01). De plus, l’index cardiaque postopératoire des patients traités à la MP (3,6 ± 1,1 L · ml−1 · m−2) est plus élevé que celui des patients non traités 2,3 ± 0,8 L · ml−1 · m− 2 (P < 0,05). Les niveaux maximaux de 1’IL-8 sont en corrélation négative avec l’index cardiaque postopératoire (y = 0,67). Ces resultats suggèrent que la méthylprednisolone supprime la production de l’IL-8 et de l’IL-6.

Plasma endotoxin and cytokine concentrations in patients with hemorrhagic shock

ObjectivesThe roles of cytokines and endotoxin in hemorrhagic shock, particularly the translocation of endotoxin and bacteria during hemorrhagic shock, were investigated. DesignProspective study. SettingCritical care and emergency center of a university hospital. PatientsTwenty-nine patients with hemorrhagic shock and 20 healthy controls. InterventionsSerial blood samples were collected from both study and control patients. Standard resuscitation techniques were used. Measurements and Main ResultsPlasma levels of endotoxin and various cytokines were determined repeatedly during hemorrhagic shock. Endotoxin was measured using an endo-toxin-specific assay in addition to a new perchloric acid method for pretreatment of plasma. Cytokines were measured by commercial enzyme-linked immunosorbent assays. Plasma endotoxin concentrations remained within the normal range for 7 days after admission. Although levels of tumor necrosis factor-α and several interleukins increased slightly in some patients, these cytokines did not reach the levels seen in septic shock. ConclusionTranslocation of bacteria or endotoxin from the gastrointestinal tract into the bloodstream has been noted in animal experiments; however, translocation was not detected in our patients with hemorrhagic shock. (Crit Care Med 1994; 22:949–955)

Plasma tumour necrosis factor-α (TNF-α) levels in patients with burns

Abstract Levels of plasma tumour necrosis factor-α (TNF-α) were determined consecutively in 42 patients with burns > 20 per cent of the total body surface area using an enzyme-linked immunosorbent assay. In the early period after injury (including the period of burn shock), 24 patients had detectable TNF-α levels in their plasma. However, the plasma TNF-α levels at the time of admission were very low and did not correlate with the extent of the burn or the prognosis. In contrast, the maximum plasma TNF-α level over the whole clinical course was significantly correlated with the area of the burn and the prognosis. No correlation was found between the plasma TNF-α and plasma endotoxin levels. TNF-α may be produced locally in infected burns and monitoring of plasma TNF-α levels may be a useful prognostic indicator for burns patients.

Chronological Changes in the Complement System in Sepsis

The time courses of serum complement levels and the severity of sepsis were compared in two groups of septic patients, one in which the patients survived (surviving group) and one in which they did not (nonsurviving group). The components of the complement system, namely, C3a, C4a, C5a, CH50, C3, C4, and C5, were measured at several points in time after the diagnosis of sepsis had been established. A 2-antibody radioimmunoassay was used to measure C3a, C4a, and C5a; the latex agglutination test was used to measure C3 and C4; nephelometry was used to measure C5; and Meyers 50% hemolysis method was used to measure CH50. Following the diagnosis of sepsis, the levels of CH50, C3, and C4 were significantly lower in the nonsurviving than the surviving group, while the levels of C3a and C4a were significantly higher in the nonsurviving than the surviving group. The C5a levels were significantly higher in the nonsurviving than the surviving group, although no significant intergroup differences were subsequently noted. These results suggest that the serum levels of C3a, C4a, C5a, CH50, C3, and C4 could serve as indices of the severity of sepsis. Thus, monitoring the complement system may be useful for predicting the outcome of patients with sepsis.

Inflammatory Cytokines Locally Elevated in Chronic Subdural Haematoma

Summary The involvement of inflammation in the development and propagation of chronic subdural haematoma (CSH) was investigated by measuring the levels of inflammatory cytokines (tumour necrosis factor [TNF]α, interleukin [IL]-1β, IL-6, and IL-8). Peripheral venous blood and subdural fluid were obtained at the time of burr hole surgery from 34 patients with CSH and from 9 with subdural effusion. The levels of the inflammatory cytokines were analysed by enzyme-linked immunosorbent assay. The blood levels of TNFα, IL-1β, IL-6, and IL-8 in both CSH and subdural effusion groups were almost within the range of normal subjects, and no differences were observed between the two groups. IL-6 and IL-8 in the subdural fluid were much higher than in the blood of both groups, and the levels in CSH patients were significantly higher (10 times) than in subdural effusion patients. Local elevation of inflammatory cytokines in the subdural space of both CSH and subdural effusion without systemic change suggests the presence of local inflammation in the two diseases. The same behavioural patterns of cytokines for these and higher levels of cytokines in the CSH also suggest that inflammatory cytokines may be involved in the continuous development from subdural effusion to CSH and propagation of CSH.

Plasma concentrations of type II phospholipase A2, cytokines and eicosanoids in patients with burns

The plasma concentrations of type II phospholipase A2 (type II PLA2) and eicosanoids, such as leukotriene B4 (LTB4), 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), and thromboxane B2 (TXB2), were determined by radioimmunoassay in 23 patients with burns covering at least 20 per cent of their body surface. Cytokines such as tumour necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6) and interleukin 8 (IL-8) were determined by enzyme-immunosorbent assay. There was no increase in type II PLA2 concentration in the early stage of burns, but an increase in type II PLA2 concentration was triggered by infection (P < 0.0001). The level of type II PLA2 was significantly higher in the non-surviving group than in the surviving group (P = 0.0006), suggesting that it reflects the severity of the disease. There was a significant correlation between the maximum level of type II PLA2 and TNF-alpha (r = 0.6346, P = 0.0011). There was a significant correlation between the maximum level of type II PLA2 and the accompanying plasma concentrations of LTB4, 6-keto-PGF1 alpha, and TXB2 throughout the observation period (r = 0.4814, P = 0.0200; r = 0.5943, P = 0.0028; r = 0.4368, P = 0.0372 respectively). Plasma levels of LTB4, and TXB2 were significantly higher in the burn patients who died than in those who survived (P = 0.0493; P = 0.0493 respectively).

Prostaglandin E1 reduces myocardial reperfusion injury by inhibiting proinflammatory cytokines production during cardiac surgery.

Objective To determine the influence of prostaglandin E1 (PGE1) on the cytokine balance and myocardial protection during cardiac surgery. Design Prospective, randomized, nonblinded study. Setting University hospital. Patients A total of 19 patients on cardiopulmonary bypass undergoing cardiac surgery. Interventions According to randomized sequence, the patients received PGE1 (0.02∼0.05 &mgr;g·kg−1·min−1) from the beginning of surgery to the end of study (PGE1 group, n = 11) or nothing (control group, n = 8). Measurements and Main Results Interleukin (IL)-6, IL-8, IL-10, IL-1 receptor antagonist (IL-1ra), soluble tumor necrosis factor receptor I (sTNF RI), and soluble tumor necrosis factor receptor II (sTNF RII) were measured by enzyme-linked immunosorbent assays. Troponin-T and isoenzyme of creatine kinase with muscle and brain subunits (CK-MB) were measured by enzyme immunoassay and ultraviolet absorption spectrophotometry method, respectively. Serum IL-6 and IL-8 concentrations in both groups increased significantly from 60 mins after declamping the aorta compared with preoperative value (p < .001), However, the increases were greater in the control group than in the PGE1 group (p < .01). Serum IL-10, IL-1ra, sTNF RI, and sTNF RII concentrations increased significantly from 60 mins after declamping the aorta compared with preoperative values in two groups (p < .001, respectively). There were no differences between the two groups. Serum troponin T and CK-MB concentrations increased significantly in the two groups from 60 mins after declamping the aorta (p < .001), but these increases were greater in the control group than in the PGE1 group (p < .01). IL-6 and IL-8 levels correlated with CK-MB concentration (r2 = 0.49, r2 = 0.36;p > .001 respectively). Conclusions PGE1 suppressed the production of IL-6 and IL-8 but not IL-10, IL-1ra, sTNF RI, or sTNF RII. The change in the balance between pro-and anti-inflammatory cytokines may be one of the most important cytoprotective mechanisms of PGE1.