Kyriaki Venetsanou

The effects of IgM-enriched immunoglobulin preparations in patients with severe sepsis: another point of view

We read with interest the paper by Tugrul et al. [1] regarding the effects of IgM-enriched immunoglobulin preparations in patients with severe sepsis managed in their intensive care unit. Apart from the global interest of reading a paper in the field of the treatment of severe sepsis and septic shock, we have an almost similar project in progress. It is well known that the immunotherapy in sepsis is still a gray zone, and it will remain so as long as the relevant literature presents conflicting results [2]. From our understanding and the interim analysis of our data, it seems that we could expect some definitive immunotherapy informationin the near future. In our study, we have presently included 34 patients in the treatment group (IgM + IgG + IgA) and 34 in the control group. Analyzing our data in a manner comparable with that of Tugrul et al. [1], we reach a different conclusion regarding the results. The only difference that exists between our protocol and that of Tugrul et al. regarding the study design and the inclusion criteria is that we include only adults older than 18 years old (the lower age limit of Tugrul et al.s study is 10 years, and adolescents are probably included). The number of patients needed per arm of the study in order to achieve a safe conclusion (statistical power analysis, 80%; P < 0.05 for a mortality decrease of 17%, which was the mortality decrease in our preliminary analysis) is 120 patients in each arm. In a study with a smaller number of patients, therefore, such as those of Tugrul et al. (21 patients in each arm) or ourselves (34 patients in each arm to the present time), any conclusion may be unsafe. Although the data in both studies (in our opinion) are so far not sufficient, a significant difference trend is recorded. The mean age in Tugrul et al.s study is 42.0 ± 18 years in the IgM + IgG + IgA group and 49.3 ± 20.6 years in the control group. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score in that same study is 10.5 ± 4.6 in the IgM + IgG + IgA group and 14.0 ± 8.5 in the control group. Although there is no statistically significant difference, there is a strong tendency for the two means to become different (P = 0.10). In our preliminary data analysis, the mean age is 50.5 ± 3.33 years in the IgM + IgG + IgA group and 50.7 ± 7.36 years in the control group. The APACHE II score in our study is 21.27 ± 7.23 in the IgM + IgG + IgA group and 23.5 ± 7.91 in the control group. The 28-day mortality rate in Tugrul et al.s study is 23.8% in the IgM + IgG + IgA group versus 33.3% in the control group. In our preliminary data analysis, the mortality rate is 22.35% and 40.0% in the IgM + IgG + IgA group and the control group, respectively. Although this difference is a statistically significant one, the analysis of the mortality rate of the subgroups according to the APACHE II scoring of inclusion to the study day is more interesting. The mortality rate in our preliminary data for the IgM + IgG + IgA group with an APACHE II score ranging between 20 and 29 was 22.22%, and that of the control group with the same APACHE II score range was 55%. As we pointed out earlier, in order to demonstrate the clinical effectiveness of immunotherapy in severe sepsis and septic shock, a number of 120 patients is necessary to be included in each arm of our study. Using our preliminary results in the same manner as those in Tugrul et al.s paper [1], we could conclude that it is sometimes possible to present the data in such a way resulting in delusive conclusions. Analyzing the data by means of definitions of sepsis and septic shock, and assuming the patients to be a uniform group, we cannot demonstrate the special subgroups of patients in whom the administration of IgM-enriched immunoglobulin preparations may have highly beneficial effects. By grouping the patients according to some characteristics (such as APACHE II score or Simplified Acute Physiology Score IIscore), the beneficial effect of immunoglobulins could be shown. Using such an approach, a beneficial effect of IgG immunotherapy in a special subgroup of septic patients has already been shown in the study by Dominioni et al. [3]. In conclusion, it seems that there is a subgroup of patients with severe sepsis or septic shock in which the delivery of IgM-enriched immunoglobulin preparations may have a beneficial effect. Further study with more patients, either in our study or that of Tugrul et al., is necessary before we decide whether to use this type of immunotherapy in the treatment of severe sepsis.

Temperature and serum proinflammatory cytokine changes in patients with NSCLC after BAL.

We examined the effects of bronchoalveolar lavage (BAL) and BAL fluid characteristics on the systemic proinflammatory cytokine expression and their relation to clinical and laboratory findings. Thirty patients suspected to have lung cancer were subjected to fiber-optic bronchoscopy (FOB) and BAL. Clinical and laboratory findings were determined at baseline, 4 h, and 24 h, including lung auscultation, temperature, chest X-ray, WBC, neutrophils, and serum IL-1β, IL-6, and TNF-α. BAL fluid characteristics were determined including cytokine levels. Fifteen volunteers served as controls to determine serum variation of the same cytokines. Significant temperature elevation was defined as 1°C increase compared to baseline. BAL was associated with temperature and serum TNF-α and IL-6 but not IL-1β increase at 4 h. Four patients (13.3%) developed temperature over 38°C. In controls there were no significant changes between baseline and 24 h measurements for the same cytokines. Eleven patients (36.6%) developed a significant temperature elevation 4 h after BAL. These patients had a statistically significant (p < 0.05) increase in serum IL-6 at 4 h and in TNF-α at both 4 and 24 h after BAL compared with the nonsignificant temperature increase group. BAL characteristics were not different between the two groups. On the other hand, BAL fluid IL-6 and TNF-α levels were significantly higher (p < 0.05) in the nonfever group. Significant temperature increase was observed in 36.6% of the patients undergoing BAL and associated with significant serum TNF-α and IL-6 increase at 4 h. Lung cytokines levels, alveolar macrophages, and BAL fluid characteristics are not related to temperature and serum proinflammatory cytokine increase. The hypothesis of alveolar macrophages derive from cytokine production and shift to the systemic circulation cannot be supported by our data.

Mechanical ventilation and the immune response

We found no statistically significant increase (paired sample t test) in the supernatant of tracheal aspirates between baseline and 2 h after MV for tumor necrosis factor (TNF) α, interleukin (IL) 6, IL-10, TNF-RI and TNF-RII concentrations (Table 1, Fig. 1). TNF-α, TNF-RI, and TNF-RII concentrations in serum were also not significantly altered after 2 h of MV (Fig. 2). On the other hand, there was a statistically significant increase in mean serum concentrations of IL-6 and IL-10. However, examining individual data, only two patients undergoing abdominal surgery (colectomy and appendecectomy) showed a significant increase in these cytokines. Our findings do not confirm in general that MV can significantly alter immune response [1] either locally in the lungs or systematically in the circulation in adult patients without preexisting lung disease undergoing MV for elective surgery. However, there is evidence in two patients of systematic alterations in immune response, both proand anti-inflammatory, which can be attributed to surgical manipulations. Our findings do not confirm the findings either Intensive Care Med (2002) 28:1365–1366 DOI 10.1007/s00134-002-1425-0 C O R R E S P O N D E N C E

Diagnostic coronary angiography is related to decreased TNF-α production after ex-vivo whole blood stimulation with LPS

BACKGROUND Several studies showed serum markers elevation as a result to coronary angiography. We investigated the effect of diagnostic coronary angiography (DCA) on the development of systemic inflammatory response syndrome (SIRS) and on whole blood cytokine production capacity after ex-vivo LPS stimulation. METHODS In this observational study, clinical characteristics and serum cytokines of the patients were recorded at baseline and at 2, 6, 12, and 24h after DCA. Peripheral blood was collected at baseline and at 2, and 24h for complete blood count, coagulation profile and ex-vivo (100 microl) stimulation with LPS (500 pg) for subsequent cytokine measurement. Values are expressed as median+/-IQR and were compared using Wilcoxons signed rank test with Bonferroni adjustment. RESULTS We included 23 male patients (mean age 52.0+/-18.0 years) undergoing DCA. None of the patients developed clinical or laboratory signs of SIRS. Serum IL-6 significantly increased at 12h. There was a significant decrease in TNF-alpha production after ex-vivo LPS stimulation of whole blood at 2 and 24h compared to baseline (median+/-IQR; 716.0+/-319.0; 576.0+/-715.0 vs. 1154+/-844.0 pg/ml; respectively) suggesting that DCA may cause transient endotoxin tolerance. CONCLUSIONS DCA is related to increased serum IL-6 levels but does not cause clinical SIRS. Development of SIRS after DCA is indicative of other in origin complication. DCA is associated with immune cells hyporesponsiveness, possibly through monocyte depression, expressed as decreased TNF-alpha production after whole blood stimulation with LPS ex vivo.

Alcohol Effects on TNF-ñ and IL-10 Production in an Ex-Vivo Model of WholeBlood Stimulated by LPS

Alcohol exposure is related to increased susceptibility to infections. We investigated the effect of acute exposure to alcohol on pro- and anti-inflammatory cytokine production in an ex-vivo model of whole blood stimulation with lipopolysacharide (LPS). Ten ml of whole blood were taken from 24 healthy volunteers (all men) aged 36.5 ± 1.4 years. Each sample was transferred into two tubes, without and with EDTA as anticoagulant, under sterile conditions. We had 14 groups: the control group in which whole blood was incubated without any other intervention, the LPS group in which whole blood was stimulated with LPS alone, and 12 alcohol groups with (6 groups) and without LPS stimulation (6 groups) using six different doses of alcohol (5‚ 12.5‚ 25‚ 50‚ 100 and 200mM). LPS (500pg) was added after pretreatment with alcohol for 10 minutes. Blood samples were diluted 1:10 in RPMI 1640 culture medium (100μl whole blood added in 900μl RPMI 1640), and then alcohol solution and LPS were added according to the study protocol for incubation period of 4 hours at 37°C. Cell culture supernatants were isolated with centrifugation at 1,800rpm, for 5 min at room temperature and stored at -70°C until measurements. Cytokine levels were determined in culture supernatant with the ELISA method. Alcohol had no effect on cytokine production when incubated with whole blood alone. TNF-α IL-6 and IL-10 significantly increased after LPS stimulation. Alcohol had no effect on IL-6 production after LPS challenge but significantly decreased TNF-α and IL-10 production in the presence of LPS challenge at 25mM to 200mM in a dose dependent manner. Conclusively TNF-α and IL-10 were significantly decreased after alcohol exposure in a dose depended manner in a model of whole blood stimulation with LPS exvivo expressing both suppression of pro- and anti-inflammatory response.