María Heredia

Pro- and anti-inflammatory responses are regulated simultaneously from the first moments of septic shock

The relationships between cytokine responses in septic shock are currently poorly understood. Some studies have pointed to a biphasic model, with an initial proinflammatory phase, followed by a reactive, anti-inflammatory response to explain the pathogenesis of the most severe form of sepsis. However, evidence for the coexistence of both responses has been found. In this study, the plasma levels of 17 cytokines and chemokines, in 20 patients with septic shock, 11 patients with systemic inflammatory response syndrome (SIRS), during the first 24 hours following diagnosis, and 10 healthy controls, were analyzed and compared. Patients with septic shock showed increased levels of IL-6, IL-8, MCP-1, MIP-1β, IFN-γ, GM-CSF and IL-10 compared to healthy controls. Patients with SIRS showed higher levels of IL-6, IL-8, MCP-1, MIP-1β, G-CSF and IL-10 than controls. Patients with septic shock showed higher levels of IL-8, GM-CSF, MIP-1β than those with SIRS. The Spearman test demonstrated a positive association between the pro-inflammatory mediators IL-6, IL-8, MCP-1, MIP-1β, IFN-γ, GM-CSF and the immunomodulatory cytokine IL-10 in septic shock. Consequently, correlation studies supported the notion that secretion of pro- and anti-inflammatory mediators in septic shock occurs as a simultaneous immune response program initiated early in the course of the disease, revealing that both types of cytokine play a role from the very beginning of this life-threatening condition.

Evolution of neutrophil apoptosis in septic shock survivors and nonsurvivors

PURPOSE The aims were to analyze the temporal evolution of neutrophil apoptosis, to determine the differences in neutrophil apoptosis among 28-day survivors and nonsurvivors, and to evaluate the use of neutrophil apoptosis as a predictor of mortality in patients with septic shock. MATERIALS AND METHODS Prospective multicenter observational study carried out between July 2006 and June 2009. The staining solution study included 80 patients with septic shock and 25 healthy volunteers. Neutrophil apoptosis was assessed by fluorescein isothiocyanate (FITC)-conjugated annexin V and aminoactinomycin D staining. RESULTS The percentage of neutrophil apoptosis was significantly decreased at 24 hours, 5 days, and 12 days after the diagnosis of septic shock (14.8% ± 13.4%, 13.4% ± 8.4%, and 15.4% ± 12.8%, respectively; P < .0001) compared with the control group (37.6% ± 12.8%). The difference in apoptosis between 28-day surviving and nonsurviving patients was nonsignificant (P > .05). The mortality rate at 28 days was 53.7%. The crude hazard ratio for mortality in patients with septic shock did not differ according to the percentage of apoptosis (hazard ratio, 1.006; 95% confidence interval, 0.98-1.03; P = .60). CONCLUSIONS During the first 12 days of septic shock development, the level of neutrophil apoptosis decreases and does not recover normal values. No differences were observed between surviving and nonsurviving patients.

Beneficial role of endogenous immunoglobulin subclasses and isotypes in septic shock

PURPOSE There is increasing evidence on the relationship between endogenously produced immunoglobulins and the clinical outcome in septic shock (SS). MATERIALS AND METHODS Levels of immunoglobulin G (IgG) subclasses, immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin E were measured in plasma from 42 patients with SS and in 36 patients with systemic inflammatory response syndrome at diagnosis. Association of immunoglobulins levels with disease severity and outcome was evaluated. RESULTS Eighteen patients with SS finally died. Both patients with systemic inflammatory response syndrome and SS showed subnormal levels of total IgG, IgG2, and IgM. Patients with SS who died showed the lowest levels of total IgG and IgG1. Total IgG, IgG1, IgG2, IgG3, IgG4, and IgA correlated inversely with Acute Physiology and Chronic Health Evaluation II score in SS. Univariate Cox regression analysis showed that levels of IgG1, IgG2, IgG3, IgM, IgA, and total IgG were inversely associated to the probability of death at 28 days. Multivariate analysis showed that IgG1, total IgG, IgM, and IgA behaved as independent protective factors against mortality (hazard ratio, P): 0.23, 0.026; 0.16, 0.028; 0.11, 0.042; 0.05, 0.010, respectively, whereas IgG3 showed a protective trend also. CONCLUSIONS Our study evidenced that, in addition to IgG1, other major endogenous immunoglobulins isotypes and subclasses seem to play a beneficial role in SS.

Genetic polymorphisms located in TGFB1, AGTR1, and VEGFA genes are associated to chronic renal allograft dysfunction.

BACKGROUND Persistent inflammation and fibrosis have been related to active progression of renal deterioration and reduced survival of kidney transplant. The aim of this study was to determine the impact of single-nucleotide polymorphisms (SNPs) located in regions related to inflammatory and immune processes on the development of chronic renal allograft dysfunction (CRAD). METHODS A retrospective study was carried out on 276 patients who received kidney transplant (KT). SNPs were genotyped via the SNPlex platform. Statistical analysis was performed with SNPstat and regression logistic analyses were adjusted by age and gender of recipients and donors, cold ischemia time and the number of human leukocyte antigen (HLA) mismatches. RESULTS From 276 patients with KT, 118 were non-CRAD and 158 were CRAD. Three SNPs showed significant associations with CRAD development: rs1800471 in transforming growth factor beta 1 (TGFB1), rs5186 in angiotensin II receptor type 1 (AGTR1), and rs699947 in vascular endothelial growth factor A (VEGFA). GC genotype of rs1800471 was associated with increased odds of CRAD compared to GG genotype (OR=2.65 (95% confidence interval (CI)=1.09; 6.47), p=0.025), as well as AC and AA genotype of rs699947 assuming a dominant model (OR=1.80 (95% CI=1.02; 3.20), p=0.044). Besides, AC and CC genotypes of rs5186 were associated with reduced odds of CRAD assuming a dominant model (OR=0.56 (95% CI=0.33; 0.96), p=0.033). CONCLUSION Our findings suggest that three genes related to immunity and inflammation (rs1800471, rs5186 and rs699947) are associated to susceptibility or protection to CRAD, and might have diagnostic utility in predicting the likelihood of developing CRAD.

Mitochondrial DNA haplogroups are associated with severe sepsis and mortality in patients who underwent major surgery

OBJECTIVE To analyse whether mitochondrial DNA (mtDNA) haplogroups are associated with severe sepsis and mortality after major surgery. METHODS We performed a case-control study on 240 cardiac or abdominal surgery patients developing severe sepsis (Case-group) and 267 cardiac or abdominal surgery patients without severe sepsis and with systemic inflammatory response syndrome (SIRS, Control-group). Furthermore, a longitudinal substudy was performed for analysing the survival in septic patients. Only European white patients within the N macro-cluster were included. RESULTS Case-group underwent cardiac surgery had lower frequencies of cluster HV (p = 0.005) and haplogroup H (p = 0.005) and higher frequencies of cluster JT (p = 0.028) than Control-group; but no significant differences were found for abdominal surgery. Besides, both cluster HV and haplogroup H were associated with decreased odds of severe sepsis (adjusted odds ratio (aOR) = 0.45 (95%CI = 0.25; 0.82); p = 0.009 and aOR = 0.48 (95%CI = 0.26; 0.87); p = 0.015, respectively) among patients underwent cardiac surgery. In Case-group, 45.4% (109/240) patients died with a survival median of 39 (95%CI = 31.4; 46.62) days. When the clusters were examined, 41% (55/134) patients within cluster HV died versus 71.4% (10/14) patients within cluster IWX (p = 0.018). Additionally, patients within cluster IWX had an increased risk of death (adjusted hazard ratio (aHR) = 2.22; (95%CI = 1.14; 4.34); p = 0.019). CONCLUSIONS European mitochondrial haplogroups might be related to the onset of severe sepsis in patients who underwent major cardiac surgery, but not in patients underwent major abdominal surgery. Besides, mtDNA haplogroups could have influence on mortality in septic patients.

Genetic polymorphisms located in genes related to immune and inflammatory processes are associated with end-stage renal disease: a preliminary study

BackgroundChronic kidney disease progression has been linked to pro-inflammatory cytokines and markers of inflammation. These markers are also elevated in end-stage renal disease (ESRD), which constitutes a serious public health problem.ObjectiveTo investigate whether single nucleotide polymorphisms (SNPs) located in genes related to immune and inflammatory processes, could be associated with ESRD development.Design and methodsA retrospective case-control study was carried out on 276 patients with ESRD and 288 control subjects. Forty-eight SNPs were genotyped via SNPlex platform. Logistic regression was used to assess the relationship between each sigle polymorphism and the development of ESRD.ResultsFour polymorphisms showed association with ESRD: rs1801275 in the interleukin 4 receptor (IL4R) gene (OR: 0.66 (95%CI = 0.46-0.95); p = 0.025; overdominant model), rs4586 in chemokine (C-C motif) ligand 2 (CCL2) gene (OR: 0.70 (95%CI = 0.54-0.90); p = 0.005; additive model), rs301640 located in an intergenic binding site for signal transducer and activator of transcription 4 (STAT4) (OR: 1.82 (95%CI = 1.17-2.83); p = 0.006; additive model) and rs7830 in the nitric oxide synthase 3 (NOS3) gene (OR: 1.31 (95%CI = 1.01-1.71); p = 0.043; additive model). After adjusting for multiple testing, results lost significance.ConclusionOur preliminary data suggest that four genetic polymorphisms located in genes related to inflammation and immune processes could help to predict the risk of developing ESRD.

Diagnosis of perioperative myocardial infarction after heart valve surgery with new cut-off point of high-sensitivity troponin T and new electrocardiogram or echocardiogram changes

Objective: Criteria for diagnosing myocardial infarction (MI) after heart valve surgery are not collected in the Third Universal Definition of MI. We aimed to define cut‐offs for high‐sensitivity cardiac troponin T (hs‐cTnT) and creatine kinase‐MB (CK‐MB) for the diagnosis of perioperative MI after heart valve surgery according to perioperative MI determined by new alterations in electrocardiogram (ECG) and/or transthoracic echocardiogram (TTE). Secondary endpoints were incidence of perioperative MI, postoperative complications, 30‐day mortality, and 2‐year survival. Methods: Heart valve surgery was performed in 805 patients (June 2012‐January 2016). hs‐cTnT and CK‐MB were measured at intensive care unit (ICU) admission and 8, 16, 24, 48, and 72 hours after surgery. Blind to outcomes, we analyzed ECGs and TTEs before and after surgery. Patients were divided into 2 groups: with ECG and/or TTE criteria after surgery (following the consensus statement) and without these changes. We conducted receiver operating characteristic analyses for hs‐cTnT and CK‐MB in the group with ECG and/or TTE criteria. Results: ECG and/or TTE criteria were observed in 88 patients. Receiver operating characteristic analyses in this group showed hs‐cTnT levels of 732.3 pg/mL at ICU admission; 1008 pg/mL at 8 hours, 1057 pg/mL at 16 hours, and 958.3 pg/mL at 24 hours after surgery (P < .001) and CK‐MB levels of 26.78 mg/dL at ICU admission, 54.88 mg/dL at 8 hours, 38.98 mg/dL at 16 hours, and 18.4 mg/dL at 24 hours after surgery (P < .001). Conclusions: Cut‐offs for hs‐cTnT and CK‐MB to diagnose perioperative MI after heart valve surgery are well above upper reference limit. These findings update the Third Universal Definition providing cut‐offs to diagnose perioperative MI after heart valve surgery.

Candidemia in ICU patients with sepsis.

Critical Care Medicine www.ccmjournal.org e385 2B or Not 2B for Selective Decontamination of the Digestive Tract in the Surviving Sepsis Campaign Guidelines To the Editor: We read with great interest the excellent 2012 revision for the International Guidelines of the Surviving Sepsis Campaign for Management of Severe Sepsis and Septic Shock (1) and would like to comment on the need for a more extensive emphasis on the diagnosis and management of invasive fungal disease. In effect, several published articles in the last few years have reported on the growing prevalence of candidemia among both surgical and medical ICU patients that is related to the bigger proportion of patients who present with risk factors, such as immunocompromised status, previous broad-spectrum antibiotics, and invasive and prosthetic devices as well as the higher morbidity and mortality that they carry and that can be as high as 87% in the particular case of septic shock (2). This prompts the necessity of implementing early diagnosis and empirical treatment strategies in high-risk populations which have traditionally relied on the use of clinical scores, such as the Candida Score or measures of Candida colonization like the index of colonization. Although sensitive and useful as ruling out tools, they lack specificity and may result in overtreatment. The rapid diagnostic serum tests have provided a potentially useful tool due to their high sensitivity and specificity although there are false-positive concerns with their use. Posteraro et al (3) compared the (1–3)-β-d-glucan determination of high-risk ICU patients against the Candida score and the colonization index from samples taken at the beginning of clinical sepsis and found that the B glucan test was significantly better with a sensitivity of 93.7%, specificity of 93.6%, positive predictive value of 75%, and negative predictive value of 98.6%. We strongly believe that these results support its use in clinical practice and its inclusion in future guidelines if confirmed in multicenter trials. We would also like to add that the current guidelines of the Infectious Diseases Society of America (4) recommend that the antifungal therapy should be extended to at least 2 weeks after the demonstration of negative blood cultures and clinical improvement, a recommendation that should be emphasized because of the threat of emerging resistant Candida strains. The authors have disclosed that they do not have any potential conflicts of interest.

Cytokine profiles linked to fatal outcome in infective prosthetic valve endocarditis.

Infective endocarditis is a disease normally of bacterial cause which affects the endocardic tissue, specifically the valves (native or prosthetic). It is a serious illness and mortality rates remain high, ranging between 20% and 40%. Previous reports have evidenced the potential role of cytokines in the diagnosis of this disease, but no information is available on their relationship with outcome. We recruited 26 consecutive patients with late prosthetic valve endocarditis requiring surgical treatment according to Duke criteria. Eight cytokines were measured in plasma in the first 24 h following diagnosis by using a Bio‐Rad multiplex assay. Levels of IL‐6, IL‐8 and interferon gamma (IFN‐γ) were higher in non survivors. Receiver operating characteristic curve analysis evidenced that IL‐6, IL‐8 and IFN‐γ behaved as good diagnostic tests for identifying those patients with fatal outcome (area under the curve, CI 95%, p): IL‐6: [0.81 (0.61–1.00) 0.012]; IL‐8 [0.76 (0.56–0.96) 0.035]; IFN‐γ [0.79 (0.59–0.99) 0.021]. Levels of IL‐6, IL‐8 and IFN‐γ correlated positively between them, indicating that they are produced as consequence of a simultaneous response to the infection. Our findings support the participation of IL‐6, IL‐8 and IFN‐γ in the events linked to fatal outcome in infective prosthetic valve endocarditis.

IL-8 and mortality prediction in post-surgical septic shock.

To the Editor: We read with interest the article entitled ‘Multiplex cytokine profiling in patients with sepsis’, by Mera S and col (1). In this article, the authors simultaneously measured in 30 septic patients 17 cytokines during the first 7 days following admission. The authors found in the multivariate logistical regression analysis that the initial levels of interleukin (IL)-8 were the most predictive for fatal outcome. Although the presence of septic shock in the Mera and col cohort was limited to 9 of 30 patients, we actually tried to evaluate the prognostic role of the same cytokines in a cohort of patients with a more severe form of the disease. This way, we recruited 38 patients with post-surgical septic shock. Patients were prospectively recruited from our Intensive Care Unit from January to December 2011. Recommendations of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference were followed to define septic shock (2). Approval for the study protocol for both the scientific and the ethical aspects was obtained from the Scientific Committee for Clinical Research of our Hospital. Informed consent was obtained directly from the patients‘legal representative before enrolment. A 5 mL Ethylenediaminetetraacetic acid (EDTA) tube was collected in the 24 first hours following diagnosis of Septic Shock. Twelve patients had suffered a cardiac surgery, whereas 26 had suffered an abdominal surgery. Fifteen patients died during hospitalization at the ICU. A positive bacterial or fungal infection was found in 27 patients in blood and/or local culture. Six cases had an exclusive infection by a gram-positive bacteria; 10 cases had an exclusive infection by a gram-negative bacteria; an exclusive fungal infection was found in one patient; six patients had a combined infection by gram-positive + gram-negative bacteria; two patients had a combined infection by gram-negative bacteria + fungi; three patients had a combined infection by grampositive, gram-negative bacteria and fungi. Sixteen healthy volunteers working at our hospital of similar age were recruited as controls for comparison purposes. The multiplex cytokine kit was also a 17 plex kit purchased from BioRad (Hercules, CA, USA), including [IL-1b, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL12, IL-13, IL-17, interferon-c, granulocyte colony-stimulating factor, granulocyte macrophage colony-stimulating factor, monocyte chemotactic protein (MCP-1), macrophage inflammatory protein (MIP)-1b and tumour necrosis factor (TNF)-a]. Mann–Whitney U-test evidenced that patients with septic shock had higher plasma levels of IL-6, IL-8, IL-10, IL-13, MCP-1 and MIP-1b than controls, independently of their final outcome (data not shown). Patients who died had significant higher levels of IL-8 and MCP-1 at the moment of diagnosis than those who survived [median, interquartile rank (pg/ mL) in survivors and fatal cases]: IL-8 [(80.8, 172.4); (158.6, 217.9)] (Fig. 1); MCP-1 [(148.4, 441.7); (346.8, 1347.7)] (p < 0.05). Patients