The role of D-dimer in prediction of the course and outcome in pediatric acute pancreatitis

Identification of AP-1 as a Critical Regulator of Glutathione Peroxidase 4 (GPX4) Transcriptional Suppression and Acinar Cell Ferroptosis in Acute Pancreatitis

Glutathione peroxidase 4 (GPX4)-dependent ferroptosis in pancreatic acinar cells plays a critical role in acute pancreatitis (AP). However, potential upstream regulators of GPX4 are not well defined. Here, we observed a marked reduction in acinar GPX4 expression and ferroptotic cell death in mice with cerulein-induced AP. To determine the critical factors involved in acinar cell ferroptosis, pancreas transcriptome data from an AP mouse model were analyzed and overlapped with predicted transcription factors of Gpx4, and an upregulated transcription factor active protein 1 (AP-1) protein, Jun, was identified. The administration of a specific ferroptosis inhibitor liproxstatin-1 alleviated AP pathology and significantly decreased Jun levels. Bioinformatic analysis indicated that the Gpx4 promoter contains a putative AP-1 binding site. Jun binds directly to the Gpx4 promoter and inhibits Gpx4 transcription under pancreatic conditions. AP-1 inhibition by a selective inhibitor SR11302 reversed GPX4 reduction and ameliorated AP pathology in a GPX4-dependent manner. Collectively, our study demonstrates that the downregulation of GPX4 by AP-1 is critical in the aggravation of acinar cell ferroptosis during the progression of AP. Strategies targeting the AP-1/GPX4 axis may be potentially effective for the prevention and treatment of AP.

Admission risk factors and predictors of moderate or severe pediatric acute pancreatitis: A systematic review and meta-analysis

INTRODUCTION

Pediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP.

METHODS

We conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity.

RESULTS

We included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe.

DISCUSSION

Many predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.

The course of acute pancreatitis in children and potential simple laboratory markers of severity - a single centre retrospective study

AIM

To evaluate the usefulness of routinely measured biochemical and complete blood count parameters as potential markers of the severity of pediatric acute pancreatitis.

METHODS

The retrospective study included children with acute pancreatitis hospitalised over a 3-year period. Demographic, clinical and laboratory data were collected.

RESULTS

55 patients were enrolled in the study. Mild acute pancreatitis was diagnosed in 45 children (82%), moderately severe in 7 (13%), and severe in 3 patients (5%). Together 10 children (18%) were categorized into a single severe group. Children with severe acute pancreatitis had higher white blood cell and platelet counts on admission as well as a C-reactive protein concentration after 48 hours. The C-reactive protein concentration after 48 hours (cut-off: 127,2 mg/l) and the white blood cell count on admission (cut-off: 13,5x10³ /μl) were found to be statistically significant markers in predicting the severity of the disease. The C-reactive protein concentration after 48 hours was demonstrated as an independent predictor.

CONCLUSION

Severe acute pancreatitis is observed in a quite significant percentage of children. The white blood cell count on admission and the C-reactive protein concentration after 48 hours (as an independent predictor) may be potential simple laboratory markers of the severity of the disease.

Etiology, case fatality, recurrence, and severity in pediatric acute pancreatitis: a meta-analysis of 48 studies

For children, there are very few published reviews focusing on severe acute pancreatitis (AP). PubMed, EMBASE, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, EBSCO, and Cochrane Library were searched from inception until March 2020. Meta-regression analyses were used to estimate the etiology, case fatality, recurrence, and severity of pediatric AP in different regions (North America, Asia, South America, Europe, and Oceania). Pooled data from 47 papers (48 studies) found that main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate (CFR) of pediatric AP is 4.7% (North America), 6.2% (Europe), 2.4% (Asia), 3.1% (South America), and 7.4% (Oceania). The incidence rates of recurrent acute pancreatitis (RAP) in children who have had an episode of acute pancreatitis in North American, Asia, and Europe were 15.3, 13.1, and 13.8%, respectively. The incidence of severe acute pancreatitis (SAP) in different regions was 30.3% (Oceania), 29.2% (South America), 20.8% (Europe), 15.8% (Asia), and 13.7% (North America). It suggests that physicians should notice the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage. IMPACT: It indicates the etiology of pediatric acute pancreatitis for the initial assessment, diagnosis, and prediction of relapse. Main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate of pediatric AP is diverse worldwide. It suggests that physicians noticed the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage.

Clinical analysis of the therapeutic effect of plasma exchange on hypertriglyceridemic acute pancreatitis: A retrospective study

BACKGROUND

The therapeutic effect of plasma exchange (PE) on hypertriglyceridemic acute pancreatitis (HTGAP) is unclear. Therefore, we aimed to explore this therapeutic effect.

STUDY DESIGN AND METHODS

This study included 204 patients with HTGAP who underwent treatment at two provincial tertiary grade A hospitals in Fujian Province from October 2012 to May 2021. Patients were divided into a conventional group and a PE group. The Student's t-test and chi-square test were used for data analysis.

RESULTS

Among 204 patients, 56 and 148 were included in the PE and conventional groups, respectively. After propensity score matching (PSM), the PE and conventional groups each had 42 patients. There was no significant difference in age; sex; pregnancy; comorbidities; laboratory findings; incidences of complications, and multiple organ dysfunction syndrome (MODS); organ support treatment; surgical rate; mortality; and hospital stay between the groups (p > 0.05). The total expenses were significantly higher in the PE group than in the conventional group (p < 0.05). There was no statistically significant difference in the times of PE; total volume of PE; incidences of complications, and MODS; organ support treatment; surgical rate; mortality; and hospital stay between the early PE and delayed PE groups (p > 0.05). All patients in the PE group and conventional group with acute renal failure had significantly higher D-dimer levels than those without acute renal failure (p < 0.05).

DISCUSSION

Compared with conventional treatment, PE does not have a better therapeutic effect on HTGAP. The D-dimer level can predict whether patients with HTGAP will have acute renal failure.

Serum D-dimer levels at admission for prediction of outcomes in acute pancreatitis

BACKGROUND

Systemic alterations in coagulation are associated with complications of acute pancreatitis (AP). D-dimer, a fibrin degradation product, was recently described as a marker of pancreatitis outcome. Early prediction is essential for reducing mortality in AP. The present study aims to assess the relationship between elevated serum D-dimer levels and the severity of AP.

METHODS

We performed an observational retrospective study with data from 3451 enrolled patients with AP. Serum D-dimer levels were measured upon admission, after 24 h and during the week after admission by immunoturbidimetry. Univariate and multivariate analyses were used to determine whether elevated D-dimer levels were independently associated with the severity of AP.

RESULTS

Of the 3451 AP patients, 2478 (71.8%) had serum D-dimer levels measured within 24 h of hospital admission; 1273 of these patients had D-dimer levels ≤2.5 mg/L, and 1205 had D-dimer levels > 2.5 mg/L (934 patients had mild AP (MAP); 1086, moderately severe AP (MSAP); and 458, severe AP (SAP)). Patients with D-dimer levels > 2.5 mg/L (n = 1205) had higher incidences of SAP (75.5% vs. 24.5%), acute peripancreatic fluid collection (APFC) (53.3% vs. 46.7%), acute necrotic collection (ANC) (72.4% vs. 27.6%), pancreatic necrosis (PN) (65.2% vs. 34.8%), infected pancreatic necrosis (IPN) (77.7% vs. 22.8%), organ failure (OF) (68.5% vs. 31.5%), persistent organ failure (POF) (75.5% vs. 24.5%), ICU requirement (70.2% vs. 29.8%), and mortality (79.2% vs. 20.8%) than did patients with D-dimer levels ≤2.5 mg/L (n = 1273). The multivariate analysis showed that patients with higher serum D-dimer levels had poorer prognoses that worsened over time.

CONCLUSION

The measurement of D-dimer levels at admission may be useful for risk stratification of AP.

Young Age Predicts Acute Pancreatitis Severity in Children

OBJECTIVES

The course and evolution of pediatric acute pancreatitis (AP) is poorly understood. Prognostication models in children perform poorly and lack consensus. We aimed to identify predictors of AP severity, and the risk for AP recurrence.

METHODS

We retrospectively studied all patients hospitalized with AP at a single tertiary center, between January 1995 and June 2016. Patient demographics and admission laboratory data were assessed for severity and recurrence prediction.

RESULTS

A total of 68 patients accounting for a total of 117 (15 moderate-severe) AP episodes were reviewed. Patients with moderate-severe disease were significantly younger (median [interquartile range (IQR)] of 8.3 [4.0-14.4] vs 13.8 [8.1-16.0] years, P = 0.02). Young age at presentation was associated with odds ratio of 3.8 (confidence interval [CI] 1.2-12.1) for children younger than 12 years and 5.8 (CI 1.6-21.4) for children younger than 6 years for developing moderate-severe disease.Further subanalysis of the 59 patients with first-time AP episodes, demonstrated younger age (median [IQR] of 5.3 [2.9-10.4] vs 12.0 [6.3-15.8] years, P = 0.03) and elevated white blood cell count (median [IQR] of 22.8 [11.8-31.3] vs 11.0 [8.1-14.6] 10/L, P < 0.01) of patients with moderate-severe disease, conferring a risk for moderate-severe disease with odds ratio of 7.5 (CI 1.5-38.2) for children younger than 6 years and 5.3 (CI 1.1-25.4) for patients with white blood cell count >15 × 10/L, respectively. Fourteen (23.7%) of 59 patients with first-time episodes had recurrent AP. Analysis of the data at the primary episode failed to identify predictors to indicate future recurrence.

CONCLUSIONS

In our cohort, only young age (<12 years) predicted AP severity. No parameters were identified to predict future development of AP recurrence.

D-二聚体在急性胰腺炎中的特点

目的

回顾性分析无锡101医院近2年来急性胰腺炎(acute pancreatitis, AP)患者D-二聚体(D-dimer, DD)值与临床特点, 探讨DD与病情严重程度的相关性, 为其临床研究提供参考.

方法

收集解放军101医院2014-04-01/2016-04-01 AP患者, 记载临床特点, 根据病情分为轻、中、重3组, 分析AP患者DD水平、住院时间、费用、Rason评分及CT严重度指数(CT severity index, CTSI)评分.

结果

符合要求者共172例, 其中轻度急性胰腺炎(mild acute pancreatitis, MAP)组111例, 中度重症急性胰腺炎(moderately severe acute pancreatitis, MSAP)组52例, 重症急性胰腺炎(severe acute pancreatitis, SAP)组9例. DD水平在MSAP、SAP组中明显高于MAP组, 有统计学意义(P<0.01), 但MSAP组对比SAP组无明显差异; 另外住院天数及费用3组间呈递增, 有统计学差异. 将3组患者中年龄<60岁分为中青年组, 年龄≥60岁为老年组, 其中SAP、MSAP两组中老年患者明显高于中青年患者(P<0.05), SAP组中未见明显差异; 老年患者中MAP、MSAP、SAP 3组DD水平均无统计学差异. DD与住院天数、费用、CTSI分级、Ranson评分系统的相关系数分别为0.429、0.436、0.402、0.447, 呈正相关.

结论

DD在AP患者显著增高, 中、重度组尤为明显, 与住院时间、费用、评分呈正相关, 本研究表明血浆DD体对AP严重程度的早期判断有一定的意义, 但对于老年AP患者以及对MSAP和SAP患者的判断效果欠佳.

Serum C-reactive protein, procalcitonin, and lactate dehydrogenase for the diagnosis of pancreatic necrosis

BACKGROUND

The treatment of people with pancreatic necrosis differs from that of people with oedematous pancreatitis. It is important to know the diagnostic accuracy of serum C-reactive protein (CRP), serum procalcitonin, and serum lactate dehydrogenase (LDH) as a triage test for the detection of pancreatic necrosis in people with acute pancreatitis, so that an informed decision can be made as to whether the person with pancreatic necrosis needs further investigations such as computed tomography (CT) scan or magnetic resonance imaging (MRI) scan and treatment for pancreatic necrosis started. There is currently no standard clinical practice, although CRP, particularly an increasing trend of CRP, is often used as a triage test to determine whether the person requires further imaging. There is also currently no systematic review of the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of CRP, procalcitonin, or LDH (index test), either alone or in combination, in the diagnosis of necrotising pancreatitis in people with acute pancreatitis and without organ failure.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis using the following reference standards, either alone or in combination: radiological features of pancreatic necrosis (contrast-enhanced CT or MRI), surgeon's judgement of pancreatic necrosis during surgery, or histological confirmation of pancreatic necrosis. Had we found case-control studies, we planned to exclude them because they are prone to bias; however, we did not locate any. Two review authors independently identified the relevant studies from the retrieved references.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, including methodological quality assessment, from the included studies. As the included studies reported CRP, procalcitonin, and LDH on different days of admission and measured at different cut-off levels, it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) on each of the different days of admission and measured at different cut-off levels.

MAIN RESULTS

A total of three studies including 242 participants met the inclusion criteria for this review. One study reported the diagnostic performance of CRP for two threshold levels (> 200 mg/L and > 279 mg/L) without stating the day on which the CRP was measured. One study reported the diagnostic performance of procalcitonin on day 1 (1 day after admission) using a threshold level of 0.5 ng/mL. One study reported the diagnostic performance of CRP on day 3 (3 days after admission) using a threshold level of 140 mg/L and LDH on day 5 (5 days after admission) using a threshold level of 290 U/L. The sensitivities and specificities varied: the point estimate of the sensitivities ranged from 0.72 to 0.88, while the point estimate of the specificities ranged from 0.75 to 1.00 for the different index tests on different days of hospital admission. However, the confidence intervals were wide: confidence intervals of sensitivities ranged from 0.51 to 0.97, while those of specificities ranged from 0.18 to 1.00 for the different tests on different days of hospital admission. Overall, none of the tests assessed in this review were sufficiently accurate to suggest that they could be useful in clinical practice.

AUTHORS' CONCLUSIONS

The paucity of data and methodological deficiencies in the studies meant that it was not possible to arrive at any conclusions regarding the diagnostic test accuracy of the index test because of the uncertainty of the results. Further well-designed diagnostic test accuracy studies with prespecified index test thresholds of CRP, procalcitonin, LDH; appropriate follow-up (for at least two weeks to ensure that the person does not have pancreatic necrosis, as early scans may not indicate pancreatic necrosis); and clearly defined reference standards (of surgical or radiological confirmation of pancreatic necrosis) are important to reliably determine the diagnostic accuracy of CRP, procalcitonin, and LDH.

Serum Concentrations of Angiopoietin-2 and Soluble fms-Like Tyrosine Kinase 1 (sFlt-1) Are Associated with Coagulopathy among Patients with Acute Pancreatitis

In severe acute pancreatitis (SAP), systemic inflammation leads to endothelial dysfunction and activation of coagulation. Thrombotic disorders in acute pancreatitis (AP) include disseminated intravascular coagulation (DIC). Recently, angiopoietin-2 and soluble fms-like tyrosine kinase 1 (sFlt-1) were proposed as markers of endothelial dysfunction in acute states. Our aim was to assess the frequency of coagulation abnormalities in the early phase of AP and evaluate the relationships between serum angiopoietin-2 and sFlt-1 and severity of coagulopathy. Sixty-nine adult patients with AP were recruited: five with SAP, 15 with moderately severe AP (MSAP) and 49 with mild AP. Six patients were diagnosed with DIC according to International Society on Thrombosis and Haemostasis (ISTH) score. All patients had at least one abnormal result of routine tests of hemostasis (low platelet count, prolonged clotting times, decreased fibrinogen, and increased D-dimer). The severity of coagulopathy correlated with AP severity according to 2012 Atlanta criteria, bedside index of severity in AP and duration of hospital stay. D-dimers correlated independently with C-reactive protein and studied markers of endothelial dysfunction. Angiopoietin-2, D-dimer, and ISTH score were best predictors of SAP, while sFlt-1 was good predictor of MSAP plus SAP. In clinical practice, routine tests of hemostasis may assist prognosis of AP.

The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications

Acute pancreatitis (AP) is an inflammatory disease with varied severity, ranging from mild local inflammation to severe systemic involvement resulting in substantial mortality. Early pathologic events in AP, both local and systemic, are associated with vascular derangements, including endothelial activation and injury, dysregulation of vasomotor tone, increased vascular permeability, increased leukocyte migration to tissues, and activation of coagulation. The purpose of the review was to summarize current evidence regarding the interplay between inflammation, coagulation and endothelial dysfunction in the early phase of AP. Practical aspects were emphasized: (1) we summarized available data on diagnostic usefulness of the markers of endothelial dysfunction and activated coagulation in early prediction of severe AP; (2) we reviewed in detail the results of experimental studies and clinical trials targeting coagulation-inflammation interactions in severe AP. Among laboratory tests, d-dimer and angiopoietin-2 measurements seem the most useful in early prediction of severe AP. Although most clinical trials evaluating anticoagulants in treatment of severe AP did not show benefits, they also did not show significantly increased bleeding risk. Promising results of human trials were published for low molecular weight heparin treatment. Several anticoagulants that proved beneficial in animal experiments are thus worth testing in patients.

Antithrombin III and D-dimer levels as indicators of disease severity in patients with hyperlipidaemic or biliary acute pancreatitis

Objective To assess changes in anticoagulation and fibrinolytic systems between biliary and hyperlipidaemic acute pancreatitis (AP). Methods Patients with biliary or hyperlipidaemic AP were enrolled. Demographic and clinical data were collected, and antithrombin III (ATIII), protein C, protein S, and D-dimer levels were investigated. Results A total of 45 patients with biliary AP and 50 patients with hyperlipidaemic AP were included (68 with mild AP and 27 with moderately-severe AP). ATIII and protein C levels in the mild AP group were significantly higher, but prothrombin time and D-dimer were significantly lower, versus the moderately-severe AP group. ATIII and D-dimer were found to be risk factors for moderately-severe AP. ATIII could predict AP severity, particularly in patients with biliary AP. D-dimer was a sensitive and specific predictor for disease severity in patients with AP, particularly in patients with hyperlipidaemic AP. Conclusion ATIII and protein C levels decreased as severity of AP increased, particularly in cases of biliary AP. D-dimer levels increased with severity of AP, particularly in hyperlipidaemic AP. ATIII and D-dimer may be useful biomarkers for assessing AP severity in patients with biliary and hyperlipidaemic AP, respectively.

Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis

Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.