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Hoeboer SH, Groeneveld ABJ, Engels N, van Genderen M, Wijnhoven BPL, van Bommel J. Rising C-reactive protein and procalcitonin levels precede early complications after esophagectomy. J Gastrointest Surg 2015; 19:613-24. [PMID: 25663633 PMCID: PMC4361731 DOI: 10.1007/s11605-015-2745-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 01/05/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Elective esophagectomy with gastric tube reconstruction carries a high risk for complications. Early and accurate diagnosis could improve patient management. Increased C-reactive protein (CRP) levels may be associated with any, surgical or infectious, complication and procalcitonin (PCT) specifically with infectious complications. METHODS We measured CRP and PCT on post-operative days 0, 1, 2, and 3 in 45 consecutive patients. Complications were recorded up to 10 days post-esophagectomy. RESULTS Twenty-eight patients developed a post-operative complication (5 surgical, 14 infectious, 9 combined surgical/infectious, including anastomotic leakage), presenting on day 3 or later. Elevated days 2 and 3 and a rise in CRP preceded the diagnosis of general or combined surgical/infectious complications (minimum area under the receiver operating characteristics curve (AUROC) 0.75, P = 0.006). Elevated day 3 PCT preceded combined complications (AUROC 0.86, P < 0.001). High day 1 and 3 PCT levels preceded anastomotic leakage (minimum AUROC 0.76, P = 0.005), as did the day 3 CRP levels and their increases (minimum AUROC 0.78, P = 0.002). CONCLUSIONS This small study suggests that high or increasing CRP levels may precede the clinical diagnosis of general or surgical/infectious complications after esophagectomy. Elevated PCT levels may more specifically and timely precede combined surgical/infectious complications mainly associated with anastomotic leakage.
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Affiliation(s)
- Sandra H. Hoeboer
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - A. B. Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Noel Engels
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Michel van Genderen
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | | | - Jasper van Bommel
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Basu S, Bhattacharya M, Chatterjee TK, Chaudhuri S, Todi SK, Majumdar A. Microalbuminuria: A novel biomarker of sepsis. Indian J Crit Care Med 2011; 14:22-8. [PMID: 20606905 PMCID: PMC2888326 DOI: 10.4103/0972-5229.63034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
CONTEXT Diffused endothelial dysfunction in sepsis leads to an increase in systemic capillary permeability, the renal component manifesting as microalbuminuria. The degree of microalbuminuria correlates with the severity of the acute insult, the quantification of which may serve to predict sepsis and mortality in critically ill patients. AIMS To evaluate whether the degree of microalbuminuria could differentiate patients with sepsis from those without and predict mortality in critically ill patients. SETTINGS AND DESIGN Prospective, non-interventional study in a 20-bed Intensive Care Unit (ICU) of a tertiary care hospital. METHODS AND MATERIALS After exclusions, between Jan-May 2007, 94 consecutive adult patients were found eligible. Albumin-creatinine ratio (ACR, mg/g) was measured in urine samples collected on ICU admission (ACR1) and at 24 hours (ACR2). RESULTS PATIENTS WERE CLASSIFIED INTO TWO GROUPS: those with sepsis, severe sepsis and septic shock (n = 30) and those without sepsis [patients without systemic inflammatory response syndrome (SIRS) and with SIRS due to noninfectious causes] (n = 64). In the sepsis group, median ACR1 [206.5 (IQR129.7-506.1)] was significantly higher compared to the non sepsis group [76.4 (IQR29-167.1)] (P = 0.0016, Mann Whitney). The receiver operating characteristics (ROC) curve analysis showed that at a cut off value 124 mg/g, ACR1 may be able to discriminate between patients with and without sepsis with a sensitivity of 80%, specificity of 64.1%, positive predictive value (PPV) of 51.1% and negative predictive value (NPV) of 87.3%. The median ACR2 [154 (IQR114.4-395.3)] was significantly higher (P = 0.004) in nonsurvivors (n = 13) as compared to survivors [50.8 (IQR 21.6-144.7)]. The ROC curve analysis revealed that ACR2 at a cut-off of 99.6 mg/g could predict ICU mortality with sensitivity of 85%, specificity of 68% with a NPV of 97% and PPV of 30%. CONCLUSION Absence of significant microalbuminuria on ICU admission is unlikely to be associated with sepsis. At 24 hours, absence of elevated levels of microalbuminuria is strongly predictive of ICU survival, equivalent to the time-tested APACHE II scores.
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Affiliation(s)
- Surupa Basu
- Department of Laboratory Medicine, Advanced Medicare Research Institute Hospitals, Kolkata, India
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Márton S, Garai J, Molnár V, Juhász V, Bogár L, Köszegi T, Falusi B, Ghosh S. Kinetics of inflammatory markers following cancer-related bowel and liver resection. Ups J Med Sci 2011; 116:124-8. [PMID: 21091281 PMCID: PMC3078541 DOI: 10.3109/03009734.2010.519446] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Macrophage migration inhibitory factor (MIF) was originally described as a cytokine that inhibits migration of macrophages at the site of inflammation. Subsequently it was also identified as a stress-induced hormone released from the anterior pituitary lobe in response to some pro-inflammatory stimuli like endotoxins and tumour necrosis factor (TNF-α). AIM To compare postoperative changes in serum MIF levels of patients undergoing bowel and liver resections. It has clinical relevance to describe the kinetics of this crucial mediator of systemic inflammation in surgery. METHODS A total of 58 patients were studied over 4 years. Group A (28 patients) underwent only hepatic resection without enterotomy. Group B (30 patients) had bowel resection with enterotomy. MIF, IL-1β, IL-8, prealbumin, albumin, α1-glycoprotein, fibrinogen, and C-reactive protein levels were measured preoperatively, immediately following surgery, and postoperatively for three consecutive days. To evaluate organ functions, multiple organ dysfunction score was used. RESULTS A significantly higher level of MIF (4,505 pg/mL) was found in group A when compared to that of group B immediately following surgery. Other parameters monitored in this study were not statistically different between the two groups. CONCLUSION Higher elevations in MIF levels with liver resections, compared to bowel resections, might be attributable to MIF release from damaged liver cells. The presumably minimal endotoxin exposure during bowel surgery was either insufficient or inefficient to induce relevant MIF elevations in our patients. To fully delineate implications of this finding further studies are needed.
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Affiliation(s)
- Sándor Márton
- University of Pécs, Department of Anaesthesiology and Intensive Therapy, Pécs, Hungary
| | - János Garai
- University of Pécs, Department of Pathophysiology and Gerontology, Pécs, Hungary
| | - Valéria Molnár
- University of Pécs, Department of Pathophysiology and Gerontology, Pécs, Hungary
| | - Vera Juhász
- University of Pécs, Department of Anaesthesiology and Intensive Therapy, Pécs, Hungary
| | - Lajos Bogár
- University of Pécs, Department of Anaesthesiology and Intensive Therapy, Pécs, Hungary
| | - Tamás Köszegi
- University of Pécs, Department of Clinical Chemistry, Pécs, Hungary
| | - Boglárka Falusi
- University of Pécs, Department of Anaesthesiology and Intensive Therapy, Pécs, Hungary
| | - Subhamay Ghosh
- University of Pécs, Department of Anaesthesiology and Intensive Therapy, Pécs, Hungary
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Rinaldi S, Adembri C, Grechi S, De Gaudio AR. Low-dose hydrocortisone during severe sepsis: effects on microalbuminuria. Crit Care Med 2006; 34:2334-9. [PMID: 16850006 DOI: 10.1097/01.ccm.0000233872.04706.bb] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the effect of low-dose hydrocortisone on glomerular permeability measured by the microalbuminuria to creatinine ratio (MACR) and on other markers of sepsis in severe septic patients. DESIGN Randomized prospective study. SETTING University intensive care unit. PATIENTS The study involved 40 patients with severe sepsis randomized into the hydrocortisone group (n = 20) and the standard therapy group (n = 20). INTERVENTIONS The hydrocortisone group received standard therapy plus a continuous infusion of hydrocortisone for 6 days, whereas the standard therapy group received only standard therapy. MEASUREMENTS AND MAIN RESULTS MACR, serum C-reactive protein, and procalcitonin concentrations were recorded every day from the day before the steroid therapy (T(0)) until the 6 days after (T(1), T(2), T(3), T(4), T(5), and T(6)). Concentrations in the hydrocortisone group and the standard therapy group were compared using Mann-Whitney test at each time. We also compared with Wilcoxon signed rank test the values determined in each group at T(0) with those at each subsequent time. Median MACR decreased from T(0) to T(6) in both patient groups; however, values were significantly lower in the hydrocortisone group from T(3) through to T(6). Median serum C-reactive protein also decreased from T(0) in both patient groups, with significantly lower values in the hydrocortisone group from T(3) through to T(6). There were no significant differences in procalcitonin between groups compared with baseline values or at any individual time point. CONCLUSIONS Low-dose hydrocortisone seems to reduce MACR and serum C-reactive protein but not procalcitonin in patients with severe sepsis. Further studies are needed to confirm these results and to understand the underlying molecular mechanisms.
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Affiliation(s)
- Simone Rinaldi
- University of Florence, Department of Critical Care, Section of Anesthesiology and Intensive Care, Italy
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Gopal S, Carr B, Nelson P. Does microalbuminuria predict illness severity in critically ill patients on the intensive care unit? A systematic review. Crit Care Med 2006; 34:1805-10. [PMID: 16625124 DOI: 10.1097/01.ccm.0000217922.75068.ea] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Studies assessing the accuracy of microalbuminuria to predict illness severity on the intensive care unit have produced inconsistent results. OBJECTIVE To determine the diagnostic accuracy of microalbuminuria to predict illness severity in critically ill patients on the intensive care unit. DATA SOURCE MEDLINE (1951 to September 2004) and EMBASE (1980 to September 2004) electronic databases were searched for relevant studies. Reference lists of all abstracts were manually searched to identify studies not included in the electronic database. STUDY SELECTION Studies that prospectively evaluated the accuracy of microalbuminuria to predict illness severity and/or mortality probability in adult patients on the intensive care unit were selected. DATA EXTRACTION We included nine studies in the review. Data to evaluate methodological quality and results were abstracted. DATA SYNTHESIS The methodological quality of a number of studies was poor. Significant heterogeneity in the design and conduct of the studies circumvented the data being subjected to meta-analysis. Studies also differed in the timing of the index test, in the methods of quantifying microalbuminuria, and in the cutoff values used. CONCLUSIONS This descriptive analysis reveals that microalbuminuria may hold promise as a predictor of illness severity and mortality on the intensive care unit. However, future epidemiologic studies need to be conducted to determine the optimal timing as well as the threshold reference value for the urine albumin creatinine ratio in the adult intensive care unit population. Thereafter, multiple-center prospective epidemiologic studies must be conducted to confirm and validate the findings of these preliminary studies. Future studies should conform to the Standards for Reporting of Diagnostic Accuracy checklist in terms of study design, conduct, and reporting. Presently there is no evidence to warrant the use of this tool on the intensive care unit.
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Affiliation(s)
- Shameer Gopal
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of North Staffordshire NHS Trust, City General Hospital, Stoke-on-Trent, Staffordshire, UK
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Márton S, Szakmány T, Papp A, Cseke L, Horváth PO. Does transthoracic compared to transhiatal resection alter the early postoperative course of oesophagectomy? Dis Esophagus 2005; 18:155-9. [PMID: 16045576 DOI: 10.1111/j.1442-2050.2005.00479.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Several techniques for esophageal resections have been reported. However, clear clinical evidence is still lacking whether any of the procedures is superior to the others regarding morbidity and mortality in the early postoperative period. Two operative approaches for esophageal carcinoma, transhiatal and transthoracic, were compared with respect to operative morbidity, mortality and systemic inflammatory response. In our prospective study between 2000 and 2002 83 patients were investigated. In a retrospective post hoc analysis patients were divided into two groups due to the performed operational procedure, transhiatal (TH) or transthoracic (TT). Multiple Organ Dysfunction Score (MODS) was monitored daily (t1,t2,t3). Serum procalcitonin (PCT) levels were determined on admission to the ICU (t0), then 24 hourly (t24,t48,t72). Microalbuminuria (M:Cr) was measured before (tp), and after surgery (t0,t6,t24,t48,t72). For statistical analysis Wilcoxon rank sum test, Mann-Whitney U-test and chi-square test were used as appropriate. We examined 52 patients in the TH group, and 31 patients in the TT group. There was no significant difference between the two groups regarding age, male/female ratio, and SAPS II scores. Operations lasted significantly longer in the TT group: 375 (300-480) min compared to the TH group 240 375 (180-319) min, P < 0.001. ICU mortality was similar in both groups (TH: 46 survivors/6 non-survivors; TT: 27 survivors/4 non-survivors; P = 0.607, respectively). Daily MODS did not differ significantly between the two groups. The observed inflammatory markers (PCT and M:Cr) followed the pattern we described earlier, without significant difference. In this study there was no difference in the clinical and biochemical variables of the patients between the transthoracic and transhiatal groups. The observed early postoperative morbidity and mortality may indicate, that both procedures can be considered as procedures with similar postoperative risk.
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Affiliation(s)
- S Márton
- Department of Anesthesiology and Intensive Care, University of Pécs, Pécs, Hungary.
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Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004; 39:206-17. [PMID: 15307030 DOI: 10.1086/421997] [Citation(s) in RCA: 1063] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2003] [Accepted: 03/12/2004] [Indexed: 12/11/2022] Open
Abstract
A meta-analysis was performed to evaluate the accuracy of determination of procalcitonin (PCT) and C-reactive protein (CRP) levels for the diagnosis of bacterial infection. The analysis included published studies that evaluated these markers for the diagnosis of bacterial infections in hospitalized patients. PCT level was more sensitive (88% [95% confidence interval [CI], 80%-93%] vs. 75% [95% CI, 62%-84%]) and more specific (81% [95% CI, 67%-90%] vs. 67% [95% CI, 56%-77%]) than CRP level for differentiating bacterial from noninfective causes of inflammation. The Q value for PCT markers was higher (0.82 vs. 0.73). The sensitivity for differentiating bacterial from viral infections was also higher for PCT markers (92% [95% CI, 86%-95%] vs. 86% [95% CI, 65%-95%]); the specificities were comparable (73% [95% CI, 42%-91%] vs. 70% [95% CI, 19%-96%]). The Q value was higher for PCT markers (0.89 vs. 0.83). PCT markers also had a higher positive likelihood ratio and lower negative likelihood ratio than did CRP markers in both groups. On the basis of this analysis, the diagnostic accuracy of PCT markers was higher than that of CRP markers among patients hospitalized for suspected bacterial infections.
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Affiliation(s)
- Liliana Simon
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA.
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Szakmány T, Molnár Z. Increased glomerular permeability and pulmonary dysfunction following major surgery: correlation of microalbuminuria and PaO/FiO ratio. Acta Anaesthesiol Scand 2004; 48:704-10. [PMID: 15196102 DOI: 10.1111/j.1399-6576.2004.00388.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of our trial was to evaluate the ability of microalbuminuria as an indicator of outcome and to investigate its relationship with the postoperative respiratory dysfunction in the initial postoperative period in a high-risk patient group. METHODS In our prospective, observational study patients were consecutively recruited following elective oesophagectomy, total gastrectomy, Whipple-resection of the pancreas and liver resection due to tumour removal. Microalbuminuria (expressed as urine albumin:creatinine ratio, M:Cr) was measured before (tp), and after surgery (t0, t6, t24, t48, t72). Multiple Organ Dysfunction Scores were monitored on ICU admission than daily (t1, t2, t3). For statistical analysis, Wilcoxon's rank-sum test, Mann-Whitney's U-test, receiver operating characteristic curve analysis and Spearman's rho test were used as appropriate. RESULTS One hundred and forty patients (118 survivors and 22 non-survivors) were recruited. Significantly higher Multiple Organ Dysfunction Scores were observed in non-survivors throughout the study period (P < 0.001). Microalbuminuria (Cr) increased significantly (P < 0.01) on admission to the ICU (t0) compared with the preoperative levels, but levels returned to normal within 6 h and remained so for the rest of the study. There was a significant difference between survivors and non-survivors at t0 (P < 0.01). However the ROC curve indicated that M:Cr is not a reliable descriptor of outcome. Comparison of Cr values with the PaO2/FiO2 ratio showed an inverse relationship on admission, which remained so for t24 and t48. CONCLUSION M:Cr measured on admission to the ICU was significantly higher in non-survivors than in survivors, and also showed an inverse relationship with the PaO2/FiO2 ratio following extended abdominal surgery. However, on admission, M:Cr did not discriminate survivors from non-survivors. Further studies are required to evaluate the prognostic value of this test for postoperative patients with risk of respiratory failure.
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Affiliation(s)
- T Szakmány
- Department of Anaesthesia and Intensive Care, Faculty of General Medicine, University of Pécs, Hungary.
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Szakmany T, Molnar Z. Procalcitonin levels do not predict mortality following major abdominal surgery. Can J Anaesth 2003; 50:1082-3. [PMID: 14656802 DOI: 10.1007/bf03018387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Microalbuminuria in severe sepsis: timing is difficult, "normal" levels are uncertain. Intensive Care Med 2003. [DOI: 10.1007/s00134-003-1818-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Molnár Z, Szakmány T, Heigl P. Microalbuminuria does not reflect increased systemic capillary permeability in septic shock. Intensive Care Med 2003; 29:391-5. [PMID: 12560870 DOI: 10.1007/s00134-003-1651-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2002] [Accepted: 12/06/2002] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the correlation between microalbuminuria and extravascular lung water in patients in septic shock who require mechanical ventilation for severe respiratory failure. DESIGN AND SETTING Prospective, observational, clinical study in the 20-bed intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS 25 consecutive patients in septic shock and also in severe respiratory failure requiring mechanical ventilation. INTERVENTIONS Hemodynamic parameters and extravascular lung water were determined by single arterial thermodilution. Together with each hemodynamic measurement the PaO(2)/FIO(2) ratio and urinary microalbumin to creatinine ratio (M:Cr) was measured. Serum C-reactive protein (CRP) and procalcitonin (PCT) levels were also determined daily. MEASUREMENTS AND RESULTS The EVLW index was significantly higher than normal throughout the study. Microalbuminuria was in the normal range on entry and remained so for the rest of the study period. Serum PCT and CRP levels were significantly higher than normal at every assessment points. No significant correlation was found between M:Cr and either EVLW or PaO(2)/FIO(2). CONCLUSIONS In this study patients in septic shock with significantly elevated EVLW had normal urinary M:Cr, and there was no correlation between M:Cr and EWLV, and PaO(2)/FIO(2). Therefore based on the current results routine measurements of microalbuminuria to determine endothelial permeability cannot be recommended in critically ill patients.
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Affiliation(s)
- Zsolt Molnár
- Department of Anaesthesiology and Intensive Care, University of Pécs, Pécs, Hungary.
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Köszegi T. Immunoluminometric detection of human procalcitonin. JOURNAL OF BIOCHEMICAL AND BIOPHYSICAL METHODS 2002; 53:157-64. [PMID: 12406598 DOI: 10.1016/s0165-022x(02)00104-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Procalcitonin is a normal precursor of the active hormone calcitonin; however, its level in blood is normally undetectable. Dramatically increased levels of procalcitonin have been found in severe systemic bacterial infections and, today, this molecule is considered to be one of the earliest inflammatory markers of sepsis. In spite of the large body of data, it is still uncertain how and from which tissues procalcitonin is released into the circulation. In our experiments, we tested the analytical performance of a flash-type chemiluminescent immunoassay. The precision and accuracy of the assay was acceptable for early detection of sepsis and procalcitonin levels showed predictive information on the outcome of the infections. Using isolated leukocyte subpopulations and acridinium-labelled anti-calcitonin monoclonal antibody, we made attempts to detect procalcitonin inside the cells or in surrounding medium by measuring the chemiluminescent signal triggered after the specific binding of the antibodies had occurred. Our preliminary data showed that lymphocytes did not contain detectable amounts of procalcitonin nor neutrophils secreted it after stimulation. However, neutrophils expressed chemiluminescence of intracellular origin. This finding suggests that neutrophil leukocytes might be a potential source of serum procalcitonin under in vivo conditions.
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Affiliation(s)
- Tamás Köszegi
- Department of Clinical Chemistry, Faculty of General Medicine, Pécs University, Ifjúság u. 13, H-7624 Pécs, Hungary
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