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Dhamoon MS, Cheung YK, Moon YP, Wright CB, Willey JZ, Sacco RL, Elkind MSV. Association Between Serum Tumor Necrosis Factor Receptor 1 and Trajectories of Functional Status: The Northern Manhattan Study. Am J Epidemiol 2017; 186:11-20. [PMID: 28453789 DOI: 10.1093/aje/kwx035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/19/2016] [Indexed: 12/25/2022] Open
Abstract
We hypothesized that tumor necrosis factor receptor 1 (TNFR1) levels are associated with long-term trajectories of functional status independently of vascular risk factors and the occurrence of stroke and myocardial infarction (MI) during follow-up. In the Northern Manhattan Study, stroke-free persons aged ≥40 years in northern Manhattan (New York, New York) had annual assessments with the Barthel index (BI) for a median of 13 years (1993-2015). Assessment of baseline demographic factors, risk factors, and laboratory studies included measurement of TNFR1 (n = 1,863). Generalized estimating equations models were used to estimate standardized associations between TNFR1 and 1) baseline functional status and 2) change in function over time, adjusting for demographic factors, vascular risk factors, social variables, cognition, and depression, as well as stroke and MI occurrence during follow-up. The mean age of participants was 70 (standard deviation (SD), 10) years; 66% were women, and 55% were Hispanic. The mean TNFR1 level was 2.57 mg/L. TNFR1 was associated with baseline BI (-0.93 BI points per SD increment in TNFR1; 95% confidence interval: -1.59, -0.26) and change over time (-0.36 BI points per year per SD increment in TNFR1; 95% confidence interval: -0.69, -0.03). In this large population-based study, higher TNFR1 levels were associated with greater baseline disability and disability over time, even with adjustment for baseline covariates and stroke and MI occurrence during follow-up.
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Parlato M, Cavaillon JM. Host response biomarkers in the diagnosis of sepsis: a general overview. Methods Mol Biol 2015; 1237:149-211. [PMID: 25319788 DOI: 10.1007/978-1-4939-1776-1_15] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Critically ill patients who display a systemic inflammatory response syndrome (SIRS) are prone to develop nosocomial infections. The challenge remains to distinguish as early as possible among SIRS patients those who are developing sepsis. Following a sterile insult, damage-associated molecular patterns (DAMPs) released by damaged tissues and necrotic cells initiate an inflammatory response close to that observed during sepsis. During sepsis, pathogen-associated molecular patterns (PAMPs) trigger the release of host mediators involved in innate immunity and inflammation through identical receptors as DAMPs. In both clinical settings, a compensatory anti-inflammatory response syndrome (CARS) is concomitantly initiated. The exacerbated production of pro- or anti-inflammatory mediators allows their detection in biological fluids and particularly within the bloodstream. Some of these mediators can be used as biomarkers to decipher among the patients those who developed sepsis, and eventually they can be used as prognosis markers. In addition to plasma biomarkers, the analysis of some surface markers on circulating leukocytes or the study of mRNA and miRNA can be helpful. While there is no magic marker, a combination of few biomarkers might offer a high accuracy for diagnosis.
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Affiliation(s)
- Marianna Parlato
- Unit of Cytokines and Inflammation, Institut Pasteur, 28 rue du Dr Roux, 75724, Paris Cedex 15, France
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Luna JM, Moon Y, Liu K, Spitalnik S, Paik M, Sacco R, Elkind MSV. Tumour necrosis factor receptor 1 and mortality in a multi-ethnic cohort: the Northern Manhattan Study. Age Ageing 2013; 42:385-90. [PMID: 23321203 DOI: 10.1093/ageing/afs175] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE to study the association between soluble tumour necrosis factor receptor 1 (sTNFR1) levels and mortality in the population-based Northern Manhattan Study (NOMAS). METHODS NOMAS is a multi-ethnic, community-based cohort study with mean 8.4 years of follow-up. sTNFR1 was measured using ELISA. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals (HR, 95% CI) for the association of sTNFR1 with risk of all-cause mortality after adjusting for relevant confounders. RESULTS sTNFR1 measurements were available in 1,862 participants (mean age 69.2 ± 10.2 years) with 512 all-cause deaths. Median sTNFR1 was 2.28 ng/ml. Those with sTNFR1 levels in the highest quartile (Q4), compared with those with sTNFR1 in the lowest quartile (Q1), were at an increased risk of all-cause mortality (adjusted HR: 1.8, 95% CI: 1.4-2.4) and non-vascular mortality (adjusted HR: 2.5, 95% CI: 1.5-3.6), but not vascular mortality (adjusted HR: 1.3, 95% CI: 0.9-1.9). There were interactions between sTNFR1 quartiles and medical insurance-status [likelihood ratio test (LRT) with 3 degrees of freedom, Pinteraction = 0.02] and alcohol consumption (LRT with 3 degrees of freedom, Pinteraction < 0.01) for all-cause mortality. In participants with no insurance or Medicaid, those with sTNFR1 in the top quartile had nearly a threefold increased risk of total mortality than the lowest quartile (adjusted HR: 2.9, 95% CI: 1.9-4.4). CONCLUSION in this multi-ethnic cohort, sTNFR1 was associated with all-cause and non-vascular mortality, particularly among those of a lower socioeconomic status.
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Affiliation(s)
- Jorge M Luna
- Department of Neurology, Columbia University, New York, NY, USA.
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Riemsdijk I, Baan C, Knoop C, Vantrimpont P, Balk A, Maat A, Weimar W. Quantitative flow cytometry to measure the TNF-α and IL-2 system after heart transplantation. Transpl Int 2011. [DOI: 10.1111/j.1432-2277.2000.tb02022.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Welters I, Feurer MK, Preiss V, Müller M, Scholz S, Kwapisz M, Mogk M, Neuhäuser C. Continuous S -(+)-ketamine administration during elective coronary artery bypass graft surgery attenuates pro-inflammatory cytokine response during and after cardiopulmonary bypass. Br J Anaesth 2011; 106:172-9. [DOI: 10.1093/bja/aeq341] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP SHOCK Trial for attenuation of multiorgan dysfunction syndrome. Crit Care Med 2010; 38:152-60. [PMID: 19770739 DOI: 10.1097/ccm.0b013e3181b78671] [Citation(s) in RCA: 227] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction with cardiogenic shock (CS) are often treated with intra-aortic balloon pump counterpulsation (IABP), even though the evidence to support this is limited. We determined whether IABP as an addition to PCI-centered therapy ameliorates multiorgan dysfunction syndrome (MODS) in patients with acute myocardial infarction complicated by CS. DESIGN A prospective, randomized, controlled, open-label clinical trial recruiting patients between March 2003 and June 2004 (ClinicalTrials.gov ID NCT00469248). SETTING Tertiary care university hospital. PATIENTS AND INTERVENTIONS Forty-five consecutive patients with AMI and CS undergoing PCI were randomized to treatment with or without IABP. MEASUREMENTS AND MAIN RESULTS Acute Physiology and Chronic Health Evaluation (APACHE) II scores (primary outcome measure), hemodynamic values, inflammatory markers, and plasma brain natriuretic peptide (BNP) levels (secondary outcomes) were collected over 4 days from randomization. The prospective hypothesis was that adding IABP therapy to "standard care" would improve CS-triggered MODS. The addition of IABP to standard therapy did not result in a significant improvement in MODS (measured by serial APACHE II scoring over 4 days). IABP use had no significant effect on cardiac index or systemic inflammatory activation, although BNP levels were significantly lower in IABP-treated patients. Initial and serial APACHE II scoring correlated with mortality better than cardiac index, systemic inflammatory state, and BNP levels in this group of patients. Nonsurvivors had significantly higher initial APACHE II scores (29.9 +/- 2.88) than survivors (18.1 +/- 1.66, p < .05). Nevertheless, discrepancies among patients within the groups cannot be ruled out and might interfere with our results. CONCLUSIONS In this randomized trial addressing addition of IABP in CS patients, mechanical support was associated only with modest effects on reduction of APACHE II score as a marker of severity of disease, improvement of cardiac index, reduction of inflammatory state, or reduction of BNP biomarker status compared with medical therapy alone. However, the limitations of our present trial preclude any definitive conclusion, but request for a larger prospective, randomized, multicentered trial with mortality as primary end point.
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Abstract
Prompt diagnosis, intervention, and risk assessment are critical in caring for septic patient but remain difficult with currently available methods. Biomarkers may become useful adjuncts to clinicians and ultimately serve as targets for future therapeutic trials in sepsis. The most relevant markers are reviewed in this article, including interleukin-6, C-reactive protein, procalcitonin, triggering receptor expressed on myeloid cells-1, and biomarker panels.
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Affiliation(s)
- Corey E Ventetuolo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, College of Physicians and Surgeons, Columbia University, PH 8, Room 101, 622 W. 168th Street, New York City, NY 10032, USA
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Immunoglobulin G treatment of postcardiac surgery patients with score-identified severe systemic inflammatory response syndrome—The ESSICS study*. Crit Care Med 2008; 36:716-23. [DOI: 10.1097/01.ccm.0b013e3181611f62f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Werdan K, Pilz G, Bujdoso O, Fraunberger P, Neeser G, Schmieder RE, Viell B, Marget W, Seewald M, Walger P, Stuttmann R, Speichermann N, Peckelsen C, Kurowski V, Osterhues HH, Verner L, Neumann R, Müller-Werdan U. Score-based immunoglobulin G therapy of patients with sepsis: The SBITS study*. Crit Care Med 2007. [DOI: 10.1097/01.ccm.0000295426.37471.79] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Gelape CL, Sanches MD, Teixeira AL, Teixeira MM, Bráulio R, Pinto IF, Galdino F, Ribeiro AL. Preoperative plasma levels of soluble tumor necrosis factor receptor type I (sTNF-RI) predicts adverse events in cardiac surgery. Cytokine 2007; 38:90-5. [PMID: 17600726 DOI: 10.1016/j.cyto.2007.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 05/03/2007] [Accepted: 05/09/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective was to estimate the sTNF-RI preoperative measure in the identification of patients with bad outcome and death. METHODS We assessed prospectively sixty-two patients submitted electively to myocardial revascularization with ECC or heart valve surgery. The sTNF-RI levels were determined by the Sandwich-Type ELISA method before anesthetic induction. Clinical, surgical characteristics and sTNF-RI levels were compared among patients with good (group I, n=46) or bad outcome (group II, n=16--length of stay in the ICU for over 72 h or death). RESULTS No difference was found between the verified mortality (6.4%) and the predicted by EuroSCORE (3.0%), p=0.48. The sTNF-RI levels were higher in group II (1322) than group I (748) p=0.009 (levels >954, 69% sensitivity and 70% specificity for good outcome, 44% positive predicted value and 85% negative). The sTNF-RI levels were higher in patients who died (1556) versus (759) p=0.029, (levels >1230, 79% sensitivity, 75% specificity, 20% positive predicted value and 98% negative). In the multivariate logistic regression model sTNF-RI (OR=1.002, IC95% 1.000-1.005, p=0.014) and age (OR=1.083, IC95% 1.010-1.161, p=0.025) were independently related to the risk of bad outcome. CONCLUSIONS Basal levels of sTNF-RI yield prognostic information in patients who undergo heart surgery.
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Affiliation(s)
- C L Gelape
- Department of Surgery, Minas Gerais Federal University, Av. Professor Alfredo Balena, 190, 30130-100, Belo Horizonte, MG, Brazil.
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Osuchowski MF, Welch K, Siddiqui J, Remick DG. Circulating cytokine/inhibitor profiles reshape the understanding of the SIRS/CARS continuum in sepsis and predict mortality. THE JOURNAL OF IMMUNOLOGY 2006; 177:1967-74. [PMID: 16849510 DOI: 10.4049/jimmunol.177.3.1967] [Citation(s) in RCA: 377] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mortality in sepsis remains unacceptably high and attempts to modulate the inflammatory response failed to improve survival. Previous reports postulated that the sepsis-triggered immunological cascade is multimodal: initial systemic inflammatory response syndrome (SIRS; excessive pro-, but no/low anti-inflammatory plasma mediators), intermediate homeostasis with a mixed anti-inflammatory response syndrome (MARS; both pro- and anti-inflammatory mediators) and final compensatory anti-inflammatory response syndrome (CARS; excessive anti-, but no/low proinflammatory mediators). To verify this, we examined the evolution of the inflammatory response during the early phase of murine sepsis by repetitive blood sampling of septic animals. Increased plasma concentrations of proinflammatory (IL-6, TNF, IL-1beta, KC, MIP-2, MCP-1, and eotaxin) and anti-inflammatory (TNF soluble receptors, IL-10, IL-1 receptor antagonist) cytokines were observed in early deaths (days 1-5). These elevations occurred simultaneously for both the pro- and anti-inflammatory mediators. Plasma levels of IL-6 (26 ng/ml), TNF-alpha (12 ng/ml), KC (33 ng/ml), MIP-2 (14 ng/ml), IL-1 receptor antagonist (65 ng/ml), TNF soluble receptor I (3 ng/ml), and TNF soluble receptor II (14 ng/ml) accurately predicted mortality within 24 h. In contrast, these parameters were not elevated in either the late-deaths (day 6-28) or survivors. Surprisingly, either pro- or anti-inflammatory cytokines were also reliable in predicting mortality up to 48 h before outcome. These data demonstrate that the initial inflammatory response directly correlates to early but not late sepsis mortality. This multifaceted response questions the use of a simple proinflammatory cytokine measurement for classifying the inflammatory status during sepsis.
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Affiliation(s)
- Marcin F Osuchowski
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Hekmat K, Kroener A, Stuetzer H, Schwinger RHG, Kampe S, Bennink GBWE, Mehlhorn U. Daily assessment of organ dysfunction and survival in intensive care unit cardiac surgical patients. Ann Thorac Surg 2006; 79:1555-62. [PMID: 15854933 DOI: 10.1016/j.athoracsur.2004.10.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2004] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to develop a specific postoperative score for intensive care unit (ICU) cardiac surgical patients for assessment of organ dysfunction and survival. METHODS This prospective study consisted of all consecutive adult patients admitted after cardiac surgery to our ICU over a period of 3 years. Evaluation of variables was performed using the first year patients who stayed in the ICU for at least 24 hours. The reproducibility was then tested in two validation sets using all patients. Performance was assessed with the Hosmer-Lemeshow (chi2 statistics) goodness-of-fit test and receiver operating characteristic (ROC) curves and compared with the Acute Physiology and Chronic Health Evaluation (APACHE II) and Multiple Organ Dysfunction Score (MODS). RESULTS A total of 3,230 patients were admitted to the ICU after cardiac surgery. Mean chi2 values for the new score were 5.8 (APACHE II, 11.3; MODS, 9.7) for the construction set, 7.2 (APACHE II, 8.0; MODS, 4.5) for the validation set I, and 5.9 for the validation set II. The mean area under the ROC curve was 0.91 (APACHE II, 0.86; MODS, 0.84) for the new score in the construction set, 0.88 (APACHE II, 0.84; MODS, 0.84) in the validation set I, and 0.92 in the validation set II. CONCLUSIONS Our new 10-variable risk index performs very well, with calibration and discrimination very high, better than general severity systems; and it is an appropriate tool for daily risk stratification in ICU cardiac surgery patients. Thus, it may serve as an "expert system" for diagnosing organ failure, decision making, resource evaluation, and predicting mortality among ICU cardiac surgical patients.
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Affiliation(s)
- Khosro Hekmat
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany.
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Hildebrand F, Pape HC, Krettek C. [The importance of cytokines in the posttraumatic inflammatory reaction]. Unfallchirurg 2006; 108:793-4, 796-803. [PMID: 16175346 DOI: 10.1007/s00113-005-1005-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Alterations in the immune response after multiple trauma, posttraumatic sepsis and surgery are recognized as physiological reactions of the organism to restore homeostasis. The level of these immunological changes correlates with the degree of tissue damage as well as with the severity of haemorrhage and ischaemia. Cytokines are known to be integral components of this immune response. The local release of pro- and antiinflammatory cytokines after severe trauma indicates their potential to induce systemic immunological alterations. It appears that the balance or imbalance of these different cytokines partly controls the clinical course in these patients. Overproduction of either proinflammatory cytokines or antiinflammatory mediators may result in organ dysfunction. Whereas predominance of the proinflammatory response leads to the systemic inflammatory response syndrome (SIRS), the antiinflammatory reaction may result in immune suppression with an enhanced risk of infectious complications. Systemic inflammation, as well as immune suppression, are thought to play a decisive role in the development of multiple organ dysfunction syndrome (MODS). The major proinflammatory cytokines involved in the response to trauma and surgery include tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6 and IL-8. These cytokines, which are predominantly produced by monocytes and macrophages, mediate a variety of frequently overlapping effects, and their actions can be additive. TNF-alpha and IL-1beta are early regulators of the immune response and both induce the release of secondary cytokines, such as IL-6 and IL-8. IL-10 is an antiinflammatory cytokine which reduces the synthesis of proinflammatory mediators. Other important antiinflammatory mediators are soluble TNF receptors and the IL-1 receptor antagonist, which interfere with the effects of TNF-alpha and IL-1beta.Early evaluation of the prognosis of polytraumatized patients and assessment of their clinical status is known to be difficult. Therefore, in several clinical studies, cytokine levels during the posttraumatic course have been determined with the aim of finding predictive markers of patient outcome. The purpose of this review was to highlight our current knowledge on the interaction of posttraumatic immune reactivity and the development of complications. A better understanding of these mechanisms might lead to the introduction of preventive and therapeutic strategies into clinical practice.
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Affiliation(s)
- F Hildebrand
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover.
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Prondzinsky R, Knüpfer A, Loppnow H, Redling F, Lehmann DW, Stabenow I, Witthaut R, Unverzagt S, Radke J, Zerkowski HR, Werdan K. Surgical trauma affects the proinflammatory status after cardiac surgery to a higher degree than cardiopulmonary bypass. J Thorac Cardiovasc Surg 2005; 129:760-6. [PMID: 15821641 DOI: 10.1016/j.jtcvs.2004.07.052] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Cytokines contribute to the development of the systemic inflammatory response syndrome or multiple-organ failure frequently observed after cardiopulmonary bypass-supported cardiac surgery. To quantify the contribution of bypass-induced versus trauma-induced inflammatory response after coronary artery bypass grafting, we examined plasma cytokine levels in 120 patients with coronary artery disease who were treated with or without cardiopulmonary bypass-assisted procedures. METHODS Patients were treated in accordance with one of the following protocols: (1) elective percutaneous coronary intervention without cardiopulmonary bypass (n = 69), (2) cardiopulmonary bypass-supported percutaneous coronary intervention (cardiopulmonary bypass-percutaneous coronary intervention; n = 10), and (3) cardiopulmonary bypass-supported coronary artery bypass grafting (cardiopulmonary bypass-coronary artery bypass grafting; n = 41). Cytokine levels (picograms/milliliter) were measured by enzyme-linked immunosorbent assay from plasma samples obtained at various time points. RESULTS Interleukin-6 was measured in blood samples from all 3 patient populations. The maximum interleukin-6 level was 13.6 +/- 22.3 pg/mL in the percutaneous coronary intervention group, 170.4 +/- 165.4 pg/mL in the cardiopulmonary bypass-percutaneous coronary intervention group, and 640.3 +/- 285.7 pg/mL in the cardiopulmonary bypass-coronary artery bypass grafting group. Interleukin-6 levels were significantly different, and the 95% confidence intervals did not overlap. In the cardiopulmonary bypass-percutaneous coronary intervention group, bypass duration correlated well with interleukin-6 production ( r = 0.915; P < .001), whereas these parameters did not correlate in patients who underwent cardiopulmonary bypass-coronary artery bypass grafting ( r = 0.307; P = .054). CONCLUSIONS These findings support the suggestion that surgical trauma and cardiopulmonary bypass contribute to the inflammatory response after cardiac surgery, although trauma may contribute to a higher degree.
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Affiliation(s)
- Roland Prondzinsky
- Department of Medicine III, Martin-Luther-University Halle-Wittenberg, Halle (Salle), Germany.
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Hekmat K, Kröner A, Stützer H, Schwinger RHG, Kampe S, Bennink GBWE, Mehlhorn U. Ein neuer Score für die tägliche Schweregradklassifizierung auf herzchirurgischen Intensivstationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2004. [DOI: 10.1007/s00398-004-0473-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Goodman RB, Pugin J, Lee JS, Matthay MA. Cytokine-mediated inflammation in acute lung injury. Cytokine Growth Factor Rev 2004; 14:523-35. [PMID: 14563354 DOI: 10.1016/s1359-6101(03)00059-5] [Citation(s) in RCA: 536] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Clinical acute lung injury (ALI) is a major cause of acute respiratory failure in critically ill patients. There is considerable experimental and clinical evidence that pro- and anti-inflammatory cytokines play a major role in the pathogenesis of inflammatory-induced lung injury from sepsis, pneumonia, aspiration, and shock. A recent multi-center clinical trial found that a lung-protective ventilatory strategy reduces mortality by 22% in patients with ALI. Interestingly, this protective ventilatory strategy was associated with a marked reduction in the number of neutrophils and the concentration of pro-inflammatory cytokines released into the airspaces of the injured lung. Further research is needed to establish the contribution of cytokines to both the pathogenesis and resolution of ALI.
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Affiliation(s)
- Richard B Goodman
- Medical Research Service, Department of Veterans Affairs, VA Puget Sound Health Care System, VA Puget Sound Medical Center, Division of Pulmonary & Critical Care, University of Washington School of Medicine, Seattle, WA 98108, USA
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Parks RW, Halliday MI, McCrory DC, Erwin P, Smye M, Diamond T, Rowlands BJ. Host immune responses and intestinal permeability in patients with jaundice. Br J Surg 2003; 90:239-45. [PMID: 12555304 DOI: 10.1002/bjs.4029] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Systemic endotoxaemia is implicated in the development of complications associated with obstructive jaundice. The aims of these studies were to assess the systemic immune response to intervention in patients with jaundice and to compare the effects of surgical and non-surgical biliary drainage on host immune function and gut barrier function. METHODS In the first study, 18 jaundiced and 12 control patients were studied to assess systemic immune responses before and after intervention. In the second study, immune responses and gut barrier function were assessed following surgical and non-operative biliary decompression in 45 patients with jaundice. RESULTS Endotoxin antibody concentrations fell significantly in patients with jaundice immediately after surgical intervention, but not after non-operative biliary drainage. This decrease was associated with a significant increase in serum P(55) soluble tumour necrosis factor (sTNF) receptor concentration (5.3 versus 10.5 ng/ml; P < 0.001), urinary excretion of P(55) TNF receptors (21.4 versus 78.8 ng/ml; P = 0.002) and intestinal permeability (lactulose : mannitol ratio 0.032 versus 0.082; P = 0.048). Intestinal permeability was significantly increased in patients with jaundice compared with controls (0.033 versus 0.015; P = 0.002). CONCLUSION These data suggest that obstructive jaundice is associated with impaired gut barrier function and activation of host immune function that is exacerbated by intervention. Surgery causes an exaggerated pathophysiological disturbance not seen with non-operative biliary drainage procedures.
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Affiliation(s)
- R W Parks
- Department of Surgery, Queen's University of Belfast, Northern Ireland, UK.
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Gosling P, Brudney S, McGrath L, Riseboro S, Manji M. Mortality prediction at admission to intensive care: a comparison of microalbuminuria with acute physiology scores after 24 hours. Crit Care Med 2003; 31:98-103. [PMID: 12545001 DOI: 10.1097/00003246-200301000-00016] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare low level albumin excretion (microalbuminuria), a marker of systemic capillary permeability, with mortality, Acute Physiologic And Chronic Health Evaluation (APACHE II) score, the Simplified Acute Physiologic (SAP II) score, and their derived mortality probabilities in patients admitted to a general intensive care unit. DESIGN Prospective observational study. SETTING A 14-bed intensive care unit in a university teaching hospital. PATIENTS A total of 140 consecutive patients (59 surgical, 48 medical, 22 trauma, and 11 burns). INTERVENTIONS Urine collection within 15 mins of intensive care unit admission for assessment of microalbuminuria. MEASUREMENTS AND MAIN RESULTS Microalbuminuria, expressed as the albumin-creatinine ratio (ACR: normal, <2.3 mg/mmol), was compared with mortality, APACHE II and SAP II scores and their derived mortality probabilities after 24 hrs, intensive care unit stay, and markers of organ function and inflammation. Median (95% confidence interval) ACR at admission for survivors (n = 115) and nonsurvivors (n = 25) were 4.2 (3.6-6.5) and 17.8 (8.0-40.8) mg/mmol, respectively (p =.0002 Mann Whitney). For 92 surgical, trauma, and burn patients, of whom 81 survived, ACR of >5.9 mg/mmol gave a sensitivity for death of 100%, specificity of 59%, positive predictive value of 25%, and negative predictive value of 100%. Mortality probability receiver operator characteristic curve areas for ACR, APACHE II, and SAP II were 0.843 (p <.0001), 0.793 (p =.0004), and 0.770 (p =.0017), respectively. ACR was associated with intensive care unit stay (p =.0021) and highest serum C-reactive protein (p =.0002), serum creatinine (p <.0001), and bilirubin (p =.0009). For 48 medical patients, of whom 34 survived, admission ACRs for survivors and nonsurvivors were 8.3 (5.7-10.8) and 10.7 (4.1-48.2) mg/mmol, respectively (p =.32). SAP II, but not APACHE II, score was significantly higher for nonsurvivors. CONCLUSIONS For surgical, trauma, and burn patients, but not medical patients, microalbuminuria within 15 mins of intensive care unit admission predicted death as well as APACHE II and SAP II scores calculated after 24 hrs, and it shows promise as a predictor of outcome.
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Affiliation(s)
- Peter Gosling
- Department of Clinical Biochemistry, University Hospital Birmingham NHS Trust, UK.
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Bach F, Grundmann U, Bauer M, Buchinger H, Soltész S, Graeter T, Larsen R, Silomon M. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand 2002; 46:1227-35. [PMID: 12421195 DOI: 10.1034/j.1399-6576.2002.461010.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction. Microcirculation-dependent alteration of the gut mucosal barrier with subsequent translocation of endotoxins is a postulated mechanism for this inflammatory response. This study was designed to elucidate whether two different approaches to modulate splanchnic perfusion may influence systemic inflammation to CPB. METHODS We examined 40 patients scheduled for elective coronary bypass surgery in a prospective, randomized study. One group (DPX) received dopexamine (1 micro g. kg-1. min-1) continuously after induction of anesthesia until 18 h after CPB. The control group (CON) received equal volumes of NaCl 0.9% in a time-matched fashion. In a third group (EPI) a continuous epidural infusion of bupivacaine 0.25% [(body height (cm) - 100). 10-1=ml.h-1] was administered for the whole study period. Procalcitonin (PCT), tumor necrosis factor (TNF-alpha), soluble TNF receptor, human soluble intercellular adhesion molecule-1, C-reactive protein (CRP) and leukocyte count were measured as parameters of inflammation. RESULTS All parameters significantly increased following CPB. Increases of PCT, TNF-alpha and leukocyte count were significantly attenuated in the DPX and EPI groups at different time points. However, neither splanchnic blood flow nor oxygen delivery and consumption were different when compared with the CON-group. CONCLUSION These results do suggest that mechanisms other than an improved splanchnic blood flow by DPX and EPI treatment have to be considered for the anti-inflammatory effects.
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Affiliation(s)
- F Bach
- Department of Anesthesiology and Critical Care Medicine, University of Saarland, Homburg/Saarland, Germany
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22
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Sason-Ton Y, Ben Abraham R, Lotan D, Dagan O, Prince T, Barzilay Z, Paret G. Tumor necrosis factor and clinical and metabolic courses after cardiac surgery in children. J Thorac Cardiovasc Surg 2002; 124:991-8. [PMID: 12407384 DOI: 10.1067/mtc.2002.124391] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study was undertaken to determine the relationship between plasma tumor necrosis factor concentrations and hemodynamic and metabolic parameters during the postoperative clinical course in children undergoing cardiac surgery. METHODS Tumor necrosis factor levels of 10 consecutive children undergoing surgery for repair of congenital heart defects were analyzed in blood samples drawn at predetermined time points during surgery and up to 24 hours thereafter. Clinical data were collected at these times for correlation to tumor necrosis factor levels. RESULTS All the patients survived. Tumor necrosis factor was detected in all 10 children. Tumor necrosis factor levels declined after induction of general anesthesia (201 +/- 65 pg/mL) steadily decreasing during surgery, reaching 80 +/- 50 pg/mL at 24 hours after the operation. Tumor necrosis factor levels were found to be inversely correlated with mean blood pressure values and indicators of acidosis (bicarbonate levels and base excess, P <.03). They were not correlated with the durations of cardiopulmonary bypass and aortic crossclamping. CONCLUSIONS Tumor necrosis factor released into the circulation during and after pediatric cardiac surgery under cardiopulmonary bypass may be related to the hemodynamic and acid-base changes observed after cardiac surgery. Elucidation of the relationship between tumor necrosis factor and patient outcome in high-risk patients awaits further studies.
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Affiliation(s)
- Yokrat Sason-Ton
- Department of Pediatric Intensive Care, Chaim Sheba Medical Center, Tel Hashomer, Israel
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23
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Kanaoka Y, Yagi T, Sadamori H, Matsukawa H, Matsuda H, Inagaki M, Ishikawa T, Saito S, Iwagaki H, Tanaka N. Analysis of host response to hepatectomy by simultaneous measurement of cytokines in the portal vein, caval vein and radial artery. J Int Med Res 2002; 30:496-505. [PMID: 12449519 DOI: 10.1177/147323000203000505] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We analysed the host response to hepatectomy by simultaneous measurement of various cytokines and their antagonists in the portal vein, caval vein and radial artery in 10 patients with hepatocellular carcinoma. Concentrations of tumour necrosis factor-alpha (TNF), interleukin (IL) 1 beta, IL-2, IL-6, IL-10, soluble TNF receptor type I (sTNF-R), soluble IL-2 receptor (sIL-2R), IL-1 receptor antagonist (IL-1ra), soluble CD14 (sCD14) and endotoxin were determined just before and 1 h after hepatectomy. The values of IL-6, sTNF-R and IL-1ra were significantly increased after hepatectomy at each sampling site. In contrast, the levels of sIL-2R and sCD14 after hepatectomy were significantly decreased, and the levels of IL-1 beta, IL-2 and IL-10 were below the detection limits. Differences in cytokine concentrations between sampling sites revealed that the surgical stress of hepatectomy induced significant IL-1ra production in the liver and sTNF-R and IL-6 production in the lungs. These results suggest that hepatic resection is followed by the production of cytokine antagonists, such as IL-1ra, sTNF-R and IL-6, which could represent an important regulatory mechanism against surgical stress.
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Affiliation(s)
- Y Kanaoka
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
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24
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el-Barbary M, Khabar KSA. Soluble tumor necrosis factor receptor p55 predicts cytokinemia and systemic inflammatory response after cardiopulmonary bypass. Crit Care Med 2002; 30:1712-6. [PMID: 12163781 DOI: 10.1097/00003246-200208000-00006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the behavior of soluble tumor necrosis factor (TNF) receptors in circulation before and after cardiopulmonary bypass and the relationship to the development of cytokinemia and acute complications comprising systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). The predictive value of soluble TNF receptor is assessed herein. DESIGN Prospective study comparing prebypass and postbypass levels in patients with and without complications indicative of SIRS and MODS. SETTING Cardiac surgical intensive care unit in a tertiary care hospital. PATIENTS A total of 20 pediatric patients who underwent cardiopulmonary bypass during open heart surgery. INTERVENTIONS Blood samples were collected from catheters before and 2 hrs and 24 hrs after the onset of bypass. MEASUREMENTS AND MAIN RESULTS We measured plasma levels of soluble TNF receptors by using enzyme-linked immunosorbent assay in 20 patients before and after cardiopulmonary bypass. Clinical data, including duration of bypass and tests or signs indicative of SIRS/MODS, were collected. Soluble TNF receptor I (p55 sR), significantly increased (2241 +/- 312 pg/mL) at 2 hrs after bypass (p <.0005) and remained elevated (2826 +/- 695 pg/mL) at 1 day after bypass (p <.005) when compared with prebypass levels (725 +/- 130 pg/mL). Patients with the acute complications of SIRS/MODS had a higher ratio of postbypass to prebypass p55 sR levels (5.0-fold, p <.001) when compared with patients with no SIRS/MODS (1.75-fold). Remarkably, before surgery, levels of TNF p55 sR predict both cytokinemia (r =.67 to.73, p <.05) and SIRS/MODS (p <.01). The prebypass levels of TNF p55 sR were consistently higher (range, 1000-1400 pg/mL) in patients who subsequently developed SIRS/MODS than the levels (range, 400-570 pg/mL) in patients who did not develop SIRS/MODS. Hypotension, respiratory dysfunctions, and coagulopathy were particularly more prevailing (p <.005) among the complications that were associated with high prebypass levels of TNF p55 sR. CONCLUSIONS Soluble TNF receptor p55 can be employed as a predictive marker for cytokinemia and the development of SIRS/MODS that may arise from a major insult to the body such as cardiopulmonary bypass.
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Affiliation(s)
- Mahmoud el-Barbary
- Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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25
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Poeze M, Ramsay G, Buurman WA, Greve JWM, Dentener M, Takala J. Increased hepatosplanchnic inflammation precedes the development of organ dysfunction after elective high-risk surgery. Shock 2002; 17:451-8. [PMID: 12069179 DOI: 10.1097/00024382-200206000-00002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study investigated the relationship of the hepatosplanchnic production and uptake of inflammatory mediators, hepatosplanchnic perfusion, and outcome during major abdominal surgery to evaluate the hypothesis that regional production of inflammatory mediators precedes the development of hepatic dysfunction. This retrospective analysis of data and blood samples collected during a randomized controlled clinical trial included high-risk surgical patients undergoing major abdominal surgery in a 24-bed university-afilliated intensive care unit. Patients were divided into a subgroup that developed hepatic dysfunction (HD+) postoperatively and a subgroup without hepatic dysfunction (HD-). Hepatic vein and arterial plasma levels of IL-6, IL-8, s-E-selectin, s-ICAM-1, and the TNF-receptors 55 and 75 were measured, and the flux was calculated by multiplying the difference in hepatic vein minus arterial levels of the mediators by the hepatosplanchnic flow. Systemic (thermodilution) and total hepatosplanchnic blood flow (using indocyanine green [ICG]-dilution method) and gastric intramucosal pH (pHi) were assessed preoperatively, 4, 24, and 36 h postoperatively. Of a total of 26 patients, 6 patients developed hepatic dysfunction after their abdominal surgery (mean 6 days postoperatively). The number of sepsis-related deaths and postoperative days on the ventilator were significantly higher in this group. A higher production of IL-8, TNF-receptor-75 and 55 in the hepatosplanchnic area in the HD+ subgroups was found, which preceded the development of organ dysfunction (P = 0.04, P = 0.02, and P = 0.02, respectively). Moreover, the uptake of s-ICAM-1 was significantly increased in this subgroup. Furthermore, total hepatosplanchnic blood flow was significantly higher and pHi was significantly lower in the HD+ group, whereas global hemodynamic data were similar in the two subgroups. In conclusion, the development of postoperative organ dysfunction is preceded by an increased regional inflammatory response, indicated by an increased soluble TNF-receptor shedding and IL-8 production from the hepatosplanchnic area together with an increased uptake of s-ICAM-1. Moreover, an increased total hepatosplanchnic blood flow with intramucosal acidosis was associated with this regional inflammatory response.
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Affiliation(s)
- Martijn Poeze
- Department of Surgery, University Hospital Maastricht, The Netherlands
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26
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Werdan K. Pathophysiology of septic shock and multiple organ dysfunction syndrome and various therapeutic approaches with special emphasis on immunoglobulins. Ther Apher Dial 2001; 5:115-22. [PMID: 11354295 DOI: 10.1046/j.1526-0968.2001.005002115.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The pathophysiology of sepsis and septic shock is dominated by an imbalance of pro- and antiinflammatory mediators produced by toxin-activated inflammatory cells. Both the overshooting of proinflammatory mediators as well as the development of immune paralysis are deleterious to the patient. Available therapeutic approaches with monoclonal antibodies and antagonists targeted against toxins and mediators have focused mainly on inhibition of overshooting proinflammation: the results, however, have been disappointing. Due to these disappointing results of specific antiinflammatory regimens, adjuvant treatment of sepsis and septic shock with intravenous immunoglobulins (IVIgs) has regained interest although this indication has at best been validated in part. Likely beneficial mechanisms of action may include the improvement of serum bactericidal activity due to neutralizing and opsonizing IgG and IgM antibodies as well as stimulation of phagocytosis and neutralization of bacterial endo- and exotoxins; another attractive mode of action may represent Ig-mediated modification and specific suppression of proinflammatory cytokine release from endotoxin- and superantigen-activated blood cells. For the total group of patients with sepsis and septic shock, a reduction in mortality by IVIg could not be documented; however, in the SBITS study with 653 patients included, a moderate improvement in sepsis morbidity and multiple organ dysfunction syndrome was demonstrated. In defined sepsis sub-groups, a reduction in mortality by IVIg has been seen in each small, not yet confirmed trial. Thus, IVIg is not a magic bullet of sepsis treatment, but it may reduce morbidity and thereby may be useful in the therapeutic mosaic of sepsis treatment.
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Affiliation(s)
- K Werdan
- Department of Medicine III, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany.
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27
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Retter AS, Frishman WH. The role of tumor necrosis factor in cardiac disease. HEART DISEASE (HAGERSTOWN, MD.) 2001; 3:319-25. [PMID: 11975813 DOI: 10.1097/00132580-200109000-00008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Tumor necrosis factor (TNF) is a proinflammatory cytokine that can produce widespread deleterious effects when expressed in large amounts. It is produced in the heart by both cardiac myocytes and resident macrophages under conditions of cardiac stress, and is thought to be responsible for many of the untoward manifestations of cardiac disease. This article discusses the role of TNF in heart disease and some potential therapeutic modalities that can influence the cytokine activity. The results of controlled studies would suggest that TNF inhibition does not influence the clinical course of patients with heart failure.
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Affiliation(s)
- A S Retter
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania 19004, USA
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28
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Kimura F, Miyazaki M, Suwa T, Sugiura T, Shinoda T, Itoh H, Nagakawa K, Ambiru S, Shimizu H, Yoshitome H. Anti-inflammatory response in patients with obstructive jaundice caused by biliary malignancy. J Gastroenterol Hepatol 2001; 16:467-72. [PMID: 11354287 DOI: 10.1046/j.1440-1746.2001.02465.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Obstructive jaundice potentially modulates the host defense mechanism resulting in perioperative infection. It has been reported that a systemic inflammatory response occurs in patients with obstructive jaundice. An anti-inflammatory response was studied in 29 jaundiced patients undergoing biliary drainage. RESULTS Plasma concentrations of interleukin (IL)-10, soluble tumor necrosis factor receptor (STNFR) p55, STNFR p75, IL-1 receptor antagonist (IL-1ra), IL-6 and soluble CD14 (sCD14) were measured by using immunoassay. Plasma concentrations of IL-10, STNFR p55, STNFR p75, IL-1ra, IL-6 and sCD14 were significantly higher in jaundiced patients than in the controls (P < 0.01). After biliary drainage, the concentrations of IL-10, the three cytokine antagonists, and IL-6 decreased significantly (P < 0.05). The sCD14 concentration did not decrease. At the time of drainage, the concentrations of STNFR p55 and STNFR p75 were significantly higher in 10 patients with positive bile cultures than in 19 patients with negative bile cultures (P < 0.05). Bile cultures became positive 14 days after drainage in 10 patients, and remained negative in nine. The concentration of STNFR p55 before drainage was significantly higher in the former group (P = 0.05). The plasma concentrations of IL-10 and STNFRs were significantly correlated with the IL-6 concentration, body temperature and the white blood cell count (P < 0.05). Serum total bilirubin levels did not affect plasma levels of anti-inflammatory mediators, and sCD14. CONCLUSION Jaundiced patients exhibited an anti-inflammatory immune response that potentially modulates the host defense mechanism and results in anergy and increased susceptibility to infection. Biliary infection may be one of the major stimuli of the immune response.
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Affiliation(s)
- F Kimura
- Department of Surgery, Omiya Red Cross Hospital, Yono, Japan.
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29
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Kuhn C, Müller-Werdan U, Schmitt DV, Lange H, Pilz G, Kreuzer E, Mohr FW, Zerkowski HR, Werdan K. Improved outcome of APACHE II score-defined escalating systemic inflammatory response syndrome in patients post cardiac surgery in 1996 compared to 1988-1990: the ESSICS-study pilot project. Eur J Cardiothorac Surg 2000; 17:30-7. [PMID: 10735409 DOI: 10.1016/s1010-7940(99)00345-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Cardiac surgery using extracorporeal circulation leads to the release of cytokines and subsequently to a systemic inflammatory response syndrome, which is thought to be a negative prognostic factor for patients' outcome. A stratification for the risk of an escalating systemic inflammatory response syndrome had been achieved in a monocenter study carried out in 1988-1990, using APACHE II scoring on the morning of the 1st postoperative day. We now re-evaluated this concept prospectively in three independent centers. METHODS The APACHE II based risk stratification was put to test in three independent heart surgery centers in the period from June to December 1996. Nine hundred and forty-five patients after elective cardiac surgery (excluding heart transplantation) with the assistance of the cardiopulmonary bypass were prospectively monitored. RESULTS We found an increase in mortality with higher APACHE II score values determined on the 1st postoperative day. The mortality rose to nearly 50% with an APACHE II score of > or = 28. Patients at high risk for the development of a systemic inflammatory response syndrome (APACHE II score > or = 24) significantly differed from patients at lower risk (APACHE II score < 19) in the duration of mechanical ventilation and extracorporeal circulation, age and New York Heart Association (NYHA) classification (P < 0.05). CONCLUSION The APACHE II score determined on the morning of the 1st postoperative day helps identifying the subgroup of patients with escalating systemic inflammatory response syndrome. Comparison with the data obtained in the years 1988-1990, suggests a better prognosis in the current trial for patients at high risk with a similar degree of escalating systemic inflammatory response syndrome.
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Affiliation(s)
- C Kuhn
- Department of Medicine III, University of Halle-Wittenberg, Halle, Germany
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30
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Carlson GL, Saeed M, Little RA, Irving MH. Serum leptin concentrations and their relation to metabolic abnormalities in human sepsis. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 276:E658-62. [PMID: 10198301 DOI: 10.1152/ajpendo.1999.276.4.e658] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Circulating leptin concentrations are raised in animal models of inflammation and sepsis. The purpose of this study was to determine the effect of sepsis on serum leptin concentration in humans and to examine the relationship between leptin and the metabolic consequences of sepsis. Resting energy expenditure, insulin sensitivity, and fasting serum leptin, plasma insulin, and cortisol concentrations were measured in 20 subjects with intra-abdominal sepsis and 20 healthy control subjects, before and during a 2-h period of euglycemic hyperinsulinemia. Fasting serum leptin concentrations were similar in septic and control subjects. In simple regression analysis, serum leptin concentrations correlated significantly with percent body fat in both septic patients (r = 0. 64, P < 0.005) and healthy subjects (r = 0.75, P < 0.0001). Multiple regression analyses additionally indicated that percent body fat, fasting plasma insulin, and plasma cortisol, but not sepsis, were significant and independent determinants of serum leptin concentration. No relationship between leptin and resting energy expenditure or insulin sensitivity was identifiable. A major metabolic role for leptin in human sepsis therefore appears unlikely.
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Affiliation(s)
- G L Carlson
- North Western Injury Research Centre, University of Manchester, Hope Hospital, Salford M6 8HD, United Kingdom.
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31
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Abstract
Intravenous immune globulins are widely used as supplemental treatment of sepsis, septic shock and systemic inflammation in the critically ill, although this indication has at best been validated in part. Likely beneficial mechanisms of action may include the improvement of serum bactericidal activity due to neutralizing and opsonizing immunoglobulin (Ig)G- and IgM-antibodies, as well as stimulation of phagocytosis and neutralization of bacterial endo- and exotoxins; another attractive mode of action may represent immune globulin-mediated modification and specific suppression of proinflammatory cytokine release from endotoxin- and superantigen-activated blood cells. For the "entire group of patients with sepsis and septic shock" a reduction in mortality by intravenous immune globulin could not be documented; however, in the score-based immunoglobulin in sepsis (SBITS)-study with 653 patients included, a moderate improvement in sepsis morbidity and multiple organ dysfunction syndrome was demonstrated. In defined sepsis subgroups, a reduction in mortality by intravenous immune globulin has been seen in individual small, not yet confirmed trials. Finally, the incidence of some severe infections in well characterized "patients at risk" and "operations at risk" is reduced by intravenous immune globulin prophylaxis. Thus, intravenous immune globulin is not a "magic bullet"of sepsis treatment, but it may reduce morbidity and thereby represent a useful piece of stone in the therapeutic mosaic of sepsis treatment.
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Affiliation(s)
- K Werdan
- Department of Medicine, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany.
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32
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Kimura F, Miyazaki M, Suwa T, Sugiura T, Shinoda T, Itoh H, Ambiru S, Shimizu H, Nakagawa K. Plasma concentration of cytokine antagonists in patients with infection following liver resection. Br J Surg 1998; 85:1631-5. [PMID: 9876064 DOI: 10.1046/j.1365-2168.1998.00949.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The interactions between endogenous cytokine antagonists, surgical injury and perioperative infection are poorly understood. METHODS Perioperative plasma concentrations of soluble tumour necrosis factor receptor p55 (STNFR p55), interleukin (IL) 1 receptor antagonist (IL-1ra) and IL-6 were measured by immunoassay in 29 consecutive patients undergoing liver resection. RESULTS Plasma concentrations of STNFR p55, IL-1ra and IL-6 showed a striking increase immediately after operation (day 0) and on postoperative day 1. STNFR p55 concentrations correlated significantly with operating time (P< 0.05); IL-1ra levels with operating time, blood loss and weight of resected liver (P < 0.05); and IL-6 concentrations with operating time and blood loss (P< 0.05). Eight of the 29 subjects developed postoperative infections, of whom four had positive cultures of enteric organisms. Plasma STNFR p55 and IL-6 concentrations were significantly higher in the infected group than in the uninfected group (P < 0.05). STNFR p55 and IL-6 concentrations on day 0 differentiated between the two groups with a diagnostic accuracy of 79 and 83 per cent respectively. CONCLUSION These results suggest that STNFR p55, IL-1ra and IL-6 are produced during operation in response to surgical stress. This production of STNFR p55 and IL-6 may be enhanced further by intraoperative bacterial translocation. Measurement of plasma STNFR and IL-6 concentrations may predict the development of postoperative infectious complications.
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Affiliation(s)
- F Kimura
- Department of Surgery, Omiya Red Cross Hospital, Kamiochiai, Yono, Japan
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33
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34
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Affiliation(s)
- C E Hack
- Central Laboratory of the Netherlands Red Cross Blood Transfusion Service, University of Amsterdam, The Netherlands
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35
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Werdan K, Müller-Werdan U. Elucidating molecular mechanisms of septic cardiomyopathy--the cardiomyocyte model. Mol Cell Biochem 1996; 163-164:291-303. [PMID: 8974069 DOI: 10.1007/bf00408670] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In the multiple organ dysfunction syndrome of sepsis and septic shock the heart is one of the organs subject to failure. Many new insights into the mechanisms underlying septic cardiomyopathy were gained in the last years. Experimental work with neonatal and adult cardiomyocytes considerably contributed to this progress, facilitating the documentation of direct attenuation of the contractions of the heart muscle cell by toxins and mediators, as well as investigating the underlying cellular mechanisms. With this respect, contractile-depressant effects have been found in cardiomyocytes for many toxins and sepsis mediators, with endotoxin, Pseudomonas exotoxin A, tumor necrosis factor alpha, interleukin-1 and nitric oxide being the most relevant ones identified. These substances interfere at clinically relevant concentrations with several main inotropic axes, not only with the beta-adrenoceptor/adenylyl cyclase and with the NO-cGMP-system-on which most of the interest is focused at present-but also with the alpha 1-adrenoceptor/phosphoinositide pathway and the Ca2+ homeostasis of the cardiomyocyte, the latter representing the common final inotropic pathway. Not a single cardiodepressant factor, but more likely a total bunch of toxins and mediators with different attack mechanisms seem to contribute to the picture of septic cardiomyopathy.
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Affiliation(s)
- K Werdan
- Department of Cardiac Intensive Care Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany
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