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Özer Aslan İ, Doğan K, Kural A, Baghaki S, Helvaci N, Ekin M, Yaşar L. Is it possible to identify COVID-19 infection-related biomarkers during pregnancy?: A prospective study in Turkish population. Medicine (Baltimore) 2024; 103:e38062. [PMID: 38728492 PMCID: PMC11081580 DOI: 10.1097/md.0000000000038062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) has raised concerns about the potential complications it may cause in pregnant women. Therefore, biomarkers that can predict the course of COVID-19 in pregnant women may be of great benefit as they would provide valuable insights into the prognosis and, thus, the management of the disease. In this context, the objective of this study is to identify the biomarkers that can predict COVID-19 progression in pregnant women, focusing on composite hemogram parameters and systemic inflammatory and spike markers. The population of this single-center prospective case-control study consisted of all consecutive pregnant women with single healthy fetuses who tested positive for COVID-19 and who were admitted to Bakirköy Dr Sadi Konuk Training and Research Hospital in Istanbul, Turkey, a COVID-19 referral hospital, between April 2020 and March 2021, with an obstetric indication, during their second or third trimester. The control group consisted of consecutive pregnant women with a single healthy fetus who were admitted to the same hospital within the same date range, had demographic and obstetric characteristics matching the patient group, but tested negative for COVID-19. The patient and control groups were compared in terms of platelet-to-lymphocyte ratio (PLR), platelet-to-neutrophil ratio (PNR), and neutrophil-to-lymphocyte ratio (NLR), and systemic inflammatory and spike markers, including C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-10 (IL-10), cluster of differentiation 26 (CD26), and B7 homolog 4 (B7H4). There were 45 (51.1%) and 43 (48.8%) pregnant women in the patient and control groups, respectively. There was no significant difference between the groups in demographic and obstetric characteristics (P > .05). The PNR, PLR, and CRP values were significantly higher in the patient group than in the control group (P < .05). On the other hand, there was no significant difference between the groups in IL-6, IL-10, CD26, and B7H4 levels (P > .05). The findings of our study showed that specific inflammatory markers, such as CRP, PLR, and PNR, can potentially predict the course of COVID-19 in pregnant women. However, more comprehensive, well-controlled studies are needed to corroborate our study's findings and investigate other potential inflammatory markers.
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Affiliation(s)
- İlke Özer Aslan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tekirdag Namik Kemal University, Tekirdag, Türkiye
| | - Keziban Doğan
- Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Türkiye
| | - Alev Kural
- Department of Biochemistry, University of Health Sciences, Bakirkoy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Türkiye
| | - Sema Baghaki
- Department of Obstetrics and Gynecology, University of Pittsburgh, PA
| | - Nazli Helvaci
- Department of Biochemistry, Hamidiye Faculty of Medicine, University of Health Sciences, Istanbul, Türkiye
| | - Murat Ekin
- Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Türkiye
| | - Levent Yaşar
- Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Türkiye
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Rico-Feijoó J, Bermejo JF, Pérez-González A, Martín-Alfonso S, Aldecoa C. Influence of lymphopenia on long-term mortality in septic shock, a retrospective observational study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00036-2. [PMID: 38387503 DOI: 10.1016/j.redare.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/12/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND OBJECTIVE The diagnosis of infection, to diagnose septic shock, has been qualified by leukocyte counts and protein biomarkers. Septic shock mortality is persistently high (20%-50%), and rising in the long term. The definition of sepsis does not include leukocyte count, and lymphopenia has been associated with its mortality in the short term. Immunosuppression and increased mortality in the long term due to sepsis have not been demonstrated. The aim is to relate the occurrence of lymphopenia and its lack of recovery during septic shock with mortality at 2 years. PATIENTS AND METHODS Cohort of 332 elderly patients diagnosed with septic shock. Mortality at 28 days and 2 years was analysed according to leukocyte, neutrophil, and lymphocyte counts, and the ability to recover from lymphopenia (LRec). RESULTS A total of 74.1% of patients showed lymphopenia, and 73.5% did not improve during ICU stay. Mortality was 31.0% and 50.3% at 28 days and 2 years, respectively. Lymphopenia was a predictor of early mortality (OR 2.96) and LRec of late mortality (OR 3.98). Long-term mortality was associated with LRec (HR 1.69). CONCLUSIONS In elderly patients with septic shock, 28-day mortality is associated with lymphopenia and neutrophilia, and LRec with 2-year mortality; this may represent 2 distinct phenotypes of behaviour after septic shock.
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Affiliation(s)
- J Rico-Feijoó
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Gerencia Regional de Salud Valladolid Oeste, Valladolid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CiberES), CB22/06/00035, Instituto de Salud Carlos III, Madrid, Spain
| | - J F Bermejo
- Group for Biomedical Research in Sepsis (BioSepsis), Instituto de Investigación Biomédica de Salamanca, Gerencia Regional de Salud de Castilla y León, Salamanca, Spain; Universidad de Salamanca, Salamanca, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CiberES), CB22/06/00035, Instituto de Salud Carlos III, Madrid, Spain
| | - A Pérez-González
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Gerencia Regional de Salud Valladolid Oeste, Valladolid, Spain
| | - S Martín-Alfonso
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Gerencia Regional de Salud Valladolid Oeste, Valladolid, Spain
| | - C Aldecoa
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Gerencia Regional de Salud Valladolid Oeste, Valladolid, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CiberES), CB22/06/00035, Instituto de Salud Carlos III, Madrid, Spain.
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Zhang L, Xu C, Bai L, Li L, Guo J, Li Y. The Clinical Value of Comprehensive Nursing Intervention in Preventing Severe Lymphopenia and Improving the Survival Rate Among Patients with Sepsis. Open Access Emerg Med 2023; 15:393-403. [PMID: 37886229 PMCID: PMC10599247 DOI: 10.2147/oaem.s433980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Background Intensive care unit (ICU) patients with sepsis who experience severe lymphopenia are at a higher risk of mortality, and they serve as a more accurate indicator of bacteremia compared to traditional infection markers. Aim Our study aimed to examine the influence of severe lymphopenia on ICU mortality and outcomes in sepsis patients, while also evaluating the clinical significance of comprehensive nursing intervention in preventing severe lymphopenia. Methods Patients with sepsis in the ICU at our hospital between January 2015 and January 2021 were split into a control group and a test group.The control group received regular nursing care, while the test group was provided with comprehensive nursing care in addition to the control group. The results encompassed mortality rates of 28 days, mortality rates of 1 year, and lengths of stay in the ICU. Results Our attention was directed towards day 4 absolute lymphocyte counts, taking into account the receiver operating characteristic (ROC) outcome. Patients with severe lymphopenia were older, more patients with 2 above comorbidities, higher co-infection rates and SOFA score. In addition, patients with severe lymphopenia required longer days stay in ICU (P<0.001), and presented with higher 28-day mortality (P=0.038) and 1-year mortality (P=0.004). Patients in control group have a higher incidence of severe lymphopenia (P=0.006), 28-day mortality (P=0.015) and 1-year mortality (P=0.019) compared with the test group. Conclusion Comprehensive nursing intervention can prevent the occurrence of severe lymphopenia, improve patients satisfaction and reduce mortality.
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Affiliation(s)
- Lin Zhang
- Department of Intensive Care Unit, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, 150036, People’s Republic of China
| | - Chao Xu
- Department of Intensive Care Unit, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, 150036, People’s Republic of China
| | - Lin Bai
- Department of Intensive Care Unit, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, 150036, People’s Republic of China
| | - Lin Li
- Department of Intensive Care Unit, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, 150036, People’s Republic of China
| | - Jinyan Guo
- Department of Intensive Care Unit, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, 150036, People’s Republic of China
| | - Yanyi Li
- Department of Intensive Care Unit, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, 150036, People’s Republic of China
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Yamaguchi M, Sugiyama H, Nobata H, Kinashi H, Asai A, Kitamura F, Katsuno T, Ando M, Kubo Y, Banno S, Ito Y, Ishimoto T. Lymphopenia is a risk factor for severe infections in older patients with microscopic polyangiitis: a retrospective cohort study in Japan. Rheumatol Adv Pract 2023; 7:rkad073. [PMID: 37692053 PMCID: PMC10483030 DOI: 10.1093/rap/rkad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/17/2023] [Indexed: 09/12/2023] Open
Abstract
Objective Previous studies have identified the predictors of severe infections in ANCA-associated vasculitis. However, lymphopenia has not been fully evaluated as a predictor of subsequent severe infections in patients with microscopic polyangiitis (MPA). The aim of this study was to assess the association between lymphopenia and severe infections requiring hospitalization after receiving immunosuppressive therapy for MPA. Methods This single-centre retrospective cohort study included 130 consecutive patients with newly diagnosed MPA from Aichi Medical University Hospital, Japan, who received immunosuppressive therapy between March 2004 and December 2020. The relationship between lymphopenia and subsequent severe infections was assessed using time-dependent multivariate Cox proportional hazard models adjusted for clinically relevant factors. Results During the follow-up period (median: 38 months; interquartile range: 15-63 months), 56 severe infectious episodes occurred in 51 patients (39.2%). Time-dependent multivariate Cox proportional hazard analyses identified older age [adjusted hazard ratio (HR) = 1.74 per 10 years, 95% CI: 1.13, 2.67], methylprednisolone pulse therapy (adjusted HR = 2.04, 95% CI: 1.03, 4.02), moderate lymphopenia (vs normal, adjusted HR = 7.17, 95% CI: 3.10, 16.6) and severe lymphopenia (vs normal, adjusted HR = 36.1, 95% CI: 11.8, 110.9) as significant predictors of severe infection. Conclusion Lymphopenia is a predictor of subsequent severe infections in patients with MPA who receive immunosuppressive therapy. These results suggest the importance of sustained infection surveillance, particularly in older patients who develop lymphopenia during strong immunosuppressive therapy.
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Affiliation(s)
- Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hirokazu Sugiyama
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Akimasa Asai
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Fumiya Kitamura
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
- Department of Nephrology and Rheumatology, Aichi Medical University Medical Center, Okazaki, Aichi, Japan
| | - Masahiko Ando
- Data Coordinating Center, Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoko Kubo
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
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Mustafa SS. Steroid-induced secondary immune deficiency. Ann Allergy Asthma Immunol 2023:S1081-1206(23)00011-X. [PMID: 36681272 DOI: 10.1016/j.anai.2023.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/19/2023]
Abstract
Despite their widespread clinical use, oral corticosteroids (OCSs) are well known to be associated with a myriad of adverse effects, including immunosuppression. By inhibiting transcription factors and affecting leukocyte function, prolonged OCS use leads to significant CD4 lymphopenia and often a decrease in serum immunoglobulin (Ig)G. Conversely, OCS use has minimal impact on circulating B cell, serum IgM, or serum IgA levels. Although there is a paucity of literature, individuals treated with prolonged OCS seem to typically maintain humoral response to various vaccinations despite hypogammaglobinemia, but this area warrants additional research, especially in the setting of the coronavirus disease 2019 pandemic. Individuals treated with prolonged OCS use are most at risk for opportunistic infections, especially those with underlying malignancy and history of bone marrow transplant. Risk mitigation strategies to decrease infectious complication with OCS use include limiting the dose and duration of therapy, appropriately completing a full vaccination series, consideration for passive immunization, and prophylaxis against opportunistic infections.
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Affiliation(s)
- S Shahzad Mustafa
- Rochester Regional Health, Rochester, New York; University of Rochester School of Medicine & Dentistry, Rochester, New York.
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Mustafa SS, Rider NL, Jolles S. Immunosuppression in Patients With Primary Immunodeficiency-Walking the Line. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3088-3096. [PMID: 36049628 DOI: 10.1016/j.jaip.2022.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022]
Abstract
Individuals with primary immunodeficiency (PIDD) experience not only infectious complications but also immune dysregulation leading to autoimmunity, inflammation, and lymphoproliferative manifestations. Management of these complications often requires treatment with additional immunosuppressive medications, which pose an additional risk of infectious complications. Immunosuppression in individuals with PIDD therefore requires careful assessment and consideration of risks and benefits. Medications should be closely monitored, and strategies for risk mitigation of adverse events considered, such as exposure reduction, appropriate vaccination, use of antibiotics/antivirals, and optimization of immunoglobulin replacement therapy. In a subset of individuals who are not tolerating immune modulation or experiencing disease progression despite appropriate interventions, hematopoietic stem-cell transplantation is a management option.
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Affiliation(s)
- S Shahzad Mustafa
- Rochester Regional Health, Division of Allergy, Immunology, and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, NY; Liberty University College of Osteopathic Medicine and the Liberty Mountain, Chair, Division of Clinical Informatics; Associate Professor of Pediatrics, Allergy-Immunology Medical Group, Rochester, NY.
| | - Nicholas L Rider
- Liberty University College of Osteopathic Medicine and the Liberty Mountain Medical Group, Lynchburg, Va
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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Becker S, Jonigk D, Luft A, Dübbel L, Werlein C, Malik E, Schild-Suhren M. COVID-19 can lead to rapid progression of cervical intraepithelial neoplasia by dysregulating the immune system: A hypothesis. J Reprod Immunol 2022; 154:103763. [PMID: 36399874 PMCID: PMC9645588 DOI: 10.1016/j.jri.2022.103763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/11/2022] [Accepted: 11/08/2022] [Indexed: 11/10/2022]
Abstract
COVID-19 is a multisystem disease and cause of a global pandemic. Lately, cases of disease progression of HPV-infected CIN under SARS-CoV-2 infection were reported giving rise to the hypothesis of direct virus-infection induced pro-carcinogenic effect of SARS-CoV-2. We herein present a case of rapid progression from HPV-induced CIN 2 to microinvasive carcinoma within three months under COVID-19 without direct virus infection. Histopathologic evaluation, Fluorescence-in-situ hybridization and qRT-PCR against SARS-CoV-2 RNA as well as gene expression analysis were performed from the available FFPE-tissue and accompanied by an analysis of white blood cell differential. No signs of direct SARS-CoV-2 infection or COVID-19 typical alterations of cervical tissue were found. As expected, p53 decreased in expression with progression of dysplasia, while APOBEC3A and VISTA showed a decrease in expression contrary to observations in dysplasia progression. PD-L1 was expressed consistently or increased slightly but did not show the expected strong induction of expression. DNMT1 showed an increase in expression in CIN III and a slight decrease in carcinoma, while DNMT3a is consistently expressed in CIN II and decreased in carcinoma. Blood tests after COVID-19 showed substantial reduction of lymphocytes, eosinophils, T-cells, and NK-cells. Our results hint at an indirect effect of COVID-19 on the cervical neoplasm. We conclude that the immune system might be preoccupied and exhausted by the concurring COVID-19 disease, leading to less immunological pressure on the HPV-infected cervical dysplasia enabling rapid disease progression. Further, indirect proangiogenic and proinflammatory micromilieu due to the multisystemic effects of COVID-19 might play an additional role.
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Affiliation(s)
- Sabeth Becker
- University clinic of Gynaecology and Obstetrics, Carl von Ossietzky University Oldenburg, Emsstraße 20, 26382 Wilhelmshaven, Germany,University clinic of Gynaecology and Obstetrics, Klinikum Oldenburg, Rahel-Straus-Straße 10, 26133 Oldenburg, Germany
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany,Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Germany
| | - Angelina Luft
- University clinic of Gynaecology and Obstetrics, Carl von Ossietzky University Oldenburg, Emsstraße 20, 26382 Wilhelmshaven, Germany
| | - Lena Dübbel
- University clinic of Gynaecology and Obstetrics, Carl von Ossietzky University Oldenburg, Emsstraße 20, 26382 Wilhelmshaven, Germany,Corresponding author
| | | | - Eduard Malik
- University clinic of Gynaecology and Obstetrics, Carl von Ossietzky University Oldenburg, Emsstraße 20, 26382 Wilhelmshaven, Germany,University clinic of Gynaecology and Obstetrics, Klinikum Oldenburg, Rahel-Straus-Straße 10, 26133 Oldenburg, Germany
| | - Meike Schild-Suhren
- University clinic of Gynaecology and Obstetrics, Carl von Ossietzky University Oldenburg, Emsstraße 20, 26382 Wilhelmshaven, Germany,University clinic of Gynaecology and Obstetrics, Klinikum Oldenburg, Rahel-Straus-Straße 10, 26133 Oldenburg, Germany
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8
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Zhang X, Zhang S, Wang C, Li A. Neutrophil-to-albumin ratio as a novel marker predicting unfavorable outcome in aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2022; 99:282-288. [DOI: 10.1016/j.jocn.2022.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/09/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022]
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9
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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10
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Barr DA, Schutz C, Balfour A, Shey M, Kamariza M, Bertozzi CR, de Wet TJ, Dinkele R, Ward A, Haigh KA, Kanyik JP, Mizrahi V, Nicol MP, Wilkinson RJ, Lalloo DG, Warner DF, Meintjes G, Davies G. Serial measurement of M. tuberculosis in blood from critically-ill patients with HIV-associated tuberculosis. EBioMedicine 2022; 78:103949. [PMID: 35325781 PMCID: PMC8938880 DOI: 10.1016/j.ebiom.2022.103949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/16/2022] [Accepted: 03/04/2022] [Indexed: 11/25/2022] Open
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11
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Liao Z, Tang J, Luo L, Deng S, Luo L, Wang F, Yuan X, Hu X, Feng J, Li X. Altered circulating CCR6 +and CXCR3 + T cell subsets are associated with poor renal prognosis in MPO-ANCA-associated vasculitis. Arthritis Res Ther 2021; 23:194. [PMID: 34289887 PMCID: PMC8293504 DOI: 10.1186/s13075-021-02576-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/26/2021] [Indexed: 11/15/2022] Open
Abstract
Background Effector memory T cells are pivotal effectors of adaptive immunity with enhanced migration characteristics and are involved in the pathogenesis of ANCA-associated vasculitis (AAV). The diversity of effector memory T cells in chemokine receptor expression has been well studied in proteinase 3 (PR3)-AAV. However, few studies have been conducted in myeloperoxidase (MPO)-AAV. Here, we characterized chemokine receptor expression on effector memory T cells from patients with active MPO-AAV. Methods Clinical data from newly diagnosed MPO-AAV patients and healthy subjects were collected and analyzed. Human peripheral blood mononuclear cells (PBMCs) isolated from patients with active MPO-AAV were analyzed by flow cytometry. The production of effector memory T cell-related chemokines in serum was assessed by ELISA. Results We observed decreased percentages of CD4+ and CD8+ T cells in the peripheral blood, accompanied by a significant decrease in CCR6-expressing T cells but an increase in CXCR3+ T cells, in active MPO-AAV. Furthermore, the decrease in CCR6 and increase in CXCR3 expression were mainly limited to effector memory T cells. Consistent with this finding, the serum level of CCL20 was increased. In addition, a decreasing trend in the TEM17 cell frequency, with concomitant increases in the frequencies of CD4+ TEM1 and CD4+ TEM17.1 cells, was observed when T cell functional subsets were defined by chemokine receptor expression. Moreover, the proportions of peripheral CD8+ T cells and CD4+ TEM subsets were correlated with renal prognosis and inflammatory markers. Conclusions Our data indicate that dysregulated chemokine receptor expression on CD4+ and CD8+ effector memory T cells and aberrant distribution of functional CD4+ T cell subsets in patients with active MPO-AAV have critical roles related to kidney survival.
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Affiliation(s)
- Zhonghua Liao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Jiale Tang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Liying Luo
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Shuanglinzi Deng
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Lisa Luo
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Fangyuan Wang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xiangning Yuan
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xinyue Hu
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Juntao Feng
- Department of Respiratory and Critical Care Medicine, Key Cite of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xiaozhao Li
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
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12
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Grondman I, de Nooijer AH, Antonakos N, Janssen NAF, Mouktaroudi M, Leventogiannis K, Medici M, Smit JWA, van Herwaarden AE, Joosten LAB, van der Veerdonk FL, Pickkers P, Kox M, Jaeger M, Netea MG, Giamarellos-Bourboulis EJ, Netea-Maier RT. The Association of TSH and Thyroid Hormones With Lymphopenia in Bacterial Sepsis and COVID-19. J Clin Endocrinol Metab 2021; 106:1994-2009. [PMID: 33713408 PMCID: PMC7989224 DOI: 10.1210/clinem/dgab148] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Lymphopenia is a key feature of immune dysfunction in patients with bacterial sepsis and coronavirus disease 2019 (COVID-19) and is associated with poor clinical outcomes, but the cause is largely unknown. Severely ill patients may present with thyroid function abnormalities, so-called nonthyroidal illness syndrome, and several studies have linked thyrotropin (thyroid stimulating hormone, TSH) and the thyroid hormones thyroxine (T4) and 3,5,3'-triiodothyronine (T3) to homeostatic regulation and function of lymphocyte populations. OBJECTIVE This work aimed to test the hypothesis that abnormal thyroid function correlates with lymphopenia in patients with severe infections. METHODS A retrospective analysis of absolute lymphocyte counts, circulating TSH, T4, free T4 (FT4), T3, albumin, and inflammatory biomarkers was performed in 2 independent hospitalized study populations: bacterial sepsis (n = 224) and COVID-19 patients (n = 161). A subgroup analysis was performed in patients with severe lymphopenia and normal lymphocyte counts. RESULTS Only T3 significantly correlated (ρ = 0.252) with lymphocyte counts in patients with bacterial sepsis, and lower concentrations were found in severe lymphopenic compared to nonlymphopenic patients (n = 56 per group). Severe lymphopenic COVID-19 patients (n = 17) showed significantly lower plasma concentrations of TSH, T4, FT4, and T3 compared to patients without lymphopenia (n = 18), and demonstrated significantly increased values of the inflammatory markers interleukin-6, C-reactive protein, and ferritin. Remarkably, after 1 week of follow-up, the majority (12 of 15) of COVID-19 patients showed quantitative recovery of their lymphocyte numbers, whereas TSH and thyroid hormones remained mainly disturbed. CONCLUSION Abnormal thyroid function correlates with lymphopenia in patients with severe infections, like bacterial sepsis and COVID-19, but future studies need to establish whether a causal relationship is involved.
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Affiliation(s)
- Inge Grondman
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aline H de Nooijer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nikolaos Antonakos
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nico A F Janssen
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria Mouktaroudi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Marco Medici
- Department of Internal Medicine, Division of Endocrinology, Radboud University Nijmegen, GA, Nijmegen, the Netherlands
- Academic Center for Thyroid Diseases and Departments of Internal Medicine and Epidemiology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Jan W A Smit
- Department of Internal Medicine, Division of Endocrinology, Radboud University Nijmegen, GA, Nijmegen, the Netherlands
| | | | - Leo A B Joosten
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank L van der Veerdonk
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Immunology and Metabolism, Life & Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Matthijs Kox
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Immunology and Metabolism, Life & Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Martin Jaeger
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Romana T Netea-Maier
- Department of Internal Medicine, Division of Endocrinology, Radboud University Nijmegen, GA, Nijmegen, the Netherlands
- Corresponding author (and to whom reprints should be addressed): Romana Netea-Maier, MD PhD, Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, The Netherlands, Tel: +31-24-3614599, Email
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13
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Wacrenier S, Riou J, Jourdain P, Guibert F, Henry N, Djema A, Coindre JP, Crochette R, Cousin M, Croue A, Subra JF, Piccoli G, Augusto JF, Brilland B. Lymphopenia at diagnosis of ANCA-vasculitis with renal involvement is correlated with severity and renal prognosis. Nephrol Dial Transplant 2021; 37:1078-1087. [PMID: 33856482 DOI: 10.1093/ndt/gfab158] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lymphopenia is commonly observed in autoimmune diseases, where it has been associated with disease activity or prognosis. However, in ANCA-associated vasculitis (AAV) only few, small-scale studies have been targeted to this issue. Research has not yet focused on AAV with renal involvement (AAV-RI) patients. Thus, the aim of this study was to analyze the association between lymphocyte counts and outcomes in a large cohort of AAV-RI patients. METHODS We used the Maine-Anjou AAV registry that retrospectively gathers data on consecutive patients affected by AAV in four French Nephrology Centers, recorded since January 2000. We analyzed clinical, biological, and histological data at diagnosis of AAV-RI. Risk factors for end-stage kidney disease (ESKD) were analyzed. Event-free survival was also assessed. RESULTS Among the 145 patients included in the study, those with lymphopenia at diagnosis had a lower renal function at baseline (eGFR 13 mL/min vs 26 mL/min, p = 0.002) and were more likely to require kidney replacement therapy (51% vs 25%, p = 0.003). Lymphopenia was correlated with histological lesions and especially with the percentage of sclerotic glomeruli (p = 0.0027). ESKD-free survival was lower in lymphopenic patients (p < 0.0001). In multivariate Cox analysis, lymphopenia was an independent risk factor for ESKD (HR 4.47 (95% confidence interval: [2.06-9.72], p < 0.001). CONCLUSION Lymphopenia correlates with the severity of AAV glomerulonephritis at diagnosis and predicts poor renal outcome. In this view, lymphopenia could be used as a simple and cost-effective biomarker to assess renal prognosis at AAV-RI diagnosis.
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Affiliation(s)
- Samuel Wacrenier
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie, Centre Hospitalier du Mans, Le Mans, France
| | - Jérémie Riou
- Micro et Nanomédecines Translationnelles, MINT, Université d'Angers, UMR INSERM 6021, UMR CNRS 6021, Angers, France.,Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Angers University Hospital, Angers, France
| | - Pierre Jourdain
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Fanny Guibert
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie, Centre Hospitalier de Cholet, Cholet, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France.,Service de Néphrologie, Centre Hospitalier de Laval, Laval, France
| | - Assia Djema
- Service de Néphrologie, Centre Hospitalier de Cholet, Cholet, France
| | | | - Romain Crochette
- Service de Néphrologie, Centre Hospitalier du Mans, Le Mans, France
| | - Maud Cousin
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Anne Croue
- Département de pathologie cellulaire et tissulaire, Université d'Angers, CHU Angers, Angers, France
| | - Jean-François Subra
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Giorgina Piccoli
- Service de Néphrologie, Centre Hospitalier du Mans, Le Mans, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'Angers, CHU Angers, Angers, France
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14
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Analysis of absolute lymphocyte count in patients with COVID-19. Am J Emerg Med 2021; 46:16-19. [PMID: 33706251 PMCID: PMC7923864 DOI: 10.1016/j.ajem.2021.02.054] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Symptoms of COVID-19 vary in severity and presentation. When admitting patients to the hospital, it is desirable to isolate patients with COVID-19 from those without the disease. However, reliably identifying patients with COVID-19 in the emergency department before hospital admission is often limited by the speed and availability of testing. Previous studies determined a low lymphocyte count is commonly found in patients with COVID-19. We sought to explore the sensitivity of absolute lymphocyte count in patients presenting to the emergency department requiring subsequent hospitalization who were found to have COVID-19. Methods A retrospective chart review was performed on 312 patients with laboratory-confirmed COVID-19 who were admitted to the hospital from the emergency department. The absolute lymphocyte count for these patients was used to calculate sensitivities at various cut-off values. The relationships between absolute lymphocyte count and variables, including age, sex, need for intubation, and mortality, were also explored. Results Cut-off values for absolute lymphocyte count ranged from 1.1 K/uL to 2.0 K/uL, with sensitivities of 72% and 94%, respectively. Additionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. Conclusion Knowing the sensitivity of absolute lymphocyte count in patients with COVID-19 may help identify patients who are unlikely to have the disease. Additionally, absolute lymphocyte count can be used as a marker of disease severity in patients with COVID-19.
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15
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Cizmecioglu A, Akay Cizmecioglu H, Goktepe MH, Emsen A, Korkmaz C, Esenkaya Tasbent F, Colkesen F, Artac H. Apoptosis-induced T-cell lymphopenia is related to COVID-19 severity. J Med Virol 2021; 93:2867-2874. [PMID: 33331657 DOI: 10.1002/jmv.26742] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/01/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022]
Abstract
Increased levels of acute-phase reactants and lymphopenia are predictors of disease severity in coronavirus disease 2019 (COVID-19). This study aimed to investigate the role of apoptosis in the etiology of lymphopenia in patients with COVID-19. This multicentered, prospective, and case-control study was conducted with polymerase chain reaction (+) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients, and an age-gender-matched control group. Samples were taken at the time of diagnosis and analyzed via flow cytometry within 24 h. The participants' demographic data and initial laboratory tests were also recorded. In total, 33 patients with COVID-19 (mean age = 45.4 ± 17.2) and 25 controls (mean age = 43.4 ± 17.4) participated in the study. All patients were identified as having mild (16), moderate (5), or severe (12) disease severity. Both early and late apoptotic cells in B and T lymphocytes were increased in all patients with COVID-19 (p < .05). Early apoptotic (EA) B and T lymphocytes were also higher in severe cases compared to mild cases (p = .026). There was no significant difference between lymphopenia and apoptosis in patients with COVID-19. However, patients with lymphopenia (n = 14) and severe COVID-19 (p = .013) had increased EA T lymphocytes. This study's results show that B and T lymphocytes' apoptosis increases in patients with COVID-19. In addition, enhanced T lymphocyte apoptosis is associated with disease severity in lymphopenic patients with COVID-19.
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Affiliation(s)
- Ahmet Cizmecioglu
- Department of Internal Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Hilal Akay Cizmecioglu
- Department of Internal Medicine, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Mevlut Hakan Goktepe
- Department of Internal Medicine, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ayca Emsen
- Department of Pediatric Immunology and Allergy, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Celalettin Korkmaz
- Department of Chest Disease and Tuberculosis, Faculty of Medicine, Necmettin Erbakan University, Konya
| | - Fatma Esenkaya Tasbent
- Department of Medical Microbiology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Fatma Colkesen
- Department of Infectious Disease, Konya Training and Research Hospital, Health Sciences University, Konya, Turkey
| | - Hasibe Artac
- Division of Immunology and Allergy, Department of Pediatrics, Faculty of Medicine, Selcuk University, Konya, Turkey
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16
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Bagheri Z, Labbani-Motlagh Z, Mirjalili M, Karimzadeh I, Khalili H. Types and outcomes of cytopenia in critically ill patients. J Comp Eff Res 2020; 9:627-637. [PMID: 32495631 DOI: 10.2217/cer-2020-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cytopenia is common complication in critically ill patients. Aim: Incidence and pattern of different types of cytopenia as well as its impact on mortality and length of stay in critically ill patients were evaluated. Methods: Critically ill patients with any kind of cytopenia for more than 2 days were evaluated. Results: Anemia was the most common type of cytopenia in the patients (99.14%), followed by lymphocytopenia (32.17%), thrombocytopenia (27.82%), and leukopenia (19.13%). Mortality rate was significantly higher in patients with anemia (p < 0.0001), thrombocytopenia (p < 0.0001), leukopenia (p < 0.0001), neutropenia (p = 0.004), lymphopenia (p = 0.002) and pancytopenia (p < 0.0001). Higher duration of anemia, lymphopenia and thrombocytopenia were associated with longer intensive care unit stay (p < 0.0001, p < 0.0001 and p < 0.001, respectively). Conclusion: Among all assessed variables, incidence of thrombocytopenia could independently predict the mortality.
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Affiliation(s)
- Zahra Bagheri
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Labbani-Motlagh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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17
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Giede-Jeppe A, Reichl J, Sprügel MI, Lücking H, Hoelter P, Eyüpoglu IY, Kuramatsu JB, Huttner HB, Gerner ST. Neutrophil-to-lymphocyte ratio as an independent predictor for unfavorable functional outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 2020; 132:400-407. [DOI: 10.3171/2018.9.jns181975] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEStroke-associated immunosuppression and inflammation are increasingly recognized as factors triggering infections and thus potentially influencing outcome after stroke. Several studies have demonstrated that elevated neutrophil-to-lymphocyte ratio (NLR) is a significant predictor of adverse outcomes for patients with ischemic stroke or intracerebral hemorrhage. Thus far, in patients with subarachnoid hemorrhage the association between NLR and outcome is insufficiently established. The authors sought to investigate the association between NLR on admission and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH).METHODSThis observational study included all consecutive aSAH patients admitted to a German tertiary center over a 5-year period (2008–2012). Data regarding patient demographics and clinical, laboratory, and in-hospital measures, as well as neuroradiological data, were retrieved from institutional databases. Functional outcome was assessed at 3 and 12 months using the modified Rankin Scale (mRS) score and categorized into favorable (mRS score 0–2) and unfavorable (mRS score 3–6). Patients’ radiological and laboratory characteristics were compared between aSAH patients with favorable and those with unfavorable outcome at 3 months. In addition, multivariate analysis was conducted to investigate parameters independently associated with favorable outcome. Receiver operating characteristic (ROC) curve analysis was undertaken to identify the best cutoff for NLR to discriminate between favorable and unfavorable outcome in these patients. To account for imbalances in baseline characteristics, propensity score matching was carried out to assess the influence of NLR on outcome measures.RESULTSOverall, 319 patients with aSAH were included. Patients with unfavorable outcome at 3 months were older, had worse clinical status on admission (Glasgow Coma Scale score and Hunt and Hess grade), greater amount of subarachnoidal and intraventricular hemorrhage (modified Fisher Scale grade and Graeb score), and higher rates of infectious complications (pneumonia and sepsis). A significantly higher NLR on admission was observed in patients with unfavorable outcome according to mRS score (median [IQR] NLR 5.8 [3.0–10.0] for mRS score 0–2 vs NLR 8.3 [4.5–12.6] for mRS score 3–6; p < 0.001). After adjustments, NLR on admission remained a significant predictor for unfavorable outcome in SAH patients (OR [95% CI] 1.014 [1.001–1.027]; p = 0.028). In ROC analysis, an NLR of 7.05 was identified as the best cutoff value to discriminate between favorable and unfavorable outcome (area under the curve = 0.614, p < 0.001, Youden’s index = 0.211; mRS score 3–6: 94/153 [61.4%] for NLR ≥ 7.05 vs 67/166 [40.4%] for NLR < 7.05; p < 0.001). Subanalysis of patients with NLR levels ≥ 7.05 vs < 7.05, performed using 2 propensity score–matched cohorts (n = 133 patients in each group), revealed an increased proportion of patients with unfavorable functional outcome at 3 months in patients with NLR ≥ 7.05 (mRS score 3–6 at 3 months: NLR ≥ 7.05 82/133 [61.7%] vs NLR < 7.05 62/133 [46.6%]; p = 0.014), yet without differences in mortality at 3 months (NLR ≥ 7.05 37/133 [27.8%] vs NLR < 7.05 27/133 [20.3%]; p = 0.131).CONCLUSIONSAmong aSAH patients, NLR represents an independent parameter associated with unfavorable functional outcome. Whether the impact of NLR on functional outcome is related to preexisting comorbidities or represents independent causal relationships in the context of stroke-associated immunosuppression should be investigated in future studies.
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18
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Farmer JR, DeLelys M. Flow Cytometry as a Diagnostic Tool in Primary and Secondary Immune Deficiencies. Clin Lab Med 2019; 39:591-607. [PMID: 31668272 DOI: 10.1016/j.cll.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Flow cytometry is an incredibly powerful diagnostic tool in the evaluation of primary and secondary immune deficiencies. Assay design and setup involves a methodological consideration of specimen collection, marker and fluorochrome selection, antibody titration, instrumentation, compensation, gating, reference range development, and cross validation. Commonly used analyses for lymphocytes are the lymphocyte subset, T-cell subset, B-cell and T-cell naive/memory, double-negative T-cell, and plasmablast panels. Flow cytometry has direct clinical applicability to the workup of severe forms of primary immune deficiency disorders and is used diagnostically and for therapeutic monitoring in the context of secondary immune deficiency disorders.
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Affiliation(s)
- Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, COX 201, MGH, 55 Fruit Street, Boston, MA 02114, USA; Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA.
| | - Michelle DeLelys
- Cellular Therapeutics and Transplantation/Flow Cytometry, Department of Pathology, Massachusetts General Hospital, WRN 506, MGH, 55 Fruit Street, Boston, MA 02114, USA; Cellular Therapeutics and Transplantation/Flow Cytometry, Department of Cancer Center, Massachusetts General Hospital, WRN 506, MGH, 55 Fruit Street, Boston, MA 02114, USA
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19
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Su L, Pan P, Yan P, Long Y, Zhou X, Wang X, Zhou R, Wen B, Xie L, Liu D. Role of vimentin in modulating immune cell apoptosis and inflammatory responses in sepsis. Sci Rep 2019; 9:5747. [PMID: 30952998 PMCID: PMC6451033 DOI: 10.1038/s41598-019-42287-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/27/2019] [Indexed: 01/04/2023] Open
Abstract
New diagnostic biomarkers or therapeutic targets for sepsis have substantial significance for critical care medicine. In this study, 192 differentially expressed proteins were selected through iTRAQ. Based on cluster analysis of protein expression dynamics and protein-protein interactions, hemopexin, vimentin, and heat shock protein 90 were selected for further investigation. It was demonstrated that serum vimentin (VIM) levels were significantly increased in patients with sepsis and septic shock compared to controls and that VIM expression was significantly increased in lymphocytes isolated from septic shock and sepsis patients compared to controls. Moreover, a nonsurvivor group had higher serum VIM levels and VIM expression in lymphocytes. Caspase-3 was significantly upregulated in Jurkat T cells lacking VIM and when exposed to LPS compared to control cells. In contrast, caspase-3 was reduced nearly 40% in cells over-expressing VIM. IL-2, IL-10 and IFN-α levels were significantly decreased in cells lacking VIM compared to control cells, whereas they were not significantly altered in cells over-expressing VIM. These findings suggest that VIM modulates lymphocyte apoptosis and inflammatory responses and that VIM could be a new target for the diagnosis and prognostic prediction of patients with sepsis or septic shock.
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Affiliation(s)
- Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Pan Pan
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili the 6th, Dongcheng District, Beijing, 100050, China
| | - Peng Yan
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Rd, Haidian District, Beijing, 100853, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ruo Zhou
- Shenzhen Proteome Engineering Laboratory, BGI Shenzhen, Shenzhen, 518083, Guangdong Province, China
| | - Bo Wen
- Shenzhen Proteome Engineering Laboratory, BGI Shenzhen, Shenzhen, 518083, Guangdong Province, China
| | - Lixin Xie
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, 28th Fuxing Rd, Haidian District, Beijing, 100853, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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20
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Monneret G, Gossez M, Aghaeepour N, Gaudilliere B, Venet F. How Clinical Flow Cytometry Rebooted Sepsis Immunology. Cytometry A 2019; 95:431-441. [PMID: 30887636 DOI: 10.1002/cyto.a.23749] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/22/2019] [Accepted: 02/28/2019] [Indexed: 12/16/2022]
Abstract
On May 2017, the World Health Organization (WHO) recognized sepsis as a global health priority by adopting a resolution to improve the prevention, diagnosis, and management of this deadly disease. While it has long been known that sepsis deeply perturbs immune homeostasis by inducing a tremendous systemic inflammatory response, pivotal observations based on clinical flow cytometry indicate that sepsis indeed initiates a more complex immune response that varies over time, with the concomitant occurrence of both pro- and anti-inflammatory mechanisms. As a resultant, some septic patients enter a stage of protracted immunosuppression. This paved the way for immunostimulation approaches in sepsis. Clinical flow cytometry permitted this evolution by drawing a new picture of pathophysiology and reshaping immune trajectories in patients. Additional information from cytometry by time of flight mass cytometry and other high-dimensional flow cytometry platform should rapidly enrich our understanding of this complex disease. This review reports on landmarks of clinical flow cytometry in sepsis and how this single-cell analysis technique permitted to breach the wall of decades of unfruitful anti-inflammatory-based clinical trials in sepsis. © 2019 International Society for Advancement of Cytometry.
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Affiliation(s)
- Guillaume Monneret
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Laboratoire d'Immunologie, Lyon, 69003, France.,EA 7426 "Pathophysiology of Injury-Induced Immunosuppression", Université Claude Bernard Lyon 1, Hospices Civils de Lyon, BioMérieux, Hôpital Edouard Herriot, Lyon, France
| | - Morgane Gossez
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Laboratoire d'Immunologie, Lyon, 69003, France.,EA 7426 "Pathophysiology of Injury-Induced Immunosuppression", Université Claude Bernard Lyon 1, Hospices Civils de Lyon, BioMérieux, Hôpital Edouard Herriot, Lyon, France
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, 94121, USA
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, 94121, USA
| | - Fabienne Venet
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Laboratoire d'Immunologie, Lyon, 69003, France.,EA 7426 "Pathophysiology of Injury-Induced Immunosuppression", Université Claude Bernard Lyon 1, Hospices Civils de Lyon, BioMérieux, Hôpital Edouard Herriot, Lyon, France
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21
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Özdin S, Böke Ö. Neutrophil/lymphocyte, platelet/lymphocyte and monocyte/lymphocyte ratios in different stages of schizophrenia. Psychiatry Res 2019; 271:131-135. [PMID: 30472508 DOI: 10.1016/j.psychres.2018.11.043] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/02/2018] [Accepted: 11/18/2018] [Indexed: 01/29/2023]
Abstract
The inflammation hypothesis is frequently mentioned in the pathogenesis of schizophrenia. The objective of this study was to compare inflammation markers during relapse and remission periods in patients with schizophrenia. Complete blood count (CBC) of 105 patients diagnosed with schizophrenia who were hospitalized due to psychotic relapse at Ondokuz Mayıs University Medical Faculty Psychiatry Service between 2012 and 2016 and 105 healthy control subjects were retrospectively analyzed. Relapse CBC was also compared with remission CBC of the same patients and with the control group. Neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and monocyte/lymphocyte ratio (MLR) of the patients during relapse period were found to be significantly higher when compared with the control group. MLR and PLR were found to be significantly higher in the remission period when compared with the control group. NLR, PLR and MLR values were significantly increased in the relapse period when compared with the remission period of the same patients. The findings of our study support the inflammation hypothesis of schizophrenia. As a result of our study, we believe MLR and PLR are important markers. There is a decrease in inflammatory response in schizophrenia following treatment.
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Affiliation(s)
- Selçuk Özdin
- Kanuni Research and Training Hospital, Psychiatry Clinic, Trabzon, Turkey.
| | - Ömer Böke
- Ondokuz Mayıs University Faculty of Medicine, Psychiatry Clinic, Samsun, Turkey
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Groen-Hakan F, Eurelings L, Rothova A, van Laar J. Lymphopaenia as a predictor of sarcoidosis in patients with a first episode of uveitis. Br J Ophthalmol 2018; 103:1296-1300. [DOI: 10.1136/bjophthalmol-2018-313212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/23/2018] [Accepted: 11/01/2018] [Indexed: 11/04/2022]
Abstract
Background/aimsThe diagnostic properties of conventional diagnostic tests (ACE and chest radiography) for sarcoidosis-associated uveitis are not ideal. The diagnostic value of lymphopaenia for sarcoidosis-associated uveitis is investigated.MethodsA retrospective study of 191 consecutive patients with a first uveitis episode visiting the ophthalmology department (Erasmus Medical Center, Rotterdam, The Netherlands). Receiver operating characteristics (ROC) analysis was performed and compared with known ROC values from literature of conventional diagnostic tests for sarcoidosis-associated uveitis. An ideal cut-off was determined for lymphopaenia by calculation of the highest Youden index.ResultsOut of all patients with first uveitis attack, 32/191 or 17% were subsequently diagnosed with biopsy-proven or radiological diagnosis of sarcoidosis. Lymphopaenia (<1.5×109/L) was significantly more often observed in patients with sarcoidosis-associated uveitis compared with patients with non-sarcoidosis-associated uveitis (p<0.05). The sensitivity and specificity of lymphopaenia was 75 % and 77 %, respectively. The optimal cut-off for lymphopaenia for diagnosing sarcoidosis-associated uveitis was 1.47 ×109/L. Lymphopaenia resulted in a 12.0 (95% CI 4.7 to 30.5 fold risk for having sarcoidosis, corrected for sex, race and age at onset of uveitis in patients with a first uveitis attack.ConclusionLymphopaenia is a non-invasive and useful marker for diagnosing sarcoidosis-associated uveitis.
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Warny M, Helby J, Nordestgaard BG, Birgens H, Bojesen SE. Lymphopenia and risk of infection and infection-related death in 98,344 individuals from a prospective Danish population-based study. PLoS Med 2018; 15:e1002685. [PMID: 30383787 PMCID: PMC6211632 DOI: 10.1371/journal.pmed.1002685] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/02/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Neutropenia increases the risk of infection, but it is unknown if this also applies to lymphopenia. We therefore tested the hypotheses that lymphopenia is associated with increased risk of infection and infection-related death in the general population. METHODS AND FINDINGS Of the invited 220,424 individuals, 99,191 attended examination. We analyzed 98,344 individuals from the Copenhagen General Population Study (Denmark), examined from November 25, 2003, to July 9, 2013, and with available blood lymphocyte count at date of examination. During a median of 6 years of follow-up, they developed 8,401 infections and experienced 1,045 infection-related deaths. Due to the completeness of the Danish civil and health registries, none of the 98,344 individuals were lost to follow-up, and those emigrating (n = 385) or dying (n = 5,636) had their follow-up truncated at the day of emigration or death. At date of examination, mean age was 58 years, and 44,181 (44.9%) were men. Individuals with lymphopenia (lymphocyte count < 1.1 × 109/l, n = 2,352) compared to those with lymphocytes in the reference range (1.1-3.7 × 109/l, n = 93,538) had multivariable-adjusted hazard ratios of 1.41 (95% CI 1.28-1.56) for any infection, 1.31 (1.14-1.52) for pneumonia, 1.44 (1.15-1.79) for skin infection, 1.26 (1.02-1.56) for urinary tract infection, 1.51 (1.21-1.89) for sepsis, 1.38 (1.01-1.88) for diarrheal disease, 2.15 (1.16-3.98) for endocarditis, and 2.26 (1.21-4.24) for other infections. The corresponding hazard ratio for infection-related death was 1.70 (95% CI 1.37-2.10). Analyses were adjusted for age, sex, smoking status, cumulative smoking, alcohol intake, body mass index, plasma C-reactive protein, blood neutrophil count, recent infection, Charlson comorbidity index, autoimmune diseases, medication use, and immunodeficiency/hematologic disease. The findings were robust in all stratified analyses and also when including only events later than 2 years after first examination. However, due to the observational design, the study cannot address questions of causality, and our analyses might theoretically have been affected by residual confounding and reverse causation. In principle, fluctuating lymphocyte counts over time might also have influenced analyses, but lymphocyte counts in 5,181 individuals measured 10 years after first examination showed a regression dilution ratio of 0.68. CONCLUSIONS Lymphopenia was associated with increased risk of hospitalization with infection and increased risk of infection-related death in the general population. Notably, causality cannot be deduced from our data.
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Affiliation(s)
- Marie Warny
- Department of Hematology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Jens Helby
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Børge Grønne Nordestgaard
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Henrik Birgens
- Department of Hematology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Stig Egil Bojesen
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- * E-mail:
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Girardot T, Rimmelé T, Venet F, Monneret G. Apoptosis-induced lymphopenia in sepsis and other severe injuries. Apoptosis 2018; 22:295-305. [PMID: 27812767 DOI: 10.1007/s10495-016-1325-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Sepsis and other acute injuries such as severe trauma, extensive burns, or major surgeries, are usually followed by a period of marked immunosuppression. In particular, while lymphocytes play a pivotal role in immune response, their functions and numbers are profoundly altered after severe injuries. Apoptosis plays a central role in this process by affecting immune response at various levels. Indeed, apoptosis-induced lymphopenia duration and depth have been associated with higher risk of infection and mortality in various clinical settings. Therapies modulating apoptosis represent an interesting approach to restore immune competence after acute injury, although their use in clinical practice still presents several limitations. After briefly describing the apoptosis process in physiology and during severe injuries, we will explore the immunological consequences of injury-induced lymphocyte apoptosis, and describe associations with clinically relevant outcomes in patients. Therapeutic perspectives targeting apoptosis will also be discussed.
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Affiliation(s)
- Thibaut Girardot
- Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France.,EA 7426 Pathophysiology of Injury-Induced Immunosuppression (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Edouard Herriot Hospital, Lyon, France
| | - Thomas Rimmelé
- Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France.,EA 7426 Pathophysiology of Injury-Induced Immunosuppression (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Edouard Herriot Hospital, Lyon, France
| | - Fabienne Venet
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hospital, Pavillon E, 5, place d'Arsonval, 69437 Cedex 03, Lyon, France.,EA 7426 Pathophysiology of Injury-Induced Immunosuppression (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Edouard Herriot Hospital, Lyon, France
| | - Guillaume Monneret
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hospital, Pavillon E, 5, place d'Arsonval, 69437 Cedex 03, Lyon, France. .,EA 7426 Pathophysiology of Injury-Induced Immunosuppression (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Edouard Herriot Hospital, Lyon, France.
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Girardot T, Rimmelé T, Monneret G, Textoris J, Venet F. Intra-cellular lactate concentration in T lymphocytes from septic shock patients - a pilot study. Intensive Care Med Exp 2018; 6:5. [PMID: 29404815 PMCID: PMC5799155 DOI: 10.1186/s40635-018-0167-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/09/2018] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis-associated hyperlactatemia is a widely used biomarker, associated with initial severity and poor outcomes. This increased circulating lactate concentration has been proposed to result in part from a mismatch between oxygen delivery and demand in organs. However, other mechanisms may participate. In particular, a metabolic reprogramming similar to the Warburg effect initially described in cancer cells could lead to increased lactate production by immune cells such as T lymphocytes after sepsis. The objective of this study was to set up a protocol for lactate measurement in T lymphocytes, and to evaluate whether lactate production by T lymphocytes was increased in septic shock patients. Methods We first optimized protocols for lactate and pyruvate measurements in T lymphocytes purified from healthy volunteers’ blood, either stimulated with phytohaemagglutinine (PHA) or left untreated. We then conducted a pilot study to confirm the feasibility of this protocol in samples from septic shock patients. Results PHA stimulation induced aerobic glycolysis in human lymphocytes ex vivo, with increased lactate and pyruvate productions. To correctly measure this phenomenon, minimal cell number was 250,000 and optimal culture duration was 40 h. We also observed a significant correlation between lactate concentration in T lymphocytes and in their culture supernatants. We were able to measure lactate concentration in T lymphocytes from septic shock patients. Our preliminary results showed that intra-lymphocyte lactate concentration was not different between patients and healthy volunteers. Conclusion This protocol should now be tested in a larger cohort of patients. The association between immune cell metabolic reprogramming as measured by lactate concentration in T cells and functionality represents an exciting field for research.
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Affiliation(s)
- Thibaut Girardot
- Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Edouard Herriot Hospital, Lyon, France.,EA 7426 (Université Claude Bernard Lyon 1) "Pathophysiology of Injury-Induced Immunosuppression-PI3", Edouard Herriot Hospital, Lyon, France.,Joint Research Unit (bioMérieux-Hospices Civils de Lyon-Université Claude Bernard Lyon 1), Edouard Herriot Hospital, Lyon, France
| | - Thomas Rimmelé
- Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Edouard Herriot Hospital, Lyon, France.,EA 7426 (Université Claude Bernard Lyon 1) "Pathophysiology of Injury-Induced Immunosuppression-PI3", Edouard Herriot Hospital, Lyon, France.,Joint Research Unit (bioMérieux-Hospices Civils de Lyon-Université Claude Bernard Lyon 1), Edouard Herriot Hospital, Lyon, France
| | - Guillaume Monneret
- Hospices Civils de Lyon, Immunology Laboratory, Edouard Herriot Hospital, Lyon, France.,EA 7426 (Université Claude Bernard Lyon 1) "Pathophysiology of Injury-Induced Immunosuppression-PI3", Edouard Herriot Hospital, Lyon, France.,Joint Research Unit (bioMérieux-Hospices Civils de Lyon-Université Claude Bernard Lyon 1), Edouard Herriot Hospital, Lyon, France
| | - Julien Textoris
- Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Edouard Herriot Hospital, Lyon, France.,EA 7426 (Université Claude Bernard Lyon 1) "Pathophysiology of Injury-Induced Immunosuppression-PI3", Edouard Herriot Hospital, Lyon, France.,Joint Research Unit (bioMérieux-Hospices Civils de Lyon-Université Claude Bernard Lyon 1), Edouard Herriot Hospital, Lyon, France
| | - Fabienne Venet
- Hospices Civils de Lyon, Immunology Laboratory, Edouard Herriot Hospital, Lyon, France. .,EA 7426 (Université Claude Bernard Lyon 1) "Pathophysiology of Injury-Induced Immunosuppression-PI3", Edouard Herriot Hospital, Lyon, France. .,Joint Research Unit (bioMérieux-Hospices Civils de Lyon-Université Claude Bernard Lyon 1), Edouard Herriot Hospital, Lyon, France. .,Laboratoire Commun de Recherche Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, Pavillon P, 5ème étage, 5, place d'Arsonval, 69003, Lyon, France.
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26
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Wong CHY, Jenne CN, Tam PP, Léger C, Venegas A, Ryckborst K, Hill MD, Kubes P. Prolonged Activation of Invariant Natural Killer T Cells and T H2-Skewed Immunity in Stroke Patients. Front Neurol 2017; 8:6. [PMID: 28154551 PMCID: PMC5244395 DOI: 10.3389/fneur.2017.00006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/05/2017] [Indexed: 01/09/2023] Open
Abstract
Background Infection is highly prevalent and contribute significantly to mortality of stroke patients. In addition to the well described robust systemic lymphocytopenia and skewed T helper 2 (TH2)-immunity after stroke, emerging experimental evidence demonstrate that the development of infection poststroke is attributed by the activation of invariant natural killer T (iNKT) cells. In this prospective study, we examined the levels of a broad spectrum of inflammatory mediators, the activation status of iNKT cell in the blood of patients with various degree of stroke severity, and investigate whether these parameters differ in patients who later develop poststroke infections. Methods and results We obtained blood from stroke patients and matching controls to perform flow cytometry and multiplex measurement of inflammatory mediators. Our data suggest a pronounced activation of iNKT cells in stroke patients as compared with matched Healthy and Hospital control patients. The magnitude of iNKT activation is positively correlated with the severity of stroke, supporting the hypothesis that iNKT cells may contribute in the modulation of the host immune response after stroke-associated brain injury. In addition, stroke severity is closely correlated with decreased TH1/TH2 ratio, increased production of interleukin (IL)-10, with infected stroke patients showing exacerbated production of IL-10. Conclusion Stroke triggers a robust and sustained shift in systemic immunity in patients, including specific lymphopenia, robust activation of iNKT cells, systemic production of IL-10, and a prolonged TH2-skewed immunity, all are potential contributors to severe immune suppression seen in patients after stroke. Future studies with large sample size will provide potential causality relationship insights.
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Affiliation(s)
- Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Science, Monash University, Melbourne, VIC, Australia; Department of Physiology and Pharmacology, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Craig N Jenne
- Department of Physiology and Pharmacology, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada; Department of Critical Care, Snyder Institute for Critical Care, University of Calgary, Calgary, AB, Canada
| | - Patrick P Tam
- Department of Critical Care, Snyder Institute for Critical Care, University of Calgary , Calgary, AB , Canada
| | - Caroline Léger
- Department of Critical Care, Snyder Institute for Critical Care, University of Calgary , Calgary, AB , Canada
| | - Andres Venegas
- Stroke Unit, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary , Calgary, AB , Canada
| | - Karla Ryckborst
- Stroke Unit, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary , Calgary, AB , Canada
| | - Michael D Hill
- Stroke Unit, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary , Calgary, AB , Canada
| | - Paul Kubes
- Department of Physiology and Pharmacology, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada; Department of Critical Care, Snyder Institute for Critical Care, University of Calgary, Calgary, AB, Canada
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Girardot T, Mouillaux J, Idealisoa E, Poujol F, Rouget C, Rimmelé T, Monneret G, Textoris J, Venet F. An optimized protocol for adenosine triphosphate quantification in T lymphocytes of lymphopenic patients. J Immunol Methods 2016; 439:59-66. [PMID: 27720850 DOI: 10.1016/j.jim.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/20/2016] [Accepted: 10/05/2016] [Indexed: 01/11/2023]
Abstract
In several clinical contexts, the measurement of ATP concentration in T lymphocytes has been proposed as a biomarker of immune status, predictive of secondary infections. However, the use of such biomarker in lymphopenic patients requires some adaptations in the ATP dosage protocol. We used blood from healthy volunteers to determine the optimal experimental settings. We investigated technical aspects such as the type of anticoagulant for blood sampling, the effect of freeze and thaw cycles, the reagent and sample mixing sequence, and the optimal dilution buffer. We also shortened the incubation time to 8h, and even showed that a 30min incubation may be sufficient. To evaluate the ATP rise upon lymphocyte activation, the optimal dose of stimulant was defined to be 4μg/mL of phytohaemagglutinin. Lastly, we determined that the number of T cells needed for this measurement was as low as 50,000, which is compatible with the existing lymphopenia in clinical settings. This optimized protocol appears ready to be assessed in lymphopenic patients to further investigate the interconnection between T lymphocyte metabolism and impaired phenotype and functions.
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Affiliation(s)
- Thibaut Girardot
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France; Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Hôpital Edouard Herriot, Lyon, France
| | - Julie Mouillaux
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France
| | - Estellie Idealisoa
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France
| | - Fanny Poujol
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France
| | - Christelle Rouget
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France; Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Hôpital Edouard Herriot, Lyon, France
| | - Thomas Rimmelé
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France; Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Hôpital Edouard Herriot, Lyon, France
| | - Guillaume Monneret
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France; Hospices Civils de Lyon, Immunology Laboratory, Hôpital Edouard Herriot, Lyon, France
| | - Julien Textoris
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France; Hospices Civils de Lyon, Anesthesia and Critical Care Medicine Department, Hôpital Edouard Herriot, Lyon, France
| | - Fabienne Venet
- EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) Joint Research Unit "Pathophysiology of Injury-Induced Immunosuppression - PI3", Hôpital Edouard Herriot, Lyon, France; Hospices Civils de Lyon, Immunology Laboratory, Hôpital Edouard Herriot, Lyon, France.
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Ishihara Y, Kimura SI, Akahoshi Y, Harada N, Nakano H, Kameda K, Ugai T, Wada H, Yamasaki R, Kawamura K, Sakamoto K, Ashizawa M, Sato M, Terasako-Saito K, Kikuchi M, Nakasone H, Yamazaki R, Kanda J, Kako S, Tanihara A, Nishida J, Usuki K, Kanda Y. Impact of D-index and L-index on pulmonary infection in induction chemotherapy for acute lymphoblastic leukemia and lymphoblastic lymphoma. ACTA ACUST UNITED AC 2015; 21:19-25. [PMID: 26352559 DOI: 10.1179/1607845415y.0000000051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The D-index and the L-index, calculated as the area over the neutrophil and lymphocyte curves, respectively, reflect both the intensity and duration of cytopenia. We, retrospectively, investigated the impact of these indexes on pulmonary infection (PI) in induction chemotherapy for acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL). METHODS We included 92 patients (ALL 83, LBL 9) from two institutions. We calculated the D-index and cumulative D-index until the development of PI (c-D-index), which enables real-time risk assessment for infection. We also calculated the L-index (35), defined as the area over the lymphocyte curve during lymphopenia (<700/µl) until day 35 and the cumulative-L-index until the development of PI (c-L-index). RESULTS Eight patients developed PI on day 20 (median). Two patients were strongly suspected to have bacterial pneumonia, and the others were suspected to have pulmonary fungal infection. The D-index and the L-index (35) in patients with PI were higher than those in patients without PI (7230 ± 4734 vs. 4519 ± 3416, P = 0.041 and 15 458 ± 5243 vs. 8920 ± 5901, P = 0.018), while the c-D-index and the c-L-index were not significantly different. Although the c-L-index did not have predictive value for PI, c-D-index, when treated as a dichotomous variable with a cutoff value of 5589 as determined by a receiver operating characteristic curve analysis, showed a significant difference between two groups (P = 0.045). This association became clearer when we focused on suspected pulmonary fungal infection. DISCUSSION AND CONCLUSION In induction chemotherapy for ALL/LBL, c-D-index with a cutoff value of 5589 might have predictive value for the development of PI.
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Shao R, Li CS, Fang Y, Zhao L, Hang C. Low B and T lymphocyte attenuator expression on CD4+ T cells in the early stage of sepsis is associated with the severity and mortality of septic patients: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:308. [PMID: 26329820 PMCID: PMC4556404 DOI: 10.1186/s13054-015-1024-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/11/2015] [Indexed: 12/29/2022]
Abstract
Introduction B and T lymphocyte attenuator (BTLA) is an inhibitory receptor, whose primary role in CD4+ T cell is thought to inhibit cytokine production. We explore BTLA expression on CD4+ T cells in healthy controls and septic patients, and assess the correlation of BTLA expression on CD4+ T cells in the early stage of sepsis with the severity and mortality of septic patients in the emergency department (ED). Methods 336 consecutive patients were included in this study. BTLA expression on CD4+ T cells was measured by flow cytometry within 24h of ED admission. Results Our results showed that the percentage of BTLA+/CD4+ T cells was high expression in healthy volunteers and it was statistically reduced in severe sepsis and septic shock compared with healthy controls(all P<0.01). The area under the receiver operating characteristic (AUC) curves of BTLA expression on CD4+ T cells was slightly lower than that of procalcitonin (PCT) and Mortality in Emergency Department Sepsis (MEDS) score. The percentage of BTLA+/CD4+T cells was lower in non-survivors than in survivors (P<0.01), and similar results were obtained when expressed as mean of fluorescence intensities (MFI) (P<0.01). Adjusted logistic regression analysis suggested that the percentage of BTLA+/CD4+ T cells was associated with 28-day mortality in septic patients (odds ratio (OR) = 0.394). Conclusion Our study shows that the percentage of BTLA+/CD4+ T cells was high in healthy volunteers. Furthermore, lower percentage of BTLA+/CD4+ T cells during the early stage of sepsis is associated with the severity and the mortality of septic patients.
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Affiliation(s)
- Rui Shao
- Department of Emergency Medicine, Beijing Chao-yang Hospital, Capitcal Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
| | - Chun-Sheng Li
- Department of Emergency Medicine, Beijing Chao-yang Hospital, Capitcal Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
| | - Yingying Fang
- Department of Emergency Medicine, Beijing Chao-yang Hospital, Capitcal Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
| | - Lianxing Zhao
- Department of Emergency Medicine, Beijing Chao-yang Hospital, Capitcal Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
| | - Chenchen Hang
- Department of Emergency Medicine, Beijing Chao-yang Hospital, Capitcal Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
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Sudarshan M, Feldman LS, St Louis E, Al-Habboubi M, Hassan MME, Fata P, Deckelbaum DL, Razek TS, Khwaja KA. Predictors of mortality and morbidity for acute care surgery patients. J Surg Res 2014; 193:868-73. [PMID: 25439507 DOI: 10.1016/j.jss.2014.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 08/19/2014] [Accepted: 09/04/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay. METHODS Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors. RESULTS A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis. CONCLUSIONS Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.
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Affiliation(s)
- Monisha Sudarshan
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Liane S Feldman
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Etienne St Louis
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Mostafa Al-Habboubi
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | | | - Paola Fata
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Dan Leon Deckelbaum
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Tarek S Razek
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada
| | - Kosar A Khwaja
- Division of General Surgery, Montreal General Hospital, Montreal, Québec, Canada.
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Faddah S, Elwakd M, Aboelenein A, Hussein M. Lymphopenia and systemic lupus erythematosus, a preliminary study: Correlation with clinical manifestations, disease activity and damage indices. EGYPTIAN RHEUMATOLOGIST 2014. [DOI: 10.1016/j.ejr.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cabrera-Perez J, Condotta SA, Badovinac VP, Griffith TS. Impact of sepsis on CD4 T cell immunity. J Leukoc Biol 2014; 96:767-77. [PMID: 24791959 DOI: 10.1189/jlb.5mr0114-067r] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Sepsis remains the primary cause of death from infection in hospital patients, despite improvements in antibiotics and intensive-care practices. Patients who survive severe sepsis can display suppressed immune function, often manifested as an increased susceptibility to (and mortality from) nosocomial infections. Not only is there a significant reduction in the number of various immune cell populations during sepsis, but there is also decreased function in the remaining lymphocytes. Within the immune system, CD4 T cells are important players in the proper development of numerous cellular and humoral immune responses. Despite sufficient clinical evidence of CD4 T cell loss in septic patients of all ages, the impact of sepsis on CD4 T cell responses is not well understood. Recent findings suggest that CD4 T cell impairment is a multipronged problem that results from initial sepsis-induced cell loss. However, the subsequent lymphopenia-induced numerical recovery of the CD4 T cell compartment leads to intrinsic alterations in phenotype and effector function, reduced repertoire diversity, changes in the composition of naive antigen-specific CD4 T cell pools, and changes in the representation of different CD4 T cell subpopulations (e.g., increases in Treg frequency). This review focuses on sepsis-induced alterations within the CD4 T cell compartment that influence the ability of the immune system to control secondary heterologous infections. The understanding of how sepsis affects CD4 T cells through their numerical loss and recovery, as well as function, is important in the development of future treatments designed to restore CD4 T cells to their presepsis state.
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Affiliation(s)
- Javier Cabrera-Perez
- Microbiology, Immunology, and Cancer Biology Graduate Program Medical Scientist Training Program
| | | | - Vladimir P Badovinac
- Department of Pathology and Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Thomas S Griffith
- Microbiology, Immunology, and Cancer Biology Graduate Program Center for Immunology, and Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Minneapolis Veterans Administration Health Care System, Minneapolis, Minnesota, USA; and
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Monneret G, Villars-Méchin A, Demaret J, Foray AP, Venet F. L’interleukine-7 comme thérapeutique immuno-adjuvante dans le traitement du choc septique. Med Sci (Paris) 2014; 30:160-5. [DOI: 10.1051/medsci/20143002013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Absolute lymphocyte count as a predictor of mortality in emergency department patients with paraquat poisoning. PLoS One 2013; 8:e78160. [PMID: 24205140 PMCID: PMC3813447 DOI: 10.1371/journal.pone.0078160] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 09/18/2013] [Indexed: 11/19/2022] Open
Abstract
Background Paraquat (PQ) is a potent, highly toxic and widely used herbicide. The major medical problems associated with PQ are accidental or suicidal ingestion. There are several prognostic markers of PQ poisoning, with the serum PQ concentration considered to be the best indicator of outcome. However, the measurement of such markers is limited in many hospitals. Objective The present study was conducted to investigate the association of absolute lymphocyte count (ALC) and the 30-day mortality rate in patients with PQ poisoning. Methods We performed a retrospective analysis of patients admitted to the emergency department after paraquat poisoning between January 2010 and April 2013. Independent risk factors including ALC for 30-day mortality were determined. The ALC was categorized in quartiles as ≤1700, 1700 to 3200, 3200 to 5000, and >5000. Univariate and multivariate Cox proportional hazard analysis were performed to determine the independent risk factors for mortality. Results A total of 136 patients were included in the study, and the 30-day mortality was 73.5%. ALC was significantly higher in nonsurvivors than in survivors. The highest ALC quartile (ALC>5000; hazard ratio, 2.58; 95% CI, 1.08–6.21) was associated with increased mortality in multivariate analysis. In addition, old age, lower arterial PaCO2, increased peripheral neutrophil count, and high serum levels of creatinine were associated with mortality. Conclusion The absolute lymphocyte count is associated with the 30-day mortality rate in patients with paraquat poisoning.
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Condotta SA, Cabrera-Perez J, Badovinac VP, Griffith TS. T-cell-mediated immunity and the role of TRAIL in sepsis-induced immunosuppression. Crit Rev Immunol 2013; 33:23-40. [PMID: 23510024 DOI: 10.1615/critrevimmunol.2013006721] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sepsis is the leading cause of death in most intensive care units, and the death of septic patients usually does not result from the initial septic event but rather from subsequent nosocomial infections. Patients who survive severe sepsis often display severely compromised immune function. Not only is there significant apoptosis of lymphoid and myeloid cells that depletes critical components of the immune system during sepsis, there is also decreased function of the remaining immune cells. Studies of animals and humans suggest the immune defects that occur during sepsis may be critical to pathogenesis and subsequent mortality. This review focuses on sepsis-induced alterations with the cluster differentiation (CD) 8 T-cell compartment that can affect the control of secondary heterologous infections. Understanding how a septic event directly influences CD8 T-cell populations through apoptotic death and homeostatic proliferation and indirectly by immune-mediated suppression will provide valuable starting points for developing new treatment options.
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Keppel MP, Yang L, Cooper MA. Murine NK cell intrinsic cytokine-induced memory-like responses are maintained following homeostatic proliferation. THE JOURNAL OF IMMUNOLOGY 2013; 190:4754-62. [PMID: 23530145 DOI: 10.4049/jimmunol.1201742] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Several recent studies have demonstrated that innate immune NK cells exhibit memory-like properties with enhanced nonspecific and specific recall responses. Cytokine activation alone of murine NK cells induces the differentiation of memory-like cells that are more likely to produce IFN-γ, a key NK cell cytokine important for activation of the immune response. Using an adoptive cotransfer system, we first show that cytokine-induced memory-like responses are NK intrinsic. However, engraftment of donor NK cells in NK-competent hosts is poor because of homeostatic control mechanisms. Therefore, we used alymphoid Rag- and common γ-chain-deficient mice as recipients and observed homeostatic expansion of cotransferred cytokine-activated and control donor NK cells. Despite proliferation of all cells, NK cells derived from those cells originally activated by cytokines retained an intrinsic enhanced capacity to produce IFN-γ when restimulated in vitro with cytokines or target cells. These NK cell memory-like responses persisted for at least 4 wk in alymphoid hosts and 12 wk in NK-competent hosts. These findings indicate that memory-like NK cells can readily self-renew and maintain enhanced function in a lymphopenic host for at least a month.
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Affiliation(s)
- Molly P Keppel
- Division of Rheumatology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
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Vaduganathan M, Ambrosy AP, Greene SJ, Mentz RJ, Subacius HP, Maggioni AP, Swedberg K, Nodari S, Zannad F, Konstam MA, Butler J, Gheorghiade M. Predictive value of low relative lymphocyte count in patients hospitalized for heart failure with reduced ejection fraction: insights from the EVEREST trial. Circ Heart Fail 2012; 5:750-8. [PMID: 23051949 DOI: 10.1161/circheartfailure.112.970525] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low lymphocyte count has been shown to be an independent prognostic marker in heart failure (HF) in the outpatient setting. Limited data exist regarding whether relative lymphocyte count correlates with postdischarge outcomes in patients hospitalized for HF. METHODS AND RESULTS We performed a post hoc analysis of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial, which randomized 4133 patients hospitalized for worsening HF with an ejection fraction ≤40% within 48 hours of admission to tolvaptan or placebo for a median follow-up of 9.9 months. The primary end points of all-cause mortality and cardiovascular mortality or HF hospitalization were analyzed in patients with available baseline complete blood counts (n=3717). Lymphocyte percentage was analyzed as a continuous variable. Times to events were compared using log-rank tests and multivariable Cox regression models. Patients with low lymphocyte percentage tended to be older and had higher rates of comorbid disease (diabetes mellitus, atrial fibrillation, and renal insufficiency). Low lymphocyte counts were associated with wide QRS duration, high natriuretic peptides, and low ejection fraction, blood pressure, and serum sodium. These patients were less likely to receive evidence-based HF medications. After adjusting for 22 known clinical risk factors, a 10% decrease in lymphocytes was associated with an increased hazard of all-cause mortality (adjusted hazard ratio 1.31 [95% CI: 1.14-1.150], P<0.001) and cardiovascular mortality or HF hospitalization (adjusted hazard ratio 1.14 [95% CI: 1.04-1.25], P=0.007) in the first 100 days postdischarge. Lymphopenia during hospitalization normalizes in majority of patients in the early postdischarge period. CONCLUSIONS Low relative lymphocyte count during hospitalization for HF is an independent predictor of poor outcomes in the early postdischarge period, beyond traditional prognostic indicators.
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Monneret G, Lepape A, Venet F. [Reversing ICU-acquired immunosuppression: an innovative biomarker-guided therapeutic strategy for decreasing sepsis mortality and nosocomial infection rate]. ACTA ACUST UNITED AC 2011; 59:329-33. [PMID: 21981928 DOI: 10.1016/j.patbio.2011.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 02/10/2011] [Indexed: 11/30/2022]
Abstract
Septic syndromes (systemic inflammatory response associated with infection) remain a major although largely under-recognized health care problem and represent the first cause of mortality in intensive care units. Regarding immune response, it is now agreed that sepsis induces an anti-inflammatory process, acting as a negative feedback. This inhibitory mechanism becomes deleterious as nearly all immune functions are rapidly compromised. The magnitude and persistence over time of this immunosuppression is correlated with nosocomial infections and mortality. Decreased HLA-DR expression on monocytes/increased percentage of regulatory T cells are biomarkers identifying patients at risk who could benefit from immunotherapy. This review attempts to integrate these new facts into an up-to-date account of sepsis pathophysiology.
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Affiliation(s)
- G Monneret
- Laboratoire d'Immunologie Cellulaire, Hospices Civils de Lyon, Hôpital E.-Herriot, 5 Place d'Arsonval, 69437 Lyon cedex 03, France.
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Deibener-Kaminsky J, Lesesve JF, Kaminsky P. Leukocyte differential for acute abdominal pain in adults. LABORATORY HEMATOLOGY : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR LABORATORY HEMATOLOGY 2011; 17:1-5. [PMID: 21421538 DOI: 10.1532/lh96.10023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Abdominal pain is a common symptom underlying a variety of disorders with different prognoses. Neutrophilia or lymphopenia have been used as prognostic markers in several stress- or infection-mediated disorders. We studied the clinical relevance of the leukocyte differential in the initial workup of adult patients presenting with abdominal pain. METHODS We reviewed all leukocyte differentials and medical records of 441 consecutive patients admitted for abdominal pain in an emergency department. Patients were matched by age and sex with controls and were assigned to 4 groups: functional disorders (group FUN), infectious medical disorders (group INF) and noninfectious medical disorders (group MED), and surgical disorders (group SUR). Patients of groups INF and SUR were pooled into group INF+SUR to predict severe illness, and this group was compared with others with nonsevere illness. RESULTS All patients exhibited neutrophilia, along with a neutrophil count that increased with illness severity. Lymphopenia, eosinopenia, and basopenia characterized patients of group INF+SUR. Neutrophilia, eosinopenia, and lymphopenia were independent predictors of the most severely affected patients. The association of a neutrophil count >9.0 × 10⁹/L with lymphopenia (<1.4 × 10⁹L) and eosinopenia (<0.04 × 10⁹/L) had a specificity of 94.9% (95% confidence interval, 91.2%-97.1%) for inclusion in group INF+SUR, although with a low sensitivity (27.5%). CONCLUSION Lymphocyte, eosinophil, and neutrophil counts should be considered in medical admissions of adults with abdominal pain. Lymphopenia associated with eosinopenia and significant neutrophilia is highly suggestive of a more severe illness.
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Affiliation(s)
- Joelle Deibener-Kaminsky
- Service de Gériatrie et Médecine Interne, Centre Hospitalier Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre, France
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40
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Bian C, Wu Y, Shi Y, Xu G, Wang J, Xiang M, Weng S, Jiang J, Ma J. Predictive value of the relative lymphocyte count in coronary heart disease. Heart Vessels 2010; 25:469-73. [DOI: 10.1007/s00380-010-0010-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 12/17/2009] [Indexed: 10/19/2022]
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Jariwala SP, Fodeman J, Hudes G, Ahuja K, Rosenstreich D. Functional antibody deficiency in a patient with type I Gaucher disease. J Inherit Metab Dis 2008; 31 Suppl 2:S267-70. [PMID: 18392747 DOI: 10.1007/s10545-008-0824-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 01/17/2008] [Accepted: 01/22/2008] [Indexed: 10/22/2022]
Abstract
Gaucher disease (GD), the most common lysosomal storage disorder, demonstrates an autosomal recessive pattern of inheritance. The genetic defect in GD leads to decreased production of the lysosomal enzyme glucosylceramide hydrolase, thereby resulting in the deposition of glucosylceramide sphingolipids within multiple organ systems. Although the precise mechanisms remain unclear, GD is usually associated with chronic antigenic stimulation and hyperimmunoglobulinaemia. We report a novel case of type I GD coexisting with relatively low serum immunoglobulins, impaired antibody production, and recurrent bacterial infections in a 62-year-old male. The patient had been diagnosed with GD 30 years previously and had subsequently started enzyme replacement therapy. Since being diagnosed with GD, the patient had suffered from repeated episodes of acute bronchitis and a recent severe bout of community-acquired pneumonia that required a lengthy hospitalization. On our initial evaluation, the patient had laboratory testing that demonstrated: decreased serum IgG, IgG2, and IgA levels; reduced absolute CD3(+)/CD4(+), CD3(+)/CD8(+), and lymphocyte counts; low IgG titres to pneumococcal polysaccharide vaccine; and decreased anti-tetanus antibodies. Lymphocyte function analysis demonstrated a normal response to phytohaemagglutinin, and decreased responses to concanavalin A and pokeweed mitogen. Repeat testing after 6 months revealed normal serum immunoglobulin levels and mitogenic responses. Although the explanation for our observed transient hypogammaglobulinaemia remains unclear, this patient's clinical constellation (i.e. repeated infections, hypogammaglobulinaemia and lymphopenia, decreased post-vaccination titres, and impaired responses to some mitogens) shares overlapping features with common variable immunodeficiency (CVID).
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Affiliation(s)
- S P Jariwala
- Albert Einstein/Montefiore Medical Center, 111 East 210th Street, Bronx, New York, NY 10463, USA.
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Abstract
Bacteraemia often carries a poor prognosis despite prompt antibiotic therapy and is associated with late morbidity and mortality that is difficult to explain. Here, we describe perisistent B- and T- cell lymphopenia in a cohort of patients with Gram-positive and Gram-negative bacteraemia. This suggests previously unrecognized mechanisms of subversion of immunity by pathogens and might explain the comorbidity of blood stream infection with bacteria.
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Affiliation(s)
- C A Hawkins
- Department of Clinical Immunology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia.
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Rudiger A, Burckhardt OA, Harpes P, Müller SA, Follath F. The relative lymphocyte count on hospital admission is a risk factor for long-term mortality in patients with acute heart failure. Am J Emerg Med 2006; 24:451-4. [PMID: 16787804 DOI: 10.1016/j.ajem.2005.10.010] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2005] [Revised: 10/07/2005] [Accepted: 10/09/2005] [Indexed: 11/28/2022] Open
Affiliation(s)
- Alain Rudiger
- Bloomsbury Institute of Intensive Care Medicine, Wolfson Institute of Biomedical Research, University College London, WC1E 6BT London, UK, and Department of Internal Medicine, University Hospital Zurich, Switzerland.
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Kao AH, Manzi S, Ramsey-Goldman R. Review of ACR hematologic criteria in systemic lupus erythematosus. Lupus 2005; 13:865-8. [PMID: 15580984 DOI: 10.1191/0961203304lu2025oa] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We have conducted a thorough literature review to evaluate the relative value of the hematologic criterion in making a diagnosis of systemic lupus erythematosus (SLE), its clinical relevance, and its prognostic significance. In the updated 1982 ACR criteria, the presence of one or more of the four elements: 1) hemolytic anemia (with reticulocytosis); 2) leukopenia (<4000/microL on two or more occasions); 3) lymphopenia (< 1500/microL on two or more occasions); or 4) thrombocytopenia (< 100,000/microL in the absence of offending drugs) is now considered as a single hematologic disorder. The sensitivity and specificity of the individual elements of the hematologic criterion range from 18 to 46% and 89 to 99%, respectively. The accuracy of the hematologic criterion requires proper interpretation. For example, many studies reported the presence of anemia that was not clearly defined and likely included anemia from etiologies other than hemolytic anemia, thereby causing an overestimation of the prevalence. In addition, medications such as corticosteroids and cytotoxic agents, and viral infections, can also contribute to a reduction in lymphocyte count. Despite these limitations, the SLICC committee recommends no change in the elements of the hematologic criterion when this criterion is properly interpreted and other causes of cytopenia are excluded.
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Affiliation(s)
- A H Kao
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, PA, USA
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45
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Romano F, Cesana G, Berselli M, Gaia Piacentini M, Caprotti R, Bovo G, Uggeri F. Biological, histological, and clinical impact of preoperative IL-2 administration in radically operable gastric cancer patients. J Surg Oncol 2004; 88:240-7. [PMID: 15565596 DOI: 10.1002/jso.20155] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgery induces lymphocytopenia and this decrease of host defenses, related to interleukin-2 (IL-2) endogenous imbalance during postoperative period could promote the proliferation of possible micrometastases and the implantation of surgically disseminated tumor cells. Moreover, tumor infiltrating lymphocytes (TILs), activated by endogenous IL-2 release, are linked to prognosis in cancer patients. The aim of this randomized study is to assess the biological (peripheral blood cells count, related to the grade of immunosuppression), histological (TILs), and clinical (overall and disease-free survival) impact of preoperative low doses administration of IL-2 in patients with radically operable gastric cancer. METHODS This prospective study enrolled 69 consecutive patients with histologically proven gastric adenocarcinoma who underwent radical surgery from October 1999 to December 2002 (M/F 39/30; mean age 66; range 42-82) who underwent radical surgery from October 1999 to December 2000. Patients were randomized to be treated with surgery alone as controls (35 patients) or surgery plus preoperative treatment with recombinant human IL-2 (34 patients). We considered the total lymphocyte count and lymphocyte subset (CD4, CD4/CD8) during the preoperative period, before IL-2 administration, and on the 14th and 50th day, peritumoral stromal (fibrosis) reaction, neutrophils, lymphocytes, and eosinophils infiltration in tumor histology, and morbidity disease free and overall survival were evaluated. RESULTS Two groups were well matched for type of surgery and extent of disease. All the patients underwent radical surgery plus D2 lymphadenectomy. At baseline, there were no significant differences in total lymphocyte and lymphocyte subsets between groups. The control group showed a significant decrease of total lymphocytes, CD4 cells, and CD4/CD8 ratio at the 14th postoperative day relative to the baseline value. In the control group 65% of patients had a decrease of CD4 under 500 cells/mmc. Instead it has been observed in IL-2 group a significant increase over the control group values of total lymphocytes and CD4 cells (14th total lymphocytes and CD4: IL-2 vs. control P < 0.05). Moreover in this group only 15% patients had CD4 under 500 cells/mmc. This difference, in CD4 count, is significant even at the 50th postoperative day (P = 0.006). IL-2 group showed lower postoperative complications (2/34 vs. 11/35; P < 0.05), and higher lymphocyte/eosinophil infiltration into the tumor (P < 0.0002). Median follow-up was 26 months (range 10-48) and median overall and disease-free survivals were longer, even if not significantly, in the IL-2 group than in the control arm (P = 0.07 and P = 0.06 respectively). CONCLUSIONS This randomized study would suggest that a preoperative immunotherapy with IL-2 is a well-tolerated treatment able to prevent surgery-induced lymphocytopenia. IL-2 seems to neutralize the immunosuppression induced by operation and so to stimulate the host reaction against tumor tissue (lymphocytes/eosinophils infiltration). Furthermore IL-2 seems to have an impact on clinical course reducing morbidity of surgery and ameliorating overall and disease-free survival.
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Affiliation(s)
- Fabrizio Romano
- Department of Surgery, San Gerardo Hospital--II University of Milan--Bicocca, Italy.
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Abstract
The underlying principles of sepsis therapy have remained unchanged for decades. These include: prompt institution of antimicrobial agents aimed at the inciting pathogen, source control directed at removal of the infection nidus whenever possible, and support of organ dysfunction. Despite advances in antibiotics, surgical techniques and organ support technology, the morbidity and mortality from sepsis-related diseases have remained substantially unchanged (30 - 50%). Immunomodulation of the inflammatory cascade has been suggested as a crucial but inadequately addressed element in the treatment of sepsis. The list of potential therapeutic targets has been growing as more and more mediators are identified in the pathogenesis of sepsis. To date, numerous anti-inflammatory agents, found to have favourable effects in animal models of septic shock, have been tested in a number of clinical trials on thousands of patients. In this first of a three part series, we go through some of the background and current strategies in sepsis therapy. In this review, we include the two novel therapies that have shown clear survival benefit in large, randomised, placebo-controlled, multi-centre trials, low-dose steroids and recombinant activated protein C. Also included in this review are studies on antithrombin III, platelet-activating factor antagonists, complement modulators, nitric oxide synthase inhibitors and caspase inhibitors (apoptosis inhibitors).
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Affiliation(s)
- R L Añel
- Section of Critical Care Medicine, Rush-Presbyterian-St. Luke's Medical Center and Cook County Hospital, Rush Medical College, Chicago, Illinois, USA
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Oberholzer C, Oberholzer A, Clare-Salzler M, Moldawer LL. Apoptosis in sepsis: a new target for therapeutic exploration. FASEB J 2001; 15:879-92. [PMID: 11292647 DOI: 10.1096/fj.00-058rev] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The treatment of sepsis and septic shock remains a clinical conundrum, and recent prospective trials with biological response modifiers aimed at the inflammatory response have shown only modest clinical benefit. Recently, interest has shifted toward therapies aimed at reversing the accompanying periods of immune suppression. Studies in experimental animals and critically ill patients have demonstrated that increased apoptosis of lymphoid organs and some parenchymal tissues contributes to this immune suppression, anergy, and organ system dysfunction. During sepsis syndromes, lymphocyte apoptosis can be triggered by the absence of IL-2 or by the release of glucocorticoids, granzymes, or the so-called 'death' cytokines: tumor necrosis factor alpha or Fas ligand. Apoptosis proceeds via auto-activation of cytosolic and/or mitochondrial caspases, which can be influenced by the pro- and anti-apoptotic members of the Bcl-2 family. In experimental animals, not only can treatment with inhibitors of apoptosis prevent lymphoid cell apoptosis; it may also improve outcome. Although clinical trials with anti-apoptotic agents remain distant due in large part to technical difficulties associated with their administration and tissue targeting, inhibition of lymphocyte apoptosis represents an attractive therapeutic target for the septic patient.
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Affiliation(s)
- C Oberholzer
- Departments of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610, USA
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Oberholzer C, Oberholzer A, Clare-Salzler M, Moldawer LL. Apoptosis in sepsis: a new target for therapeutic exploration. FASEB J 2001. [DOI: 10.1096/fsb2fj00058rev] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Caroline Oberholzer
- Departments of Surgery and †Pathology, Immunology and Laboratory Medicine University of Florida College of Medicine Gainesville Florida 32610 USA
| | - Andreas Oberholzer
- Departments of Surgery and †Pathology, Immunology and Laboratory Medicine University of Florida College of Medicine Gainesville Florida 32610 USA
| | - Michael Clare-Salzler
- Departments of Surgery and †Pathology, Immunology and Laboratory Medicine University of Florida College of Medicine Gainesville Florida 32610 USA
| | - Lyle L. Moldawer
- University of Florida College of Medicine Gainesville Florida 32610 USA
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Grzegorzewska A, Leander M. Total Lymphocyte Count during the Course of CAPD Treatment. Perit Dial Int 2000. [DOI: 10.1177/089686080002000517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- A.E. Grzegorzewska
- Department of Nephrology Karol Marcinkowski University of Medical Sciences Poznan, Poland
| | - M. Leander
- Department of Nephrology Karol Marcinkowski University of Medical Sciences Poznan, Poland
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&NA;. Drug-induced lymphopenia: a common but poorly understood event. DRUGS & THERAPY PERSPECTIVES 2000. [DOI: 10.2165/00042310-200016020-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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