Endotoxin Activity Reflects an Increase in Body Temperature in Cirrhotic Patients With Ascites Undergoing Cell-free and Concentrated Ascites Reinfusion Therapy

BACKGROUND

Ascites commonly complicates cirrhosis and is refractory to the vasopressin-2 antagonist tolvaptan and fluid restriction in approximately 60% of patients. We aimed to identify risk factors associated with adverse events following cell-free and concentrated ascites reinfusion therapy (CART) in patients with cirrhosis and ascites.

PATIENTS AND METHODS

We evaluated the efficacy and tolerability to the CART system in 18 patients with decompensated liver cirrhosis and ascites. We determined serum endotoxin activity using endotoxin activity (EA) assays and serum and ascitic fluid concentrations of interleukin 6 (IL6) and tumor necrosis factor-α (TNFα) before and after the CART procedures.

RESULTS

Body weight and waist circumference significantly decreased after CART (both p<0.001). Body temperature (BT) increased significantly at an average rate of 1.1°C during CART (p<0.001). The change in BT was correlated with EA and not interleukin IL6 or TNFα. The rise in BT was positively correlated with serum EA levels at baseline. The increase in BT was significantly higher in the group with high EA (≥0.37) than in the low EAA group (<0.37) (p=0.02). TNFα and serum IL6 levels in ascites were significantly increased during CART (both p<0.001). However, no significant differences in the EA, serum TNFα or IL6 levels were found in ascitic fluid before and after the CART procedures.

CONCLUSION

Although this discovery warrants further study, EA assay can indicate an increase in BT during effective CART in patients with cirrhosis and ascites.

Endotoxemia in Critically Ill Patients with COVID-19

Introduction

Mechanism(s) mediating critical illness in coronavirus disease 2019 (COVID-19) remain unclear. Previous reports demonstrate the existence of endotoxemia in viral infections without superimposed gram-negative bacteremia, but the rate and severity of endotoxemia in critically ill patients with COVID-19 requires further exploration.

Materials and Methods

This is a single-center cross-sectional study of 92 intensive care unit patients diagnosed with COVID-19 pneumonia. Endotoxin activity (EA) was measured in patients that met the following criteria: (1) age ≥18 years and (2) multi-organ dysfunction score >9 from March 24, 2020, to June 20, 2020.

Results

A total of 32 patients met the inclusion/exclusion criteria for measurement of EA. The median age of the study cohort was 60 years with a majority male (21/32, 65%) with hypertension (50%). A significant proportion of the patients exhibited either elevated EA in the intermediate range (0.40–0.59 EA units) (10/32, 31%) or high range (≥0.60 EA units) (14/32, 44%) or were nonresponders (NRs, low neutrophil response) to EA (6/32, 19%), with the presence of gram-negative bacteremia only in 2/32 (6%) patients. Low EA was reported in 2/32 patients. NRs (5/6, 83%) and patients with high EA (7/14, 50%) exhibited higher acute kidney injury (AKI) as compared to patients with low/intermediate EA level (1/12, 8.3%).

Discussion/Conclusion

Elevated EA was observed in a large majority of critically ill patients with COVID-19 and multi-organ dysfunction despite a low incidence of concurrent gram-negative bacteremia. While we observed that elevated EA and nonresponsiveness to EA were associated with AKI in critically ill patients with COVID-19, these findings require further validation in larger longitudinal cohorts.

The wind changed direction and the big river still flows: from EUPHRATES to TIGRIS

The overall result of the randomized controlled double-blinded trial for polymyxin B-immobilized fiber column on septic shock (EUPHRATES trial) was disappointing. However, post hoc analysis showed benefits for patients with certain Endotoxin Activity Assay (EAA) levels. Thus, the study will be repeated, and the data will be added to the former trial. Using a precision medicine approach, eligibility criteria have been modified in TIGRIS to include patients with MODS score > 9 and EAA levels between 0.60 and 0.89. We are currently feeling the change in the wind as the rivers continue to flow towards PMX therapy for endotoxemic septic shock.

IL-7 and procalcitonin are useful biomarkers in the comprehensive evaluation of the severity of acute cholangitis

BACKGROUND

The incidence of biliary tract infection (BTI), especially healthcare-associated cholangitis, is increasing. However, there are few reports concerning biomarkers of acute cholangitis. We therefore performed an exhaustive investigation of several biomarkers.

METHODS

We retrospectively measured 11 cytokines, six chemokines and procalcitonin (PCT), and endotoxin activity assay (EAA) values (IRB: 110512019) of 61 samples with acute cholangitis.

RESULT

The 28-day mortality rate was 9.8%. The levels of most cytokines and chemokines were significantly correlated with each other. A low IL-7 level was found to predict blood culture positivity. Low IL-7 level was also found to predict disseminated intravascular coagulation. Low IL-7 levels and a high PCT level were found to be predictors of severe cholangitis. The 28-day mortality in the group of patients with an IL-7 level of ≤6.0 and a PCT level of >0.5 was 18.2%. It was significantly higher than in the other group.

CONCLUSION

The combined use of IL-7 and PCT may be useful for evaluating severe acute cholangitis; these results may suggest that severe acute cholangitis is affected by immunosuppressive changes.

Is polymyxin B-immobilized fiber column ineffective for septic shock? A discussion on the press release for EUPHRATES trial

The efficacy of polymyxin B-immobilized (PMX) fiber column on septic shock is still under debate. Recently, the result from "Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock (EUPHRATES)" trial has been announced as a press release. According to that report, less than a 5% mortality difference was recognized in the "per protocol population" (n = 244, 31.9 vs. 36.9%) and the decrease was not statistically significant. However, among the patients in refractory shock with a multiple organ dysfunction score of more than 9 and an EAA between 0.6 and 0.9, a 10.7% reduction in 28-day mortality was recognized (p = 0.0474) when they received two sessions of hemoperfusion using the PMX fiber column. Since this favorable effect was obtained from "post hoc" analysis, further study is expected.

Novel Insights into the Direct Removal of Endotoxin by Polymyxin B Hemoperfusion

AIM

To demonstrate the capacity of polymyxin B-direct hemoperfusion (PMX-DHP) column Toraymyxin® 20R (PMX-20R) in removing endotoxin (LPS) from perfused blood, serum and plasma.

METHODS

Endotoxin-spiked bovine serum was perfused in PMX-20R as per the recommended performance testing protocol. Samples were taken at various time points to assess the amount of endotoxin removed during a 4-h session. In another set of experiments, FITC-labelled LPS (FITC-LPS) was spiked into a pool of human whole blood, followed by perfusion with the spiked blood for 2 h in order to allow FITC-LPS to bind PMX-20R. The amount of LPS was extracted from the columns and the amount of specifically bound LPS was determined by fluorometry.

RESULTS

PMX-20R columns perfused with bovine serum had an average binding rate of 88%, equivalent to approximately 12 µg of LPS. When PMX-20R was perfused with human whole blood, the columns bound an average of 20 µg of FITC-LPS.

CONCLUSION

PMX-20R can bind LPS in all the biological fluids tested. The calculated binding capacity of 12-20 µg LPS suggests that in septic cases where endotoxin is present in the circulation, PMX-20R is able to adsorb clinically significant levels of endotoxin.

Severity and prognostic assessment of the endotoxin activity assay in biliary tract infection

BACKGROUND

Acute cholangitis and cholecystitis (AC) often progress to severe septic conditions. We evaluated the endotoxin activity assay (EAA) for assessment and prediction of the severity of AC.

METHODS

We retrospectively reviewed 98 patients diagnosed with AC. We divided them into low (<0.4) and high (≥0.4) groups based on EAA values.

RESULTS

Endotoxin levels showed no correlation with EAA values. Serum C-reactive protein (8.57 vs. 5.23 mg/dl, P = 0.02), procalcitonin (2.45 vs. 0.48 ng/ml, P = 0.004), and the positive culture rate of blood (50% vs. 15%, P < 0.001) were significantly higher in the high group than in the low group. Platelet counts were significantly lower in the high group than in the low group (23.9 vs. 13.5 10(4) /ml, P = 0.004). The ratio of patients with a Japanese Association for Acute Medicine disseminated intravascular coagulation score ≥4 (32% vs. 14%, P = 0.032) was significantly higher in the high group than in the low group. There was a significantly higher percentage of patients with a severe grade of AC in the high group than patients with a mild or moderate grade (32% vs. 15%, P = 0.05).

CONCLUSIONS

Endotoxin activity assay is useful for assessment and early prediction of septic conditions due to AC.

Impact of hepatic clearance of endotoxin using endotoxin activity assay

BACKGROUND

Endotoxin (Et) in the portal vein blood is processed by the hepatic reticuloendothelial system, and therefore, it is possible that the hepatic clearance of Et may become a biological index for liver function. In this study, Et levels of preoperative peripheral and portal vein blood at the time of liver transplantation (LT) were measured in order to study the meaning.

METHODS

The study population comprised 19 patients in whom pediatric living donor LT was performed. In the preoperative peripheral and the portal vein blood at the time of LT, we measured Et activity (EA) by the Et activity assay (EAA) and the Limulus amebocyte lysate (LAL) method.

RESULTS

The preoperative peripheral vein blood showed a low EA in all cases. In the EA of the peripheral and the portal vein blood, the latter showed a significantly high level (p = 0.049). With the LAL method, 5.3% (2/38) of patients were positive for Et.

CONCLUSIONS

The EAA is considered to be superior to the LAL method for the detection of Et, even in low endotoxinemia, and is also capable of elucidating the Et kinetics by accurately reflecting hepatic clearance.