Distinct Patterns of Blood Cytokines Beyond a Cytokine Storm Predict Mortality in COVID-19

Background

COVID-19 comprises several severity stages ranging from oligosymptomatic disease to multi-organ failure and fatal outcomes. The mechanisms why COVID-19 is a mild disease in some patients and progresses to a severe multi-organ and often fatal disease with respiratory failure are not known. Biomarkers that predict the course of disease are urgently needed. The aim of this study was to evaluate a large spectrum of established laboratory measurements.

Patients and Methods

Patients from the prospective PULMPOHOM and CORSAAR studies were recruited and comprised 35 patients with COVID-19, 23 with conventional pneumonia, and 28 control patients undergoing elective non-pulmonary surgery. Venous blood was used to measure the serum concentrations of 79 proteins by Luminex multiplex immunoassay technology. Distribution of biomarkers between groups and association with disease severity and outcomes were analyzed.

Results

The biomarker profiles between the three groups differed significantly with elevation of specific proteins specific for the respective conditions. Several biomarkers correlated significantly with disease severity and death. Uniform manifold approximation and projection (UMAP) analysis revealed a significant separation of the three disease groups and separated between survivors and deceased patients. Different models were developed to predict mortality based on the baseline measurements of several protein markers. A score combining IL-1ra, IL-8, IL-10, MCP-1, SCF and CA-9 was associated with significantly higher mortality (AUC 0.929).

Discussion

Several newly identified blood markers were significantly increased in patients with severe COVID-19 (AAT, EN-RAGE, myoglobin, SAP, TIMP-1, vWF, decorin) or in patients that died (IL-1ra, IL-8, IL-10, MCP-1, SCF, CA-9). The use of established assay technologies allows for rapid translation into clinical practice.

A TruCulture Whole Blood Assay to Evaluate Annual Flu Vaccine Recall Responses

Evaluation of vaccine efficacy to protect against future infection remains a challenge. One of the difficulties lies in developing an antigen specific recall assay that can be applied across clinical sites. TruCulture is a whole blood collection and culture system that was designed for ex vivo/in vitro evaluation of immune responses for clinical trials. This abstract demonstrates a TruCulture tube that is highly effective in eliciting recall responses against Influenza A hemagglutinin (HA) proteins after the annual flu vaccine. Whole blood from 10 healthy donors were collected at 2 days pre- and 14 days post-vaccination (Afluria, Sequiris). Blood was collected in TruCulture tubes containing 5mg recombinant HA antigens (Immune Technology Corporation). After incubation at 37°C for 48 hours, the supernatants were collected and analyzed for 13 analytes by OptiMAP and 47 analytes by TruCulture MAP (Myriad RBM). Several analytes (such as IFNγ, IL-1β, IL-3, IL-4, IL-6, IL-10, IL-12, IL-17, and IL-23) demonstrated an increase at 14 days after the flu vaccination compared to samples taken prior to vaccination. This increase is specific to the recombinant HA antigens from flu strains included in the flu vaccine administered. The increase in these analytes were either not observed or at significantly reduced levels when the recall response was conducted using recombinant HA antigens from flu strains not included in the vaccine administered. TruCulture preloaded with HA antigens can be a valuable tool to evaluate human immune responses to the annual flu vaccine and indicates that a similar strategy using antigen-specific TruCulture tubes can be developed for the evaluation of any novel vaccine.

Large-scale Analyses of Disease Biomarkers and Apremilast Pharmacodynamic Effects

Finding biomarkers that provide shared link between disease severity, drug-induced pharmacodynamic effects and response status in human trials can provide number of values for patient benefits: elucidating current therapeutic mechanism-of-action, and, back-translating to fast-track development of next-generation therapeutics. Both opportunities are predicated on proactive generation of human molecular profiles that capture longitudinal trajectories before and after pharmacological intervention. Here, we present the largest plasma proteomic biomarker dataset available to-date and the corresponding analyses from placebo-controlled Phase III clinical trials of the phosphodiesterase type 4 inhibitor apremilast in psoriasis (PSOR), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) from 526 subjects overall. Using approximately 150 plasma analytes tracked across three time points, we identified IL-17A and KLK-7 as biomarkers for disease severity and apremilast pharmacodynamic effect in psoriasis patients. Combined decline rate of KLK-7, PEDF, MDC and ANGPTL4 by Week 16 represented biomarkers for the responder subgroup, shedding insights into therapeutic mechanisms. In ankylosing spondylitis patients, IL-6 and LRG-1 were identified as biomarkers with concordance to disease severity. Apremilast-induced LRG-1 increase was consistent with the overall lack of efficacy in ankylosing spondylitis. Taken together, these findings expanded the mechanistic knowledge base of apremilast and provided translational foundations to accelerate future efforts including compound differentiation, combination, and repurposing.

Combining TruCulture and OptiMAP to Profile Human Immune Immunity

TruCulture® is a whole blood collection and culture system designed for use at clinical sites. TruCulture outperforms traditional peripheral blood mononuclear cell (PBMC) culturing methods, with improved reproducibility and higher levels of stimulation (Duffy et. al. Clinical Immunology 2017). The TruCulture proprietary culture medium ensures minimal non-specific immune activation, delivering a steady baseline and decreased variation during stimulating parameters. OptiMAP is a multiplex immunoassay panel that measures 13 cytokines of the major immune response pathways (TH1, TH2, TH17, and monocyte/macrophage). Using TruCulture and OptiMAP, we analyzed healthy donor whole blood responses to common stimulants: T cell activators, TLR agonists, and superantigens. The subjects ranged from 24 to 70 years old and consisted of 48% males and 52% females. The results indicated that healthy donors responded similarly to stimulation with anti-CD3/CD28 and Staphylococcal enterotoxin type B (SEB) in production of T cell cytokines (IFN-γ, IL-2, and IL-17). Response to SEB is positively correlated to the monocyte population in whole blood. T cell responses to SEB and CytoStim (an antibody based alternative to SEB) are similar in production of IFN-γ and IL-17, but CytoStim had a reduced stimulation of IL-2. All healthy donors responded to a TLR-4 agonist (LPS) by producing high levels of TNF-α, IL- 6, and IL-1β. LPS stimulated production of IFN-γ was similar to SEB, most likely due to bystander activation. The TLR-7 agonist (gardiquimod, GDQ) stimulated IL-10 levels at a level comparable to LPS. These data illustrate the utility of combining TruCulture and OptiMAP to investigate human immune stimulation pathways for clinical research.

Evaluation of Temporal Changes in Urine-based Metabolomic and Kidney Injury Markers to Detect Compound Induced Acute Kidney Tubular Toxicity in Beagle Dogs

Urinary protein biomarkers and metabolomic markers have been leveraged to detect acute Drug Induced Kidney Injury (DIKI) in rats; however, the utility of these indicators to enable early detection of DIKI in canine models has not been well documented. Therefore, we evaluated temporal changes in biomarkers and metabolites in urine from male and female beagle dogs. Gentamicin- induced kidney lesions in male dogs were characterized by moderate to severe tubular epithelial cell degeneration/necrosis, epithelial cell regeneration and dilation; and a unique urinebased metabolomic fingerprint. These metabolite changes included time and treatment-dependent increases in lactate, taurine, glucose, lactate, alanine, and citrate as well as 9 other known metabolites. As early as 3 days post dose, gentamicin induced increases in urinary albumin, clusterin, neutrophil gelatinase associated protein (NGAL) and total protein concentrations. Urinary albumin, clusterin, and NGAL showed earlier and more robust elevations than traditional kidney safety biomarkers, blood urea nitrogen and serum creatinine. Elevations in urinary kidney injury molecule 1 (KIM-1) were less reliable for detection of gentamicin nephrotoxicity in dogs based on values generated utilizing multiple first-generation, canine-specific KIM-1 immunoassays. The metabolic fingerprint was further evaluated in male and female dogs that received Compound A which induced slightly reversible renal tubular alterations characterized as degeneration/necrosis and concurrent significant increases in urinary taurine amongst other markers. These data support further investigations to demonstrate the value of urinary metabolites, albumin, clusterin, NGAL and taurine as promising markers to enable early detection of DIKI in dogs.

Plasma biomarkers in carbon monoxide poisoning

OBJECTIVES

The severity of acute carbon monoxide (CO) poisoning is often based on non-specific clinical criteria because there are no reliable laboratory markers. We hypothesized that a pattern of plasma protein values might objectively discern CO poisoning severity. This was a pilot study to evaluate protein profiles in plasma samples collected from patients at the time of initial hospital evaluation. The goal was to assess whether any values differed from age- and sex-matched controls using a commercially available plasma screening package.

METHODS

Frozen samples from 63 suspected CO poisoning patients categorized based on clinical signs, symptoms, and blood carboxyhemoglobin level were analyzed along with 42 age- and sex-matched controls using Luminex-based technology to determine the concentration of 180 proteins.

RESULTS

Significant differences from control values were found for 99 proteins in at least one of five CO poisoning groups. A complex pattern of elevations in acute phase reactants and proteins associated with inflammatory responses including chemokines/cytokines and interleukins, growth factors, hormones, and an array of auto-antibodies was found. Fourteen protein values were significantly different from control in all CO groups, including patients with nominal carboxyhemoglobin elevations and relatively brief intervals of exposure.

CONCLUSIONS

The data demonstrate the complexity of CO pathophysiology and support a view that exposure causes acute inflammatory events in humans. This pilot study has insufficient power to discern reliable differences among patients who develop neurological sequelae but future trials are warranted to determine whether plasma profiles predict mortality and morbidity risks of CO poisoning.

What is the future of wildlife rabies control in Europe?

Over the last fifteen years or so, classical rabies in terrestrial wildlife has been eliminated from large areas of Western Europe. Over the next few years, terrestrial rabies is likely to occur only east of a line from the Baltic Sea to the Black Sea; the overall aim is to eliminate terrestrial rabies from the whole European Union. Elimination of rabies from the less rich countries of Eastern Europe, and the protection of Europe against a resurgence of rabies in the longer term requires modifications to existing OIE and WHO strategies. Here we discuss the options available to eliminate rabies in wildlife while taking account of financial cost, and how to maintain a 'cordon sanitaire' along the eastern boundary of the EU in order to protect the rabies-free areas from rabies incursion. Minimising financial costs at the national level is obviously essential, considering the competing priorities for development and health. This could be achieved either by increasing external funding (for example by the EU) and/or by changing the currently agreed vaccination strategy to reduce costs; any such change must not substantially reduce the chances of rabies elimination. A cordon sanitaire might be placed outside the economic area of the EU, to protect the whole of the EU, or it might be placed within the easternmost countries to ensure logistical consistency of vaccination. Policy must also anticipate an emergency due to rabies breaking out in a previously freed region. Strategic planning may be complicated by the increasing range and abundance of the raccoon dog, an introduced species that is increasingly important as a host for fox rabies. It is argued here that models help to evaluate altemative strategies, exploring options for optimising costs by minimising bait density and frequency or by reducing the vaccination area.

The strength of 70%: revision of a standard threshold of rabies control

The success of oral vaccination of foxes (ORV) conceptually is linked to the immunisation of host individuals beyond the herd immunity threshold. However, field evidence and theoretical analysis suggests that mathematically derived values of herd immunity might be rather conservative and, moreover, restrict the adjustment of standard ORV protocols in the case of limited resources. Here, the relationship between baiting effort, duration of ORV programmes and rabies elimination is analysed. An individual-based, spatially explicit model for the control of rabies in foxes that incorporates the important peculiarities of the vaccination process, i.e. the spatial distribution of infected hosts, irregular home-range use, heterogeneous bait coverage etc., is applied. Using multiple repetitions of simulated ORV programmes, the control outcome is analysed in a chance-like fashion overriding the yes-or-no prediction inherent in the herd immunity concept. It is shown why control planning must not only aim at particular immunisation levels but, simultaneously, has to specify the allowed time horizon of control success. It is demonstrated that planning a higher chance of elimination increases necessary effort non-linearly. It was found that low immunisation results (i.e. 50%) still provide a reasonable chance of control success. The potential changes in ORV planning and evaluation allowing for the integration of risk concepts in strategies are discussed.

Scenario-analysis evaluating semergency strategies after rabies re-introduction

Now that the elimination of rabies in Western Europe is nearly complete, thanks to the oral mass vaccination of foxes (ORV) which took place over the last 25 years, it is necessary to prepare for emergency situations due to the re-introduction of rabies from still infected areas. Such emergency strategies should aim at minimizing the risk of falling back to large-scale vaccination, in a cost efficient manner. An approved spatially-explicit simulation model of spread and control of rabies was adapted to the new problem of re-introduction of rabies into free areas. The logic of the model and options for local emergency vaccination (for example ring-vaccination vs. compact area treatment or heavily concentrated vs. thin extended control areas) were determined. Based on systematic simulation experiments the performance of strategic options was assessed. Key issues such as public health risk (i.e. number of rabies cases), failure risk (i.e. disease breakout from the control area), and budgetary risk (i.e. duration of the emergency program) were simultaneously considered. The results obtained reveal efficiency relations that contradict a priori derived management suggestions.

Multiplex Analysis of Intracellular Signaling Pathways in Lymphoid Cells by Microbead Suspension Arrays

Phosphorylation analysis of signaling proteins is key for examining intracellular signaling pathways. Conventional biochemical approaches, e.g. immunoprecipitation, Western blot, and ELISA, have played a major role in elucidation of individual signaling events. However, these methods are laborious, time-consuming, and difficult to adapt for high throughput analysis. A multiplex approach to measure phosphorylation state of multiple signaling proteins simultaneously would significantly enhance the efficiency and scope of signaling pathway analysis for mechanistic studies and clinical application. This report describes a novel multiplex microbead suspension array approach to examine phosphoproteomic profiles in lymphoid cells. In the Jurkat T-cell leukemia line, the multiplex assay enabled targeted investigation of phosphorylation kinetics of signal transduction from receptor proximal events (tyrosine phosphoproteins CD3, Lck, Zap-70, and linker for T-cell activation) to cytosolic events (serine/threonine phosphoproteins Erk and Akt) to transcription factors (serine/threonine phosphorylated Rsk, cyclic AMP-response element-binding protein, and STAT3). To broaden the application of the multiplex analysis, signaling pathways were also studied in B-cell lymphoid tumor lines that included chronic lymphocytic leukemia lines. In these cell lines, multiplex suspension array enabled phosphoproteomic analysis of signaling cascade mediated by Syk, a homolog of Zap-70. Results obtained by multiplex analysis were confirmed by immunoprecipitation and Western blot methods. The examples of T-cell and B-cell signaling pathway analyses in this report demonstrate the utility of the multiplex suspension arrays to investigate phosphorylation dynamics and kinetics of several signaling proteins simultaneously in signal transduction pathways.

Nephrogenic adenoma of the bladder in renal transplant and non-renal transplant patients: a review of 22 cases

OBJECTIVES

To review diagnoses of nephrogenic adenoma and in particular to evaluate its association with transitional cell carcinoma (TCC) of the bladder and its relationship to renal transplantation.

METHODS

A retrospective review of 22 cases of nephrogenic adenoma (NA) diagnosed between 1989 and 1996 was conducted, 7 of which were in renal transplant patients. Data collected in each case included demographic details, predisposing factors, associated urologic pathology, mode of presentation, cystoscopic finding, management, and follow-up.

RESULTS

There was a 3:1 predominance of men. Mean follow-up was 21.4 months (range 3 to 50). Six patients (27%) had one or more recurrences. All 22 patients had some form of previous bladder insult or surgery, including recurrent urine infections, urinary tract instrumentation, placement of ureteric stents, cystodiathermy, and open bladder surgery. Six cases were associated with TCC of the bladder, of which 4 had NA lesions directly over or close to the site of previous fulguration. In 4 patients, there was a temporal relationship between the administration of intravesical doxorubicin hydrochloride or bacille Calmette-Guérin (BCG) and the onset of NA lesions. One case was associated with an inverted papilloma that had not been described before. In 7 renal transplant cases, 3 lesions were found contralateral to the side of the ureterovesical anastomosis. All 22 cases were benign histologically, but one NA was found within a low-grade baldder TCC. Nineteen cases were followed up regularly with no malignant transformation. Three patients were lost to follow-up.

CONCLUSIONS

This study has demonstrated an association between NA and bladder cancer. Patients with NA, especially those treated with intravesical chemotherapy or BCG, should have regular cystoscopies. Fulguration or transurethral resection appear to be sufficient treatment. No renal transplant patients had vesical TCC and NA simultaneously. Neither immunosuppression nor ureterovesical anastomosis appeared to be a significant predisposing factor in the transplant patients.