Addition of platelet-lymphocyte ratio to risk factors to improve the early prediction of acute kidney injury and mortality in critically ill neonates

BACKGROUND

To determine whether early neutrophil, lymphocyte, and platelet ratio (NLPR), neutrophillymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR), calculated based on easily available parameters in complete blood count, are associated with the development of acute kidney injury (AKI) and mortality during neonatal intensive care unit (NICU) stay, and to evaluate whether these ratios could act as a predictor of AKI and mortality in neonates.

METHODS

The pooled data of 442 critically ill neonates from our previously published prospective observational studies of urinary biomarkers were analyzed. Complete blood count (CBC) was measured on NICU admission. The clinical outcomes included AKI developed during the first 7 days after admission and NICU mortality.

RESULTS

Of the neonates, 49 developed AKI and 35 died. The association of the PLR, but not NLPR and NLR, with AKI and mortality remained significant after adjustment for potential confounders including birth weight and illness severity as assessed by the score for neonatal acute physiology (SNAP). The area under the curve (AUC) of the PLR for predicting AKI and mortality was 0.62 (P=0.008) and 0.63 (P=0.010), respectively, with additional predictive value when combined with other perinatal risk factors. The combination of PLR with birth weight, SNAP, and serum creatinine (SCr) had an AUC of 0.78 (P<0.001) in predicting AKI, and its combination with birth weight and SNAP had an AUC of 0.79 (P<0.001) in predicting mortality.

CONCLUSIONS

Low PLR on admission is associated with increased risk for AKI and NICU mortality. Although the PLR alone is not predictive of AKI and mortally, it adds predictive value to other risk factors for AKI prediction in critically ill neonates.

Prediction of urinary dickkopf-3 for AKI, sepsis-associated AKI, and PICU mortality in children

BACKGROUND

Preoperative urinary dickkopf-3 (DKK3) is proposed as an early biomarker for the prediction of acute kidney injury (AKI) in patients undergoing cardiac surgery. We explored the clinical utility of urinary DKK3 for the early predictive value for AKI, sepsis-associated AKI (SA-AKI), and pediatric intensive care unit (PICU) mortality in critically ill children.

METHODS

Urine samples were collected during the first 24 h after admission for measurement of DKK3. AKI diagnosis was based on serum creatinine and urine output using the KDIGO criteria. SA-AKI was defined as AKI that occurred in children who met the sepsis criteria in accordance with the surviving sepsis campaign international guidelines for children.

RESULTS

Of the 420 children, 73 developed AKI, including 24 with SA-AKI, and 30 died during the PICU stay. The urinary DKK3 level was significantly associated with AKI, SA-AKI, and PICU mortality, even after adjustment for confounders. The area under the receiver operating characteristic curve of urinary DKK3 for the discrimination of AKI, SA-AKI, and PICU mortality was 0.70, 0.80, and 0.78, respectively.

CONCLUSION

Urinary DKK3 was independently associated with an increased risk for AKI, SA-AKI, and PICU mortality and may be predictive of the aforementioned issues in critically ill children.

IMPACT

Urinary dickkopf-3 (DKK3) has been identified as a preoperative biomarker for the prediction of acute kidney injury (AKI) following cardiac surgery or coronary angiography in adult patients. However, little is known about the clinical utility of urinary DKK3 in pediatric cohorts. This study demonstrated that urinary DKK3 is capable of early predicting AKI and pediatric intensive care unit (PICU) mortality and discriminating sepsis-associated AKI (SA-AKI) from other types of AKI. Urinary DKK3 may be an early biomarker for predicting AKI, SA-AKI, and PICU mortality in critically ill children.

The outcome of acute kidney injury substages based on urinary cystatin C in critically ill children

BACKGROUND

The concept of acute kidney injury (AKI) substages has been recommended to better phenotype AKI and identify high-risk patient groups and therefore improve the diagnostic accuracy of AKI. However, there remains a gap between the recommendation and the clinical application. The study aimed to explore the incidence of AKI substages based on a sensitive AKI biomarker of urinary cystatin C (uCysC), and to determine whether AKI substages were relevant with respect to outcome in critically ill children.

RESULTS

The multicenter cohort study enrolled 793 children in pediatric intensive care unit (PICU) of four tertiary hospitals in China. Children were classified as non-AKI, sub-AKI and AKI substages A and B according to uCysC level at PICU admission. Sub-AKI was defined by admission uCysC level ≥ 1.26 mg/g uCr in children not meeting the KDIGO criteria of AKI. In children who fulfilled KDIGO criteria, those with uCysC < 1.26 was defined as AKI substage A, and with ≥ 1.26 defined as AKI substage B. The associations of AKI substages with 30-day PICU mortality were assessed. 15.6% (124/793) of patients met the definition of sub-AKI. Of 180 (22.7%) patients with AKI, 90 (50%) had uCysC-positive AKI substage B and were more likely to have classical AKI stage 3, compared to substage A. Compared to non-AKI, sub-AKI and AKI substages A and B were risk factors significantly associated with mortality, and the association of sub-AKI (adjusted hazard ratio HR = 2.42) and AKI substage B (adjusted HR = 2.83) with mortality remained significant after adjustment for confounders. Moreover, AKI substage B had increased risks of death as compared with sub-AKI (HR = 3.10) and AKI substage A (HR = 3.19).

CONCLUSIONS

Sub-AKI defined/based on uCysC occurred in 20.2% of patients without AKI and was associated with a risk of death close to patients with AKI substage A. Urinary CysC-positive AKI substage B occurred in 50% of AKI patients and was more likely to have classical AKI stage 3 and was associated with the highest risk of mortality.

Comparison of diagnostic criteria for acute kidney injury in critically ill children: a multicenter cohort study

Background

Substantial interstudy heterogeneity exists in defining acute kidney injury (AKI) and baseline serum creatinine (SCr). This study assessed AKI incidence and its association with pediatric intensive care unit (PICU) mortality under different AKI and baseline SCr definitions to determine the preferable approach for diagnosing pediatric AKI.

Methods

In this multicenter prospective observational cohort study, AKI was defined and staged according to the Kidney Disease: Improving Global Outcome (KDIGO), modified KDIGO, and pediatric reference change value optimized for AKI (pROCK) definitions. The baseline SCr was calculated based on the Schwartz formula or estimated as the upper normative value (NormsMax), admission SCr (AdmSCr) and modified AdmSCr. The impacts of different AKI definitions and baseline SCr estimation methods on AKI incidence, severity distribution and AKI outcome were evaluated.

Results

Different AKI definitions and baseline SCr estimates led to differences in AKI incidence, from 6.8 to 25.7%; patients with AKI across all definitions had higher PICU mortality ranged from 19.0 to 35.4%. A higher AKI incidence (25.7%) but lower mortality (19.0%) was observed based on the Schwartz according to the KDIGO definition, which however was overcome by modified KDIGO (AKI incidence: 16.3%, PICU mortality: 26.1%). Furthermore, for the modified KDIGO, the consistencies of AKI stages between different baseline SCr estimation methods were all strong with the concordance rates > 90.0% and weighted kappa values > 0.8, and PICU mortality increased pursuant to staging based on the Schwartz. When the NormsMax was used, the KDIGO and modified KDIGO led to an identical AKI incidence (13.6%), but PICU mortality did not differ among AKI stages. For the pROCK, PICU mortality did not increase pursuant to staging and AKI stage 3 was not associated with mortality after adjustment for confounders.

Conclusions

The AKI incidence and staging vary depending on the definition and baseline SCr estimation method used. The modified KDIGO definition based on the Schwartz method leads AKI to be highly relevant to PICU mortality, suggesting that it may be the preferable approach for diagnosing AKI in critically ill children and provides promise for improving clinicians’ ability to diagnose pediatric AKI.

Prediction of acute kidney injury, sepsis and mortality in children with urinary CXCL10

BACKGROUND

To determine the associations of urinary CXC motif chemokine 10 (uCXCL10) with AKI, sepsis and pediatric intensive care unit (PICU) mortality in critically ill children, as well as its predictive value for the aforementioned issues.

METHODS

Urinary CXCL10 levels were serially measured in 342 critically ill children during the first week after PICU admission. AKI diagnosis was based on the criteria of KDIGO. Sepsis was diagnosed according to the surviving sepsis campaign's international guidelines for children.

RESULTS

Fifty-two (15.2%) children developed AKI, 132 (38.6%) were diagnosed with sepsis, and 30 (12.3%) died during the PICU stay. Both the initial and peak values of uCXCL10 remained independently associated with AKI, sepsis, septic AKI and PICU mortality. The AUCs of the initial uCXCL10 for predicting AKI, sepsis, septic AKI and PICU mortality were 0.63 (0.53-0.72), 0.62 (0.56-0.68), 0.75 (0.64-0.87) and 0.77 (0.68-0.86), respectively. The AUCs for prediction by using peak uCXCL10 were as follows: AKI 0.65 (0.56-0.75), sepsis 0.63 (0.57-0.69), septic AKI 0.76 (0.65-0.87) and PICU mortality 0.84 (0.76-0.91).

CONCLUSIONS

Urinary CXCL10 is independently associated with AKI and sepsis and may be a potential indicator of septic AKI and PICU mortality in critically ill children.

IMPACT

Urinary CXC motif chemokine 10 (uCXCL10), as an inflammatory mediator, has been proposed to be a biomarker for AKI in a specific setting. AKI biomarkers are often susceptible to confounding factors, limiting their utility as a specific biomarker, especially in heterogeneous population. This study revealed that uCXCL10 levels are independently associated with increased risk for AKI, sepsis, septic AKI and PICU mortality. A higher uCXCL10 may be predictive of septic AKI and PICU mortality in critically ill children.

The study of functional connectivity of attention cognitive impairment in children with nocturnal enuresis

We aimed to explore the brain functional connectivity mechanism of attention cognitive impairment in children with nocturnal enuresis (NE). Children with NE often show attention cognitive deficit, but its brain mechanism remains unclear. Most previous studies have only focused on a single brain region, without involving the association among brain regions. In this study, 26 NE and 26 normal children were selected. Functional magnetic resonance imaging (fMRI) and integrated visual and auditory continuous performance test (IVA-CPT) were performed. The 12 key brain regions of the dorsal attention network (DAN), default mode network (DMN), and ventral attention network (VAN) were selected as areas of interest, and 66 groups of functional connectivity (FC) were analyzed among these 12 brain regions. The correlation between FC and IVA-CPT in the two groups was analyzed. The FC values showed that the groups with significant differences between NE and normal children were lFEF-aMPFC, rFEF-lIFG, rFEF-rIPS, and lAG-VFC (P<0.05), and the FC value of lAG-VFC was positively correlated with the Full-Scale Attention Quotient (FAQ). Our results showed that attention deficit in children with NE was associated with all three networks and was relative to the FC among the three attention networks. DAN was the brain network most related to attention cognition in children with NE, and most of the brain regions with abnormal connectivity in NE were related to the prefrontal lobe. The lAG was also an important brain region in attention impairment in NE.

In PICU acute kidney injury stage 3 or mortality is associated with early excretion of urinary renin

BACKGROUND

Urinary renin is proposed to be a novel prognostic biomarker of acute kidney injury (AKI) in adults. The intention of our study was to evaluate the early predictive value of urinary renin for AKI and pediatric intensive care unit (PICU) mortality in critically ill children.

METHODS

The first available urine sample during the first 24 h after admission was collected upon PICU admission for the measurement of renin using ELISA. Urinary renin concentrations were corrected for urinary creatinine (urinary renin-to-creatinine ratio, uRenCR). AKI was defined based on KDIGO criteria.

RESULTS

Of the 207 children, 22 developed AKI, including 6 with stage 1, 6 with stage 2, and 10 with stage 3, and 14 died during PICU stay. There was a significant difference in uRenCR between non-AKI children and those with AKI stage 3 (P = 0.001), but not with AKI stage 1 or 2. The uRenCR remained associated with AKI stage 3 and PICU mortality after adjustment for potential confounders. The area under the receiver operating characteristic curve of uRenCR for discrimination of AKI stage 3 was 0.805, and PICU mortality was 0.801.

CONCLUSIONS

Urinary renin was associated with the increased risk for AKI stage 3 and PICU mortality in critically ill children.

IMPACT

Urinary renin is proposed to be a novel prognostic biomarker of AKI in adult patients. There are some differences between children and adults in physiological and pathophysiological characteristics. This study demonstrated that urinary renin was associated with the increased risk for AKI stage 3 and PICU mortality in critically ill children. Accurate identification of patients with severe renal injury or at high risk for mortality early in the disease course could augment the efficacy of available interventions and improve patient outcomes.

Derivation and validation of urinary TIMP-1 for the prediction of acute kidney injury and mortality in critically ill children

Background

Acute kidney injury (AKI) is associated with high morbidity and mortality. Multiple urinary biomarkers have been identified to be associated with the prediction of AKI and outcomes. However, the accuracy of these urinary biomarkers for AKI and associated outcomes has not been clearly defined, especially in heterogeneous populations. The aims of the study were to compare the ability of 10 existing or potential urinary biomarkers to predict AKI and pediatric intensive care unit (PICU) mortality and validate urinary tissue inhibitor of metalloproteinases-1 (uTIMP-1) as a better biomarker for early prediction in heterogeneous critically ill children.

Methods

A derivation-validation approach with separate critically ill cohorts was designed. We first conducted a prospective cohort study to determine the ability of 10 urinary biomarkers serially measured in 123 children during the first 7 days of PICU stay to predict AKI and PICU mortality (derivation study) and further validated the better biomarker of uTIMP-1 in a separate cohort of 357 critically ill children (validation study). AKI diagnosis was based on KDIGO classification with serum creatinine and urine output. PICU mortality was defined as all-cause mortality.

Results

In the derivation cohort, 17 of 123 (13.8%) children developed AKI stage 3 or died during the PICU stay, and both the initial and peak uTIMP-1 displayed the highest AUCs of 0.87 (0.79–0.94) and 0.90 (0.84–0.96), respectively, for predicting AKI stage 3 or death. In the validation cohort, 78 of 357 (21.8%) developed AKI during the first week after admission, and 38 (10.6%) died during the PICU stay. The initial uTIMP-1 level was validated to be independently associated with AKI (AOR = 2.88, 95% CI 1.97–4.21), severe AKI (AOR = 2.62, 95% CI 1.78–3.88), AKI stage 3 (AOR = 2.94, 95% CI 1.84–4.68) and PICU mortality (AOR = 1.92, 95% CI 1.11–3.30) after adjustment for potential confounders. The predictive values of uTIMP-1 for AKI, severe AKI, AKI stage 3 and PICU mortality were 0.80 (0.74–0.86), 0.83 (0.77–0.89), 0.84 (0.77–0.92) and 0.83 (0.76–0.89), respectively.

Conclusions

Urinary TIMP-1 levels have been identified and validated to be independently associated with AKI and PICU mortality in independent prospective cohorts and may be an early potential indicator of AKI and PICU mortality in critically ill children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03302-0.

Sepsis Inflammation Impairs the Generation of Functional Dendritic Cells by Targeting Their Progenitors

Background

Sepsis is a complex systemic immune dysfunction syndrome induced by infection. Sepsis has a high mortality rate, with most patients dying due to systemic organ failure or secondary infection. Dendritic cells (DCs) are professional antigen-presenting cells. Upon infection with microbes, DCs are activated to induce adaptive immune responses for controlling infection. DC generation and function are impaired during sepsis; however, the underlying mechanisms remain largely unknown.

Methods

Peripheral blood samples from sepsis patients were collected to examine DC subsets, DC progenitors, and apoptosis of DCs by flow cytometer. In vitro induction of DCs from hematopoietic stem/progenitor cells were established and a variety of sepsis-associated inflammatory mediators [e.g., interferon-gamma (IFN-γ), interleukin-1beta (IL-1β), tumor necrosis factor-alpha (TNF-α) and granulocyte-colony stimulating factor (G-CSF)] and Lipopolysaccharide (LPS) were determined for the impact on DC generation and function in vitro.

Results

Our results demonstrate that sepsis-induced systemic inflammation impairs the capacity of hematopoietic stem and progenitor cells (HSPCs) to produce DCs, including conventional DCs (cDCs) and plasmacytoid DCs (pDCs). We investigated peripheral blood (PB) samples from 34 pediatric patients on days 1 to 7 following diagnosis. Compared to healthy donors (n = 18), the sepsis patients exhibited a significantly fewer percentage and number of pDCs and cDCs, and a lower expression of antigen presenting molecule HLD-DR and co-stimulatory molecules (e.g., CD86) on the surface of DCs. This sepsis-induced DC impairment was associated with significantly increased apoptotic death of DCs and marked decreases of progenitor cells that give rise to DCs. Furthermore, we observed that among the tested sepsis-associated cytokines (e.g., IFN-γ, IL-1β, TNF-α, and G-CSF), G-CSF and IFN-γ impaired DC development from cultured HSPCs. G-CSF also markedly decreased the expression of HLA-DR on HSPC-derived DCs and their cytokine production, including IL-12 and IFN-β.

Conclusions

Collectively, these findings indicate that sepsis impairs the survival of functional DCs and their development from HSPCs. Strategies for improving DC reconstitution following sepsis may restore DC progenitors and their associated function.

Early clinical predictors for the prognosis of invasive pneumococcal disease

Background

Risk factors related to mortality due to invasive pneumococcal disease (IPD) have been unveiled previously, but early clinical manifestations of IPD based on prognosis remain uncovered.

Methods

The demographic characteristics, clinical features, serotype, antibiotic susceptibility, and outcomes of 97 hospitalized children with laboratory-confirmed IPD from Suzhou, China, were collected and analyzed retrospectively.

Results

The median age was 0.69 (0.49–1.55) years in the non-survivor group compared with 2.39 (0.90–3.81) years in the survivor group. The mortality of 97 children with laboratory-confirmed IPD was 17.5% (17/97), and 53.6% of them were aged less than 2 years. Pathogens were mainly from the blood and cerebrospinal fluid, and sepsis was the most frequent type. Statistically significant differences were found in hyperpyrexia, vomiting, anorexia, lethargy, poor perfusion of extremities, Hb level, and Plt count between the nonsurvival and survival groups. Further, the multivariate regression analysis showed that early signs, including hyperpyrexia, vomiting, anorexia, lethargy, and poor perfusion of extremities, were independent risk factors for the in-hospital mortality of children with laboratory-confirmed IPD. The mortality was also associated with antimicrobial sensitivity in pneumococcal isolates. The microbes in 1/17 (5.9%) children who were prescribed an antibiotic showed antimicrobial sensitivity in the nonsurvival group, compared with 21/80 (26.3%) children who survived. The most common serotypes identified were 6B (35.3%, 6/17), 14 (23.5%, 4/17), 19F (23.5%, 4/17), 19A (5.9%, 1/17), 23F (5.9%, 1/17), and 20 (5.9%, 1/17) in the nonsurvival group. The coverage of IPD serotypes of the 7-valent pneumococcal conjugate vaccine (PCV7) was 88.2% (15/17), while that of the 13-valent S. pneumoniae vaccine (PCV13) was 94.1% (16/17) of the coverage in the nonsurvival group.

Conclusions

Recurrent hyperpyrexia, vomiting, anorexia, lethargy, and poor perfusion of extremities in the early stage were independent predictors for the in-hospital mortality of children with laboratory-confirmed IPD. Appropriate use of antibiotics and PCV immunization were the keys to improve the outcome of IPD.

The effectiveness of urinary TIMP-2 and IGFBP-7 in predicting acute kidney injury in critically ill neonates

BACKGROUD

Urinary tissue inhibitor of metalloproteinase-2 (TIMP-2), insulin-like growth factor binding protein-7 (IGFBP-7) and the combination of TIMP-2 and IGFBP-7 ([TIMP-2]•[IGFBP7]) are proposed to be predictive biomarkers for acute kidney injury (AKI). The intention of our study was to determine whether there is any significant predictive value of these biomarkers for the occurrence of AKI and severe AKI in critically ill neonates.

METHODS

Urinary samples were serially collected in 237 neonates during neonatal intensive care unit (NICU) stay for measurements of TIMP-2 and IGFBP-7 in this prospective study. AKI diagnosis was based on KDIGO classification without urine output or serum creatinine >1.2 mg/dL.

RESULTS

Twenty neonates developed AKI, including 11 with KDIGO stage 1, defined as mild AKI, and 9 with stages 2 and 3, defined as severe AKI. Urinary IGFBP-7 and [TIMP-2]•[IGFBP7] remained associated with AKI after adjustment for gestational age, gender and illness severity. Urinary [TIMP-2]•[IGFBP7] achieved an AUC of 0.71 (P = 0.034) and displayed a sensitivity of 88.9% and a specificity of 50.9% for discriminating severe AKI at the optimal cut-off value of 0.045.

CONCLUSION

The combination of TIMP-2 and IGFBP-7 had independent discriminative value for severe AKI in critically ill neonates.

Long noncoding RNA and messenger RNA abnormalities in pediatric sepsis: a preliminary study

Background

Sepsis represents a complex disease with dysregulated inflammatory response and high mortality rate. Long noncoding RNAs (lncRNAs) have been reported to play regulatory roles in a variety of biological processes. However, studies evaluating the function of lncRNAs in pediatric sepsis are scarce, and current knowledge of the role of lncRNAs in pediatric sepsis is still limited. The present study explored the expression patterns of both lncRNAs and mRNAs between pediatric sepsis patients and healthy controls based on a comprehensive microarray analysis.

Methods

LncRNA and mRNA microarray was used to detect the expression of lncRNAs and mRNAs in the septic and control groups. Aberrantly expressed mRNAs and lncRNAs identified were further interpreted by enrichment analysis, receiver operating characteristic (ROC) curve analysis, co-expression network analysis, and quantitative real-time PCR (qPCR).

Results

A total of 1488 differetially expressed lncRNAs and 1460 differentially expressed mRNAs were identified. A co-expression network of the identified lncRNAs and mRNAs was constructed. In this network, lncRNA lnc-RP11-1220 K2.2.1–7 is correlated with mRNA CXCR1 and CLEC4D; lncRNA lnc-ANXA3–2 is correlated with mRNA CLEC4D; lncRNA lnc-TRAPPC5–1 is correlated with mRNA DYSF and HLX; lncRNA lnc-ZNF638–1 is correlated with mRNA DYSF and HLX. Significantly different expressions between pediatric sepsis patients and controls were validated by qPCR for the 4 lncRNAs and 4 co-expressed mRNAs, validating the microarray results.

Conclusions

Our study contributes to a comprehensive understading of the involvment of lncRNAs and mRNAs in pediatric sepsis, which may guide subsequent experimental research. Furthermore, our study may also provide potential candidate lncRNAs and mRNAs for the diagnosis and treatment of pediatric sepsis.

Association Between Furosemide Exposure and Clinical Outcomes in a Retrospective Cohort of Critically Ill Children

Furosemide is commonly prescribed in critically ill patients to increase the urine output and prevent fluid overload (FO) and acute kidney injury (AKI), but not supported by conclusive evidence. There remain conflicting findings on whether furosemide associates with AKI and adverse outcomes. Information on the impact of furosemide on adverse outcomes in a general population of pediatric intensive care unit (PICU) is limited. The aim of the cohort study was to investigate the associations of furosemide with AKI and clinical outcomes in critically ill children. Study Design: We retrospectively reviewed a cohort of 456 critically ill children consecutively admitted to PICU from January to December 2016. The exposure of interest was the use of furosemide in the first week after admission. FO was defined as ≥5% of daily fluid accumulation, and mean FO was considered significant when mean daily fluid accumulation during the first week was ≥5%. The primary outcomes were AKI in the first week after admission and mortality during PICU stay. AKI diagnosis was based on Kidney Disease: Improving Global Outcomes criteria with both serum creatinine and urine output. Results: Furosemide exposure occurred in 43.4% of all patients (n = 456) and 49.3% of those who developed FO (n = 150) in the first week after admission. Patients who were exposed to furosemide had significantly less degree of mean daily fluid accumulation than those who were not (1.10 [-0.33 to 2.61%] vs. 2.00 [0.54-3.70%], P < 0.001). There was no difference in the occurrence of AKI between patients who did and did not receive furosemide (22 of 198 [11.1%] vs. 36 of 258 [14.0%], P = 0.397). The mortality rate was 15.4% (70 of 456), and death occurred more frequently among patients who received furosemide than among those who did not (21.7 vs. 10.5%, P = 0.002). Furosemide exposure was associated with increased odds for mortality in a multivariate logistic regression model adjusted for body weight, gender, illness severity assessed by PRISM III score, the presence of mean FO, and AKI stage [adjusted odds ratio (AOR) 1.95; 95%CI, 1.08-3.52; P = 0.026]. Conclusion: Exposure to furosemide might be associated with increased risk for mortality, but not AKI, in critically ill children.

Prognostic Significance of CIP2A in Esophagogastric Junction Adenocarcinoma: A Study of 65 Patients and a Meta-Analysis

Background

The expression of the cancerous inhibitor protein phosphatase 2A (CIP2A) appears to be predictive of the prognosis of various solid tumors. However, the association between this protein and the risk of esophagogastric junction adenocarcinoma (EGJA) remains unclear. We investigated CIP2A expression and its clinical significance in EGJA and conducted a meta-analysis to explore the relationship between CIP2A and the prognosis of patients with solid tumors.

Methods

Immunohistochemistry (IHC) was performed to detect the expression of CIP2A in EGJA. Kaplan-Meier estimation, Cox analysis, and ROC curves were performed to analyze the survival of patients and the prognostic factors. In the meta-analysis, we searched relevant publications in several widely used databases and used 15 studies (2348 patients).

Results

IHC demonstrated that CIP2A was elevated in EGJA and correlated with poor survival as an independent indicator. It could forecast the survival more precisely when combined with the grade, which is another independent prognosis marker of EGJA. Meta-analysis demonstrated that the associations between the expression of CIP2A and the prognosis were detected for overall survival (HR = 1.98, 95%CI = 1.69‐2.32), disease-specific survival (HR = 1.72, 95%CI = 1.50‐1.97), and time to tumor progression (pooled HR = 1.95, 95%CI = 1.56‐2.43).

Conclusion

High expression of CIP2A was a poor indicator of the prognosis of EGJA, and CIP2A may be a new biomarker for the diagnosis and treatment of EGJA. The meta-analysis suggested that CIP2A expression can be a predictive marker of overall survival, disease-specific survival, and time to tumor progression in patients with solid tumors.

Urinary Nephrin as a Biomarker of Glomerular Maturation and Injury Is Associated with Acute Kidney Injury and Mortality in Critically Ill Neonates

BACKGROUND

Nephrin is a key component of the slit diaphragm of the glomerular podocyte, and increased urinary nephrin level may reflect glomerular injury.

OBJECTIVES

To determine whether urinary nephrin is a useful biomarker of glomerular maturation and injury and whether it is associated with acute kidney injury (AKI) and neonatal intensive care unit (NICU) mortality in critically ill neonates.

METHODS

Urinary samples were serially collected in 234 neonates during NICU stay for measurements of nephrin, cystatin C (CysC), and albumin. AKI diagnosis was based on neonatal Kidney Disease: Improving Global Outcome (KDIGO) criteria.

RESULTS

Of the neonates, 26 developed AKI and 24 died during NICU stay. The independent contributors to the initial urinary nephrin level obtained on the first 24 h admitted to NICU were gestational age (p = 0.004) and initial urinary CysC level (p < 0.001). Both initial (p = 0.037) and peak (p = 0.039) urinary nephrin were significantly associated with AKI, even after controlling for significant covariates, and had an area under the receiver-operating characteristic curve (AUC) of 0.71 and 0.70, respectively, for predicting AKI. At the optimal cutoff value of 0.375 μg/mg urinary creatinine, the initial urinary nephrin displayed sensitivity of 61.5% and specificity of 76.9% for predicting AKI. The AUCs for initial and peak urinary nephrin to predict NICU mortality were 0.81 and 0.83, respectively.

CONCLUSIONS

Urinary nephrin, which may decrease with increasing glomerular maturity, is significantly associated with increased risk for AKI and NICU mortality even after adjustment for potential confounders. A higher level of urinary nephrin may be independently predictive of AKI and NICU mortality in critically ill neonates.

Subclinical acute kidney injury is associated with adverse outcomes in critically ill neonates and children

Background

Research on acute kidney injury (AKI) has focused on identifying early biomarkers. However, whether AKI could be diagnosed in the absence of the classic signs of clinical AKI and whether the condition of subclinical AKI, identified by damage or functional biomarkers in the absence of oliguria or increased serum creatinine (sCr) levels, is clinically significant remains to be elucidated in critically ill children. The aims of the study were to investigate the associations between urinary cystatin C (uCysC) levels and AKI and mortality and to determine whether uCysC-positive subclinical AKI is associated with adverse outcomes in critically ill neonates and children.

Methods

In this prospective cohort study, uCysC levels were serially measured during the first week after intensive care unit (ICU) admission in a heterogeneous group of patients (n = 510) presenting to a tertiary neonatal and pediatric ICU. The diagnosis of neonatal AKI that developed during the first week after admission was based on neonatal KDIGO criteria or sCr >1.5 mg/dL, and pediatric AKI was based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The term “uCysC(−)” or “uCysC(+)”, indicating the absence or presence of tubular injury, was defined by the optimal peak uCysC cutoff value for predicting ICU mortality.

Results

The initial and peak uCysC levels were significantly associated with AKI and mortality, and had an area under the receiver operating characteristic curve of 0.76 and 0.81, respectively, for predicting mortality. At the optimal cutoff value of 1260 ng/mg uCr, the peak uCysC displayed sensitivity of 79.2% and specificity of 72.3% for predicting mortality. Among all patients, 130 (25.5%) developed uCysC(+)/AKI(−) status during the first week after admission. The adjusted odds ratio for patients with uCysC(+)/AKI(−) status in association with an increased risk of mortality compared with that for patients with uCysC(−)/AKI(−) was 9.34 (P < 0.001). Patients with uCysC(+)/AKI(−) spent 2.8 times as long in the ICU as those with uCysC(−)/AKI(−) (P < 0.001).

Conclusions

Both initial and peak uCysC levels are associated with AKI and mortality and are independently predictive of mortality in critically ill neonates and children. Subclinical AKI may occur without detectable loss of kidney function, and uCysC-positive subclinical AKI is associated with worse clinical outcomes in this population.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2193-8) contains supplementary material, which is available to authorized users.

KPT-330, a potent and selective CRM1 inhibitor, exhibits anti-inflammation effects and protection against sepsis

Sepsis, a systemic inflammatory response caused by infection or injury, is still one of the most important causes of death in clinical patients. The ongoing search for the pathogenesis of sepsis and novel therapeutic methods are highly urgent. In this study, we hypothesized that KPT330, a potent and specific small molecule inhibitor of CRM1, could reduce inflammation and attenuate the severity of sepsis. In LPS-induced sepsis model in vivo, administration of KPT330 increased survival rate and ameliorated LPS-induced lung injury, with suppressed levels of TNF-α, IL-6 and HMGB1 in the circulation and decreased macrophage and PMN subpopulations in peritoneal cavity. In vitro investigations showed that KPT330 dose-dependently inhibited LPS-triggered proinflammatory cytokines production including TNF-α, IL-6 and HMGB1 in macrophages. Furthermore, KPT330 treatment significantly suppressed TNF-α and IL-6 mRNA expression and inhibited HMGB1 necleocytoplasmic translocation by inhibiting CRM1 distribution. Moreover, the mechanism analysis demonstrated that KPT330 exerted anti-inflammation effects by inhibiting the production of pro-inflammatory cytokines through suppressing activation of NF-κB and p38 signaling. Thus, pharmacologic stimulation of KPT330 may present a promising therapeutic strategy for sepsis.

Serum and urine FGF23 and IGFBP-7 for the prediction of acute kidney injury in critically ill children

Background

Fibroblast growth factor 23 (FGF23) and insulin-like growth factor binding protein 7 (IGFBP-7) are suggested to be biomarkers for predicting acute kidney injury (AKI). We compared them with proposed AKI biomarker of cystatin C (CysC), and aimed (1) to examine whether concentrations of these biomarkers vary with age, body weight, illness severity assessed by pediatric risk of mortality III score, and kidney function assessed by estimated glomerular filtration rate (eGFR), (2) to determine the association between these biomarkers and AKI, and (3) to evaluate whether these biomarkers could serve as early independent predictors of AKI in critically ill children.

Methods

This prospective single center study included 144 critically ill patients admitted to the pediatric intensive care unit (PICU) regardless of diagnosis. Serum and spot urine samples were collected during the first 24 h after PICU admission. AKI was diagnosed based on the AKI network (AKIN) criteria.

Results

Twenty-one patients developed AKI within 120 h of sample collection, including 11 with severe AKI defined as AKIN stages 2 and 3. Serum FGF23 levels were independently associated with eGFR after adjustment in a multivariate linear analysis (P < 0.001). Urinary IGFBP-7 (Adjusted OR = 2.94 per 1000 ng/mg increase, P = 0.035), serum CysC (Adjusted OR = 5.28, P = 0.005), and urinary CysC (Adjusted OR = 1.13 per 1000 ng/mg increase, P = 0.022) remained significantly associated with severe AKI after adjustment for body weight and illness severity, respectively. Urinary IGFBP-7 level was predictive of severe AKI and achieved the AUC of 0.79 (P = 0.001), but was not better than serum (AUC = 0.89, P < 0.001) and urinary (AUC = 0.88, P < 0.001) CysC in predicting severe AKI.

Conclusions

Serum FGF23 levels were inversely related to measures of eGFR. In contrast to serum and urinary FGF23 which are not associated with AKI in a general and heterogeneous PICU population, an increased urinary IGFBP-7 level was independently associated with the increased risk of severe AKI diagnosed within the next 5 days after sampling, but not superior to serum or urinary CysC in predicting severe AKI in critically ill children.

Antagonism of Integrin CD11b Affords Protection against Endotoxin Shock and Polymicrobial Sepsis via Attenuation of HMGB1 Nucleocytoplasmic Translocation and Extracellular Release

High mobility group box 1 (HMGB1), a chromatin-binding nuclear protein, plays a critical role in sepsis by acting as a key "late-phase" inflammatory mediator. Integrin CD11b is essential for inflammatory cell activation and migration, thus mediating inflammatory responses. However, it is unclear whether CD11b participates in the development of sepsis. In this study, we report that CD11b contributes to LPS-induced endotoxin shock and microbial sepsis, as antagonism of CD11b with the CD11b blocking Ab or CD11b inhibitor Gu-4 protects mice against LPS- and microbial sepsis-related lethality, which is associated with significantly diminished serum HMGB1 levels. Consistent with this, CD11b-deficient mice were more resistant to microbial sepsis with a much lower serum HMGB1 level compared with wild-type mice. Pharmacological blockage and genetic knockdown/knockout of CD11b in murine macrophages hampered LPS-stimulated HMGB1 nucleocytoplasmic translocation and extracellular release. Furthermore, silencing CD11b interrupted the interaction of HMGB1 with either a nuclear export factor chromosome region maintenance 1 or classical protein kinase C and inhibited classical protein kinase C-induced HMGB1 phosphorylation, the potential underlying mechanism(s) responsible for CD11b blockage-induced suppression of HMGB1 nucleocytoplasmic translocation and subsequent extracellular release. Thus, our results highlight that CD11b contributes to the development of sepsis, predominantly by facilitating nucleocytoplasmic translocation and active release of HMGB1.

Identification of potential transcriptomic markers in developing pediatric sepsis: a weighted gene co-expression network analysis and a case-control validation study

Background

Sepsis represents a complex disease with the dysregulated inflammatory response and high mortality rate. The goal of this study was to identify potential transcriptomic markers in developing pediatric sepsis by a co-expression module analysis of the transcriptomic dataset.

Methods

Using the R software and Bioconductor packages, we performed a weighted gene co-expression network analysis to identify co-expression modules significantly associated with pediatric sepsis. Functional interpretation (gene ontology and pathway analysis) and enrichment analysis with known transcription factors and microRNAs of the identified candidate modules were then performed. In modules significantly associated with sepsis, the intramodular analysis was further performed and “hub genes” were identified and validated by quantitative real-time PCR (qPCR) in this study.

Results

15 co-expression modules in total were detected, and four modules (“midnight blue”, “cyan”, “brown”, and “tan”) were most significantly associated with pediatric sepsis and suggested as potential sepsis-associated modules. Gene ontology analysis and pathway analysis revealed that these four modules strongly associated with immune response. Three of the four sepsis-associated modules were also enriched with known transcription factors (false discovery rate-adjusted P < 0.05). Hub genes were identified in each of the four modules. Four of the identified hub genes (MYB proto-oncogene like 1, killer cell lectin like receptor G1, stomatin, and membrane spanning 4-domains A4A) were further validated to be differentially expressed between septic children and controls by qPCR.

Conclusions

Four pediatric sepsis-associated co-expression modules were identified in this study. qPCR results suggest that hub genes in these modules are potential transcriptomic markers for pediatric sepsis diagnosis. These results provide novel insights into the pathogenesis of pediatric sepsis and promote the generation of diagnostic gene sets.

Electronic supplementary material

The online version of this article (10.1186/s12967-017-1364-8) contains supplementary material, which is available to authorized users.

Identification of potential transcriptomic markers in developing asthma: An integrative analysis of gene expression profiles

The goal of this study was to identify potential transcriptomic markers in developing asthma by an integrative analysis of multiple public microarray data sets. Using the R software and bioconductor packages, we performed a statistical analysis to identify differentially expressed (DE) genes in asthma, and further performed functional interpretation (enrichment analysis and co-expression network construction) and classification quality evaluation of the DE genes identified. 3 microarray datasets (192 cases and 91 controls in total) were collected for this analysis. 62 DE genes were identified in asthma, among which 43 genes were up-regulated and 19 genes were down-regulated. The up-regulated gene with the highest Log2 Fold Change (LFC) was CLCA1 (LFC=2.81). The down-regulated gene with the highest absolute LFC was BPIFA1 (LFC=-1.45). Enrichment analysis revealed that those DE genes strongly associated with proteolysis, retina homeostasis, humoral immune response, and salivary secretion. A support vector machine classifier (asthma versus healthy control) was also trained based on DE genes. In conclusion, the consistently DE genes identified in this study are suggested as candidate transcriptomic markers for asthma diagnosis, and provide novel insights into the pathogenesis of asthma.

Melatonin alleviates brain and peripheral tissue edema in a neonatal rat model of hypoxic-ischemic brain damage: the involvement of edema related proteins

Background

Previous studies have indicated edema may be involved in the pathophysiology following hypoxic-ischemic encephalopathy (HIE), and melatonin may exhibit neuro-protection against brain insults. However, little is known regarding the mechanisms that involve the protective effects of melatonin in the brain and peripheral tissues after HIE. The present study aimed to examine the effects of melatonin on multiple organs, and the expression of edema related proteins in a neonatal rat model of hypoxic-ischemic brain damage (HIBD).

Methods

One hundred ninety-two neonatal rats were randomly divided into three subgroups that underwent a sham surgery or HIBD. After the HIBD or sham-injury, the rats received an intraperitoneal injection of melatonin or an equal volume vehicle, respectively. We investigated the effects of melatonin on brain, kidney, and colon edema via histological examination and the expression of edema related proteins, including AQP-4, ZO-1 and occludin, via qPCR and western blot.

Results

Our data indicated (1) Melatonin reduced the histological injury in the brain and peripheral organs induced by HIBD as assessed via H-E staining and transmission electron microscopy. (2) Melatonin alleviated the HIBD-induced cerebral edema characterized by increased brain water content. (3) HIBD induced significant changes of edema related proteins, such as AQP-4, ZO-1 and occludin, and these changes were partially reversed by melatonin treatment.

Conclusions

These findings provide substantial evidence that melatonin treatment has protective effects on the brain and peripheral organs after HIBD, and the edema related proteins, AQP4, ZO-1, and occludin, may indirectly contribute tothe mechanism of the edema protection by melatonin.