Neutrophil Gelatinase-Associated Lipocalin Measured on Clinical Laboratory Platforms for the Prediction of Acute Kidney Injury and the Associated Need for Dialysis Therapy: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction.

STUDY DESIGN

Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines.

SETTING & STUDY POPULATIONS

Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms.

SELECTION CRITERIA FOR STUDIES

PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI.

DATA EXTRACTION

Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis.

ANALYTICAL APPROACH

Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses.

RESULTS

We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively.

LIMITATIONS

Practice variability in initiation of dialysis. Imperfect harmonization of data across studies.

CONCLUSIONS

Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.

Endothelial progenitor cells mobilization after maximal exercise according to heart failure severity

BACKGROUND

Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Patients with CHF are characterized by impaired vasodilation and inflammation of the vascular endothelium. They also have low levels of endothelial progenitor cells (EPCs). EPCs are bone marrow derived cells involved in endothelium regeneration, homeostasis, and neovascularization. Exercise has been shown to improve vasodilation and stimulate the mobilization of EPCs in healthy people and patients with cardiovascular comorbidities. However, the effects of exercise on EPCs in different stages of CHF remain under investigation.

AIM

To evaluate the effect of a symptom-limited maximal cardiopulmonary exercise testing (CPET) on EPCs in CHF patients of different severity.

METHODS

Forty-nine consecutive patients (41 males) with stable CHF [mean age (years): 56 ± 10, ejection fraction (EF, %): 32 ± 8, peak oxygen uptake (VO₂, mL/kg/min): 18.1 ± 4.4] underwent a CPET on a cycle ergometer. Venous blood was sampled before and after CPET. Five circulating endothelial populations were quantified by flow cytometry: Three subgroups of EPCs [CD34⁺/CD45^-/CD133⁺, CD34⁺/CD45^-/CD133⁺/VEGFR₂ and CD34⁺/CD133⁺/vascular endothelial growth factor receptor 2 (VEGFR₂)] and two subgroups of circulating endothelial cells (CD34⁺/CD45^-/CD133^- and CD34⁺/CD45^-/CD133^-/VEGFR₂). Patients were divided in two groups of severity according to the median value of peak VO₂ (18.0 mL/kg/min), predicted peak VO₂ (65.5%), ventilation/carbon dioxide output slope (32.5) and EF (reduced and mid-ranged EF). EPCs values are expressed as median (25th-75th percentiles) in cells/10⁶ enucleated cells.

RESULTS

Patients with lower peak VO₂ increased the mobilization of CD34⁺/CD45^-/CD133⁺ [pre CPET: 60 (25-76) vs post CPET: 90 (70-103) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD45^-/CD133⁺/VEGFR₂ [pre CPET: 1 (1-4) vs post CPET: 5 (3-8) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD45^-/CD133^- [pre CPET: 186 (141-361) vs post CPET: 488 (247-658) cells/10⁶ enucleated cells, P < 0.001] and CD34⁺/CD45^-/CD133^-/VEGFR₂ [pre CPET: 2 (1-2) vs post CPET: 3 (2-5) cells/10⁶ enucleated cells, P < 0.001], while patients with higher VO₂ increased the mobilization of CD34⁺/CD45^-/CD133⁺ [pre CPET: 42 (19-73) vs post CPET: 90 (39-118) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD45^-/CD133⁺/VEGFR₂ [pre CPET: 2 (1-3) vs post CPET: 6 (3-9) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD133⁺/VEGFR₂ [pre CPET: 10 (7-18) vs post CPET: 14 (10-19) cells/10⁶ enucleated cells, P < 0.01], CD34⁺/CD45^-/CD133^- [pre CPET: 218 (158-247) vs post CPET: 311 (254-569) cells/10⁶ enucleated cells, P < 0.001] and CD34⁺/CD45^-/CD133^-/VEGFR₂ [pre CPET: 1 (1-2) vs post CPET: 4 (2-6) cells/10⁶ enucleated cells, P < 0.001]. A similar increase in the mobilization of at least four out of five cellular populations was observed after maximal exercise within each severity group regarding predicted peak, ventilation/carbon dioxide output slope and EF as well (P < 0.05). However, there were no statistically significant differences in the mobilization of endothelial cellular populations between severity groups in each comparison (P > 0.05).

CONCLUSION

Our study has shown an increased EPCs and circulating endothelial cells mobilization after maximal exercise in CHF patients, but this increase was not associated with syndrome severity. Further investigation, however, is needed.

A cardiac rehabilitation program increases the acute respond of endothelial progenitor cells after maximum exercise in patients with chronic heart failure

Background

Chronic heart failure (CHF) remains a leading cause of morbidity and mortality and it is characterized by vascular endothelial dysfunction. During the last decades, endothelial progenitor cells (EPCs) are being used as an index of the endothelium restoration potential, therefore reflecting the vascular endothelial function. Exercise training has been shown to stimulate the mobilization of EPCs at rest in CHF patients. However, the effect of exercise training on the acute respond of EPCs after maximum exercise in CHF patients remains unknown.

Purpose

The purpose of the study was to assess the effect of a cardiac rehabilitation (CR) program on the acute respond of EPCs after maximum exercise in patients with CHF.

Methods

Forty-four consecutive patients (35 males) with stable CHF [mean±SD, Age (years): 56±10, BMI (kg/m2): 28.7±5.2, EF (%): 33±8, Peak VO2 (ml/kg/min): 18.4±4.4, Peak work rate (watts): 101±39] enrolled a 36-session CR program based on high-intensity interval exercise training. All patients underwent an initial symptom limited maximal cardiopulmonary exercise testing (CPET) on an ergometer before the CR program and a final maximal CPET after the CR program. Venous blood was drawn before and after each CPET. Five circulating endothelial populations were identified and quantified by flow cytometry; CD34+/CD45-/CD133+, CD34+/CD45-/CD133+/VEGFR2, CD34+/CD133+/VEGFR2, CD34+/CD45-/CD133- and CD34+/CD45-/CD133-/VEGFR2. EPCs values are expressed as cells/million enucleated cells in medians (25th-75th percentiles).

Results

The acute mobilization of EPCs after the final CPET was higher than after the initial CPET in 4 out of 5 circulating endothelial populations. Most specifically, difference of the acute mobilization of CD34+/CD45-/CD133+ cells [initial CPET: 25 (15–46) vs final CPET: 49 (26–71), p=0.002], CD34+/CD45-/CD133+/VEGFR2 cells [initial CPET: 3 (2–5) vs final CPET: 8 (5–12), p&lt;0.001], CD34+/CD45-/CD133- cells [initial CPET: 129 (52–338) vs final CPET: 250 (129–518), p=0.03] and CD34+/CD45-/CD133-/VEGFR2 cells [initial CPET: 2 (1–4) vs final CPET: 6 (3–9), p&lt;0.001] increased after the final CPET. The acute mobilization of CD34+/CD133+/VEGFR2 cells [initial CPET: 3 (−1–7) vs final CPET: 5 (0–15), p=0.441] did not differ between the 2 CPETS.

Conclusion

A 36-session cardiac rehabilitation program increases the acute respond of endothelial progenitor cells after maximum cardiopulmonary exercise training in patients with chronic heart failure, therefore indicating the beneficial effect of exercise training on the vascular endothelial function.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme “Human Resources Development, Education and Lifelong Learning” in the context of the project

The comparison between two different exercise training programs on the mobilization of endothelial progenitor cells in patients with chronic heart failure

Background

Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Endothelial progenitor cells (EPCs) are being used as an index of vascular endothelial function. Cardiac rehabilitation (CR) programs have been shown to stimulate the mobilization of EPCs in CHF patients. However, the effect of different exercise training programs on the EPCs in CHF patients has not been investigated.

Purpose

The purpose of the study was to assess the effect of 2 different exercise training programs on the mobilization of EPCs in patients with CHF and investigate if there were differences between them.

Methods

Forty-four consecutive patients (35 males) with stable CHF [mean±SD, Age (years): 56±10, EF (%): 33±8, Peak VO2 (ml/kg/min): 18.4±4.4] enrolled a 36-session CR program and they were randomized in one exercise training protocol; either high-intensity interval training (HIIT) or HIIT combined with muscle strength (COM). Venous blood was drawn at rest before and after the CR program. Five circulating endothelial populations were identified and quantified by flow cytometry (Table 1). EPCs values are expressed as cells/million enucleated cells in medians (25th-75th percentiles).

Results

In both HIIT and COM groups, the mobilization of all circulating endothelial populations increased after the CR program (p&lt;0.05, Table 1). However, there was no difference in the mobilization of EPCs between HIIT and COM groups (p&gt;0.05, Table 1).

Conclusion

A 36-session cardiac rehabilitation program increases the mobilization of endothelial progenitor cells in patients with chronic heart failure. High-intensity interval exercise training and HIIT combined with muscle strength have similar beneficial effect on endothelial progenitor cells, and therefore on vascular endothelial function.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme “Human Resources Development, Education and Lifelong Learning” in the context of the project

Evaluation of Chronic Total Occlusion Recanalization: A Physiologic Assessment Perspective by Dynamic Exercise Tests

Chronic total occlusion (CTO) recanalization and its effects on left ventricular function and patient outcomes has intrigued the interventional community over the last several years. Now that there is plenty of knowledge and experience on "how to treat" the lesion, another scientific effort should focus on "when to treat" the lesion. Physiologic assessment has altered the way we treat coronary artery stenosis to improve cardiovascular outcomes. We tend to assess the effects of CTO recanalization by evaluating resting parameters, although the effects of ischemia and concomitant left ventricular dysfunction manifest mainly during exercise. Physiologic assessment in CTOs by implementation of cardiopulmonary exercise testing, in order to indirectly assess the physiological effect of exercise-induced left ventricular dysfunction, could represent a novel approach to monitor the effects of CTO recanalization and hopefully to identify the responders after recanalization.

P753Exercise has similar beneficial effect in the mobilization of endothelial progenitor cells in patients with chronic heart failure of different severity

Introduction

Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Exercise has been shown to stimulate the mobilization of endothelial progenitor cells (EPC) in healthy populations. EPC contribute to the regeneration of the inflammatory endothelium and promote neovascularization.

Purpose

The purpose of the present study was to investigate the mobilization of EPC between CHF patients with different severity after a 36-session exercise training program.

Methods

Thirty eight consecutive patients (32 ♂, 6 ♀) with stable CHF [mean±SD, age (years): 56±10, EF (%): 32±9, peak VO2 (ml/kg/min): 18.1±4.1] enrolled a 36-session exercise training program. All patients underwent a symptom limited maximal cardiopulmonary exercise testing (CPET) on a cycle ergometer before and after the training program. Venous blood was sampled before and after each CPET. Five endothelial circulating populations were quantified by flow cytometry (Table 1). Patients were divided in severity groups according to the median values of peak VO2, predicted peak VO2, VE/VCO2 slope and EF. EPC values are expressed as “cells/million enucleated cells” in medians (25th, 75th percentiles).

Results

In all patients, rehabilitation showed a statistical significant effect as well as a significant acute effect in all endothelial circulating populations (p<0.001). Although there was statistical significant mobilization of endothelial circulating populations within each severity group (groups separated by peak VO2), no differences were observed between groups (p>0.05, Table 1). Similar results were also shown for the rest of CPET parameters and EF.

Cellular populations in severity groups Endothelial cellular populations Peak VO2 <18 ml/kg/min Peak VO2 ≥18 ml/kg/min Before rehabilitation After rehabilitation Before rehabilitation After rehabilitation Before CPET After CPET Before CPET After CPET Before CPET After CPET Before CPET After CPET CD34+/CD45–/CD133+ 54 (24–74) 90 (40–104)* 96 (54–120) 154 (100–169)* 37 (16–66) 60 (33–93)* 79 (46–106) 122 (96–159)* CD34+/CD45–/CD133+/VEGFR2 1 (1–3) 3 (2–8)* 8 (4–9) 14 (10–19)* 2 (1–3) 4 (3–8)* 5 (4–7) 13 (9–16)* CD34+/CD133+/VEGFR2 13 (8–18) 13 (9–25) 22 (16–31) 27 (14–38) 10 (7–19) 14 (9–20)** 16 (13–37) 22 (15–62)** CD34+/CD45–/CD133– 186 (131–368) 494 (202–640)* 431 (301–564) 738 (590–921)* 214 (150–270) 306 (233–575)* 434 (277–835) 740 (524–1588)* CD34+/CD45–/CD133–/VEGFR2 2 (1–2) 3 (2–5)* 4 (3–5) 10 (9–14)* 1 (1–1) 3 (2–5)* 4 (2–8) 9 (7–12)* Differences within groups *p<0.001, **p<0.05.

Conclusion

A 36-session training program stimulates the long term mobilization of EPC in CHF patients. This mobilization seems to be similar in all patients irrespective of their severity. The clinical relevance of these findings and the potential mechanisms need further investigation.

Acknowledgement/Funding

Greece and the European Union (European Social Fund-ESF) through the Operational Programme “Human Resources Development, Education, Lifelong Learning”

Targeting skeletal muscle tissue oxygenation (StO2) in adults with severe sepsis and septic shock: a randomised controlled trial (OTO-StS Study)

OBJECTIVE

Evaluation of the ratio of oxyhaemoglobin to total haemoglobin in skeletal muscle (StO₂) using near-infrared spectroscopy may aid in the monitoring of patients with sepsis. This study assessed the benefits and risks of targeting StO₂ in adults with severe sepsis or septic shock.

DESIGN

A European randomised controlled trial was performed on two parallel groups.

SETTING

Five intensive care units (ICU) in France, Greece, Spain and Germany were used for the study.

PARTICIPANTS

A total of 103 adults with severe sepsis or septic shock on ICU admission were randomised (54 subjects in the experimental arm and 49 subjects in the control arm).

INTERVENTIONS

Haemodynamic management using an algorithm that was adapted from the 2004 Surviving Sepsis Campaign guidelines with (experimental arm) or without (control arm) targeting an StO₂ value greater than 80% at a minimum of two different sites.

OUTCOMES

The primary outcome was a composite: 7-day all-cause mortality or worsening of organ function, defined as a positive difference in Sepsis-related Organ Failure Assessment (SOFA) score between day 7 and randomisation (ie, delta SOFA >0). Secondary endpoints: 30-day mortality, duration of mechanical ventilation and vasopressor therapy up to 30 days from randomisation.

RESULTS

The study ended prematurely due to lack of funding after enrolment of 103/190 patients. Eighteen patients (33.3%) in the experimental arm and 14 (28.6%, P=0.67) in the control arm died or exhibited delta SOFA >0 on day 7. The mean number of days on mechanical ventilation was 12.2±10.6 in the experimental group and 7.6±7.9 in the control group (P=0.03). Thirty-one (57%) patients in the experimental arm and 14 (29%) patients in the control arm received red cells by day 7 (P=0.01).

CONCLUSION

Despite the limitation related to premature termination, this study provides no data to support the routine implementation of resuscitation protocols incorporating StO₂ >80% at two or more muscle sites as a target. StO₂-guided therapy may be associated with prolonged use of mechanical ventilation and an increased number of red blood cell transfusions.

TRIAL REGISTRATION NUMBER

NCT00167596; Results.

Muscle microcirculation alterations and relation to dipping status in newly diagnosed untreated patients with arterial hypertension-A pilot study

OBJECTIVE

The importance of abnormalities observed in the microcirculation of patients with arterial hypertension (AH) is being increasingly recognized. The authors aimed to evaluate skeletal muscle microcirculation in untreated, newly diagnosed hypertensive patients with NIRS, a noninvasive method that evaluates microcirculation.

METHODS

We evaluated 34 subjects, 17 patients with AH (13 males, 49±13 years, BMI: 26±2 kg/m² ) and 17 healthy controls (12 males, 49±15 years, BMI: 25±3 kg/m² ). The thenar muscle StO₂ (%) was measured by NIRS before, during and after 3-minutes vascular occlusion to calculate OCR (%/min), EF (%/min), and RHT (minute). The dipping status of hypertensive patients was assessed.

RESULTS

The RHT differed between AH patients and healthy subjects (2.6±0.3 vs 2.1±0.3 minutes, P<.001). Dippers had higher EF than nondippers (939±280 vs 710±164%/min, P=.05).

CONCLUSIONS

The study suggests an impaired muscle microcirculation in newly diagnosed, untreated AH patients.

Exercise training improves characteristics of exercise oscillatory ventilation in chronic heart failure

Background Exercise oscillatory ventilation in chronic heart failure has been suggested as a factor related to adverse cardiac events, aggravated prognosis and higher mortality. Exercise training is well known to affect exercise capacity and mechanisms of pathophysiology beneficially in chronic heart failure. Little is known, however, about the exercise training effects on characteristics of exercise oscillatory ventilation in chronic heart failure patients. Design and methods Twenty (out of 38) stable chronic heart failure patients exhibited exercise oscillatory ventilation (age 54 ± 11 years, peak oxygen uptake 15.0 ± 5.0 ml/kg per minute). Patients attended 36 sessions of high intensity interval exercise. All patients underwent cardiopulmonary exercise testing before and after the programme. Assessment of exercise oscillatory ventilation was based on the amplitude of cyclic fluctuations in breathing during rest and exercise. All values are mean ± SD. Results Exercise training reduced ( P < 0.05) the percentage of exercise oscillatory ventilation duration (79.0 ± 13.0 to 50.0 ± 25.0%), while average amplitude (5.2 ± 2.0 to 4.9 ± 1.6 L/minute) and length (44.0 ± 10.9 to 41.0 ± 6.7 seconds) did not change ( P > 0.05). Exercise oscillatory ventilation patients also increased exercise capacity ( P < 0.05). Conclusions A rehabilitation programme based on high intensity interval training improved exercise oscillatory ventilation observed in chronic heart failure patients, as well as cardiopulmonary efficiency and functional capacity.

Clinical factors affecting costs in patients receiving systemic antifungal therapy in intensive care units in Greece: Results from the ESTIMATOR study

Invasive fungal infections are common in intensive care units (ICUs) but there is a great variability in factors affecting costs of different antifungal treatment strategies in clinical practice. To determine factors affecting treatment cost in adult ICU patients with or without documented invasive fungal infection receiving systemic antifungal therapy (SAT) we have performed a prospective, multicentre, observational study enrolling patients receiving SAT in participating ICUs in Greece. During the study period, 155 patients received SAT at 14 participating ICUs: 37 (23.9%) for proven fungal infection before treatment began, 10 (6.5%) prophylactically, 77 (49.7%) empirically and 31 (20.0%) pre-emptively; 66 patients receiving early SAT (55.9%) were subsequently confirmed to have proven infection with Candida spp. (eight while on treatment). The most frequently used antifungal drugs were echinocandins (89/155; 57.4%), fluconazole (31/155; 20%) and itraconazole (20/155; 12.9%). Mean total cost per patient by SAT strategy was €20 458 (proven), €15 054 (prophylaxis), €23 594 (empiric) and €22 184 (pre-emptive). Factors associated with significantly increased cost were initial treatment failure, length of stay (LOS) in ICU before starting SAT (i.e. from admission until treatment start), fever and proven candidaemia (all P≤.05).

CONCLUSION

Early administration of antifungal drugs was not a substantial component of total hospital costs. However, there was a significant adverse impact on costs with increasing LOS in febrile patients in ICU for whom diagnosis of fungaemia was delayed before starting SAT, and with initial treatment failure. Awareness of potential candidaemia and initiation of pre-emptive or empirical strategy as early appropriate treatment may improve ICU patient outcomes while reducing direct medical costs.

Increased glucocorticoid receptor expression in sepsis is related to heat shock proteins, cytokines, and cortisol and is associated with increased mortality

Background

The purposes of this study are to examine if the human glucocorticoid receptor (hGR) isoform-α mRNA and hGR protein expressions are deficient in the acute phase of sepsis (S) compared to systemic inflammatory response syndrome (SIRS) and healthy subjects (H) and to evaluate if the hGRα and hGR alterations are associated with cortisol changes and if they are related to (1) extracellular and intracellular heat shock proteins (HSP) 72 and 90α; (2) ACTH, prolactin, and interleukins (ILs); and (3) outcome.

Methods

Patients consecutively admitted to a university hospital intensive care unit (ICU) with S (n = 48) or SIRS (n = 40) were enrolled in the study. Thirty-five H were also included. Total mRNA was isolated from peripheral blood samples and cDNA was prepared. RT-PCR was performed. Intracellular hGR and HSP expression in monocytes and/or neutrophils was evaluated using four-colour flow cytometry. Serum prolactin, ACTH, and cortisol concentrations were also measured. ELISA was used to evaluate serum ILs and extracellular (e) HSPs (eHSP72, eHSP90α).

Results

hGR protein was higher in S compared to H and SIRS; hGRα mRNA was higher in S compared to H (p < 0.05). In sepsis, hGR protein and eHSP72 were higher among non-survivors compared to survivors (p < 0.05). The hGR MFI and hGRα mRNA fold changes were significantly related to each other (r_s = 0.64, p < 0.001). Monocyte hGR protein expression was positively correlated with extracellular and intracellular HSPs, cortisol, and ILs and negatively to organ dysfunction (p < 0.05). HSPs, hGR, and cortisol were able to discriminate sepsis from SIRS (AUROC > 0.85, p < 0.05). In sepsis, monocyte-hGR protein and eHSP72 were strong predictors of mortality (AUROC > 0.95, p < 0.04).

Conclusions

Acute-phase sepsis is associated with increased hGR expression and cortisol concentrations, possibly implying no need for exogenous steroids. At this stage, hGR is able to predict sepsis and outcome and is related to stress-activated bio-molecules and organ dysfunction.

Immunoparalysis: Clinical and immunological associations in SIRS and severe sepsis patients

INTRODUCTION

This study was designed to identify changes in the monocytic membrane marker HLA-DR and heat shock proteins (HSPs) in relation to T-regulatory cells (T-regs) and other immunological marker changes in patients with systemic inflammatory response syndrome (SIRS) or sepsis/septic shock.

METHODS

Healthy volunteers, intensive care unit (ICU) patients with SIRS due to head injury and ICU patients with severe sepsis/septic shock were enrolled in the current study. Determination of CD14+/HLA-DR+ cells, intracellular heat-shock proteins and other immunological parameters were performed by flow cytometry and RT-PCR techniques as appropriate. Univariate and multivariate analysis examined associations of CD14/HLA-DR, HSPs, T-regs and suppressor of cytokine signalling (SOCS) proteins with SIRS, sepsis and outcome.

RESULTS

Fifty patients (37 with severe sepsis and 13 with SIRS) were enrolled, together with 20 healthy volunteers used as a control group. Compared to healthy individuals, patients with SIRS and severe sepsis showed progressive decline of their CD14/HLA-DR expression (0% to 7.7% to 50% within each study subpopulation, p<0.001). Mean fluorescent intensity (MFI) levels of HSP70 and HSP90 on monocytes and polymorphonuclear cells were significantly higher in SIRS patients compared to controls and fell significantly in severe sepsis/septic shock patients (p<0.05 for all comparisons). There was no statistically significant difference between subgroups for levels of T-regulatory cells or relative copies of Suppressor of Cytokine Signalling 3 (SOCS3) proteins. In univariate models percent of CD14/HLA-DR was associated with mortality (OR: 1.8 95%CI 1.02-3.2, p=0.05), while in multivariate models after adjusting for CD14/HLA-DR only younger age and lower Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were associated with increased chances of survival (beta -0.05, OR 0.9, 95% CI 0.9-0.99, p=0.038 for age and beta -0.11, OR 0.89, 95% CI 0.8-0.99, p=0.037 for APACHE II score).

CONCLUSIONS

Significant associations with SIRS and sepsis were found for CD14/HLA-DR expression and monocyte and polymorphonuclear cell levels of HSP70 and 90. The role of these biomarkers in assessing the prognosis of sepsis needs to be further explored and validated in prospective studies.

Effects of High-Intensity Interval Exercise Training on Skeletal Myopathy of Chronic Heart Failure

BACKGROUND

It remains controversial which type of exercise elicits optimum adaptations on skeletal myopathy of heart failure (HF). Our aim was to evaluate the effect of high-intensity interval training (HIIT), with or without the addition of strength training, on skeletal muscle of HF patients.

METHODS AND RESULTS

Thirteen male HF patients (age 51 ± 13 years, body mass index 27 ± 4 kg/m²) participated in either an HIIT (AER) or an HIIT combined with strength training (COM) 3-month program. Biopsy samples were obtained from the vastus lateralis. Analyses were performed on muscle fiber type, cross-section area (CSA), capillary density, and mRNA expression of insulin-like growth factor (IGF) 1 isoforms (ie, IGF-1Ea, IGF-1Eb, IGF-1Ec), type-1 receptor (IGF-1R), and binding protein 3 (IGFBP-3). Increased expression of IGF-1Ea, IGF-1Eb, IGF-1Ec, and IGFBP-3 transcripts was found (1.7 ± 0.8, 1.5 ± 0.8, 2.0 ± 1.32.4 ± 1.4 fold changes, respectively; P < .05). Type I fibers increased by 21% (42 ± 10% to 51 ± 7%; P < .001) and capillary/fiber ratio increased by 24% (1.27 ± 0.22 to 1.57 ± 0.41; P = .005) in both groups as a whole. Fibers' mean CSA increased by 10% in total, but the increase in type I fibers' CSA was greater after AER than COM (15% vs 6%; P < .05). The increased CSA correlated with the increased expression of IGF-1Ea and IGF-1Εb.

CONCLUSIONS

HIIT reverses skeletal myopathy of HF patients, with the adaptive responses of the IGF-1 bioregulation system possibly contributing to these effects. AER program seemed to be superior to COM to induce muscle hypertrophy.