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Hardenberg JHB, Stockmann H, Aigner A, Gotthardt I, Enghard P, Hinze C, Balzer F, Schmidt D, Zickler D, Kruse J, Körner R, Stegemann M, Schneider T, Schumann M, Müller-Redetzky H, Angermair S, Budde K, Weber-Carstens S, Witzenrath M, Treskatsch S, Siegmund B, Spies C, Suttorp N, Rauch G, Eckardt KU, Schmidt-Ott KM. Critical Illness and Systemic Inflammation Are Key Risk Factors of Severe Acute Kidney Injury in Patients With COVID-19. Kidney Int Rep 2021; 6:905-915. [PMID: 33817450 PMCID: PMC8007085 DOI: 10.1016/j.ekir.2021.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/12/2020] [Accepted: 01/11/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is an important complication in COVID-19, but its precise etiology has not fully been elucidated. Insights into AKI mechanisms may be provided by analyzing the temporal associations of clinical parameters reflecting disease processes and AKI development. METHODS We performed an observational cohort study of 223 consecutive COVID-19 patients treated at 3 sites of a tertiary care referral center to describe the evolvement of severe AKI (Kidney Disease: Improving Global Outcomes stage 3) and identify conditions promoting its development. Descriptive statistics and explanatory multivariable Cox regression modeling with clinical parameters as time-varying covariates were used to identify risk factors of severe AKI. RESULTS Severe AKI developed in 70 of 223 patients (31%) with COVID-19, of which 95.7% required kidney replacement therapy. Patients with severe AKI were older, predominantly male, had more comorbidities, and displayed excess mortality. Severe AKI occurred exclusively in intensive care unit patients, and 97.3% of the patients developing severe AKI had respiratory failure. Mechanical ventilation, vasopressor therapy, and inflammatory markers (serum procalcitonin levels and leucocyte count) were independent time-varying risk factors of severe AKI. Increasing inflammatory markers displayed a close temporal association with the development of severe AKI. Sensitivity analysis on risk factors of AKI stage 2 and 3 combined confirmed these findings. CONCLUSION Severe AKI in COVID-19 was tightly coupled with critical illness and systemic inflammation and was not observed in milder disease courses. These findings suggest that traditional systemic AKI mechanisms rather than kidney-specific processes contribute to severe AKI in COVID-19.
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Affiliation(s)
- Jan-Hendrik B. Hardenberg
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Helena Stockmann
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Annette Aigner
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Inka Gotthardt
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Hinze
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Danilo Schmidt
- Division IT, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jan Kruse
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Roland Körner
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Schneider
- Department of Gastroenterology, Infectiology and Rheumatology (CBF), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Schumann
- Department of Gastroenterology, Infectiology and Rheumatology (CBF), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Holger Müller-Redetzky
- Department of Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Angermair
- Department of Anesthesiology and Operative Intensive Care Medicine (CBF), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine (CBF), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Britta Siegmund
- Department of Gastroenterology, Infectiology and Rheumatology (CBF), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kai M. Schmidt-Ott
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
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Simsek O, Kocael A, Kocael P, Orhan A, Cengiz M, Balcı H, Ulualp K, Uzun H. Inflammatory mediators in the diagnosis and treatment of acute pancreatitis: pentraxin-3, procalcitonin and myeloperoxidase. Arch Med Sci 2018; 14:288-296. [PMID: 29593801 PMCID: PMC5868652 DOI: 10.5114/aoms.2016.57886] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/07/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is the third most common gastrointestinal disease at hospital admission. The etiology and pathogenesis of this disease are not completely clear. Our study was intended to determine the systemic levels of pentraxin-3 (PTX-3), myeloperoxidase (MPO), procalcitonin (PCT), and C-reactive protein (CRP) as prognostic parameters in early stages of AP. We also determined the effects of treatment on PTX-3, MPO, PCT and CRP levels in AP. MATERIAL AND METHODS The study group comprised 44 AP patients (22 male, 22 female; age: 49.3 ±16.9 years) referred to our outpatient clinic. Additionally, our investigation included a control group of 30 healthy volunteers (18 male, 12 female; age: 50.8 ±12.6 years). RESULTS Leukocytes, glucose, aspartate aminotransferase (AST (SGOT)), alanine aminotransferase (ALT (SGPT)), alkaline phosphatase (ALP), total and direct bilirubin levels were significantly higher in the AP group (p < 0.05, all). CRP, PTX-3, MPO and PCT were considerably higher in the AP group (p < 0.001, all), and after treatment, CRP, PTX-3, MPO and PCT levels were significantly lower (p < 0.001, all). CONCLUSIONS Our findings indicated that the CRP, PTX-3, MPO and PCT levels increase in patients with AP and hence these indicators can be used as diagnostic factors to predict inflammation severity in AP. It was revealed that after treatment, there were significant reductions in biomarker levels. However, further research is needed in order to understand how these biomarkers can help to monitor inflammatory responses in AP.
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Affiliation(s)
- Osman Simsek
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ahmet Kocael
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pınar Kocael
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Anıl Orhan
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mahir Cengiz
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Huriye Balcı
- Central Research Laboratory, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Kenan Ulualp
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hafize Uzun
- Department of Biochemistry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Komolafe O, Pereira SP, Davidson BR, Gurusamy KS. Serum C-reactive protein, procalcitonin, and lactate dehydrogenase for the diagnosis of pancreatic necrosis. Cochrane Database Syst Rev 2017; 4:CD012645. [PMID: 28431197 PMCID: PMC6478063 DOI: 10.1002/14651858.cd012645] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The treatment of people with pancreatic necrosis differs from that of people with oedematous pancreatitis. It is important to know the diagnostic accuracy of serum C-reactive protein (CRP), serum procalcitonin, and serum lactate dehydrogenase (LDH) as a triage test for the detection of pancreatic necrosis in people with acute pancreatitis, so that an informed decision can be made as to whether the person with pancreatic necrosis needs further investigations such as computed tomography (CT) scan or magnetic resonance imaging (MRI) scan and treatment for pancreatic necrosis started. There is currently no standard clinical practice, although CRP, particularly an increasing trend of CRP, is often used as a triage test to determine whether the person requires further imaging. There is also currently no systematic review of the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis. OBJECTIVES To compare the diagnostic accuracy of CRP, procalcitonin, or LDH (index test), either alone or in combination, in the diagnosis of necrotising pancreatitis in people with acute pancreatitis and without organ failure. SEARCH METHODS We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase. SELECTION CRITERIA We included all studies that evaluated the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis using the following reference standards, either alone or in combination: radiological features of pancreatic necrosis (contrast-enhanced CT or MRI), surgeon's judgement of pancreatic necrosis during surgery, or histological confirmation of pancreatic necrosis. Had we found case-control studies, we planned to exclude them because they are prone to bias; however, we did not locate any. Two review authors independently identified the relevant studies from the retrieved references. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, including methodological quality assessment, from the included studies. As the included studies reported CRP, procalcitonin, and LDH on different days of admission and measured at different cut-off levels, it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) on each of the different days of admission and measured at different cut-off levels. MAIN RESULTS A total of three studies including 242 participants met the inclusion criteria for this review. One study reported the diagnostic performance of CRP for two threshold levels (> 200 mg/L and > 279 mg/L) without stating the day on which the CRP was measured. One study reported the diagnostic performance of procalcitonin on day 1 (1 day after admission) using a threshold level of 0.5 ng/mL. One study reported the diagnostic performance of CRP on day 3 (3 days after admission) using a threshold level of 140 mg/L and LDH on day 5 (5 days after admission) using a threshold level of 290 U/L. The sensitivities and specificities varied: the point estimate of the sensitivities ranged from 0.72 to 0.88, while the point estimate of the specificities ranged from 0.75 to 1.00 for the different index tests on different days of hospital admission. However, the confidence intervals were wide: confidence intervals of sensitivities ranged from 0.51 to 0.97, while those of specificities ranged from 0.18 to 1.00 for the different tests on different days of hospital admission. Overall, none of the tests assessed in this review were sufficiently accurate to suggest that they could be useful in clinical practice. AUTHORS' CONCLUSIONS The paucity of data and methodological deficiencies in the studies meant that it was not possible to arrive at any conclusions regarding the diagnostic test accuracy of the index test because of the uncertainty of the results. Further well-designed diagnostic test accuracy studies with prespecified index test thresholds of CRP, procalcitonin, LDH; appropriate follow-up (for at least two weeks to ensure that the person does not have pancreatic necrosis, as early scans may not indicate pancreatic necrosis); and clearly defined reference standards (of surgical or radiological confirmation of pancreatic necrosis) are important to reliably determine the diagnostic accuracy of CRP, procalcitonin, and LDH.
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Affiliation(s)
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
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Sato M, Takahashi G, Shibata S, Onodera M, Suzuki Y, Inoue Y, Endo S. Clinical Performance of a New Soluble CD14-Subtype Immunochromatographic Test for Whole Blood Compared with Chemiluminescent Enzyme Immunoassay: Use of Quantitative Soluble CD14-Subtype Immunochromatographic Tests for the Diagnosis of Sepsis. PLoS One 2015; 10:e0143971. [PMID: 26623644 PMCID: PMC4666562 DOI: 10.1371/journal.pone.0143971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/11/2015] [Indexed: 12/04/2022] Open
Abstract
We previously reported that a soluble CD14-subtype (sCD14-ST) immunochromatographic test (ICT) for plasma is more convenient than chemiluminescent enzyme immunoassay (CLEIA), but plasma separation makes bedside measurements difficult. We developed a new sCD14-ST ICT for whole blood and investigated whether quantitative determinations of sCD14-ST by ICT were useful for diagnosing sepsis and severe sepsis/septic shock. We studied 20 patients who fulfilled two or more systemic inflammatory response syndrome (SIRS) criteria and 32 patients who had been diagnosed with sepsis or severe sepsis/septic shock. Whole blood was collected on day 0 (on admission) and day 7, and the sCD14-ST concentration was quantitatively measured by CLEIA and ICT for whole blood. The patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), and Mortality in Emergency Department Sepsis (MEDS) scores were also calculated. The cut-off values obtained by the quantitative measurements made by ICT were 464.5 pg/mL for sepsis and 762.7 pg/mL for severe sepsis/septic shock (P < 0.0001). A Bland–Altman plot showed that no fixed bias or proportional bias was detected between CLEIA and quantitative ICT for whole blood. sCD14-ST concentrations were significantly correlated with APACHE II, SOFA, and MEDS scores (P < 0.0001). These results suggest that the new sCD14-ST ICT for whole blood may be a useful tool for the convenient, rapid bedside diagnosis and treatment of sepsis.
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Affiliation(s)
- Masayuki Sato
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
- * E-mail:
| | - Gaku Takahashi
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
| | - Shigehiro Shibata
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
| | - Makoto Onodera
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
| | - Yasushi Suzuki
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
| | - Yoshihiro Inoue
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
| | - Shigeatsu Endo
- Department of Critical Care Medicine, Iwate Medical University, Uchimaru, Morioka, Iwate, Japan
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Phillip V, Steiner JM, Algül H. Early phase of acute pancreatitis: Assessment and management. World J Gastrointest Pathophysiol 2014; 5:158-168. [PMID: 25133018 PMCID: PMC4133515 DOI: 10.4291/wjgp.v5.i3.158] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/25/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.
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Peter JV, Karthik G, Ramakrishna K, Griffith MF, Jude Prakash JA, Job V, Chacko B, Graham PL. Elevated procalcitonin is associated with increased mortality in patients with scrub typhus infection needing intensive care admission. Indian J Crit Care Med 2013; 17:174-7. [PMID: 24082615 PMCID: PMC3777372 DOI: 10.4103/0972-5229.117063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Context: Procalcitonin is a biomarker of bacterial sepsis. It is unclear if scrub typhus, a rickettsial illness, is associated with elevated procalcitonin levels. Aim: To assess if scrub typhus infection is associated with high procalcitonin levels and whether high levels portend a poorer prognosis. Setting and Design: Retrospective study of patients with severe scrub typhus infection, admitted to the medical intensive care unit of a tertiary care university affiliated teaching hospital. Materials and Methods: Eighty-four patients with severe scrub typhus infection that also had procalcitonin levels were assessed. Statistical Analysis: Relationship between procalcitonin and mortality explored using univariate and multivariate analyses. Results: The mean (±standard deviation) age was 40.0 ± 15.5 years. Patients were symptomatic for 8.3 ± 4.3 days prior to presentation. The median admission procalcitonin level was 4.0 (interquartile range 1.8 to 8.5) ng/ml; 59 (70.2%) patients had levels >2 ng/ml. Invasive mechanical ventilation was required in 65 patients; 20 patients died. On univariate analysis, admission procalcitonin was associated with increased odds of death [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03 to 1.18]. On multivariate logistic regression analysis including procalcitonin and APACHE-II score, the APACHE-II score was significantly associated with mortality (OR 1.16, 95% CI 1.06 to 1.30, P = 0.004) while a trend was observed with procalcitonin (OR 1.05, 95%CI 1.01 to 1.13, P = 0.09). The area under the receiver operating characteristic (ROC) curve, AUC, for mortality was 0.77 for procalcitonin and 0.78 for APACHE-II. Conclusions: Procalcitonin is elevated in severe scrub typhus infection and may be associated with higher mortality.
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Affiliation(s)
- John Victor Peter
- Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
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Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, Jang JS, Lee JH, Choi SR, Park BH. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med 2013; 28:322-9. [PMID: 23682226 PMCID: PMC3654130 DOI: 10.3904/kjim.2013.28.3.322] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/19/2012] [Accepted: 07/19/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND/AIMS The bedside index of severity in acute pancreatitis (BISAP) is a new, convenient, prognostic multifactorial scoring system. As more data are needed before clinical application, we compared BISAP, the serum procalcitonin (PCT), and other multifactorial scoring systems simultaneously. METHODS Fifty consecutive acute pancreatitis patients were enrolled prospectively. Blood samples were obtained at admission and after 48 hours and imaging studies were performed within 48 hours of admission. The BISAP score was compared with the serum PCT, Ranson's score, and the acute physiology and chronic health examination (APACHE)-II, Glasgow, and Balthazar computed tomography severity index (BCTSI) scores. Acute pancreatitis was graded using the Atlanta criteria. The predictive accuracy of the scoring systems was measured using the area under the receiver-operating curve (AUC). RESULTS The accuracy of BISAP (≥ 2) at predicting severe acute pancreatitis was 84% and was superior to the serum PCT (≥ 3.29 ng/mL, 76%) which was similar to the APACHE-II score. The best cutoff value of BISAP was 2 (AUC, 0.873; 95% confidence interval, 0.770 to 0.976; p < 0.001). In logistic regression analysis, BISAP had greater statistical significance than serum PCT. CONCLUSIONS BISAP is more accurate for predicting the severity of acute pancreatitis than the serum PCT, APACHE-II, Glasgow, and BCTSI scores.
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Affiliation(s)
- Byung Geun Kim
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Myung Hwan Noh
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Choong Heon Ryu
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Hwa Seong Nam
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Su Mi Woo
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Seung Hee Ryu
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jin Seok Jang
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jong Hun Lee
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Seok Ryeol Choi
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Byeong Ho Park
- Department of Radiology, Dong-A University College of Medicine, Busan, Korea
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Woo SM, Noh MH, Kim BG, Hsing CT, Han JS, Ryu SH, Seo JM, Yoon HA, Jang JS, Choi SR, Cho JH. Comparison of serum procalcitonin with Ranson, APACHE-II, Glasgow and Balthazar CT severity index scores in predicting severity of acute pancreatitis. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 58:31-7. [PMID: 21778801 DOI: 10.4166/kjg.2011.58.1.31] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIMS The aim of this study is to assess serum procalcitonin (PCT) for early prediction of severe acute pancreatitis compared with multiple scoring systems and biomarkers. METHODS Forty-four patients with acute pancreatitis confirmed by radiological evidences, laboratory assessments, and clinical manifestation were prospectively enrolled. All blood samples and image studies were obtained within 24 hours of admission. RESULTS Acute pancreatitis was graded as severe in 19 patients and mild in 25 patients according to the Atlanta criteria. Levels of serum PCT were significantly higher in severe acute pancreatitis (p=0.001). The accuracy of serum PCT as a predicting marker was 77.3%, which was similar to the acute physiology and chronic health examination (APACHE)-II score, worse than the Ranson score (93.2%) and better than the Balthazar CT index (65.9%). The most effective cut-off level of serum PCT was estimated at 1.77 ng/mL (AUC=0.797, 95% CI=0.658-0.935). In comparision to other simple biomarkers, serum PCT had more accurate value (77.3%) than C-reactive protein (68.2%), urea (75.0%) and lactic dehydrogenase (72.7%). Logistic regression analysis revealed that serum PCT has statistical significance in acute severe pancreatitis. Assessment of serum PCT levels and length of hospital stay by simple linear regression analysis revealed effective p-value with low R square level, which could make only possibilty for affection of serum PCT to admission duration (r2=0.127, p=0.021). CONCLUSIONS Serum PCT was a promising simple biomarker and had similar accuracy of APACHE-II scores as predicting severity of acute pancreatitis.
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Affiliation(s)
- Su Mi Woo
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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Abstract
OBJECTIVES This study investigated the effects of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) on gut barrier function in critically ill surgical patients. METHODS A prospective observational cohort study on patients with severe acute pancreatitis or abdominal sepsis admitted to an intensive care or high-dependency unit. Intra-abdominal pressure (IAP) and plasma levels of immunoglobulin G (IgG) and IgM antiendotoxin core antibodies (EndoCAb) and procalcitonin (ProCT) were measured serially. RESULTS Among 32 recruited patients, 24 (75%) and 8 patients (25%) developed IAH and ACS, respectively. The state of ACS was associated with significant reductions in plasma IgG EndoCAb (P = 0.015) and IgM EndoCAb (P = 0.016) and higher concentrations of plasma ProCT (P = 0.056) compared with absence of ACS. Resolution of IAH and ACS was associated with significant recovery of plasma IgG EndoCAb (P = 0.003 and P = 0.009, respectively) and IgM EndoCAb (P = 0.002 and P = 0.003, respectively) and reduction in plasma ProCT concentration (P = 0.049 and P = 0.019, respectively). Negative correlations were observed between IAP and plasma IgG EndoCAb (P = 0.003) and IgM EndoCAb (P = 0.002). CONCLUSIONS Intra-abdominal hypertension and ACS are associated with significantly higher endotoxin exposure and ProCT concentrations, suggestive of gut barrier dysfunction. Resolution of IAH and ACS is associated with evidence for recovery of gut barrier function.
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Becker KL, Snider R, Nylen ES. Procalcitonin in sepsis and systemic inflammation: a harmful biomarker and a therapeutic target. Br J Pharmacol 2010; 159:253-64. [PMID: 20002097 PMCID: PMC2825349 DOI: 10.1111/j.1476-5381.2009.00433.x] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 06/17/2009] [Accepted: 06/29/2009] [Indexed: 02/06/2023] Open
Abstract
The worldwide yearly mortality from sepsis is substantial, greater than that of cancer of the lung and breast combined. Moreover, its incidence is increasing, and its response to therapy has not appreciably improved. In this condition, the secretion of procalcitonin (ProCT), the prohormone of calcitonin, is augmented greatly, attaining levels up to thousands of fold of normal. This hypersecretion emanates from multiple tissues throughout the body that are not traditionally viewed as being endocrine. The serum values of ProCT correlate with the severity of sepsis; they recede with its improvement and worsen with exacerbation. Accordingly, as highlighted in this review, serum ProCT has become useful as a biomarker to assist in the diagnosis of sepsis, as well as related infectious or inflammatory conditions. It is also a useful monitor of the clinical course and prognosis, and sensitive and specific assays have been developed for its measurement. Moreover, it has been demonstrated that the administration of ProCT to septic animals greatly increases mortality, and several toxic effects of ProCT have been elucidated by in vitro experimental studies. Antibodies have been developed that neutralize the harmful effects of ProCT, and their use markedly decreases the symptomatology and mortality of animals that harbour a highly virulent sepsis analogous to that occurring in humans. This therapy is facilitated by the long duration of serum ProCT elevation, which allows for a broad window of therapeutic opportunity. An experimental groundwork has been established that suggests a potential applicability of such therapy in septic humans.
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Affiliation(s)
- Kenneth L Becker
- George Washington University and Veterans Affairs Medical Center, Washington, DC 20422, USA.
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Gravante G, Garcea G, Ong SL, Metcalfe MS, Berry DP, Lloyd DM, Dennison AR. Prediction of mortality in acute pancreatitis: a systematic review of the published evidence. Pancreatology 2009; 9:601-14. [PMID: 19657215 DOI: 10.1159/000212097] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis. SUMMARY BACKGROUND DATA Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality. METHODS All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded. RESULTS 58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power. CONCLUSIONS Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.
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Affiliation(s)
- G Gravante
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK.
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Assessment of the prognostic value of certain acute-phase proteins and procalcitonin in the prognosis of acute pancreatitis. Pancreas 2008; 37:449-53. [PMID: 18953261 DOI: 10.1097/mpa.0b013e3181706d67] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Of patients with acute pancreatitis (AP), 20% develop severe attacks that need early and intensive therapy. Yet, to administer such treatment, it is important to classify early on the patients with mild and severe pancreatitis. The aim of this study was to evaluate the role of serum amyloid A, C-reactive protein, procalcitonin, and routinely measured parameters in the early prediction of the course of AP. METHODS A total of 40 consecutive patients with AP confirmed by computed tomography were prospectively enrolled in the study-29 were graded as mild and 11 were graded as severe. Blood samples were obtained on admission and 24 hours thereafter. RESULTS Procalcitonin concentration in both measurements was significantly higher in patients with severe pancreatitis, and the cutoff level was estimated at 0.5 ng/mL. Although serum amyloid A and C-reactive protein levels rose significantly during the period of observation, these were not differentiated between both groups. Among the routinely measured parameters, a prognostic value was found for total calcium concentration, lactic dehydrogenase activity, and glucose concentration. CONCLUSIONS The best efficiency in the early prediction of severe AP would be achieved with the measurement of procalcitonin, total calcium level, and lactic acid dehydrogenase activity immediately after admission to the ward.
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Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations. Crit Care Med 2008; 36:941-52. [PMID: 18431284 DOI: 10.1097/ccm.0b013e318165babb] [Citation(s) in RCA: 368] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The use of procalcitonin (ProCT) as a marker of several clinical conditions, in particular, systemic inflammation, infection, and sepsis, will be clarified, and its current limitations will be delineated. In particular, the need for a more sensitive assay will be emphasized. For these purposes, the medical literature comprising clinical studies pertaining to the measurement of serum ProCT in various clinical settings was examined. DATA SOURCE AND SELECTION A PubMed search (1965 through November 2007) was conducted, including manual cross-referencing. Pertinent complete publications were obtained using the MeSH terms procalcitonin, C-reactive protein, sepsis, and biological markers. Textbook chapters were also read and extracted. DATA EXTRACTION AND SYNTHESIS Available clinical and other patient data from these sources were reviewed, including any data relating to precipitating factors, clinical findings, associated illnesses, and patient outcome. Published data concerning sensitivity, specificity, and reproducibility of ProCT assays were reviewed. CONCLUSIONS Based on available data, the measurement of serum ProCT has definite utility as a marker of severe systemic inflammation, infection, and sepsis. However, publications concerning its diagnostic and prognostic utility are contradictory. In addition, patient characteristics and clinical settings vary markedly, and the data have been difficult to interpret and often extrapolated inappropriately to clinical usage. Furthermore, attempts at meta-analyses are greatly compromised by the divergent circumstances of reported studies and by the sparsity and different timing of the ProCT assays. Although a high ProCT commonly occurs in infection, it is also elevated in some noninfectious conditions. Thus, the test is not a specific indicator of either infection or sepsis. Moreover, in any individual patient, the precipitating cause of an illness, the clinical milieu, and complicating conditions may render tenuous any reliable estimations of severity or prognosis. It also is apparent that even a febrile septic patient with documented bacteremia may not necessarily have a serum ProCT that is elevated above the limit of functional sensitivity of the assay. In this regard, the most commonly applied assay (i.e., LUMItest) is insufficiently sensitive to detect potentially important mild elevations or trends. Clinical studies with a more sensitive ProCT assay that is capable of rapid and practicable day-to-day monitoring are needed and shortly may be available. In addition, investigations showing that ProCT and its related peptides may have mediator relevance point to the need for evaluating therapeutic countermeasures and studying the pathophysiologic effect of hyperprocalcitonemia in serious infection and sepsis.
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Abstract
Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis (SAP). An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as effective as multifactorial scoring systems (MFSS) at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, matrix metalloproteinase-9 (MMP-9) and serum amyloid A (SAA) have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis (PN), infected PN (IPN) and mortality.
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Affiliation(s)
- Peter A Banks
- Division of Gastroenterology, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ammori BJ, Becker KL, Kite P, Snider RH, Nylén ES, White JC, Barclay GR, Larvin M, McMahon MJ. Calcitonin precursors: early markers of gut barrier dysfunction in patients with acute pancreatitis. Pancreas 2003; 27:239-43. [PMID: 14508129 DOI: 10.1097/00006676-200310000-00008] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Severe acute pancreatitis is associated with an early increase in intestinal permeability and endotoxemia. Endotoxin is a potent stimulator for the production and release of procalcitonin and its components (calcitonin precursors; [CTpr]). The aim of this study is to evaluate the role of plasma CTpr as an early marker for gut barrier dysfunction in patients with acute pancreatitis. METHODS Intestinal permeability to macromolecules (polyethylene glycol 3350), serum endotoxin and antiendotoxin core antibodies, plasma CTpr, and serum C-reactive protein (CRP) were measured on admission in 60 patients with acute pancreatitis. Attacks were classified as mild (n = 48) or severe (n = 12) according to the Atlanta criteria. RESULTS Compared with mild attacks of acute pancreatitis, severe attacks were significantly associated with an increase in intestinal permeability index (median: 0.02 vs. 0.006, P < 0.001), the frequency of endotoxemia (73% vs. 41%, P = 0.04), and the extent of depletion of serum IgM antiendotoxin antibodies (median: 43 MMU vs. 100 MMU, P = 0.004). Plasma CTpr levels were significantly elevated in patients with severe attacks compared with mild attacks on both the day of admission and on day 3 (median: 64 vs. 22 fmol/mL, P = 0.03; and 90 vs. 29 fmol/mL, P = 0.003 respectively). A positive and significant correlation was observed between the admission serum endotoxin and plasma CTpr levels on admission (r = 0.7, P < 0.0001) and on day 3 (r = 0.96, P < 0.0001), and between plasma CTpr on day 7 and the intestinal permeability index (r = 0.85, P = 0.0001). In contrast, only a weak positive correlation was observed between peak serum levels of CRP and plasma CTpr on admission (r = 0.3, P = 0.017) and on day 7 (r = 0.471, P = 0.049), as well as between CRP and each of the admission serum endotoxin (r = 0.3, P = 0.03) and the intestinal permeability index (r = 0.375, P = 0.007). CONCLUSIONS In patients with acute pancreatitis, plasma concentrations of CTpr appear to reflect more closely the derangement in gut barrier function rather than the extent of systemic inflammation.
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Affiliation(s)
- B J Ammori
- Division of Surgery at the University of Leeds, The General Infirmary, Leeds, UK.
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