Soluble receptor for urokinase plasminogen activator in community-acquired pneumonia in children

Ketamine study: Protocol for naturalistic prospective multicenter study on subcutaneous ketamine infusion in depressed patients with active suicidal ideation

Background

Psychiatric disorders are associated with more than 90% of reported suicide attempts worldwide, but few treatments have demonstrated a direct effect in reducing suicide risk. Ketamine, originally an anesthetic, has been shown anti-suicide effects in clinical trials designed to treat depression. However, changes at the biochemical level were assessed only in protocols of ketamine with very limited sample sizes, particularly when the subcutaneous route was considered. In addition, the inflammatory changes associated with ketamine effects and their correlation with response to treatment, dose-effect, and suicide risk warrant further investigation. Therefore, we aimed to assess whether ketamine results in better control of suicidal ideation and/or behavior in patients with depressive episodes and whether ketamine affects psychopathology and inflammatory biomarkers.

Materials and methods

We report here the design of a naturalistic prospective multicenter study protocol of ketamine in depressive episodes carried out at Hospital de Clínicas de Porto Alegre (HCPA) and Hospital Moinhos de Vento (HMV). The study was planned to recruit adult patients with Major depressive disorder (MDD) or Bipolar disorder (BD) types 1 or 2, who are currently in a depressive episode and show symptoms of suicidal ideation and/or behavior according to the Columbia-Suicide Severity Rating Scale (C-SSRS) and have been prescribed ketamine by their assistant psychiatrist. Patients receive ketamine subcutaneously (SC) twice a week for 1 month, but the frequency can be changed or the dose decreased according to the assistant physician’s decision. After the last ketamine session, patients are followed-up via telephone once a month for up to 6 months. The data will be analyzed using repeated measures statistics to evaluate the reduction in suicide risk as a primary outcome, as per C-SSRS.

Discussion

We discuss the need for studies with longer follow-ups designed to measure a direct impact on suicide risk and that additional information about the safety and tolerability of ketamine in particular subset of patients such as those with depression and ideation suicide. In line, the mechanism behind the immunomodulatory effects of ketamine is still poorly understood.

Trial registration

https://clinicaltrials.gov/, identifier NCT05249309.

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

Levels of Soluble Urokinase Plasminogen Activator Receptor in Pediatric Lower Respiratory Tract Infections

Background: Lower respiratory tract infections (LTRIs) are the most common cause of pediatric emergency department visits and are associated with significant morbidity and mortality. The aim of this study was to evaluate the soluble urokinase plasminogen activator receptor (suPAR) levels in pediatric patients with LRTIs and to investigate the correlation of suPAR with disease severity. Methods: This is a prospective case-control study of children with LTRIs. Demographic data, diagnoses, vital signs, disease severity scores, length of hospital stay, laboratory findings, and viral polymerase chain reaction results for nasopharyngeal aspirates were recorded. Blood samples for suPAR were collected and assessed by enzyme-linked immunosorbent assay. Results: There were 94 patients with LTRIs and 32 children in the control group. Patients were further subdivided into 2 groups based on diagnosis of acute bronchiolitis (n: 31, 33%) or pneumonia (n: 63, 67%). The median levels of suPAR were significantly higher in patients with LTRIs than in healthy controls (4.3 and 3.5 ng/mL, respectively; P = 0.003). There was an association between suPAR levels and disease severity in pneumonia patients. suPAR values were higher in patients with severe pneumonia than mild pneumonia (5.5 and 3.6 ng/mL, respectively; P < 0.001). Conclusion: We have shown that suPAR levels increased in patients with LTRIs and suPAR values were higher in patients with severe pneumonia than mild pneumonia. Further studies with large case series are needed to clarify the role of suPAR levels in children with LTRIs.

Soluble urokinase-type plasminogen activator receptor as a measure of treatment response in acute exacerbation of COPD

Objective:

To evaluate the value of soluble urokinase-type plasminogen activator receptor (suPAR) in the diagnosis of acute exacerbation of COPD (AECOPD) and in monitoring treatment response, analyzing the relationship between suPAR and fibrinogen in AECOPD. AECOPD leads to increased airway inflammation, contributing to an exaggerated release of inflammatory mediators.

Methods:

We recruited 45 patients with AECOPD and 20 healthy control subjects. Medical histories were taken, and all subjects underwent clinical examination, chest X-ray, pulmonary function tests, and blood gas analysis. On day 1 (treatment initiation for the AECOPD patients) and day 14 (end of treatment), blood samples were collected for the determination of serum suPAR and plasma fibrinogen.

Results:

Serum levels of suPAR were significantly higher in the AECOPD group than in the control group. In the AECOPD patients, there was a significant post-treatment decrease in the mean serum suPAR level. The sensitivity, specificity, and accuracy of suPAR were 95.6%, 80.0%, and 93.0%, respectively. The Global Initiative for Chronic Obstructive Lung Disease stage (i.e., COPD severity) correlated positively and significantly with serum levels of suPAR and plasma levels of fibrinogen.

Conclusions:

Monitoring the serum suPAR level can be helpful in the evaluation of the COPD treatment response and might be a valuable biomarker for determining the prognosis of AECOPD. Because serum suPAR correlated with plasma fibrinogen, both markers could be predictive of AECOPD.

Prognostic scores and biomarkers for pediatric community-acquired pneumonia: how far have we come?

This article aimed to review the current prognostic and diagnostic tools used for community-acquired pneumonia (CAP) and highlight those potentially applicable in children with CAP. Several scoring systems have been developed to predict CAP mortality risk and serve as guides for admission into the intensive care unit. Over the years, clinicians have adopted these tools for improving site-of-care decisions because of high mortality rates in the extremes of age. The major scoring systems designed for geriatric patients include the Pneumonia Severity Index and the confusion, uremia, respiratory rate, blood pressure, age >65 years (CURB-65) rule, as well as better predictors of intensive care unit admission, such as the systolic blood pressure, multilobar chest radiography involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation and arterial pH (SMART-COP) score, the Infectious Diseases Society of America/American Thoracic Society guidelines, the criteria developed by España et al as well as the systolic blood pressure, oxygenation, age and respiratory rate (SOAR) criteria. Only the modified predisposition, insult, response and organ dysfunction (PIRO) score has so far been applied to children with CAP. Because none of the tools is without its limitations, there has been a paradigm shift to incorporate biomarkers because they are reliable diagnostic tools and good predictors of disease severity and outcome, irrespective of age group. Despite the initial preponderance of reports on their utility in geriatric CAP, much progress has now been made in demonstrating their usefulness in pediatric CAP.

Soluble Urokinase Plasminogen Activator Receptor: A New Biomarker in the Pediatric Intensive Care Unit

OBJECTIVE

To evaluate the value of soluble urokinase plasminogen activator receptor (suPAR) in diagnosing sepsis and predicting mortality in critically ill children.

METHODS

In a prospective cohort study, 69 critically ill children admitted into the pediatric intensive care unit (PICU) were randomly enrolled in addition to 15 healthy children as a control group. Clinical examination was performed, including calculation of the Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality2 (PIM2). suPAR was measured in patients at admission as well as in the controls. Patients were followed up for 30 d.

RESULTS

suPAR level was significantly higher among the total patient cohort compared to controls (p < 0.0001). suPAR was also significantly higher among patients with sepsis compared to both controls (p < 0.0001) and patients without sepsis (p < 0.0001). Furthermore, suPAR level was significantly elevated in non-survivors compared to survivors (p 0.008). Receiver operating characteristic curve (ROC curve) analysis revealed an area under the curve (AUC) of 0.80 for suPAR for diagnosis of sepsis while C-reactive protein (CRP) had an AUC of 0.82. Regarding the prognosis, suPAR had an AUC of 0.69 for prediction of mortality, whereas the AUC for PRISM, PIM2, and CRP were 0.82, 0.81, and 0.77 respectively.

CONCLUSIONS

suPAR has both a diagnostic and a prognostic value for critically ill children. However, it does not seem to be superior to the classic laboratory markers and clinical scoring systems.

The role of the soluble urokinase plasminogen activator (suPAR) in children with pneumonia

Although pneumonia is one of the most important health problems in children, there is still no widely accepted disease severity score, the data on the correlation between the conventional inflammatory markers or chest X-ray and the disease severity remain disputable, and thus, there is an urgent need for a new pneumonia biomarker. The soluble urokinase plasminogen activator (suPAR) is a soluble form of the urokinase plasminogen activator that plays an important role in the innate host defense in the pulmonary tissue. suPAR levels have been associated with a general activation of the immune system rather than with a particular etiological factor. suPAR has a high prognostic value in critically ill patients, especially with sepsis, but there is a growing number of studies focusing on suPAR in respiratory diseases. The aim of this review is to summarize the knowledge on the role of the suPAR/uPAR in lung pathology and its possible use in pneumonia in children.

suPAR and Team Nephrology

Primary focal segmental glomerulosclerosis (FSGS) accounts for nearly 10 % of patients who require renal replacement therapy. Elevated circulating levels of soluble urokinase receptor (suPAR) have been identified as a biomarker to discriminate primary FSGS from other glomerulopathies. Subsequent reports have questioned the diagnostic utility of this test. In a study in BMC Medicine, Huang et al. demonstrate that urinary soluble urokinase receptor (suPAR) excretion assists in distinguishing primary FSGS from other glomerular diseases, and that high plasma suPAR concentrations are not directly linked to a decline in glomerular filtration rate (GFR). This observation suggests that further investigation of suPAR is warranted in patients with FSGS. It should be interpreted in light of a recent report that B7-1 is expressed in the podocytes of a subset of patients with FSGS, and that blocking this molecule may represent the first successful targeted intervention for this disease. These advances highlight the rapid pace of scientific progress in the field of nephrology. Nephrologists should work together, share resources, and expedite the design of protocols to evaluate these novel biomarkers in a comprehensive and scientifically valid manner.

Clinical value of plasma soluble urokinase-type plasminogen activator receptor levels in term neonates with infection or sepsis: a prospective study

Background. suPAR, the soluble form of the urokinase-type plasminogen activator receptor, has been identified as a biomarker of infection in adults but its properties in neonatal infection are not known. Methods. Plasma suPAR levels were determined by ELISA in 47 term neonates with infection (19 bacterial and 28 viral) and in 18 healthy neonates as controls. Thirteen out of 47 infected neonates were septic. In all infected neonates, suPAR levels were repeated at 24 hours, 48 hours, 3–5 days, and 7–10 days following admission. Results. Plasma suPAR levels were significantly increased in infected neonates upon admission, whereas they were highest in septic neonates, in comparison with controls (P < 0.001) and correlated positively with serum CRP levels (P = 0.001). At infection subsidence, suPAR concentrations decreased significantly in comparison with baseline (P < 0.001) but remained higher than in controls (P = 0.01). Receiver operating characteristic analysis resulted in significant areas under the curve for detecting either infected or septic neonates, but not for discriminating between bacterial and viral cause of infection. Conclusions. suPAR is a diagnostic biomarker of infection or sepsis in term neonates; however, it cannot discriminate bacterial from viral infections and also its utility for monitoring the response to treatment is questioned.

Soluble urokinase plasminogen activator receptor: an indicator of pneumonia severity in children

Enhanced level of soluble urokinase plasminogen activator receptor (suPAR) level has been associated with activation of the immune system. It may be a novel biomarker for pneumonia severity, yet data on this subject are limited. In the present study we seek to determine the suPAR level in hospitalized children with community-acquired pneumonia (CAP), its correlation with pneumonia severity, and to compare the suPAR level between pneumonia and healthy conditions. The study encompassed a total of 596 children: 447 with pneumonia and 119 healthy. suPAR was measured in 227 out of the 447 pneumonia patients and in all healthy subjects. We used clinical indicators (fever, time for defeverscence, heart and breath rate, saturation, and length of antibiotic treatment and of hospitalization) and laboratory indicators (CRP, procalcitonin, white blood cell count, and sodium) to assess the CAP severity. The finding were that the suPAR concentration in children with pneumonia was significantly higher (median 7.11 ng/mL) than in healthy individuals (4.68 ng/mL). We found a positive correlation between the suPAR and the following factors: fever, time for defeverscence, length of hospital stay, and elevated CRP and procalcitonin levels. There was a reverse correlation with sodium concentration and capillary blood saturation. Moreover, the suPAR level was significantly higher in children with a severe course of pneumonia compared with those having non-severe pneumonia (7.79 vs. 6.87 ng/mL; p = 0.006). In conclusion, suPAR elevation is observed in pneumonia and may reflect its severity.