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Lin MJ, Su TH, Liu CJ, Yang HC, Chen CL, Liou JM, Tseng TC, Liu CH, Hong CM, Chen PJ, Kao JH. Serum cytokine profiles predict outcomes of chronic hepatitis B patients discontinuing entecavir or tenofovir therapy. J Formos Med Assoc 2023; 122:564-573. [PMID: 36872131 DOI: 10.1016/j.jfma.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND/PURPOSE Distinct hepatitis relapse has been observed after discontinuing entecavir (ETV) or tenofovir disoproxil fumarate (TDF) therapy in chronic hepatitis B (CHB) patients. End-of-therapy (EOT) serum cytokines were compared and used for outcome prediction. METHODS A total of 80 non-cirrhotic CHB patients in a tertiary medical center in Taiwan who discontinued ETV (n = 51) or TDF (n = 29) therapy after fulfilling the APASL guidelines were prospectively enrolled. Serum cytokines were measured at EOT and 3rd month afterwards. Multivariable analysis was performed to predict virological relapse (VR, HBV DNA >2000 IU/mL), clinical relapse (CR, VR and alanine aminotransferase > 2-fold upper limit of normal) and hepatitis B surface antigen (HBsAg) seroclearance. RESULTS Compared with TDF group, ETV stoppers had greater interleukin 5 (IL-5), IL-12 p70, IL-13, IL-17 A and tumor necrosis factor alpha (TNF-alpha) (all P < 0.05) at EOT. Older age, TDF use, higher EOT HBsAg and IL-18 (Hazard ratio [HR], 1.01; 95% CI, 1.00-1.02) levels at EOT predicted VR, while older age, higher EOT HBsAg and IL-7 (HR, 1.25; 95% CI, 1.00-1.56) levels predicted CR. In TDF stoppers, higher IL-7 (HR, 1.29; 95% CI, 1.05-1.60) and IL-18 (HR, 1.02; 95% CI, 1.00-1.04) levels predicted VR, while IL-7 (HR, 1.34; 95% CI, 1.08-1.65) and interferon-gamma (IFN-gamma) (HR, 1.08; 95% CI, 1.02-1.14) levels predicted CR. A lower EOT HBsAg level was associated with HBsAg seroclearance. CONCLUSION Distinct cytokine profiles were observed after stopping ETV or TDF. Higher EOT IL-7, IL-18, and IFN-gamma could be probable predictors for VR and CR in patients discontinuing NA therapies.
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Affiliation(s)
- Meng-Ju Lin
- School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chun-Jen Liu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hung-Chih Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Ling Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jyh-Ming Liou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai-Chung Tseng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chen-Hua Liu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Ming Hong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Jer Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Kao J, Reid N, Hubbard RE, Homes R, Hanjani LS, Pearson E, Logan B, King S, Fox S, Gordon EH. Frailty and solid-organ transplant candidates: a scoping review. BMC Geriatr 2022; 22:864. [PMID: 36384461 PMCID: PMC9667636 DOI: 10.1186/s12877-022-03485-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates. METHODS A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria. RESULTS We found that studies used a wide range of frailty tools (N = 22), including four 'established' frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population. CONCLUSION Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.
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Affiliation(s)
- Jonathan Kao
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland, Australia.
- Geriatrics and Rehabilitation Unit, Building 7 Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD, 4102, Australia.
| | - Natasha Reid
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Ruth E Hubbard
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland, Australia
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Ryan Homes
- School of Biomedical Science, The University of Queensland, Queensland, Australia
| | - Leila Shafiee Hanjani
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Ella Pearson
- School of Biomedical Science, The University of Queensland, Queensland, Australia
| | - Benignus Logan
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
| | - Shannon King
- North Metropolitan Health Service, WA Health, Western Australia, Australia
| | - Sarah Fox
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
- The Prince Charles Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Emily H Gordon
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland, Australia
- Centre for Health Services Research, The University of Queensland, Queensland, Australia
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Granata N, Vigoré M, Steccanella A, Ranucci L, Sarzi Braga S, Baiardi P, Pierobon A. The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review. Front Med (Lausanne) 2022; 9:967952. [PMID: 36052327 PMCID: PMC9425100 DOI: 10.3389/fmed.2022.967952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs). Methods An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs. Findings After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%). Discussion CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.
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Affiliation(s)
- Nicolò Granata
- Department of Cardiac Respiratory Rehabilitation of Tradate Institute, Istituti Clinici Scientifici Maugeri IRCCS, Varese, Italy
| | - Martina Vigoré
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
- *Correspondence: Martina Vigoré
| | - Andrea Steccanella
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
| | - Luca Ranucci
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
| | - Simona Sarzi Braga
- Cardio-vascular Department, MultiMedica IRCCS, Sesto San Giovanni, Italy
| | - Paola Baiardi
- Central Scientific Direction, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Antonia Pierobon
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
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Li T, Ning N, Li B, Luo D, Qin E, Yu W, Wang J, Yang G, Nan N, He Z, Yang N, Gong S, Li J, Liu A, Sun Y, Li Z, Jia T, Gao J, Zhang W, Huang Y, Hou J, Xue Y, Li D, Wei Z, Zhang L, Li B, Wang H. Longitudinal Metabolomics Reveals Ornithine Cycle Dysregulation Correlates With Inflammation and Coagulation in COVID-19 Severe Patients. Front Microbiol 2021; 12:723818. [PMID: 34925252 PMCID: PMC8678452 DOI: 10.3389/fmicb.2021.723818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023] Open
Abstract
COVID-19 is a severe disease in humans, as highlighted by the current global pandemic. Several studies about the metabolome of COVID-19 patients have revealed metabolic disorders and some potential diagnostic markers during disease progression. However, the longitudinal changes of metabolomics in COVID-19 patients, especially their association with disease progression, are still unclear. Here, we systematically analyzed the dynamic changes of the serum metabolome of COVID-19 patients, demonstrating that most of the metabolites did not recover by 1-3 days before discharge. A prominent signature in COVID-19 patients comprised metabolites of amino acids, peptides, and analogs, involving nine essential amino acids, 10 dipeptides, and four N-acetylated amino acids. The levels of 12 metabolites in amino acid metabolism, especially three metabolites of the ornithine cycle, were significantly higher in severe patients than in mild ones, mainly on days 1-3 or 4-6 since onset. Integrating blood metabolomic, biochemical, and cytokine data, we uncovered a highly correlated network, including 6 cytokines, 13 biochemical parameters, and 49 metabolites. Significantly, five ornithine cycle-related metabolites (ornithine, N-acetylornithine, 3-amino-2-piperidone, aspartic acid, and asparagine) highly correlated with "cytokine storms" and coagulation index. We discovered that the ornithine cycle dysregulation significantly correlated with inflammation and coagulation in severe patients, which may be a potential mechanism of COVID-19 pathogenicity. Our study provided a valuable resource for detailed exploration of metabolic factors in COVID-19 patients, guiding metabolic recovery, understanding the pathogenic mechanisms, and creating drugs against SARS-CoV-2 infection.
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Affiliation(s)
- Tao Li
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Nianzhi Ning
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Bo Li
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Deyan Luo
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Enqiang Qin
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Wenjing Yu
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Jianxin Wang
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Guang Yang
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Nan Nan
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Zhili He
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Ning Yang
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Saisai Gong
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Jiajia Li
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Aixia Liu
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yakun Sun
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Zhan Li
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Tianye Jia
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Jie Gao
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Wang Zhang
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yanyu Huang
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Jun Hou
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Ying Xue
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Deyu Li
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Zhen Wei
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Liangyan Zhang
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Boan Li
- Department of Clinical Laboratory, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Hui Wang
- State Key Laboratory of Pathogens and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
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Beeckmans H, Bos S, Vos R. Selection Criteria for Lung Transplantation: Controversies and New Developments. Semin Respir Crit Care Med 2021; 42:329-345. [PMID: 34030197 DOI: 10.1055/s-0041-1728756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. The imbalance between limited availability and vast need of donor organs necessitates careful selection of recipient candidates, ensuring the best possible utilization of the scarce resource of organs. Nonetheless, possible lung transplant candidates who could experience a meaningful improvement in survival and quality of life should not be excluded solely based on the complexity of their case. In this review, controversial issues or difficult limitations for lung transplantation, and new developments in recipient selection criteria, are discussed, which may help broaden recipient eligibility for lung transplantation without compromising long-term outcomes.
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Affiliation(s)
- Hanne Beeckmans
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Saskia Bos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), BREATHE, Leuven, Belgium
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Frailty in Lung Transplantation - Candidate Assessment and Optimization. Transplantation 2021; 105:2201-2212. [PMID: 33982913 DOI: 10.1097/tp.0000000000003671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The concept of frailty has gained considerable interest in clinical solid organ transplantation over the past decade. Frailty as a phenotypic construct to describe a patient's risk from biologic stresses, has an impact on posttransplant survival. There is keen interest in characterizing frailty in lung transplantation, both to determine which patients are suitable candidates for listing and also to prepare for their care in the aftermath of lung transplantation. Here we review the current status of research on frailty in lung transplant candidates and recipients. This review will highlight areas of uncertainty for frailty in clinical lung transplantation which are likely to impact the state-of-the-art in the field for the next decade.
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Abstract
Frailty is a clinical state of vulnerability to stressors resulting from cumulative alterations in multiple physiological and molecular systems. Frailty assessment in patients with chronic disease is useful for identifying those who are at increased risk for poor clinical and patient reported outcomes. Due to biobehavioral changes purported to cause both frailty and certain chronic lung diseases, patients with lung disease appear susceptible to frailty and prone to developing it decades earlier than community dwelling healthy populations. Herein, we review the literature and potential pathobiological mechanisms underpinning associations between frailty in lung disease and age, sex, comorbidity and symptom burden, severity of lung disease, inflammatory biomarkers, various clinical parameters, body composition measures, and physical activity levels. We also propose a multipronged program of future research focused on improving the accuracy and precision of frailty measurement in lung disease, identifying blood-based biomarkers and measures of body composition for frailty, determining whether subphenotypes of frailty with distinct pathobiology exist, and developing personalized interventions that target the specific underlying mechanisms causing frailty.
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Stanjek-Cichoracka A, Woźniak-Grygiel E, Łaszewska A, Stącel T, Perć K, Zembala M, Ochman M. Interleukin 6 and Interleukin 10 in Patients Before and After Lung Transplantation. Transplant Proc 2020; 52:2098-2100. [PMID: 32307149 DOI: 10.1016/j.transproceed.2020.02.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
The aim of the study was to investigate the serum concentration of cytokines (interleukin 6 [IL-6] and IL-10) in patients before and after lung transplantation (LTx). The studied groups consisted of 14 patients (9 men and 5 women aged 47.7 ± 11.4; body mass index [BMI] 21.9 ± 2.3) followed for up to 6 months after LTx and 29 patients (15 men and 14 women, age 49.2 ± 9.4; BMI 23.1 ± 3.7) who were considered for LTx. The study population consisted of patients with idiopathic lung disease (ILD; 8 vs 17) and patients with chronic obstructive pulmonary disease (COPD; 6 vs 12). Cytokine serum levels were assessed using commercially available enzyme-linked immunosorbent assay kits. Significantly lower levels of IL-10 were observed in the group of patients considered for LTx compared to those in recipients (1.8 ± 0.99 vs 5.1 ± 1.44; P = .000726). Significantly lower levels of IL-10 were observed in the group of patients with ILD considered for LTx compared to recipients (1.8 ± 0.95 vs 3.4 ± 1.16; P = .005984). There were no differences in levels of IL-10 in the group of patients with COPD. There were no differences in levels of IL-6 when the studied groups were compared. The present results introduce the cytokines IL-6 and IL-10 in patients before and after LTx. The procedure of LTx influenced increasing of plasma concentration of IL-10. Immunosuppressive drugs may affect IL-10 serum levels. Further studies are needed to evaluate whether analyzed cytokines could be used as biomarkers of clinical status in patients before and after LTx.
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Affiliation(s)
- Anita Stanjek-Cichoracka
- Department of Biophysics, School of Pharmacy, Division of Laboratory Medicine, Medical University of Silesia in Katowice, Sosnowiec, Poland; Laboratory of Transplant Immunology, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | | | - Anna Łaszewska
- Laboratory of Transplant Immunology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Tomasz Stącel
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Krzysztof Perć
- Virogenetics Laboratory of Virology, Malopolska Center of Biotechnology Jagiellonian University, Kraków, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marek Ochman
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
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