Immune function in patients with acute pancreatitis

The Emerging Roles of the Adaptive Immune Response in Acute Pancreatitis

Acute pancreatitis (AP) is an abrupt, variable inflammatory condition of the pancreas, potentially escalating to severe systemic inflammation, rampant pancreatic necrosis, and multi-organ failure. Its complex pathogenesis involves an intricate immune response, with different T cell subsets (Th1, Th2, Th9, Th17, Th22, TFH, Treg, and CD8+ T cells) and B cells playing pivotal roles. Early T cell activation initiates the AP development, triggering cytokines associated with the Th1 response, which stimulate macrophages and neutrophils. Other T cell phenotypes contribute to AP's pathogenesis, and the balance between pro-inflammatory and anti-inflammatory cytokines influences its progression. Regulatory T and B cells are crucial for moderating the inflammatory response and promoting immune tolerance. B cells further contribute through antibody production, antigen presentation, and cytokine secretion. Understanding these immune cells' roles in AP could aid in developing new immunotherapies to enhance patient outcomes. However, further research is required to define these cells' precise roles in AP and their potential as therapeutic targets.

Fire in the belly: A scoping review of the immunopathological mechanisms of acute pancreatitis

Introduction

Acute pancreatitis (AP) is characterised by an inflammatory response that in its most severe form can cause a systemic dysregulated immune response and progression to acute multi-organ dysfunction. The pathobiology of the disease is unclear and as a result no targeted, disease-modifying therapies exist. We performed a scoping review of data pertaining to the human immunology of AP to summarise the current field and to identify future research opportunities.

Methods

A scoping review of all clinical studies of AP immunology was performed across multiple databases. Studies were included if they were human studies of AP with an immunological outcome or intervention.

Results

205 studies met the inclusion criteria for the review. Severe AP is characterised by significant immune dysregulation compared to the milder form of the disease. Broadly, this immune dysfunction was categorised into: innate immune responses (including profound release of damage-associated molecular patterns and heightened activity of pattern recognition receptors), cytokine profile dysregulation (particularly IL-1, 6, 10 and TNF-α), lymphocyte abnormalities, paradoxical immunosuppression (including HLA-DR suppression and increased co-inhibitory molecule expression), and failure of the intestinal barrier function. Studies including interventions were also included. Several limitations in the existing literature have been identified; consolidation and consistency across studies is required if progress is to be made in our understanding of this disease.

Conclusions

AP, particularly the more severe spectrum of the disease, is characterised by a multifaceted immune response that drives tissue injury and contributes to the associated morbidity and mortality. Significant work is required to develop our understanding of the immunopathology of this disease if disease-modifying therapies are to be established.

Preventive and therapeutic significance of octreotide combined with lansoprazole on post-ERCP pancreatitis and its effect on serum amylase, inflammatory factors and immune function

The study aimed to investigate the preventive and therapeutic significance of octreotide combined with lansoprazole on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and its effects on serum amylase (AMS), inflammatory factors and immune function. A total of 132 patients who underwent ERCP in Shaoxing People's Hospital (Shaoxing, China) were enrolled in the study and allocated into two groups: The study group (octreotide plus lansoprazole, 68 cases) and the control group (octreotide alone, 64 cases). The incidence of PEP and post-ERCP hyperamylasemia (PEH), the concentrations of serum AMS, interleukin-17 (IL-17) and tumor necrosis factor-α (TNF-α), as well as the T-lymphocyte population in peripheral blood were detected. The AMS levels in the study group were significantly lower than those in the control group at 6 and 24 h after treatment (P<0.001). The incidence of PEP and PEH, symptom disappearance time and hospital stay in the study group were significantly lower than those in the control group after treatment (P<0.05). The levels of IL-17 and TNF-α in the study group were significantly lower than those in the control group after treatment (all P<0.05). The percentage of CD3⁺, CD4⁺, CD8⁺ cells and the ratio of CD4⁺/CD8⁺ in the study group were significantly higher than those in the control group after treatment (all P<0.05). The results indicated that octreotide combined with lansoprazole reduces AMS levels and the incidence of PEP, alleviates inflammation and improves the immune function.

Thymosin alpha 1 in the prevention of infected pancreatic necrosis following acute necrotising pancreatitis (TRACE trial): protocol of a multicentre, randomised, double-blind, placebo-controlled, parallel-group trial

INTRODUCTION

Infected pancreatic necrosis (IPN) and its related septic complications are the major causes of death in patients with acute necrotising pancreatitis (ANP). Therefore, the prevention of IPN is of great clinical value, and immunomodulatory therapy with thymosin alpha 1 may be beneficial. This study was designed to test the hypothesis that the administration of thymosin alpha 1 during the acute phase of ANP will result in a reduced incidence of IPN.

METHODS AND ANALYSIS

This is a randomised, multicentre, double-blind, placebo-controlled study. 520 eligible patients with ANP will be randomised in a 1:1 ratio to receive either the thymosin alpha 1 or the placebo using the same mode of administration. The primary endpoint is the incidence of IPN during the index admission. Most of the secondary endpoints will be registered within the index admission including in-hospital mortality, the incidence of new-onset organ failure and new-onset persistent organ failure (respiration, cardiovascular and renal), receipt of new organ support therapy, requirement for drainage or necrosectomy, bleeding requiring intervention, human leucocyte antigens-DR(HLA-DR) on day 0, day 7, day 14, and so on and adverse events. Considering the possibility of readmission, an additional follow-up will be arranged 90 days after enrolment, and IPN and death at day 90 will also be served as secondary outcomes.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee of Jinling Hospital, Nanjing University (Number 2015NZKY-004-02). The thymosin alpha 1 in the prevention of infected pancreatic necrosis following acute necrotising pancreatitis(TRACE) trial was designed to test the effect of a new therapy focusing on the immune system in preventing secondary infection following ANP. The results of this trial will be disseminated in peer-reviewed journals and at scientific conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02473406).

Alcohol and Smoking Mediated Modulations in Adaptive Immunity in Pancreatitis

Pancreatitis is a condition of pancreatic inflammation driven by injury to the pancreatic parenchyma. The extent of acinar insult, intensity, and type of immune response determines the severity of the disease. Smoking, alcohol and autoimmune pancreatitis are some of the predominant risk factors that increase the risk of pancreatitis by differentially influencing the adaptive immune system. The overall decrease in peripheral lymphocyte (T-, B- and (natural killer T-) NKT-cell) count and increased infiltration into the damaged pancreatic tissue highlight the contribution of adaptive immunity in the disease pathology. Smoking and alcohol modulate the responsiveness and apoptosis of T- and B-cells during pancreatic insult. Acute pancreatitis worsens with smoking and alcohol, leading to the development of systemic inflammatory response syndrome and compensatory anti-inflammatory response syndrome, suggesting the critical role of adaptive immunity in fatal outcomes such as multiple organ dysfunction. The presence of CD4⁺ and CD8⁺ T-lymphocytes and perforin-expressing cells in the fibrotic tissue in chronic pancreatitis modulate the severity of the disease. Due to their important role in altering the severity of the disease, attempts to target adaptive immune mediators will be critical for the development of novel therapeutic interventions.

Circulating Lymphocyte Subsets Induce Secondary Infection in Acute Pancreatitis

Acute pancreatitis (AP) is considered a cascade of immune responses triggered by acinar cell necrosis. AP involves two main processes of systemic inflammatory response syndrome and subsequent compensatory anti-inflammatory response syndrome. Although great efforts have been made regarding AP therapy, the mortality rate of AP remains high. Secondary infection acts a lethal factor in AP. Lymphocytes act as major immune mediators in immune responses in the course of this disease. However, the relationship between lymphocytes and secondary infection in AP is unclear. This review summarizes the variation of lymphocytes and infection in AP. Knowledge of the characterization of circulating lymphocyte abnormalities is relevant for understanding the pathophysiology of AP.

Azithromycin does not improve disease severity in acute experimental pancreatitis

Acute pancreatitis is a severe systemic disease triggered by a sterile inflammation and initial local tissue damage of the pancreas. Immune cells infiltrating into the pancreas are main mediators of acute pancreatitis pathogenesis. In addition to their antimicrobial potency, macrolides possess anti-inflammatory and immunomodulatory properties which are routinely used in patients with chronic airway infections and might also beneficial in the treatment of acute lung injury. We here tested the hypothesis that the macrolide antibiotic azithromycin can improve the course of acute experimental pancreatitis via ameliorating the damage imposed by sterile inflammation, and could be used as a disease specific therapy. However, our data show that azithromycin does not have influence on caerulein induced acute pancreatitis in terms of reduction of organ damage, and disease severity. Furthermore Infiltration of immune cells into the pancreas or the lungs was not attenuated by azithromycin as compared to controls or ampicillin treated animals with acute experimental pancreatitis. We conclude that in the chosen model, azithromycin does not have any beneficial effects and that its immunomodulatory properties cannot be used to decrease disease severity in the model of caerulein-induced pancreatitis in mice.

Decreased levels of regulatory B cells in patients with acute pancreatitis: association with the severity of the disease

Early stratification of the severity of acute pancreatitis (AP) is clinically important. Regulatory B cells have been found to be associated with disease activity of autoimmune diseases. However, the role of Regulatory B cells in AP remains unknown. We investigate the dynamic longitudinal changes in circulating IL-10-producing B cells (B10) and memory CD19+CD24hiCD27hi cells in patients with AP to evaluate their prediction utility for AP severity. B10, CD19+CD24hiCD27hi cells, inflammatory markers and cytokines were detected in patients with AP immediately after admission to the hospital (day 1), then on the third and seventh days. We observed decreases in lymphocytes, CD19+, B10, CD19+CD24hiCD27hi cells and lower mean fluorescence intensity (MFI) of CD80 and CD86 on B10 or CD19+CD24hiCD27hi cells in patients with AP, especially in those with severe acute pancreatitis (SAP). CD19+CD24hiCD27hi cells from patients with AP suppressed the cytokine productions of CD4+ T cells and CD14+ monocytes, but had impaired ability to induce regulatory T cells response. B10 and CD19+CD24hiCD27hi cells significantly increased in patients with mild acute pancreatitis (MAP) from day 1 to day 7, whereas these indexes remained stable in patients with SAP. B10 or CD19+CD24hiCD27hi cells were negatively correlated with the severity index (APACHE II score), inflammatory markers (C-reactive protein, CD64 index), and cytokines (IL-6, IL-17, TNF-α). Furthermore, receiver operating characteristic (ROC) curve analysis revealed that B10 and CD19+CD24hiCD27hi cells could predict the development of SAP. Thus, the detection of B10 and CD19+CD24hiCD27hi cells may be a practical way to improve the early assessment of AP severity.

Adaptive Immune Cell Dysregulation and Role in Acute Pancreatitis Disease Progression and Treatment

Acute pancreatitis (AP) is an inflammation of the pancreas caused by various stimuli including excessive alcohol consumption, gallstone disease and certain viral infections. Managing specifically the severe form of AP is limited due to lack of an understanding of the complex immune events that occur during AP involving immune cells and inflammatory molecules such as cytokines. The relative abundance of various immune cells resulting from the immune dysregulation drives disease progression. In this review, we examine the literature on the adaptive immune cells in AP, the prognostic value of these cells in stratifying patients into appropriate care and treatment strategies based on cell frequency in different AP severities are discussed.

Different phenotypes of monocytes in patients with new-onset mild acute pancreatitis

AIM

To evaluate the numbers of different subsets of monocytes and their associations with the values of clinical measures in mild acute pancreatitis (MAP) patients.

METHODS

The study included one group of 13 healthy controls and another group of 24 patients with new-onset MAP. The numbers of different subsets of monocytes were examined in these two groups of subjects by flow cytometry. The concentrations of plasma interleukin (IL)-10 and IL-12 were determined by cytometric bead array. The acute physiology and chronic health evaluation (APACHE) II scores of individual patients were evaluated, and the levels of plasma C-reactive protein (CRP) as well as the activities of amylase and lipase were measured.

RESULTS

In comparison with that in the controls, significantly increased numbers of CD14+CD163-, CD14+CD163-MAC387+ M1 monocytes, but significantly reduced numbers of CD14+CD163+IL-10+ M2 monocytes were detected in the MAP patients (P < 0.01 or P < 0.05). Furthermore, significantly higher levels of plasma IL-10 and IL-12 were observed in the MAP patients (P < 0.01 for all). More importantly, the levels of plasma CRP were positively correlated with the numbers of CD14+CD163- (R = 0.5009, P = 0.0127) and CD14+CD163-MAC387+ (R = 0.5079, P = 0.0113) M1 monocytes and CD14+CD163+CD115+ M2 monocytes (R = 0.4565, P = 0.0249) in the patients. The APACHE II scores correlated with the numbers of CD14+CD163+CD115+ (R = 0.4581, P = 0.0244) monocytes and the levels of plasma IL-10 (R = 0.4178, P = 0.0422) in the MAP patients. However, there was no significant association among other measures tested in this population.

CONCLUSION

Increased numbers of CD14+CD163- and CD14+ CD163-MAC387+ monocytes may contribute to the pathogenesis of MAP, and increased numbers of CD14+CD163+CD115+ monocytes may be a biomarker for evaluating the severity of MAP.

Hydroxyethyl starch resuscitation downregulate pro-inflammatory cytokines in the early phase of severe acute pancreatitis: A retrospective study

In the present study, we investigated the effects of hydroxyethyl starch (HES) 130/0.4 on serum pro-inflammatory variables, immunologic variables, fluid balance (FB)-negative(-) rate and renal function in severe acute pancreatitis (SAP) patients. From October, 2007 to November, 2008, a total of 120 SAP patients were enrolled in this retrospective study. Fifty-nine patients in the HES group received 6% HES 130/0.4 combined with crystalloid solution for fluid resuscitation (HES group). In the control group, 61 patients received only crystalloid solution after admission. Interleukin (IL)-1, IL-6, IL-8 and tumor necrosis factor (TNF)-α levels in serum were measured on days 1, 2, 4 and 8. The peripheral blood CD4+CD8+ T lymphocyte rates, serum BUN and Cr values were also measured on days 1, 4 and 8. Patients with FB(-) rates were recorded from day 1 to 8. Interaction term analysis (hospital stay and fluid resuscitation methods) based on mixed-effects regression model revealed significantly lower levels of IL-1 and TNF-α in the HES group compared with the control group. The difference in curve's risk ratio was not significant for IL-6, CD4+CD8+ T lymphocyte rate, BUN and Cr values (P>0.05). In the HES group, we detected a significantly higher rate of patients with FB(-) from day 4 to 8 (P<0.05). Thus, HES 130/0.4 resuscitation could decrease the IL-1 and IL-8 levels, shorten the duration of positive FB, and preserve the patient's immune status as well as renal function during the early phase of SAP.

The Reduction of Peripheral Blood CD4+ T Cell Indicates Persistent Organ Failure in Acute Pancreatitis

OBJECTIVE

Few data are available on the potential role of inflammatory mediators and T lymphocytes in persistent organ failure (POF) in acute pancreatitis (AP). We conducted a retrospective study to characterize their role in the progression of POF in AP.

METHODS

A total of 69 AP patients presented within 24 hours from symptom onset developing organ failure (OF) on admission were included in our study. There were 39 patients suffering from POF and 30 from transient OF (TOF). On the 1st, 3rd and 7th days after admission, blood samples were collected for biochemical concentration monitoring including serum IL-1β, IL-6, TNF-α and high-sensitivity C-reactive protein (hs-CRP). The proportions of peripheral CD4(+) and CD8(+) T lymphocytes were assessed based on flow cytometry simultaneously.

RESULTS

Patients with POF showed a significantly higher value of IL-1β and hs-CRP on day 7 compared with the group of TOF (P < 0.05). Proportions of CD4(+) T cells on days 1, 3, 7 and CD4(+)/ CD8(+) ratio on day 1 were statistically lower in the group of POF patients (P < 0.05). A CD4(+) T cell proportion of 30.34% on day 1 predicted POF with an area under the curve (AUC) of 0.798, a sensitivity with 61.54% and specificity with 90.00%, respectively.

CONCLUSIONS

The reduction of peripheral blood CD4(+) T lymphocytes is associated with POF in AP, and may act as a potential predictor.

Overexpression of Fas and FasL is associated with infectious complications and severity of experimental severe acute pancreatitis by promoting apoptosis of lymphocytes

This study investigated the relationship of Fas and Fas ligand (FasL) expression and apoptosis of lymphocytes in relation to the pathogenic immune response and infectious complications observed in experimental severe acute pancreatitis in mice. Forty male Balb/c mice were randomly divided into control, mild (MAP), and severe acute pancreatitis (SAP) groups. Overexpression of Fas/FasL messenger ribonucleic acid (mRNA) and protein was observed in spleen-derived lymphocytes in SAP (p < 0.01). Apoptosis of these resulted in a depletion of circulating lymphocytes in this group (p < 0.05). A further significant change in the SAP group with infectious complications was observed. A positive relationship was found between the Fas/FasL expression and lymphocyte apoptosis, and negative relationships were observed between Fas/FasL expression and CD4⁺ and CD19⁺ lymphocytes and the CD4⁺/CD8⁺ ratio in SAP mice (p < 0.01). The results suggest that the overexpression of Fas/FasL is associated with infectious complications and severity of experimental severe acute pancreatitis by promoting apoptosis of lymphocytes.

Immunomodulatory therapies for acute pancreatitis

It is currently difficult for conventional treatments of acute pancreatitis (AP), which primarily consist of anti-inflammatory therapies, to prevent the progression of AP or to improve its outcome. This may be because the occurrence and progression of AP, which involves various inflammatory cells and cytokines, includes a series of complex immune events. Considering the complex immune system alterations during the course of AP, it is necessary to monitor the indicators related to immune cells and inflammatory mediators and to develop more individualized interventions for AP patients using immunomodulatory therapy. This review discusses the recent advances in immunomodulatory therapies. It has been suggested that overactive inflammatory responses should be inhibited and excessive immunosuppression should be avoided in the early stages of AP. The optimal duration of anti-inflammatory therapy may be shorter than previously expected (< 24 h), and appropriate immunostimulatory therapies should be administered during the period from the 3^rd d to the 14^th d in the course of AP. A combination therapy of anti-inflammatory and immune-stimulating drugs would hopefully constitute an alternative to anti-inflammatory drug monotherapy. Additionally, the detection of the genotypes of critical inflammatory mediators may be useful for screening populations of AP patients at high risk of severe infections to enable the administration of early interventions to improve their prognosis.

p8 Deficiency causes siderosis in spleens and lymphocyte apoptosis in acute pancreatitis

OBJECTIVES

The gene p8 was initially described in pancreatic tissue during acute experimental pancreatitis, a disease that is characterized by a systemic immune response. Although early reports suggested that p8 affects leukocyte migration during acute pancreatitis (AP), no studies revealing its immune-modulatory effects have been performed.

METHODS

We investigated the composition of the cellular immune system in naive p8 knockout (p8(−/−)) mice and compared with matched wild-type mice during pancreatitis.

RESULTS

In young mice, there were no relevant differences in the composition of peripheral and splenic CD3(+), CD3(+)CD4(+), CD3(+)CD8(+), CD11b(+)Gr-1(-), and Gr-1 cells. In mature p8(−/−) mice, increased splenic CD4CD25FoxP3 cells, spleen siderosis, and increased marginal zones in the splenic white pulp were found. During AP, peripheral and splenic CD3(+) and CD3CD4 declined stronger in the p8(−/−) mice. The spleen of the p8(−/−) mice showed severe hypoplasia of the white pulp and mild hyperplasia of the red pulp. This was associated with a significantly increased rate of apoptosis.

CONCLUSIONS

We conclude that p8 has no impact on the cellular composition of the adaptive and innate immune systems in noninflammatory conditions. However, it may limit apoptosis and maintain homeostasis of the immune reaction during AP.

The role of Fas expression on the occurrence of immunosuppression in severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis (SAP) is a dangerous illness with high mortality where most patients do not die of excessive inflammation, but die of immunosuppression and multiple infections at a later stage. The mechanism of immunosuppression in SAP is unknown.

AIM

The purpose of this study was to analyze the role of Fas expression on the occurrence of immunosuppression in patients with SAP.

METHODS

Forty-eight patients with pancreatitis were divided into two groups: 20 cases with SAP (7 cases with sepsis, 13 cases without sepsis) and 28 cases with mild acute pancreatitis (MAP). Twenty-eight healthy volunteers were selected as controls. Fas mRNA expression in peripheral blood was detected by qPCR and Fas protein of lymphocyte membranes; T lymphocyte subsets and expression of monocyte Human leukocyte antigen DR (HLA-DR) in peripheral blood were detected by flow cytometry.

RESULTS

Compared with MAP and control groups, expression level of Fas mRNA and lymphocyte Fas protein in peripheral blood were significantly increased in the SAP group (all P < 0.01). There was a further significant increase in the SAP group with sepsis compared to those without sepsis (all P < 0.01). The CD4(+) T cell ratio, CD4(+)/CD8(+) ratio and monocyte HLA-DR expression in the SAP group were decreased significantly compared with MAP and control groups (all P < 0.01). Significant negative relationships were observed between Fas mRNA expression and CD4(+) T-cell ratio, CD4(+)/CD8(+) ratio, and monocyte HLA-DR expression in SAP patients with sepsis (all P < 0.05).

CONCLUSIONS

The results suggest that expression level of Fas is related to severity and immune status of pancreatitis. Overexpression of Fas may lead to the occurrence of immunosuppression and sepsis.

Effects of early enteral nutrition on immune function of severe acute pancreatitis patients

AIM: To investigate the effects of early enteral nutrition (EEN) on the immune function and clinical outcome of patients with severe acute pancreatitis (SAP).

METHODS: Patients were randomly allocated to receive EEN or delayed enteral nutrition (DEN). Enteral nutrition was started within 48 h after admission in EEN group, whereas from the 8^th day in DEN group. All the immunologic parameters and C-reactive protein (CRP) levels were collected on days 1, 3, 7 and 14 after admission. The clinical outcome variables were also recorded.

RESULTS: Sixty SAP patients were enrolled to this study. The CD4+ T-lymphocyte percentage, CD4+/CD8+ ratio, and the CRP levels in EEN group became significantly lower than in DEN group from the 7^th day after admission. In contrast, the immunoglobulin G (IgG) levels and human leukocyte antigen-DR expression in EEN group became significantly higher than in DEN group from the 7^th day after admission. No difference of CD8+ T-lymphocyte percentage, IgM and IgA levels was found between the two groups. The incidences of multiple organ dysfunction syndrome, systemic inflammatory response syndrome, and pancreatic infection as well as the duration of intensive care unit stay were significantly lower in EEN group than in DEN group. However, there was no difference of hospital mortality between the two groups.

CONCLUSION: EEN moderates the excessive immune response during the early stage of SAP without leading to subsequent immunosuppression. EEN can improve the clinical outcome, but not decrease the hospital mortality of SAP patients.

Correlation of Fas expression and apoptosis of lymphocytes with occurrence of sepsis in patients with severe acute pancreatitis

AIM: To investigate Fas expression and apoptosis of lymphocytes in severe acute pancreatitis (SAP) patients with and without sepsis.

METHODS: Fas expression and apoptosis of lymphocytes were examined by flow cytometry. Serum soluble Fas (sFas) levels were measured by enzyme-linked immunosorbent assay (ELISA) in 18 SAP patients (10 cases with sepsis, 8 cases without sepsis), 20 patients with mild acute pancreatitis (MAP), and 20 healthy volunteers (control).

RESULTS: Compared to the MAP and control groups, Fas expression, apoptosis of lymphocytes, and serum sFas levels increased significantly in the SAP group (all P < 0.01), and these changes were more significant in SAP patients with sepsis than in those without sepsis (38.37% ± 4.33% vs 26.34% ± 2.65%, 13.45% ± 2.99% vs 6.33% ± 2.05%, 9.89 ng/mL ± 1.25 ng/mL vs 7.36 ng/mL ± 0.95 ng/mL, all P < 0.01). There was no significant difference in Fas expression, apoptosis of lymphocytes, and serum sFas levels between the normal control group and MAP group. A significant positive relationship was observed between Fas expression and apoptosis of lymphocytes in SAP patients with sepsis (r = 0.988, P < 0.01).

CONCLUSION: The Fas signaling pathway may be involved in apoptosis of lymphocytes and is closely related to the severity of pancreatitis. Excessive apoptosis of lymphocytes appears to be related to immunosuppression and thereby results in the occurrence and development of sepsis in SAP patients.

Clinical observation of immunity in patients with secondary infection from severe acute pancreatitis

OBJECTIVES

To observe immune system changes in patients with secondary infection from severe acute pancreatitis (SAP).

METHODS

Seventy-nine patients were recruited. The percentages of CD4+, CD8+, natural killer (NK), HLA-DR+ cells and B lymphocytes, and the CD4+/CD8+ ratio, were determined. In addition, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), and interleukin-4 (IL-4) serum levels were determined on days 1, 7, 14, and 28.

RESULTS

Fifteen patients had a secondary infection. The immune response of the infected group was quite different from the non-infected group, with a higher percentage of CD4+ and HLA-DR+ cells on days 1, 7, 14 and 28, a higher percentage of CD8+ and NK cells on days 14 and 28, a reduced CD4+/CD8+ ratio, and a reduction in B lymphocytes. The cytokine levels in the infected group were different from the non-infected group, with a rise in TNF-α and IL-6 through the first 2 weeks, but dropping at 1 month. IL-10 and IL-4 increased initially, but then dropped over the next 3 weeks.

CONCLUSIONS

An early excessive immune response followed by a subsequent immune deficiency is closely related to secondary SAP infection.

Clinical observation of immunity for severe acute pancreatitis

The aim of our study was to observe the dynamic changes of immunity for patients with severe acute pancreatitis (SAP) and intervention by traditional Chinese medicine. Twenty-three patients who met the inclusion criteria were randomized to combined treatment of traditional Chinese medicine and Western medicine (TCM) or conventional western medicine treatment (WM) groups. The clinical data for all patients were collected. Peripheral venous blood samples were obtained from patients on days 1, 7, 14, and 28 after admission. Biochemical data including the percentage of CD4+/CD8+/natural killer (NK) cells/B lymphocytes/HLA-DR and CD4+/CD8+ ratio in serum were determined by flow cytometer. Patients' characteristics and immunity at admission were similar between the two groups. The secondary infection was different. The levels of T-lymphocyte subsets in the TCM group were quite different from the WM group, with much more the percentage of CD4+ and the CD4+/CD8+ ratio on days 7, 14, and 28 and much less the percentage of CD8+ on days 4 and 28. On days 14 and 28, the levels of NK cells and B lymphocytes were significantly higher in the TCM group compared with the controls. Compared with the TCM group, the levels of HLA-DR were significantly decreased in the WM group on days 7, 14, and 28. The immune dysregulation exists in the development and progression of SAP. The combined treatment of traditional Chinese medicine and western medicine can upregulate the patient's immune and maintain the immune balance.

Admission levels of soluble CD137 are increased in patients with acute pancreatitis and are associated with subsequent complications

The progression of acute pancreatitis to necrotizing pancreatitis which often results in high morbidity and mortality is difficult to predict. Here we report that serum concentrations of sCD137 are increased in patients with acute pancreatitis. Admission levels and 10-day median sCD137 levels positively correlate with markers of biliary pancreatitis and the 10-day sCD137 median is significantly higher in metabolic than in alcoholic pancreatitis. Serum concentrations of sCD137 at time of admission and the 10-day median of sCD137 correlate with the Ranson and APACHE II disease scores but not with the radiological Balthazar and Schroeder scores that reflect pancreatic and peripancreatic necrosis. Further, sCD137 levels correlate with the probability of complications and lethality. The association of sCD137, a product of activated T cells, with the severity of acute pancreatitis suggests that T cells contribute to the pathogenesis of acute pancreatitis.

Thymosin alpha 1 is associated with improved cellular immunity and reduced infection rate in severe acute pancreatitis patients in a double-blind randomized control study

The aim of this prospective, double-blinded pilot trial study was to evaluate the effects of Thymosin alpha 1 use in the early phase on immunomodulation and clinical outcomes in patients with severe acute pancreatitis (SAP). A total of 24 patients with SAP were randomized to receive either conventional therapy for SAP or immunomodulatory therapy (TA1 group). The patients in the thymosin group were injected with Talpha1 3.2 mg twice per day for 7 days. The serum level of HLA-DR and CD4/CD8 ratio and other immune parameters were measured on admission, the 8th day and the 28th day. There was a low expression of monocyte HLA-DR in both groups on admission, and more rapid alterations in the HLA-DR were found in the TA1 group. The positive rates of blood and abdominal drainage culture were statistically significant during the 28th follow-up period. The duration of ICU stay was shorter after TA1 treatment. Improves cell-induced immunity and reduces infection rate in severe acute pancreatitis patients.

Combined perioperative plasma endoglin and VEGF--a assessment in colorectal cancer patients

Colorectal cancer growth and spread is absolutely dependent on angiogenesis with vascular endothelial growth factor (VEGF) being the most important cytokine involved in the process. Endoglin, a membrane co-receptor for TGF-beta, has recently emerged as a sensitive index of cancer stage. There is now sufficient evidence indicating that microvessel density assessed by endoglin-immunostaining can correlate with stage of colorectal cancer and patient survival. An association of a soluble form of endoglin with lymph node and distant metastases has recently been reported in two studies. Both of them used local elaborated immunoassays for endoglin assessment. The aim of our study was to determine the efficacy of plasma endoglin, assessed using a commercial kit, as a marker of tumor spread and distant metastases in colorectal cancer patients. We studied 48 colorectal cancer patients, compared with 22 healthy subjects, using ELISA. We observed that colorectal cancer patients had increased plasma VEGF-A, but not endoglin levels. However, we found an association of plasma endoglin with the stage of malignancy. Endoglin levels were increased in metastasis-positive patients when compared to both metastasis-negative patients and healthy volunteers. Plasma endoglin correlated with VEGF-A, CEA and CA19.9. Endoglin assessment in plasma does not seem useful as a maker of colorectal cancer. Our observations indicate however that it might be helpful in selecting patients with metastatic disease.

Effect of diet-induced obesity on acute pancreatitis induced by administration of interleukin-12 plus interleukin-18 in mice

Obesity is associated with increased severity of acute pancreatitis (AP). We recently developed a model of AP induced by administration of interleukin (IL)-12+IL-18, two cytokines that are elevated in patients with AP. In this model, severe AP develops in obese leptin-deficient ob/ob mice compared to lean littermates. In the present report, we evaluated the pancreatic response of diet-induced obesity (DIO) mice to IL-12+IL-18. Body weight loss and adipose tissue necrosis were more severe and prolonged in cytokine-injected DIO compared to lean mice. Edematous AP developed in lean mice, whereas DIO mice developed necrotizing AP. Obese DIO mice developed more severe hypocalcemia, increased liver damage and a heightened acute-phase response compared to lean mice, although leukopenia and thrombocytopenia were of comparable severity in lean and DIO mice. Serum levels of IL-6, IL-10, and IL-22 were significantly higher in DIO compared to lean mice, whereas interferon-gamma and tumor necrosis factor-alpha did not differ between the two groups. In conclusion, obesity induced by high-fat diet is associated with increased disease severity and duration in the model of AP induced by administration of IL-12+IL-18.

Protection of Salvia miltiorrhizae to the spleen and thymus of rats with severe acute pancreatitis or obstructive jaundice

OBJECTIVE

To investigate the therapeutic effects and mechanism of Salvia miltiorrhizae in the treatment of SAP and OJ.

METHODS

A total of 288 rats were used for SAP- and OJ-associated experiments. The rats were randomly divided into sham-operated group, model control group and treated group. The mortality rates of rats, contents of endotoxin and PLA(2) in blood, pathological changes of different indexes in spleen and thymus were observed.

RESULTS

The contents of endotoxin and PLA2 in treated group were significantly lower than those in model control group.The pathological severity scores of spleen and thymus of SAP rats as well as that of spleen of OJ rats in treated groups were significantly lower than those in model control groups (P < .05). The staining intensity as well as the product of the staining intensity and positive rate of Bax protein of spleen in model control group were significantly higher than those in treated groups (P < .01) , and the apoptosis index of spleen in treated group was significantly lower than that in model control group (P < .01).

CONCLUSION

Salvia miltiorrhizae exerts protective effects on the spleen and thymus of SAP rats and spleen of OJ rats.

Study of the protective effects of dexamethasone on ileum mucosa injury in rats with severe acute pancreatitis

OBJECTIVES

To study the protecting effects of dexamethasone on ileum mucosa injury of rats with severe acute pancreatitis (SAP).

METHODS

The SAP rats were prepared by improved Aho's methods. The plasma endotoxin and inflammatory mediators in serum were determined. The rat mortality, pathological changes of terminal ileum, nuclear factor kappa B (NF-kappaB), apoptotic indexes, and apoptotic related protein expression were observed.

RESULTS

The plasma endotoxin, inflammatory mediators, and NF-kappaB protein expression as well as pathological scores of the treatment group of ileum mucosa were lower than those of the model group at different time points. P selectin in model group significantly exceeded the dexamethasone treatment group at 3 and 6 hours (P < 0.01, P < 0.05). Caspase-3 protein expression in dexamethasone treatment group significantly exceeded the model group at 3 and 6 hours (P < 0.05), and apoptotic indexes were higher than those of the model group at 6 hours (P < 0.05), but Bax protein has shown no marked difference among groups.

CONCLUSIONS

Dexamethasone can reduce the endotoxin level and inflammatory mediators and down-regulate NF-kappaB protein expression of ileum mucosa, and ileum mucosa epithelial cell apoptosis induction was involved as well. The tissue microarrays technique is of advantage in SAP study.

Influence of dexamethasone on mesenteric lymph node of rats with severe acute pancreatitis

AIM: To study the influence and mechanisms of dexamethasone on mesenteric lymph node of rats with severe acute pancreatitis (SAP).

METHODS: The SAP rats were assigned to model, treated or sham-operated groups. The mortality, pathological changes of mesenteric lymph nodes, expression levels of NF-κB, P-selectin, Bax, Bcl-2 and caspase-3 protein and changes in apoptotic indexes in lymph nodes were observed at 3, 6 and 12 h after operation. The blood levels of endotoxin, superoxide dismutase (SOD), malondialdehyde (MDA), and endothelin-1 (ET-1) in blood were determined.

RESULTS: SOD content, expression of Bax protein and apoptotic index were significantly higher in the treated group than in the model group at different time points (P < 0.05 or P < 0.01). Other blood-detecting indexes and histopathological scores of mesenteric lymph nodes were lower in the treated than in the model group (P < 0.05, P < 0.01 or P < 0.01). NF-κB protein expression was negative in all groups. Comparing P-selectin and caspase-3 expression levels among all three groups, there was no marked difference between the model and treated group.

CONCLUSION: Dexamethasone can protect mesenteric lymph nodes. The mechanism may be by reducing the content of inflammatory mediators in the blood and inducing lymphocyte apoptosis.

Interleukin-18, together with interleukin-12, induces severe acute pancreatitis in obese but not in nonobese leptin-deficient mice

Obesity is associated with increased severity of acute pancreatitis (AP). The cytokines IL-18 and IL-12 are elevated in patients with AP, and IL-18 levels are high in obesity. We aimed to develop a pathologically relevant model to study obesity-associated severe AP. Lean WT and obese leptin-deficient ob/ob mice received two injections of IL-12 plus IL-18. Survival, pancreatic inflammation, and biochemical markers of AP were measured. Dosing with IL-12 plus IL-18 induced 100% lethality in ob/ob mice; no lethality was observed in WT mice. Disruption of pancreatic exocrine tissue and acinar cell death as well as serum amylase and lipase levels were significantly higher in ob/ob than in WT mice. Edematous AP developed in WT mice, whereas obese ob/ob mice developed necrotizing AP. Adipose tissue necrosis and saponification were present in cytokine-injected ob/ob but not in WT mice. Severe hypocalcemia and elevated acute-phase response developed in ob/ob mice. The cytokine combination induced high levels of regenerating protein 1 and pancreatitis-associated protein expression in the pancreas of WT but not of ob/ob mice. To differentiate the contribution of obesity to that of leptin deficiency, mice received short- and long-term leptin replacement therapy. Short-term leptin reconstitution in the absence of major weight loss did not protect ob/ob mice, whereas leptin deficiency in the absence of obesity resulted in a significant reduction in the severity of the pancreatitis. In conclusion, we developed a pathologically relevant model of AP in which obesity per se is associated with increased severity.

Protecting effects of dexamethasone on thymus of rats with severe acute pancreatitis

Purpose. To study the protecting effects of dexamethasone on thymus of rats with severe acute pancreatitis (SAP). Methods. The SAP rats were randomly assigned to the model group and dexamethasone-treated group, the other normal healthy rats were assigned to the sham operation group. The rat survival, thymus pathological changes, apoptotic index, as well as expression levels of NF-κB, P-selectin, Bax, Bcl-2, and Caspase-3 protein of all groups were observed, respectively, at 3 hours, 6 hours, and 12 hours. The contents of amylase and endotoxin in plasma as well as the contents of TNF-α, PLA2, and NO in serum were determined. Results. There was no marked difference between the model group and treated group in survival. The contents of different indexes in blood of treated group were lower than those of the model group to various degrees at different time points. The thymus pathological score was lower in treated group than in model group at 12 hours.The treated group in Caspase-3 protein expression of thymus significantly exceeded the model group at 12 hours. The apoptotic index was significantly higher in treated group than in model group. Conclusion. Dexamethasone has protecting effects on thymus of SAP rats.

Dynamic changes in the levels of serum interleukin-2 and interleukin-10 and the expression of Fas in the intestinal mucosa of rats with severe acute pancreatitis

AIM: To investigate the dynamic changes in the levels of serum interleukin (IL)-2 and IL-10 sFas and IL-2/IL-10 in rats with severe acute pancreatitis (SAP), and to explore the expression of Fas in the intestinal mucosa of rats with severe acute pancreatitis.

METHODS: A total of 64 Sprague-Dawley (SD) rats were randomly divided into normal control group and SAP group. A SAP model was induced by injection of 50 g/L sodium taurocholate under the pancreatic membrane. The normal control group received isovolumetric injection of 9 g/L physiological saline solution using the same method. Blood samples from the rats in each group were obtained via the superior mesenteric vein to measure the levels of IL-2, IL-10 and sFas, and to calculate the value of IL-2/IL-10. The levels of IL-2, IL-10 and sFas were determined by ELISA. The severity of pancreas and intestinal mucosal injury was evaluated by pathologic score. The expression of Fas in intestinal mucosal tissue was determined by immunohistochemistry.

RESULTS: The levels of serum IL-2 in the SAP group were significantly higher than those in the normal control group at 0.5 h after injury (3.53 ± 0.62 ng/L vs 2.79 ± 0.51 ng/L, 4.35 ± 1.11 ng/L vs 2.93 ± 0.89 ng/L, 6.94 ± 1.55 ng/L vs 4.81 ± 1.23 ng/L, 4.80 ± 1.10 ng/L vs 3.41 ± 0.72 ng/L, P < 0.01) and peaked at 6 h after injury. The levels of serum IL-10 in the SAP group were significantly higher than those in the normal control group at 6 h after injury (494.98 ± 11.23 ng/L vs 89.18 ± 32.52 ng/L, 93.28 ± 25.81 ng/L vs 77.15 ± 22.60 ng/L, P < 0.01). The IL-2/IL-10 ratio in the SAP group was significantly higher than that in the normal control group at 0.5 h and 2 h after injury, and significantly lower than that in the normal control group at 6 h after injury (P < 0.01), after which this ratio returned to the control level (P > 0.05). The pathological changes were significantly aggravated in the SAP group compared with the normal group. Immunohistochemistry staining showed. Fas from normal intestinal tissue. Fas expression in intestinal tissue gradually increased 0.5 h after the induction of pancreatitis, and its a peak at 12 h after induction.

CONCLUSION: Fas is involved in the pathogenesis of pancreatitis-associated intestinal injury. The mechanisms underlying this involvement of Fas may be related to Fas-mediated T helper cell apoptosis.

Thymosin alpha 1 improves severe acute pancreatitis in rats via regulation of peripheral T cell number and cytokine serum level

AIM

The aim of this study was to investigate the effect of thymosin alpha 1 (TA1) on severe acute pancreatitis (SAP) in rats.

METHODS

Healthy Sprague-Dawley rats (n = 72) were randomly divided into four groups: control group, SAP group, and two TA1 treated groups. SAP was induced by injection of 5% sterile sodium taurocholate into the biliopancreatic duct (BPD), after which TA1 was given subcutaneously at 0 and 2 h at a dose of 100 microg/kg. The rats were killed at 3, 6 and 12 h, respectively. Serum amylase and lipase, interleukin (IL)-1beta, tumor necrosis factor-alpha (TNF-alpha), pancreatic wet/dry weight ratio and the percentage of CD3/CD4+/CD8+ T cells in peripheral blood mononuclear cells (PBMC) were measured. Next, 30 rats were randomly divided into three groups (each group containing 10 animals): SAP group (S) and two TA1 treated groups. The effects of TA1 on the survival of SAP were assessed 72 h after the induction of SAP.

RESULTS

There was no significant change in the serum amylase and lipase levels after TA1 administration. Levels of serum IL-1beta, TNF-alpha and pancreatic wet/dry weight ratio were significantly reduced after TA1-treatment. Application of TA1 significantly balanced CD3/CD4+/CD8+ T cells of PBMC and improved histological scores and the survival rate.

CONCLUSION

TA1 can reduce pancreatic inflammation by regulating differentiation of CD3/CD4+ T cells and decreasing the release of cytokines, thus attenuates pancreatic severity in SAP rats.

Serum immunosuppressive acidic protein levels in patients with severe acute pancreatitis

OBJECTIVES

In severe acute pancreatitis (SAP), immunologic impairment in the early phase may be linked to subsequent infectious complications. Immunosuppressive acidic protein (IAP) is an immunosuppressive factor to be present in serum and ascites of cancer patients, and it is used as a tumor marker and an index of immune status of cancer hosts.

METHODS

We measured serum IAP levels in 42 patients with SAP (Japanese severity score [JSS] > or = 2) on admission and analyzed the relationships with disease severity, pancreatic necrosis, blood biochemical parameters on admission, and clinical outcome (infection and death).

RESULTS

Serum IAP level increased 791 +/- 285 microg/mL (range, 159-1430 microg/mL) on admission and recognized abnormal high level (normal range, < 500 microg/mL) in 37 patients (88.1%). Serum IAP level was significantly lower in patients of stages 3 and 4 (JSS > or = 9) (678 +/- 187 microg/mL) than that in patients of stage 2 (2 < or = JSS < or = 8) (848 +/- 311 microg/mL). It was also significantly lower in patients whose Ranson score was 5 or higher (674 +/- 287 microg/mL) than that in patients whose Ranson score was 4 or less (910 +/- 287 microg/mL). Moreover, it was significantly lower in patients with pancreatic necrosis (693 +/- 194 microg/mL) than that in patients without pancreatic necrosis (922 +/- 336 microg/mL). Among the blood biochemical parameters on admission, serum IAP was significantly negatively correlated with hematocrit, serum lipase, and serum interferon gamma and was significantly positively correlated with serum total protein. Serum IAP levels in patients of stage 2 reached higher peak at 7 days after admission and decreased more rapidly than those in patients of stages 3 and 4.

CONCLUSIONS

Serum IAP levels were elevated in patients with SAP but were significantly lower in patients with higher grade of severity or pancreatic necrosis. These results suggest that serum IAP levels may be related to systemic inflammatory response and reflect the immunoresponsiveness in patients with SAP.

[Cytokines and other immunological parameters as markers of distant organ involvement in acute pancreatitis]

BACKGROUND AND OBJECTIVE

There is a role of immunologic proinflammatory mediators in pathogenesis of distant organ disfunction in acute pancreatitis (AP). The aim is to evaluate the relationship between those mediators and liver, kidney and lung disfunction in patients with AP.

PATIENTS AND METHOD

On the day of admission in 34 patients with AP, biochemical parameters of liver function, creatinine and arterial partial pressure of oxygen (PO2) were determined, and cut points were established. Soluble tumor necrosis factor receptor I (sTNFRI), interleukin (IL) 1 receptor antagonist (IL-1Ra), IL-6, soluble IL-6 receptor (sIL-6R), IL-18, and intercellular adhesion molecule-1 (ICAM-1) were determined on days 1, 2, 3 and 7, and were compared between patients with biochemical parameters and PO2 on admission higher or lower than an established cut point.

RESULTS

Levels of sTNFRI, IL-18 and ICAM-1 were significantly higher and sustained, and IL-6 only the first day, in patients with parameters of liver function above the cut point. sTNFRI, IL-1Ra and ICAM-1 early showed significantly higher levels in relation with serum creatinine, and these and also IL-6 in those with PO2 below 60 mmHg.

CONCLUSIONS

sTNFRI, IL-6, IL-18 and ICAM-1 behaved as early markers of hepatic alteration, sTNFRI, IL-1Ra and ICAM-1 of renal disfunction and these and IL-6 of lung injury.

Effect of somatostatin on immune inflammatory response in patients with severe acute pancreatitis

OBJECTIVE

Somatostatin regulates immune inflammatory response via apoptosis and adhesion of leukocytes in many diseases. This article reported a study that aimed to observe the mechanism and effect of somatostatin on the immune inflammatory response through apoptosis and adhesion of leukocytes in severe acute pancreatitis.

METHODS

Thirty-eight patients with severe acute pancreatitis, that fulfilled the guidelines for the treatment of severe acute pancreatitis of China and Balthazar computed tomography severity index (>or=5) were enrolled consecutively. Nineteen of these patients received our routine treatment and 19 received additional somatostatin. In all patients the expressions of CD4, CD8, CD95/CD95 ligand and CD18/CD62 ligand on leukocytes were determined by flow cytometry, both upon admission and on the fourth day. Thirty healthy volunteers constituted the normal healthy group.

RESULTS

In the treatment group, CD4, CD4:CD8 ratio and CD62 ligand on leukocytes increased from 11.4+/-8.2, 0.47+/-0.10 and 25.5+/-9.2 to 22.1+/-9.7, 0.68+/-0.11 and 36.2+/-11.7 (P<0.05) respectively, while CD95 ligand on both lymphocyte and polymorphonuclear cells increased from 0.65+/-0.21 and 0.76+/-0.29 to 1.18+/-0.32 and 1.58+/-0.43 after treatment with somatostatin (P<0.05). Furthermore, lactate dehydrogenase, aspartate aminotransferase, amylase, C reactive protein and acute physiology and chronic healthy evaluation (APACHE II) score in the treatment group reduced faster than those in the control group (P<0.05), though there was no difference in mortality (15.7% vs 5.3%) between the two patient groups (P>0.05).

CONCLUSION

Somatostatin can modulate the immune inflammatory response and the severity of severe acute pancreatitis through apoptosis and adhesion of leukocytes, but this modulatory effect by itself is not strong enough to improve the final.

Protective effects of ulinastatin on proliferation and cytokine release of splenocytes from rats with severe acute pancreatitis

AIM

To clarify the contributions of ulinastatin to cellular immune responses in vivo, we examined the functional alterations of splenocytes and quantitatively evaluated the effects of ulinastatin on the splenocyte function during experimental severe acute pancreatitis.

METHODS

Severe acute pancreatitis was induced in rats by retrograde injection of 3% sodium deoxycholate. Thirty minutes after induction of pancreatitis, the rats were randomly assigned to four groups, receiving either saline or 50,000 U/kg of ulinastatin, respectively. Splenocytes were obtained aseptically and stimulated with concanavalin A for 24 h. Then the proliferative activity of cultured splenocytes was measured by using an MTT cellular proliferation assay, and the cytokine concentrations in the culture supernatants were measured by enzyme-linked immunosorbent assays.

RESULTS

Upon stimulation, the release of interleukin-2, interleukin-10, and interferon-gamma was significantly decreased in the splenocytes from rats with pancreatitis as compared with those from sham operation and control groups. The splenocyte proliferation was also significantly suppressed in this group. In contrast, the proliferative as well as the cytokine-releasing capacities of the splenocytes from rats treated with ulinastatin were significantly increased as compared with those from rats with pancreatitis.

CONCLUSIONS

The deficiencies in proliferation and cytokine release in response to antigen stimulation demonstrated an anergic state of splenocytes during severe acute pancreatitis. Treatment with ulinastatin contributed to the recovery of the immune function by improving proliferative responses and cytokine release of splenocytes. These data suggest that a protease-modulating therapy may be an effective strategy for the treatment of immunosuppression induced by severe acute pancreatitis.

Effect of Ginkgolide B on plasma levels of cytokines in severe acute pancreatitis in rats

AIM: To observe the level changes of tumor necrosis factor-alpha (TNF-α), platelet activating factor (PAF), interleukin-10 (IL-10), interleukin-12 (IL-12) and soluble TNF receptors (sTNFR) in rats with severe acute pancreatitis (SAP) and the influences of Ginkgolide B (BN52021) on the changes.

METHODS: Male Wistar rats were randomly divided into 3 groups: SAP model group (SAP, n = 15), BN52021 treatment group (BN, n = 15) and negative control group (NC, n = 15). SAP was induced by retrograde infusion of 50 g/L sodium taurocholate into the pancreatic duct of rats. Sham operation was performed in the rats of NC group, while the rats in SAP and NC groups received the femoral vein injection of normal saline (5 mL/kg) 15 min after induction of SAP. Moreover, the rats in BN group received BN52021 injection instead of normal saline. After operation, the animals were sacrificed at 1^st, 6^th and 12^th h for plasma cytokines detection with enzyme-linked immunosorbent assay (ELISA).

RESULTS: The levels of plasma TNF-α and PAF were significantly higher in SAP group than those in NC group (746.2 ± 374.1 ng/L vs 385.1 ± 86.3 ng/L, P<0.05; 82.5 ± 35.4 ng/L vs 1.1 ± 1.9 ng/L, P<0.05), but they were significantly decreased in BN group (503.7 ± 177.9, 39.9 ± 29.9 ng/L)(both P<0.05). The levels of plasma sTNFR were 50.0 ± 21.0, 488.7 ± 363.8, and 883.4 ± 552.5 ng/L in NC, SAP and BN group, respectively, and there were significant differences among them (P<0.05). Plasma IL-12 level was markedly increased in SAP group as compared with that in NC group (97.1 ± 55.9 ng/L vs 20.4 ± 19.4 ng/L, P<0.05), while it was further increased at the 1^st h in BN group as compared with that in SAP group (133.5 ± 33.4 ng/L vs 55.9 ± 14.7 ng/L, P<0.05). The level of IL-10 was not significant different among the three groups (P > 0.05).

CONCLUSION: The plasma levels of pro- and anti-cytokines are increased in SAP rats, and BN52021 can inhibit the production of pro-cytokines and promote the secretion of anti-cytokines such as IL-12 and sTNFR to some extent.

Immunosuppression in patients with severe acute pancreatitis

BACKGROUND

In severe acute pancreatitis (SAP), immunologic impairment in the early phase may be linked to subsequent infectious complications. In this study, immunologic alterations in patients with SAP were analyzed, and immunologic parameters related to infectious complications were clarified.

METHODS

A total of 101 patients with SAP were analyzed retrospectively. Various immunologic parameters on admission were analyzed and compared between the infection group and noninfection group during SAP. Furthermore, chronologic change in the lymphocyte count was investigated, and its utility for predicting infection was compared with conventional scoring systems.

RESULTS

Serum immunoglobulin G (IgG), serum IgM, lymphokine-activated killer cell activity, and natural killer cell activity were low, and the incidence of abnormally low values was 50.0%, 65.0%, 45.5%, and 42.4%, respectively. Serum complement factor 3 was significantly negatively correlated with the APACHE II score. The lymphocyte count was decreased below the normal range, and was significantly negatively correlated with the APACHE II score. CD4-, CD8-, and CD20-positive lymphocyte counts were below the normal range, and CD4- and CD8-positive lymphocyte counts were significantly lower in the infection group. The lymphocyte count on day 14 after admission was significantly lower in the infection group and was more useful for predicting infection than conventional scoring systems.

CONCLUSIONS

Immunosuppression occurs from the early phase in SAP, and quantitative impairment of lymphocytes, mainly T lymphocytes, may be closely related to infectious complications during SAP. CD4- and CD8-positive lymphocyte counts on admission and the lymphocyte count on day 14 after admission may be useful for predicting infection.

Effects of immunosuppressive and immunostimulative treatment on pancreatic injury and mortality in severe acute experimental pancreatitis

OBJECTIVES

Acute pancreatitis is associated with substantial alterations of the immunologic host response which has been claimed to promote remote organ dysfunction, septic complications, and mortality. Treatment with immunomodulating substances has been subject of few experimental studies with still conflicting results.

METHODS

We used the taurocholate-induced model of severe acute pancreatitis (SAP) in rats which were assigned to different treatment regimen: isotonic saline (SAP-S) for nontreated controls, recombinant rat interferon-gamma for immunostimulation (SAP-IFN-gamma), and FK506 for immunosuppression (SAP-FK506). Animals were killed after 3, 6, and 24 hours as well as 3 and 7 days, and parameters of local and systemic severity were assessed.

RESULTS

Treatment with IFN-gamma and FK506 attenuated the progression of intrapancreatic necrosis within the first 24 hours after pancreatitis induction along with a substantial reduction of subsequent neutrophil tissue infiltration as shown by decreased myeloperoxidase activity. Enhanced cell death by apoptosis during the postacute course was reduced in FK506-treated animals only. Pancreatic interleukin (IL) 1beta messenger RNA up-regulation occurred early and was slightly suppressed in both treatment groups; tumor necrosis factor alpha (TNF-alpha) and IL-2 messenger RNA expression paralleled the onset of apoptosis and was markedly decreased in IFN-gamma- and FK506-treated rats. The 2 therapeutic regimens had similar effects on intrapancreatic and systemic IL-1beta and TNF-alpha protein release; however, the profiles of both cytokines were differently influenced. Whereas IFN-gamma and FK506 treatment lead to an enhanced intrapancreatic and systemic TNF-alpha protein release during the early course, IL-1beta concentrations were significantly reduced within the late intervals. Seven-day mortality was 44% in saline-, 29% in IFN-gamma-, and 25% in FK506-treated rats (P = not significant).

CONCLUSIONS

Severe acute pancreatitis is associated with early alterations of the immune response comprising overt T-cell activation and impaired monocyte/macrophage function alike. Targeting either immunologic derangement improves local pancreatic damage and systemic severity. However, because mortality was not improved, a therapeutic benefit of immunomodulating substances in clinical SAP remains to be defined.

A case of severe acute pancreatitis, in overlap syndrome of systemic sclerosis and systemic lupus erythematosus, successfully treated with plasmapheresis

Here, we describe a case of severe pancreatitis in overlap syndrome of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) in an adult female patient. Treatment with plasmapheresis and high-dose prednisone successfully saved her life and led to remission of the pancreatitis. This is the first case report of severe acute pancreatitis in the setting of overlap syndrome of SLE and SSc. The advantages and disadvantages of the use of corticosteroids are discussed.

Correlation of interleukin-12 and interleukin-6 with severity of experimental acute necrotizing pancreatitis

AIM: To investigate the change of serum interleukin-12 (IL-12) and interleukin-6 (IL-6) concentrations and the correlation with the severity of pancreas damages in experimental acute necrotizing pancreatitis (ANP).

METHODS: Ninety-two Spraque-Dawley rats were randomly divided into ANP (group A, n = 36), IL-10-interfering (group I, n = 32) and control group (group C, n = 24). Rats in group A and I were injected intraperitoneally with 6% L-Arginine (3×1.0 mg/g) three times at an interval of 1 hour to induce ANP and those in group C received saline intraperitoneal injection only. Rats in Group I were treated with recombinment human IL-10 at 2^th, 5^th and 8^th hour (10 000 U for each time) after the L-arginine injection. Rats were killed at 4^th, 12^th, 24^th and 36^th hour after the last L-arginine injection. The pathological characteristics of the pancreas observed under light microscope. Serum amylase, IL-12 and IL-6 concentrations were detected by substrate-enzyme technique and ELISA respectively.

RESULTS: The pathological scores of pancreas, the concentrations of serum amylase, IL-12 and IL-6 in rats of group A were markedly higher than group C (24 h, serum amylase: 3 264.89±1 627.18 vs 364.61±64.24, P<0.01; IL-12: 104.68±23.93 vs 56.72±22.67 pg/L, P<0.01; IL-6: 132.95±26.64 vs 81.90±9.93 pg/L, P<0.01). After administration of IL-10, the pathological scores of pancreas, the concentrations of serum amylase, IL-12 and IL-6 in were significantly decreased in group I as compared with those in group A (24 h, pathological scores: 4.75±1.75 vs 7.89±1.17, P<0.01; serum amylase: 1 481.13±336.48 vs 3 264.89±1 627.18, P<0.01; IL-12: 81.31±17.23 vs 104.68±23.93 pg/L, P<0.05; IL-6: 96.80±18.28 vs 132.95±26.64 pg/L, P<0.01). The concentration of IL-12 was positively correlated with pathological scores of pancreas (r = 0.603, P<0.001) and serum amylase concentration (r = 0.323, P<0.05), but had no marked relations with IL-6 concentration (P>0.05).

CONCLUSION: The serum concentrations of IL-12 and IL-6 are markedly elevated in experimental ANP. The pancreatic damages are improved after IL-10 administration. Serum IL-12 is positively related to the severity of pancreatic damages.

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JAK and STAT proteins are expressed and activated by IFN-gamma in rat pancreatic acinar cells

The development of acute pancreatitis (AP) is triggered by acinar events, but the subsequent extra-acinar events, particularly a distinct immune response, appear to determine its severity. Cytokines modulate this immune response and are derived not only from immunocytes but also from pancreatic acinar cells. We studied whether pancreatic acinar cells were also capable of responding to cytokines. The JAK/STAT-pathway represents the main effector for many cytokines. Therefore, expression and regulation of JAK and STAT proteins were investigated in rat pancreatic acinar cells. Western blotting showed expression of JAK1, JAK2, Tyk2, and STAT1, STAT2, STAT3, STAT5, STAT6. In addition, STAT1 was reversibly tyrosine-phosphorylated upon the procedure of acinar cell isolation. In contrast, STAT3-phosphorylation occurred spontaneously after pancreas removal and was not reversible within 8 h. STAT1 phosphorylation was also observed upon treatment with IFN-gamma but not upon EGF, TNF-alpha or IL-6, and inhibited by the JAK2-inhibitor AG-490. Immunohistochemistry revealed cytoplasmic expression of unphosphorylated STAT1 in untreated acinar cells and nuclear translocation of phosphorylated STAT1 following IFN-gamma-treatment. Interestingly, although CCK leads to the activation of multiple stress pathways in pancreatic acinar cells, we found no influence of CCK on phosphorylation of STAT1, STAT3, or STAT5 in the pancreas. In conclusion, our data provide further evidence that pancreatic acinar cells are able to interact with immune cells. Besides stimulating immune cells via cytokine secretion, acinar cells are in turn capable of responding to IFN-gamma via JAK2 and STAT1 which may have an impact on the development of AP.

High-dose allopurinol for prevention of post-ERCP pancreatitis: a prospective randomized double-blind controlled trial

BACKGROUND

Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Allopurinol, a xanthine oxidase inhibitor that blocks generation of oxygen-derived free radicals, potentially may prevent post-ERCP pancreatitis. This study assessed the efficacy of high-dose oral allopurinol for prevention of post-ERCP pancreatitis.

METHODS

A prospective, double-blind, placebo-controlled trial was conducted in 250 patients undergoing ERCP. Patients were randomized to receive allopurinol (600 mg) or placebo orally at 15 and 3 hours before the procedure. Patients were clinically evaluated, and serum amylase levels were determined before ERCP and at 6 and 24 hours thereafter. Standardized criteria were used to diagnose and to grade the severity of post-ERCP pancreatitis.

RESULTS

A total of 243 patients were included in the analysis. The two groups were similar with regard to age; gender; underlying disease; indication for treatment; ERCP findings; and type of treatment, except for biliary sphincterotomy. Only 43 patients in the allopurinol group underwent biliary sphincterotomy vs. 87 in the placebo group ( p < 0.001). The frequency of acute pancreatitis was significantly lower in the allopurinol vs. the placebo group in the final multinomial regression analysis: allopurinol group, 4/125 (3.2%), with all 4 cases graded as mild, vs. placebo group, 21/118 (17.8%), of which 8/118 (6.8%) were graded as mild, 11/118 (9.3%) as moderate, and 2/118 (1.6%) as severe with fatal outcome ( p < 0.001). The protective effect of allopurinol was also apparent in the diagnostic ERCP and the biliary sphincterotomy subgroups when the frequency of post-ERCP pancreatitis was analyzed after stratification by procedure. The mean duration of hospitalization for pancreatitis was significantly shorter in the allopurinol compared with the placebo group (2.5 vs. 5.67 days; p < 0.001).

CONCLUSIONS

Pretreatment with high-dose, orally administered allopurinol decreases the frequency of post-ERCP pancreatitis. Despite the promising results of this prospective, randomized trial, further studies are needed to verify these observations before allopurinol can be recommended for routine clinical use.

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