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Jariyasakoolroj T, Chattipakorn SC, Chattipakorn N. Potential biomarkers used for risk estimation of pediatric sepsis-associated organ dysfunction and immune dysregulation. Pediatr Res 2024:10.1038/s41390-024-03289-y. [PMID: 38834784 DOI: 10.1038/s41390-024-03289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/03/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
Pediatric sepsis is a serious issue globally and is a significant cause of illness and death among infants and children. Refractory septic shock and multiple organ dysfunction syndrome are the primary causes of mortality in children with sepsis. However, there is incomplete understanding of mechanistic insight of sepsis associated organ dysfunction. Biomarkers present during the body's response to infection-related inflammation can be used for screening, diagnosis, risk stratification/prognostication, and/or guidance in treatment decision-making. Research on biomarkers in children with sepsis can provide information about the risk of poor outcomes and sepsis-related organ dysfunction. This review focuses on clinically used biomarkers associated with immune dysregulation and organ dysfunction in pediatric sepsis, which could be useful for developing precision medicine strategies in pediatric sepsis management in the future. IMPACT: Sepsis is a complex syndrome with diverse clinical presentations, where organ dysfunction is a key factor in morbidity and mortality. Early detection of organ complications is vital in sepsis management, and potential biomarkers offer promise for precision medicine in pediatric cases. Well-designed studies are needed to identify phase-specific biomarkers and improve outcomes through more precise management.
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Affiliation(s)
- Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Luo X, Zhou C, Ji C, Lu C, Luo Y, Chen Z, Zhong T, Ye R, Zeng L, Luo M. Hypofibrinogenemia is an independent predictor of hemophagocytic lymphohistiocytosis in children with sepsis. Sci Rep 2023; 13:17936. [PMID: 37863910 PMCID: PMC10589207 DOI: 10.1038/s41598-023-44628-z] [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: 10/26/2022] [Accepted: 10/10/2023] [Indexed: 10/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening condition in children with sepsis. We herein aimed to identify clinical and laboratory predictors of HLH in children with sepsis. We conducted a retrospective study of 568 children with sepsis admitted to Guangdong Women and Children Hospital from January 2019 to June 2022. HLH, while rare (6.34%), proved to be a highly fatal complication (37.14%) in children with sepsis. Children with HLH had higher levels of aspartate aminotransferase, lactate dehydrogenase, triglycerides, and ferritin than children without HLH; conversely, they displayed decreased levels of neutrophils, hemoglobin, platelets, fibrinogen, and albumin. Additionally, the HLH group showed higher rates of prolonged fever (> 10 days), hepatomegaly, and splenomegaly than the non-HLH group. Our retrospective analysis identified hypofibrinogenemia (OR = 0.440, P = 0.024) as an independent predictor for the development of HLH in patients with sepsis. The optimal cutoff value for fibrinogen was found to be < 2.43 g/L. The area under the curve for diagnosing HLH was 0.80 (95% confidence interval: 0.73-0.87, P < 0.0001), with a sensitivity of 72.41% and specificity of 76.27%. Thus, hypofibrinogenemia emerges as a potentially valuable predictor for HLH in children with sepsis.
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Affiliation(s)
- Xin Luo
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Chentao Zhou
- Laboratory Medicine, Medical College of Jiaying University, Guangzhou, 511400, People's Republic of China
| | - Cunwei Ji
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Chunmin Lu
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Yasha Luo
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Zhenhui Chen
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Tianhua Zhong
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Ruoting Ye
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Liwei Zeng
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China
| | - Mingyong Luo
- Department of Laboratory Medicine, Guangdong Women and Children Hospital, No. 453 Xing-nan Avenue, Guangzhou, 511400, People's Republic of China.
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Menon K, Sorce LR, Argent A, Bennett TD, Carrol ED, Kissoon N, Sanchez-Pinto LN, Schlapbach LJ, de Souza DC, Watson RS, Wynn JL, Zimmerman JJ, Ranjit S. Reporting of Social Determinants of Health in Pediatric Sepsis Studies. Pediatr Crit Care Med 2023; 24:301-310. [PMID: 36696549 PMCID: PMC10332854 DOI: 10.1097/pcc.0000000000003184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children. DATA SOURCES AND SELECTION We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis. DATA EXTRACTION Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories. DATA SYNTHESIS SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict. CONCLUSIONS We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis.
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Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Lauren R Sorce
- Ann & Robert H. Lurie Children's Hospital AND Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Tellen D Bennett
- Sections of Informatics and Data Science and Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Enitan D Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Niranjan Kissoon
- British Columbia Children's Hospital and The University of British Columbia, Vancouver, BC, Canada
| | - L Nelson Sanchez-Pinto
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, Children`s Research Center University Children's Hospital Zurich, Zurich, Switzerland
| | - Daniela C de Souza
- Child Health Research Centre, The University of Queensland, St Lucia, QLD, Australia
| | - R Scott Watson
- Departments of Pediatrics, Hospital Sírio-Libanês and Hospital Universitário da Universidade de São Paulo, São Paolo, Brazil
| | - James L Wynn
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Jerry J Zimmerman
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Florida, Gainesville, FL
| | - Suchitra Ranjit
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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Al-Kuraishy HM, Al-Gareeb AI, Al-Harcan NAH, Alexiou A, Batiha GES. Tranexamic Acid and Plasminogen/Plasmin Glaring Paradox in COVID-19. Endocr Metab Immune Disord Drug Targets 2023; 23:35-45. [PMID: 35927893 DOI: 10.2174/1871530322666220801102402] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/27/2022] [Accepted: 03/30/2022] [Indexed: 11/22/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by a severe acute respiratory syndrome, coronavirus type 2 (SARS-CoV-2), leading to acute tissue injury and an overstated immune response. In COVID-19, there are noteworthy changes in the fibrinolytic system with the development of coagulopathy. Therefore, modulation of the fibrinolytic system may affect the course of COVID-19. Tranexamic acid (TXA) is an anti-fibrinolytic drug that reduces the conversion of plasminogen to plasmin, which is necessary for SARS-CoV-2 infectivity. In addition, TXA has anti-inflammatory, anti-platelet, and anti-thrombotic effects, which may attenuate the COVID-19 severity. Thus, in this narrative review, we try to find the beneficial and harmful effects of TXA in COVID-19.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, AL-Mustansiriyiah University, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, AL-Mustansiriyiah University, Baghdad, Iraq
| | - Nasser A Hadi Al-Harcan
- Department of Clinical Pharmacology and Medicine, College of Medicine, Al-Rasheed University College, Baghdad, Iraq
| | - Athanasios Alexiou
- Department of Science and Engineering, Novel Global Community Educational Foundation, Hebersham, Australia.,AFNP Med Austria, Wien, Austria
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, AlBeheira, Egypt
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Prognostic Value of Albumin-to-Fibrinogen Ratio for 28-Day Mortality among Patients with Sepsis from Various Infection Sites. Mediators Inflamm 2022; 2022:3578528. [PMID: 35990041 PMCID: PMC9385315 DOI: 10.1155/2022/3578528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/25/2022] [Accepted: 07/05/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose This study investigated the prognostic value of the albumin-to-fibrinogen ratio (AFR) in patients with sepsis as a consequence of infection at various sites. Methods A total of 300 patients with sepsis caused by various infection sites, who met the diagnostic criteria for sepsis hospitalized in the intensive care unit, were enrolled in this study. The observational endpoint was 28-day mortality. Cox proportional hazard regression analysis was performed to determine the potential prognostic factors for 28-day mortality in these septic patients. Receiver operating characteristic (ROC) curve analysis was used to evaluate and compare the prognostic factors for 28-day mortality. Results Of 300 participants, 147 died, corresponding to a 28-day mortality of 49% (147/300). Baseline Acute Physiology and Chronic Health Evaluation (APACHE II) score (hazard ratio (HR) 1.18 (95% confidence interval (CI) 1.07–1.30); P < 0.001), baseline lactic acid level (HR 1.27 (95% CI 1.08–1.50); P = 0.005), the presence of septic shock (HR 21.44 (95% CI 2.51–182.76); P = 0.005), and baseline AFR (HR 0.70 (95% CI 0.62–0.80); P < 0.001) were independent prognostic factors for 28-day mortality in patients with sepsis according to multivariate Cox analysis. Baseline AFR was an effective predictor of 28-day mortality, with an area under the ROC curve (AUC) of 0.700, and a specificity and sensitivity of 90.8% and 42.1%, respectively. A low baseline AFR level was associated with increased 28-day sepsis-related mortality. The quadruple index, which included the APACHE II score, lactic acid, septic shock, and AFR, showed a more accurate predictive value for septic patients than the APACHE II score, lactic acid, septic shock, and AFR alone, with an AUC of 0.922, and specificity and sensitivity of 86.9% and 83.6%, respectively. Moreover, the triple index, which included the APACHE II score, lactic acid, and septic shock, showed a significantly lower prognostic value for 28-day mortality compared with the ROC curve of the quadruple index and triple index, with an AUC of 0.877 and specificity and sensitivity of 77.8% and 82.3%, respectively. Conclusions The results of this study demonstrate that AFR is an independent protective factor for predicting 28-day mortality in patients with sepsis due to various infection sites. AFR combined with the APACHE II score, lactic acid, and septic shock showed a higher prognostic value for sepsis prognosis.
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Zhang Q, Lin Y, Bao Y, Jin Y, Ye X, Tan Y. Analysis of Prognostic Risk Factors and Establishment of Prognostic Scoring System for Secondary Adult Hemophagocytic Syndrome. Curr Oncol 2022; 29:1136-1149. [PMID: 35200596 PMCID: PMC8871039 DOI: 10.3390/curroncol29020097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/30/2021] [Accepted: 02/07/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction: The objective of this paper is to identify the prognostic risk factors of secondary adult hemophagocytic syndrome (HLH) in hospitalized patients and establish a simple and convenient prognostic scoring system. Method:We reviewed 162 adult patients secondary with HLH treated in Zhejiang Cancer Hospital and the First Affiliated Hospital of Medical College of Zhejiang University from January 2014 to December 2018 were enrolled to form the test group; from January 2019 to February 2021, 162 adult patients in the hospitals constituted the validation group. The HLH prognosis scoring system was constructed according to the risk factors, and the patients were divided into three risk groups: low risk, medium risk, and high risk. The scoring system was verified by Kaplan–Meier method and log rank test survival analysis. The discrimination ability was evaluated according to the receiver operating characteristic (ROC) curve. Results: Univariate and multivariate analysis showed that the independent risk factors for the prognosis of HLH were male sex, activated partial prothrombin time (APTT) greater than 36 s, lactate dehydrogenase (LDH) greater than 1000 U/L, and C-reactive protein (CRP) greater than 100 mg/L. The area under the ROC curve was 0.754 (95% Cl: 0.678–0.829). The patients were divided into a low-risk group (0–1), a medium-risk group (2–4), and a high-risk group (5–6). The 5-year overall survival (OS) rate were 87.5%, 41.8% and 12.8%, respectively (p < 0.001). The area under ROC curve was 0.736 (95% Cl: 0.660–0.813) in the validation group, and the 2-year OS of patients in low-risk, medium-risk and high-risk groups were 88.0%, 45.1% and 16.7%, respectively (p < 0.001). Conclusion:The new prognostic scoring system can accurately predict the prognosis of secondary adult HLH and can further provide basis for the accurate treatment of secondary adult HLH.
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Affiliation(s)
- Qiaolei Zhang
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Youyan Lin
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Yejiang Bao
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Yuan Jin
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou 310058, China;
| | - Yamin Tan
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
- Correspondence:
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7
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Zhang L, Dai L, Li D. Risk factors of early death in pediatric hemophagocytic lymphohistocytosis: Retrospective cohort study. Front Pediatr 2022; 10:1031432. [PMID: 36340709 PMCID: PMC9634417 DOI: 10.3389/fped.2022.1031432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome in which early mortality remains high in patients with HLH. METHODS We retrospectively collected the medical records of all pediatric patients diagnosed with HLH at the West China Second Hospital of Sichuan University between January 2014 and December 2020. Collect demographic, laboratory, clinical, genetic profiles, treatment information and perform statistical analysis from records. Risk factors for death 30 days after admission were evaluated using a multivariable logistic regression model. RESULTS A total of 110 pediatric HLH patients were enrolled. The median age of patients was 44 months (IQR 23-100.5) and 62 (56.4%) in males. The 30-day mortality rate for admission to this cohort was 34 (30.9%). Multivariate logistic regression analysis showed that heart failure (OR = 13.389, 95% CI, 1.671-107.256, p = 0.015) and hypoproteinemia (OR = 4.841, 95% CI, 1.282-18.288, p = 0.020) were associated with increased early mortality in children with HLH. CONCLUSIONS These identified risk factors may help clinicians stratify patients with HLH and develop targeted treatment strategies. More research is needed to explore the best treatment strategies for patients with HLH to reduce early mortality in patients with HLH.
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Affiliation(s)
- Lijun Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Lei Dai
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Deyuan Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Elalfy MS, Ragab IA, AbdelAal NM, Mahfouz S, Rezk AR. Study of the diagnostic criteria for hemophagocytic lymphohistiocytosis in neonatal and pediatric patients with severe sepsis or septic shock. Pediatr Hematol Oncol 2021; 38:486-496. [PMID: 33622175 DOI: 10.1080/08880018.2021.1887983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Septic shock is a major public health concern. However, the clinical and laboratory criteria for sepsis overlap with those for hemophagocytic lymphohistiocytosis (HLH), and their differentiation can be challenging. The aim of this study was to compare HLH criteria among patients diagnosed with neonatal sepsis and childhood sepsis and to study the outcomes in patients fulfilling the diagnostic criteria for HLH. A cross-sectional study included 50 neonates and children with severe sepsis and/or septic shock. Clinical and laboratory data and HLH diagnostic criteria were studied in relation to patients outcome. Of all patients, 18% fulfilled three of the eight HLH diagnostic criteria, 2% fulfilled four criteria, and 4% fulfilled five criteria. All patients who fulfilled three or more of the criteria died. Mortality was higher in the presence of more positive HLH criteria and in pediatric age groups. However, the distributions of the HLH criteria were comparable for pediatric and neonatal patients with severe sepsis/septic shock, and their mortality rates were not significantly different when based on the criteria.
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Affiliation(s)
- Mohsen S Elalfy
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Iman A Ragab
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - NourEldin M AbdelAal
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Sara Mahfouz
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Ahmed R Rezk
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
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Abstract
SARS-CoV-2 has claimed 2,137,908 lives in more than a year. Some COVID-19 patients experience sudden and rapid deterioration with the onset of fatal cytokine storm syndrome (CSS), which have increased interest in CSS’s mechanisms, diagnosis and therapy. Although the prototypic concept of CSS was first proposed 116 years ago, we have only begun to study and understand CSS for less than 30 years. Actually, diseases under CSS umbrella include familial/primary and secondary hemophagocytic lymphohistiocytosis (HLH), macrophage activation syndrome (MAS), infection-associated hemophagocytic syndrome, cytokine release syndrome (CRS), and cytokine storm (CS). Hematologic malignancies and autoimmune diseases that cause CSS are named malignancy-associated hemophagocytic syndrome (MAHS) and MAS, respectively. In-depth research on the pathogenesis of HLH/CSS has greatly increased the number of patients that were able to be definitively diagnosed with HLH/CSS. However, it should be emphasized that HLH/CSS diagnosis is difficult at the early stages due to the non-specific clinical signs and symptoms, which tends to result in missed and incorrect diagnoses. Therefore, clinicians should not only possess extensive clinical experience to ensure high sensitivity to the characteristics of HLH/CSS but must also be familiar with HLH-2004/2009 diagnostic criteria, and HScore methods. The paper concisely comment evolution of CSS classifications, cytokines associated with CSS, evolution of CSS diagnostic criteria and importance of the correct identification of hemophagocytes in diagnosing CSS, which is timely and may benefit clinicians familiar HLH-2004/2009 diagnostic criteria, and HScore methods. In addition, clinicians must also understand that there are some limitations to these diagnostic criteria. Abbreviations: aBMT: autologous bone marrow transplantation; CAR-T: chimeric antigen receptor-engineered T-cell; COVID-19: coronavirus disease 2019; CSS: cytokine storm syndrome; HLH: hemophagocytic lymphohistiocytosis; MAS: macrophage activation syndrome; CRS: cytokine release syndrome; CS: cytokine storm; MAHS: malignancy-associated hemophagocytic syndrome; IAHS: infection-associated hemophagocytic syndrome; fHLH/pHLH: familial/primary hemophagocytic lymphohistiocytosis; sHLH: secondary hemophagocytic lymphohistiocytosis; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; TCR-T, T-cell receptor-engineered T-cell
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Affiliation(s)
- Xi Yongzhi
- Department of Immunology and National Center for Biomedicine Analysis; Fifth Medical Center of Chinese PLA General Hospital, Beijing, People's Republic of China
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10
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Zhang L, Wu Y, Huang H, Liu C, Cheng Y, Xu L, Tang W, Luo X. Performance of PRISM III, PELOD-2, and P-MODS Scores in Two Pediatric Intensive Care Units in China. Front Pediatr 2021; 9:626165. [PMID: 33996681 PMCID: PMC8113391 DOI: 10.3389/fped.2021.626165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/29/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: The performances of the pediatric risk of mortality score III (PRISM III), pediatric logistic organ dysfunction score-2 (PELOD-2), and pediatric multiple organ dysfunction score (P-MODS) in Chinese patients are unclear. This study aimed to assess the performances of these scores in predicting mortality in critically ill pediatric patients. Methods: This retrospective observational study was conducted at two tertiary-care PICUs of teaching hospitals in China. A total of 1,253 critically ill pediatric patients admitted to the two Pediatric Intensive Care Units (PICUs) of the First Affiliated Hospital, Sun Yat-Sen University from August 2014 to December 2019 and Shen-Zhen Children's Hospital from January 2019 to December 2019 were analyzed. The indexes of discrimination and calibration were applied to evaluate score performance for the three models (PRISM III, PELOD-2, and P-MODS scores). The receiver operating characteristic (ROC) curve was plotted, and the efficiency of PRISM III, PELOD-2, and P-MODS in predicting death were evaluated by the area under ROC curve (AUC). Hosmer-Lemeshow goodness-of-fit test was used to evaluate the degree of fitting between the mortality predictions of each scoring system and the actual mortality. Results: A total of 1,253 pediatric patients were eventually enrolled in this study (median age, 38 months; overall mortality rate, 8.9%; median length of PICU stay, 8 days). Compared to the survival group, the non-survival group showed significantly higher PRISM III, PELOD-2, and P-MODS scores [PRISM III: 18 (12, 23) vs. 11 (0, 16); PELOD-2, 8 (4, 10) vs. 4 (0, 6); and P-MODS: 5 (4, 9) vs. 3 (0, 4), all P < 0.001]. ROC curve analysis showed that the AUCs of PRISM III, PELOD-2, and P-MODS for predicting the death of critically ill children were 0.858, 0.721, and 0.596, respectively. Furthermore, in the Hosmer-Lemeshow goodness-of-fit test, PRISM III and PELOD-2 showed the better calibration between predicted mortality and observed mortality (PRISM III: χ2 = 5.667, P = 0.368; PELOD-2: χ2 = 9.582, P = 0.276; P-MODS: χ2 = 12.449, P = 0.015). Conclusions: PRISM III and PELOD-2 can discriminate well between survivors and non-survivors. PRISM III and PELOD-2 showed the better calibration between predicted and observed mortality, while P-MODS showed poor calibration.
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Affiliation(s)
- Lidan Zhang
- The Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.,Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Yuhui Wu
- The Pediatric Intensive Care Unit, Shen-Zhen Children's Hospital, Shenzhen, China
| | - Huimin Huang
- The Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chunyi Liu
- The Pediatric Intensive Care Unit, Shenzhen Baoan Maternity and Child Health Hospital, Shenzhen, China
| | - Yucai Cheng
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Lingling Xu
- The Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wen Tang
- The Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xuequn Luo
- Department of Pediatrics Hematology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Clinical Signs to Categorize Shock and Target Vasoactive Medications in Warm Versus Cold Pediatric Septic Shock. Pediatr Crit Care Med 2020; 21:1051-1058. [PMID: 32740190 DOI: 10.1097/pcc.0000000000002481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Determine level of agreement among clinical signs of shock type, identify which signs clinicians prioritize to determine shock type and select vasoactive medications, and test the association of shock type-vasoactive mismatch with prolonged organ dysfunction or death (complicated course). DESIGN Retrospective observational study. SETTING Single large academic PICU. PATIENTS Patients less than 18 years treated on a critical care sepsis pathway between 2012 and 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Agreement among clinical signs (extremity temperature, capillary refill, pulse strength, pulse pressure, and diastolic blood pressure) was measured using Fleiss and Cohen's κ. Association of clinical signs with shock type and shock type-vasoactive mismatch (e.g., cold shock treated with vasopressor rather than inotrope) with complicated course was determined using multivariable logistic regression. Of 469 patients, clinicians determined 307 (65%) had warm and 162 (35%) had cold shock. Agreement across all clinical signs was low (κ, 0.25; 95% CI, 0.20-0.30), although agreement between extremity temperature, capillary refill, and pulse strength was better than with pulse pressure and diastolic blood pressure. Only extremity temperature (adjusted odds ratio, 26.6; 95% CI, 15.5-45.8), capillary refill (adjusted odds ratio, 15.7; 95% CI, 7.9-31.3), and pulse strength (adjusted odds ratio, 21.3; 95% CI, 8.6-52.7) were associated with clinician-documented shock type. Of the 86 patients initiated on vasoactive medications during the pathway, shock type was discordant from vasoactive medication (κ, 0.14; 95% CI, -0.03 to 0.31) and shock type-vasoactive mismatch was not associated with complicated course (adjusted odds ratio, 0.3; 95% CI, 0.1-1.02). CONCLUSIONS Agreement was low among common clinical signs used to characterize shock type, with clinicians prioritizing extremity temperature, capillary refill, and pulse strength. Although clinician-assigned shock type was often discordant with vasoactive choice, shock type-vasoactive mismatch was not associated with complicated course. Categorizing shock based on clinical signs should be done cautiously.
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Yin G, Man C, Huang J, Liao S, Gao X, Tian T, Duan L, Xu J, Qiu H. The prognostic role of plasma fibrinogen in adult secondary hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:332. [PMID: 33239052 PMCID: PMC7690012 DOI: 10.1186/s13023-020-01622-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In adult patients with secondary hemophagocytic lymphohistiocytosis (sHLH), no valid immune biomarker has been available for predicting the prognosis of untreated sHLH patients. METHODS Circulating plasma levels of fibrinogen (FIB) were measured at diagnosis in 293 cases of adult sHLH. We categorized FIB levels into tertiles. Multivariable Cox proportional hazards models were used to evaluate the relationship between FIB and survival. Restricted cubic spline models and two-piecewise Cox proportional hazards models were used to address the nonlinear association between FIB and mortality. RESULTS During a median follow-up of 52 (interquartile ranges, 18-221) days, 208 deaths occurred, with 137 deaths in malignancy-associated hemophagocytic lymphohistiocytosis (MHLH) and 71 deaths in non-malignancy-associated hemophagocytic lymphohistiocytosis (non-MHLH). After multivariable adjustment, compared with the highest tertile of FIB, the hazard ratios (HRs) with 95% confidence intervals (CIs) of survival for tertile 2 and tertile 1 were 1.06 (0.90-1.24) and 0.84 (0.71-0.98), respectively. The restricted cubic spline curve displayed a nonlinear and inverse relationship between FIB and mortality. Furthermore, the threshold effect analysis demonstrated that the inflection point for the curve was at an FIB level of 1.76 g/L. The HRs (95% CIs) for survival were 0.68 (0.55-0.83) and 1.08 (0.96-1.21) on the left and right side of the inflection point, respectively. CONCLUSIONS These results suggest that plasma fibrinogen is nonlinearly and inversely associated with the risk of mortality in adult secondary hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Guangli Yin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Changfeng Man
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiayu Huang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Shengen Liao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xin Gao
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Tian Tian
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Limin Duan
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Ji Xu
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hongxia Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China. .,Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China.
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Man C, Wang M, Yin G, Huang J, Cheng W, Wu X, Liu L, Gao X, Wang J, Tian T, Duan L, Xu J, Qiu H. Clinical features of 47 secondary hemophagocytic lymphohistiocytosis patients complicated with capillary leak syndrome. Int J Hematol 2020; 113:263-270. [PMID: 33037588 PMCID: PMC7546163 DOI: 10.1007/s12185-020-03011-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/06/2020] [Accepted: 09/16/2020] [Indexed: 11/24/2022]
Abstract
The clinical features of patients with secondary hemophagocytic lymphohistiocytosis (sHLH) complicated with capillary leak syndrome (CLS) remain controversial. The data of 259 sHLH patients were retrospectively analyzed. The clinical manifestations, laboratory findings, treatment, and prognosis of the CLS-sHLH group and non-CLS-sHLH group were compared. The levels of fibrinogen, albumin, and serum calcium in the CLS-sHLH group were lower than in the non-CLS-sHLH group, and serum triglycerides in the CLS-sHLH group were higher than in the non-CLS-sHLH group (P < 0.05). Univariate analysis showed that fibrinogen level was an independent prognostic factor in sHLH patients complicated with CLS. The median survival time was significantly shorter in patients with fibrinogen ≤ 1.3 g/L than in patients with fibrinogen > 1.3 g/L (P < 0.05). Patients with improved CLS conditions in the CLS-sHLH group had significantly increased albumin and serum calcium after treatment (P < 0.05); patients without improved conditions in the CLS-sHLH group also had significantly increased albumin after treatment (P < 0.05), but the serum calcium did not change significantly (P > 0.05). sHLH patients complicated with CLS had significantly worse prognosis than without CLS. Significant reduction in fibrinogen may be an independent prognostic factor for poor prognosis in sHLH patients complicated with CLS.
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Affiliation(s)
- Changfeng Man
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Mengmeng Wang
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Guangli Yin
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiayu Huang
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Wanying Cheng
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xing Wu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Lingling Liu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xin Gao
- Department of Geriatric Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jujuan Wang
- Department of Geriatric Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Tian Tian
- Department of Geriatric Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Limin Duan
- Department of Geriatric Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Ji Xu
- Department of Geriatric Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hongxia Qiu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
- Department of Geriatric Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Profiling and bioinformatics analyses reveal differential circular RNA expression in NK/T-cell lymphoma-associated hemophagocytic syndrome. Biosci Rep 2020; 40:226205. [PMID: 32856037 PMCID: PMC7494993 DOI: 10.1042/bsr20201590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/25/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022] Open
Abstract
Circular RNAs (circRNAs) may be potential biomarkers or therapeutic targets of hemophagocytic syndrome (HPS) due to their high stability, covalently closed structure and implicated roles in gene regulation. The aim of the present study was to determine and characterize the circRNAs from natural killer (NK)/T-cell lymphoma-associated hemophagocytic syndrome (NK/T-LAHS). CircRNA in NK/T-LAHS and healthy control patient serum were assessed using next-generation sequencing (NGS). One hundred and forty-three differentially expressed circRNAs of which 114 were up-regulated and 29 were down-regulated in NK/T-LAHS patients were identified. Next, Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses to explore the roles of these circRNAs were utilized, and a microRNA (miRNA) target gene prediction software to predict the interaction of circRNAs and miRNAs was used. Moreover, five circRNAs were then selected as NK/T-LAHS candidate circRNAs which were related to tumors and contained NK/T-LAHS-related miRNA-binding sites. Using real-time PCR, the significant up-regulation of these five circRNAs in NK/T-LAHS patient serum were verified. Together these results show that circRNAs may serve as valuable diagnostic biomarkers of early NK/T-LAHS, with potential therapeutic targets in disease progression.
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Albumin-to-Fibrinogen Ratio Independently Predicts 28-Day Mortality in Patients with Peritonitis-Induced Sepsis. Mediators Inflamm 2020; 2020:7280708. [PMID: 32454793 PMCID: PMC7225846 DOI: 10.1155/2020/7280708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 01/04/2023] Open
Abstract
Background This study is aimed at investigating whether albumin-to-fibrinogen ratio (AFR) could independently predict the prognosis in patients with peritonitis-induced sepsis. Methods A total of 246 eligible patients who were scheduled to undergo surgical treatment for peritonitis-induced sepsis were enrolled in this study. The primary observational endpoint was 28-day hospital mortality. Cox proportional hazards regression analysis with the Wald test was performed to identify prognostic factors for 28-day mortality in septic patients. Receiver operating characteristic (ROC) and Kaplan-Meier curve analyses were carried out to evaluate the association of baseline AFR and prognosis in septic patients. Results Of all the cohort study participants, there were 59 nonsurvivors with a 28-day mortality of 24.0% (59/246). Baseline AFR (hazard ratio (HR): 0.67, 95% confidence interval (CI): 0.42-0.93, P = 0.018) and the presence of septic shock (HR: 2.43, 95% CI: 1.42-3.91, P = 0.021) were two independent prognostic factors for 28-day mortality in patients with peritonitis-induced sepsis by multivariate Cox analysis. Baseline AFR was a significant predictor for 28-day mortality with an area under the curve (AUC) of 0.751, a cut-off value of 8.85, a sensitivity of 66.10%, and a specificity of 70.05%, respectively (95% CI: 0.688-0.813, P < 0.001). A low baseline AFR level (≤8.85) was significantly associated with a lower overall survival rate in septic patients by Kaplan-Meier curve analysis with log-rank test (P = 0.004). Conclusions This study indicates that AFR independently predicts 28-day mortality in patients with peritonitis-induced sepsis.
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Garcia PCR, Tonial CT, Piva JP. Septic shock in pediatrics: the state‐of‐the‐art. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Garcia PCR, Tonial CT, Piva JP. Septic shock in pediatrics: the state-of-the-art. J Pediatr (Rio J) 2020; 96 Suppl 1:87-98. [PMID: 31843507 PMCID: PMC9432279 DOI: 10.1016/j.jped.2019.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. SOURCE OF DATA A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. SYNTHESIS OF DATA Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. CONCLUSIONS The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.
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Affiliation(s)
- Pedro Celiny Ramos Garcia
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Terapia Intensiva Pediátrica, Programa de Pós-Graduação em Pediatria e Saúde Infantil, Porto Alegre, RS, Brazil
| | - Cristian Tedesco Tonial
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Hospital São Lucas, Faculdade de Medicina e Terapia Intensiva Pediátrica, Departamento de Pediatria, Porto Alegre, RS, Brazil.
| | - Jefferson Pedro Piva
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, Departamento de Emergência e Cuidados Intensivos Pediátricos, Porto Alegre, RS, Brazil
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Cui Y, Xiong X, Ren Y, Wang F, Wang C, Zhang Y. CD163 as a valuable diagnostic and prognostic biomarker of sepsis-associated hemophagocytic lymphohistiocytosis in critically ill children. Pediatr Blood Cancer 2019; 66:e27909. [PMID: 31298489 DOI: 10.1002/pbc.27909] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate CD163 as an effective biomarker for identifying and predicting the outcomes of sepsis-associated hemophagocytic lymphohistiocytosis (SAHS) in children. METHODS We prospectively enrolled presumed sepsis patients who had developed prolonged fever (>7 days), hepatosplenomegaly, cytopenias, and hyperferritinemia (>500 ng/mL) despite antibiotic therapy. Blood samples were collected within 24 hours after enrolment. A nested case-control study was performed. The number of patients who fulfilled the HLH-2004 criteria, 28-day mortality outcomes, and 90-day mortality outcomes were recorded. RESULTS Sixty-nine patients were enrolled in the study. Significant increases in the levels of ferritin and soluble CD163 (sCD163) and the percentage of CD163-positive peripheral blood mononuclear cells (mCD163) and decreases in fibrinogen levels and the percentage of natural killer cells (NK %) were observed in patients with SAHS (n = 23) compared with those of patients with sepsis (n = 46). The area under the ROC curve (AUC) for ferritin combined with sCD163 was superior to the AUC for either ferritin or sCD163 for distinguishing SAHS from sepsis. Moreover, sCD163 was a prognostic factor for 28-day mortality (0.857 [0.659-1.000]). CONCLUSIONS sCD163 is a valuable biomarker for the differential diagnosis of SAHS from sepsis and effectively predicts 28-day mortality in children with SAHS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Xi Xiong
- Department of Critical Care Medicine, Shanghai Children's Hospital, Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yuqian Ren
- Department of Critical Care Medicine, Shanghai Children's Hospital, Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
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Karakike E, Giamarellos-Bourboulis EJ. Macrophage Activation-Like Syndrome: A Distinct Entity Leading to Early Death in Sepsis. Front Immunol 2019; 10:55. [PMID: 30766533 PMCID: PMC6365431 DOI: 10.3389/fimmu.2019.00055] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistocytosis (HLH) is characterized by fulminant cytokine storm leading to multiple organ dysfunction and high mortality. HLH is classified into familial (fHLH) and into secondary (sHLH). fHLH is rare and it is due to mutations of genes encoding for perforin or excretory granules of natural killer (NK) cells of CD8-lymphocytes. sHLH is also known as macrophage activation syndrome (MAS). Macrophage activation syndrome (MAS) in adults is poorly studied. Main features are fever, hepatosplenomegaly, hepatobiliary dysfunction (HBD), coagulopathy, cytopenia of two to three cell lineages, increased triglycerides and hemophagocytosis in the bone marrow. sHLH/MAS complicates hematologic malignancies, autoimmune disorders and infections mainly of viral origin. Pathogenesis is poorly understood and it is associated with increased activation of macrophages and NK cells. An autocrine loop of interleukin (IL)-1β over-secretion leads to cytokine storm of IL-6, IL-18, ferritin, and interferon-gamma; soluble CD163 is highly increased from macrophages. The true incidence of sHLH/MAS among patients with sepsis has only been studied in the cohort of the Hellenic Sepsis Study Group. Patients meeting the Sepsis-3 criteria and who had positive HSscore or co-presence of HBD and disseminated intravascular coagulation (DIC) were classified as patients with macrophage activation-like syndrome (MALS). The frequency of MALS ranged between 3 and 4% and it was an independent entity associated with early mortality after 10 days. Ferritin was proposed as a diagnostic and surrogate biomarker. Concentrations >4,420 ng/ml were associated with diagnosis of MALS with 97.1% specificity and 98% negative predictive value. Increased ferritin was also associated with increased IL-6, IL-18, IFNγ, and sCD163 and by decreased IL-10/TNFα ratio. A drop of ferritin by 15% the first 48 h was a surrogate finding of favorable outcome. There are 10 on-going trials in adults with sHLH; two for the development of biomarkers and eight for management. Only one of them is focusing in sepsis. The acronym of the trial is PROVIDE (ClinicalTrials.gov NCT03332225) and it is a double-blind randomized clinical trial aiming to deliver to patients with septic shock treatment targeting their precise immune state. Patients diagnosed with MALS are receiving randomized treatment with placebo or the IL-1β blocker anakinra.
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Affiliation(s)
- Eleni Karakike
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Hepatobiliary Dysfunction and Disseminated Intravascular Coagulation Increase Risk of Mortality in Pediatric Hemophagocytic Lymphohistiocytosis. Pediatr Crit Care Med 2018; 19:e522-e530. [PMID: 30113519 PMCID: PMC9097722 DOI: 10.1097/pcc.0000000000001684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis poses significant challenges due to limited tools to guide clinical decisions in a population at high risk of death. We sought to assess whether disseminated intravascular coagulation and hepatobiliary dysfunction, significant comorbidities seen in critical care settings, would identify hemophagocytic lymphohistiocytosis patients with increased risk of mortality. DESIGN Retrospective chart review. SETTING Single-center PICU. PATIENTS All patients admitted to a tertiary care children's hospital diagnosed with hemophagocytic lymphohistiocytosis from 2005 to 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-three patients were diagnosed with hemophagocytic lymphohistiocytosis with median age of 61 months. The 5-year overall survival was 51% (22/43). Univariate analyses revealed ferritin levels greater than 10,000 (ng/mL), international normalized ratio greater than 1.5, or platelet counts less than 100,000/µL at initiation of dexamethasone were individually associated with mortality. Development of disseminated intravascular coagulation, hepatobiliary dysfunction, or both increased the likelihood of death in hemophagocytic lymphohistiocytosis patients (relative risk; 95% CI) (6; 1.4-34; p < 0.05), (4.1; 1.8-10; p < 0.05), and (7.5; 1.8-42; p < 0.05). Of 12 autopsies performed, 75% had at least one active infection, 66% had chronic lymphopenia, 50% had lymphocyte depletion in the spleen, thymus, or bone marrow, 42% had evidence of microvascular thrombosis, and 92% had evidence of hepatocellular injury. CONCLUSIONS Hemophagocytic lymphohistiocytosis continues to have high mortality with hemophagocytic lymphohistiocytosis-1994/2004 (dexamethasone/etoposide), the current standard of care for all children with hemophagocytic lymphohistiocytosis. Hemophagocytic lymphohistiocytosis patients who developed disseminated intravascular coagulation, hepatobiliary dysfunction, or both had higher risk of death with mortalities of 60%, 77%, and 77%, respectively. Phenotypic classifications are urgently needed to guide individualized treatment strategies to improve outcomes for children with hemophagocytic lymphohistiocytosis.
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