Clinical Significance of Serum CTRP3 Level in the Prediction of Cardiac and Intestinal Mucosal Barrier Dysfunction in Patients with Severe Acute Pancreatitis

C1q/tumor necrosis factor-related protein 3 (CTRP3) has been demonstrated to play a protective role in mice with severe acute pancreatitis (SAP). However, its clinical significance in SAP remains unknown. This study was conducted to explore the clinical values of serum C1q/tumor necrosis factor-related protein 3 (CTRP3) level in the diagnosis of cardiac dysfunction (CD) and intestinal mucosal barrier dysfunction (IMBD) in SAP. Through RT-qPCR, we observed decreased CTRP3 level in the serum of SAP patients. Serum CTRP3 level was correlated with C-reactive protein, procalcitonin, creatine, modified computed tomography severity index score, and Acute Physiology and Chronic Health Evaluation II score. The receiver-operating characteristic curve revealed that CTRP3 serum level < 1.005 was conducive to SAP diagnosis with 72.55% sensitivity and 60.00% specificity, CTRP3 < 0.8400 was conducive to CD diagnosis with 80.49% sensitivity and specificity 65.57%, CTRP3 < 0.8900 was conducive to IMBD diagnosis with 94.87% sensitivity and 63.49% specificity, and CTRP3 < 0.6250 was conducive to the diagnosis of CD and IMBD co-existence with 65.22% sensitivity and 89.87% specificity. Generally, CTRP3 was downregulated in the serum of SAP patients and served as a candidate biomarker for the diagnosis of SAP and SAP-induced CD and IMBD.

Beta-Glucan Alters Gut Microbiota and Plasma Metabolites in Pre-Weaning Dairy Calves

The present study aims to evaluate the alterations in gut microbiome and plasma metabolites of dairy calves with β-glucan (BG) supplementation. Fourteen healthy newborn dairy calves with similar body weight were randomly divided into control (n = 7) and BG (n = 7) groups. All the calves were fed on the basal diet, while calves in the BG group were supplemented with oat BG on d 8 for 14 days. Serum markers, fecal microbiome, and plasma metabolites at d 21 were analyzed. The calves were weaned on d 60 and weighed. The mean weaning weight of the BG group was 4.29 kg heavier than that of the control group. Compared with the control group, the levels of serum globulin, albumin, and superoxide dismutase were increased in the BG group. Oat BG intake increased the gut microbiota richness and decreased the Firmicutes-to-Bacteroidetes ratio. Changes in serum markers were found to be correlated with the plasma metabolites, including sphingosine, trehalose, and 3-methoxy-4-hydroxyphenylglycol sulfate, and gut microbiota such as Ruminococcaceae_NK4A214, Alistipes, and Bacteroides. Overall, these results suggest that the BG promotes growth and health of pre-weaning dairy calves by affecting the interaction between the host and gut microbiota.

Effect of Early Continuous Veno-Venous Haemofiltration in Severe Acute Pancreatitis for the Prevention of Local Pancreatic Complications

Objective

To compare the conventional treatment and continuous veno-venous haemofiltration (CVVH) in severe acute pancreatitis (SAP) for the prevention of pseudocyst and walled-off necrosis. Patients and Methods. Forty-two patients were divided into two treatment groups: conventional treatment group contained 24 patients and CVVH had 18. Conventional treatment group patients were treated symptomatically and according to the causes. CVVH group patients were treated symptomatically, and CVVH was done within 2 hours of admission.

Results

In both groups, there was a decrease in amylase, lipase, CRP, IL-6, IL-10, TNF-alpha, Ranson score, Balthazar score, and APACHE-II score after 72 hours, but the decrease was significantly greater in CVVH patients. There were no any local pancreatic complications in CVVH patients, but 1 patient had an acute peripancreatic fluid collection, 2 patients had pseudocyst, and 2 patients had walled-off necrosis (WON), and a mortality one was seen in the conventional treatment group.

Conclusion

The present study shows that early CVVH may be able to prevent the formation of pseudocyst and win in SAP patients.

[Acute kidney injury following acute pancreatitis (AP-AKI): Definition, Pathophysiology, Diagnosis and Therapy]

Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Severe acute pancreatitis is often associated with multiorgan failure and especially with acute kidney injury (AKI). AKI can develop early or late in the course of the disease and is a strong determinator of outcome. The mortality in the case of dialysis-dependent AKI and acute pancreatitis raises exponentially in the affected patients. AP-induced AKI (AP-AKI) shows many similarities but also distinct differences to other causes of AKI occurring in the intensive care unit setting. The knowledge of the exact pathophysiology can help to adjust, control and improve therapeutic approaches to the disease. Unfortunately, there are only a few studies dealing with AP and AKI.In this review, we discuss recent data about pathogenesis, causes and management of AP-AKI in patients with severe acute pancreatitis and exploit in this regard the diagnostic and prognostic potential of respective newer serum and urine markers.

Intestinal barrier damage, systemic inflammatory response syndrome, and acute lung injury: A troublesome trio for acute pancreatitis

Severe acute pancreatitis (SAP), a serious inflammatory disease of the pancreas, can easily lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndromes (MODS). Acute lung injury (ALI) is one of the most serious complications of SAP. However, the specific pathogenesis of SAP-associated ALI is not fully understood. Crosstalk and multi-mechanisms involving pancreatic necrosis, bacteremia, intestinal barrier failure, activation of inflammatory cascades and diffuse alveolar damage is the main reason for the unclear pathological mechanism of SAP-associated ALI. According to previous research on SAP-associated ALI in our laboratory and theories put forward by other scholars, we propose that the complex pattern of SAP-associated ALI is based on the "pancreas-intestine-inflammation/endotoxin-lung (P-I-I/E-L) pathway". In this review, we mainly concentrated on the specific details of the "P-I-I/E-L pathway" and the potential treatments or preventive measures for SAP-associated ALI.

Continuous Hemofiltration Reduces Mortality in Severe Acute Pancreatitis: A Meta-Analysis

Background

Severe acute pancreatitis (SAP) is a deadly condition, with a mortality rate ranging from 15% to 30%. Recently, blood purification therapy has been adopted in administrating SAP patients. The present study aimed at evaluating the effect of continuous hemofiltration therapy for SAP.

Methods

A systematic search of Cochrane Library, PubMed, and Embase was carried out until October 1^st, 2019. Prospective studies comparing outcomes for SAP patients between continuous hemofiltration and standard therapy were enrolled.

Results

Continuous hemofiltration therapy was associated with lower level of PACHE II score (MD = −1.49; 95% CI: −2.69 to −0.29, P=0.02), CRP (MD = −1.56 mg/L; 95% CI: −2.64 to −0.47, P=0.005), Cr (MD = −3.57 umol/L; 95% CI: −5.50 to −1.65, P=0.003), and Bun (MD = −3.63 mmol/L; 95% CI: −6.07 to −1.20, P=0.003) at 72 h after onset of treatment. Continuous hemofiltration therapy was associated with shorter length of abdominal pain relief time (MD = −1.82 hours; 95% CI: −2.93 to −0.71, P=0.001), lower surgery rate (OR = 0.15; 95% CI: 0.03 to 0.78, P=0.02), and mortality rate (OR = 0.54; 95% CI: 0.37 to 0.77, P=0.0007).

Conclusions

continuous hemofiltration therapy could effectively alleviate SAP as early as 72 hours after onset of treatment, lowering the level of Bun, Cr, CRP, and APACHE II scores. Continuous hemofiltration therapy could confer SAP patients with lower mortality rates.

Continuous veno-venous hemofiltration for severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis is associated with high rates of mortality and life-threatening complications. Continuous veno-venous hemofiltration (CVVH) has been used in some centers to reduce mortality and avoid local or systemic complications, however its efficiency and safety is uncertain.

OBJECTIVES

To assess the benefits and harms of CVVH in patients suffering from severe acute pancreatitis; to compare the effects of different CVVH techniques; and to evaluate the optimal time for delivery of CVVH.

SEARCH METHODS

We searched the Cochrane Library (2019, Issue 8), MEDLINE (1946 to 13 September 2019), Embase (1974 to 13 September 2019), and Science Citation Index Expanded (1982 to 13 September 2019).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared CVVH versus no CVVH in participants with severe acute pancreatitis. We also included RCTs that compared different types of CVVH and different schedules for CVVH in participants with severe acute pancreatitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included two studies, involving a total of 94 participants, in the review.Continuous veno-venous hemofiltration versus no interventionWe included one study in which 64 participants with severe acute pancreatitis were randomized to undergo CVVH (32 participants) or no intervention (32 participants). There were no deaths in either group (very low-quality evidence). Adverse events, length of stay in the intensive care unit (ICU), length of hospital stay, total hospital cost, and quality of life were not reported in the study.One type of continuous veno-venous hemofiltration versus a different type of continuous veno-venous hemofiltrationWe included one study in which 30 participants with severe acute pancreatitis were randomized to undergo high-volume CVVH (15 participants) or standard CVVH (15 participants). High-volume CVVH may lead to little or no difference in in-hospital mortality rates (20.0% in the high-volume CVVH group versus 33.3% in the standard CVVH group; risk ratio (RR) 0.60, 95% confidence interval (CI) 0.17 to 2.07; 30 participants; 1 study; low-quality evidence). We are uncertain whether high-volume hemofiltration reduces rates of adverse events (13.3% in both groups; RR 1.00, 95% CI 0.16 to 6.20; 30 participants; 1 study; very low-quality evidence). Length of ICU stay, length of hospital stay, total hospital cost, and quality of life were not reported in the study.

AUTHORS' CONCLUSIONS

The quality of the current evidence is very low or low. For both comparisons addressed in this review, data are sparse. It is unclear whether CVVH has any effect on mortality or complications in patients with severe acute pancreatitis. It is also unclear whether high-volume CVVH is superior, equivalent or inferior to standard CVVH in patients with severe acute pancreatitis.

Association of endotoxaemia & gut permeability with complications of acute pancreatitis: Secondary analysis of data

Background & objectives:

In acute pancreatitis (AP) gut barrier dysfunction is considered as an important predisposing factor leading to increased intestinal permeability (IP). In this study a pooled analysis of data published in our previous four studies on various aspects of gut permeability and endotoxaemia in patients with AP was attempted to find an association between increased IP and severity of disease and associated complications.

Methods:

This study was a pooled analysis of data of four previously published prospective studies on AP. Gut permeability, assessed by lactulose/mannitol excretion in urine and endotoxin core antibodies type IgG and IgM (EndoCab IgG and IgM) were measured on days zero and seven (D0 and D7) of admission. All patients received standard treatment of AP. We studied whether IgG and IgM anti-endotoxin titres and lactulose-mannitol ratio (LMR) at admission and D7 were associated with organ failure, infection and mortality.

Results:

The titres of anti-endotoxin IgG and IgM were lower in all patients of AP (n=204), both in mild AP (n=24) and severe AP (n=180) in the first week, compared to controls (n=15). There was no significant difference in serum IgG and IgM anti-endotoxin levels and LMR at baseline and at D7 among patients with organ failure, infection and mortality.

Interpretation & conclusions:

Our findings showed that serum IgG and IgM anti-endotoxin titres and LMR at admission and at day 7 were not associated with organ failure, infection, and death of patients with AP.

AKI Associated with Acute Pancreatitis

Acute pancreatitis is a common disorder of the pancreas. It is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Its severity ranges from mild self-limited disease to severe acute necrotizing pancreatitis characterized by systemic complications and multiorgan failure. Severe acute pancreatitis develops in about 20% of patients with acute pancreatitis and may be associated with multiorgan failure (respiratory, cardiovascular, and kidney). AKI is a frequent complication of severe acute pancreatitis and develops late in the course of the disease, usually after the failure of other organs. It carries a very poor prognosis, particularly if kidney replacement therapy is required, with mortality rates exceeding 75%. The exact pathophysiology of AKI in acute pancreatitis remains unclear but appears to result from initial volume depletion followed by complex vascular and humoral factors. Here, we provide an overview of the epidemiology, pathogenesis, causes, and management of AKI in patients with severe acute pancreatitis.

Continuous blood purification for severe acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

The incidence of acute pancreatitis (AP) is rising around the world, thus further increasing the burden on healthcare services. Approximately 20% of AP will develop severe acute pancreatitis (SAP) with persistent organ failure (>48 h), which is the leading cause of high mortality. To date, there is no specific drug in treating SAP, and the main treatment is still based on supportive care. However, some clinical control studies regarding the superiority of continuous blood purification (CBP) has been published recently. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy of CBP in SAP treatment.

METHODS

Four databases (Medline, SinoMed, EMBASE, and Cochrane Library) were searched for eligible studies from 1980 to 2018 containing a total of 4 randomized controlled trials and 8 prospective studies.

RESULTS

After the analysis of data amenable to polling, significant advantages were found in favor of the CBP approach in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II) score (WMD = -3.00,95%CI = -4.65 to -1.35), serum amylase (WMD = -237.14, 95% CI = -292.77 to 181.31), serum creatinine (WMD = -80.54,95%CI = 160.17 to -0.92), length of stay in the ICU (WMD = -7.15,95%CI = -9.88 to -4.43), and mortality (OR = 0.60, 95%CI = 0.38-0.94). No marked differences were found in terms of C-reactive protein (CRP), alamine aminotransferase (ALT) and length of hospital stay (LOS).

CONCLUSION

Compared with conventional treatment, CBP remedy evidently improved clinical outcomes, including reduced incidence organ failure, decreased serum amylase, APACHE II score, length of stay in the ICU and lower mortality rate, leading us to conclude that it is a safer treatment option for SAP. Furthermore, relevant multicenter RCTs are required to prove these findings.

Th17/regulatory T cell imbalance in sepsis patients with multiple organ dysfunction syndrome: attenuated by high-volume hemofiltration

BACKGROUND

We assessed the Th17 (T-helper cell)/Treg (Regulatory T cell) imbalance in sepsis patients with multiple organ dysfunction syndrome (MODS) and the clinical benefits of continuous high-volume hemofiltration (HVHF).

METHODS

48 sepsis patients, including 22 patients with MODS (MODS group, n = 22) and 26 without (non-MODS group, n = 26), and 20 healthy volunteer controls were enrolled. The patients in MODS group were randomly divided into the continuous blood purification (CBP) group (n = 11) receiving conventional comprehensive treatment plus high-volume hemofiltration and the non-CBP group (n = 11) receiving conventional comprehensive treatment only. At day 28, all 48 patients were divided into the survival group (n = 36) and the non-survival group (n = 12). Venous blood samples, collected at 0, 6, 12 and 24 hours during hemofiltration (or equivalent times in the non-CBP group), were assessed by flow cytometry to detect the Th17 and Treg cells in peripheral blood. Serum cytokines (such as IL-6, IL-17, IL-23, IL-10 and TGF-β1) were detected by enzyme-linked immune sorbent assay (ELISA).

RESULTS

Th17%, Treg%, Th17/Treg, IL-6, IL-17, IL-23, IL-10 and TGF-β1 were significantly higher in MODS and non-MODS group than in the health control (p<0.05), while Th17%, Treg%, Th17/Treg and measured cytokines were significantly higher in the MODS group compared to the non-MODS group (p<0.05). After HVHF treatment, Th17%, Treg%, Th17/Treg, IL-6, IL-17, and IL-10 were significantly reduced (p<0.05), while there were no significant changes in the non-CBP group (p>0.05). In addition, APACHE II and SOFA scores decreased markedly after HVHF treatment. Baseline Th17%, Treg%, Th17/Treg, IL-6, IL-17, IL-23, IL-10 and TGF-β1 were significantly higher in the non-survival group compared to the survival group. Both Th17% and Th17/Treg were positivity correlated with concentration of IL-6 and APACHE II score (p<0.01).

CONCLUSIONS

The level of Th17/Treg imbalance in sepsis is related to the occurrence and prognosis of MODS. High-volume hemofiltration can attenuate the Th17/Treg imbalance in sepsis patients, possibly by removing inflammatory mediators.

Mode of renal replacement therapy determines endotoxemia and neutrophil dysfunction in chronic kidney disease

Bacterial infection and sepsis are common complications of chronic kidney disease (CKD). A vicious cycle of increased gut permeability, endotoxemia, inadequate activation of the innate immune system and resulting innate immune dysfunction is hypothesized. We assessed endotoxemia, neutrophil function and its relation to oxidative stress, inflammation and gut permeability in patients with CKD grade 3–5 without renal replacement therapy (CKD group, n = 57), patients with CKD stage 5 undergoing haemodialysis (HD, n = 32) or peritoneal dialysis (PD, n = 28) and patients after kidney transplantation (KT, n = 67) in a cross-sectional observational study. In HD patients, endotoxin serum levels were elevated and neutrophil phagocytic capacity was decreased compared to all other groups. Patients on HD had a significantly higher mortality, due to infections during follow up, compared to PD (p = 0.022). Oxidative stress, neutrophil energy charge, systemic inflammation and gut permeability could not completely explain these differences. Our findings suggest that dialysis modality and not renal function per se determine the development of neutrophil dysfunction and endotoxemia in CKD-patients. HD patients are particularly prone to neutrophil dysfunction and endotoxemia whereas neutrophil function seems to improve after KT. Multi-target approaches are therefore warranted to improve neutrophil function and potentially reduce the rate of infections with patients undergoing haemodialysis.

Up-regulation of Tight-Junction Proteins by p38 Mitogen-Activated Protein Kinase/p53 Inhibition Leads to a Reduction of Injury to the Intestinal Mucosal Barrier in Severe Acute Pancreatitis

OBJECTIVES

The aim of this study was to explore the role of the p38 mitogen-activated protein kinase (p38MAPK)/p53 signaling pathway in injury to the intestinal mucosal barrier during severe acute pancreatitis (SAP).

METHODS

Both sham operation and SAP groups had 3 subgroups analyzed 3, 6, or 12 hours after the SAP induction. The concentrations of amylase, endotoxin, diamine oxidase, tumor necrosis factor α, and phospho-p38MAPK, p53, and caspase-3 and the messenger RNA levels of zonula occludens protein-1 and occludin in the intestine were measured. Immunohistochemical staining was used to determine the expression of zonula occludens protein-1 and occludin. Pathological changes of the pancreas and intestine were also assessed. Then, rats were randomly assigned to 5 groups-sham operation group, SAP group, 3 groups treated with different concentrations of p38MAPK-inhibitor SB203580-and the abovementioned experiment was repeated and analyzed 6 hours after the SAP induction.

RESULTS

The phospho-p38MAPK reached a peak value at 6 hours after the SAP induction with obvious pathological injury to the pancreas and intestine. Treatment with SB203580 led to a less damage to the pancreatic and intestinal tissues.

CONCLUSIONS

These results suggest that SAP activates the p38MAPK/p53 signaling pathway and induces injury to the intestinal mucosal barrier, which can be alleviated by inhibiting the p38MAPK/p53 pathway.

H19 Long Noncoding RNA Regulates Intestinal Epithelial Barrier Function via MicroRNA 675 by Interacting with RNA-Binding Protein HuR

The disruption of the intestinal epithelial barrier function occurs commonly in various pathologies, but the exact mechanisms responsible are unclear. The H19 long noncoding RNA (lncRNA) regulates the expression of different genes and has been implicated in human genetic disorders and cancer. Here, we report that H19 plays an important role in controlling the intestinal epithelial barrier function by serving as a precursor for microRNA 675 (miR-675). H19 overexpression increased the cellular abundance of miR-675, which in turn destabilized and repressed the translation of mRNAs encoding tight junction protein ZO-1 and adherens junction E-cadherin, resulting in the dysfunction of the epithelial barrier. Increasing the level of the RNA-binding protein HuR in cells overexpressing H19 prevented the stimulation of miR-675 processing from H19, promoted ZO-1 and E-cadherin expression, and restored the epithelial barrier function to a nearly normal level. In contrast, the targeted deletion of HuR in intestinal epithelial cells enhanced miR-675 production in the mucosa and delayed the recovery of the gut barrier function after exposure to mesenteric ischemia/reperfusion. These results indicate that H19 interacts with HuR and regulates the intestinal epithelial barrier function via the H19-encoded miR-675 by altering ZO-1 and E-cadherin expression posttranscriptionally.

Enterogenous infection of Candida albicans in immunocompromised rats under severe acute pancreatitis

BACKGROUND

Opportunistic infection of Candida albicans (C. albicans) has become a serious problem in immunocompromised patients. The study aimed to explore the mechanism of enterogenous infection of C. albicans in immunocompromised rats under severe acute pancreatitis (SAP).

METHODS

Sprague Dawley (SD) rats (n=100) were randomly assigned into 5 groups as the following: blank group, cyclophosphamide+ceftriaxone+SAP group, cyclophosphamide+ceftriaxone group, cyclophosphamide+SAP group, and cyclophosphamide group. The rats were sacrificed at 5 and 10 days, and their jejunum, colon, mesenteric lymph nodes, pancreas, intestinal content, and blood were quickly collected to detect C. albicans. A region of the 25S rRNA gene was chosen and amplified by polymerase chain reaction (PCR) to differentiate C. albicans genotypes. The amplified products were further sequenced and compared to judge their homology.

RESULTS

Compared with the Cyclophosphamide group, the combination of immunosuppressants and broad-spectrum antibiotics significantly increased the colonization of C. albicans in intestine in 5 and 10 days. Pure SAP stress did not increase the opportunistic infection of C. albicans. The PCR products of C. albicans isolates all belonged to the genotype A family, and sequence alignment showed that the amplified fragments were homologous.

CONCLUSION

The damage of immune system and broad-spectrum antimicrobial agents are important risk factors for opportunistic fungal infection. Intestinal tract is an important source for genotype-A C. albicans to translocate and invade into bloodstream.

Long noncoding RNA SPRY4-IT1 regulates intestinal epithelial barrier function by modulating the expression levels of tight junction proteins

Epithelial cells line the intestinal mucosa and form an important barrier to a wide array of noxious substances in the lumen. Disruption of the barrier integrity occurs commonly in various pathologies. Long noncoding RNAs (lncRNAs) control diverse biological processes, but little is known about the role of lncRNAs in regulation of the gut permeability. Here we show that the lncRNA SPRY4-IT1 regulates the intestinal epithelial barrier function by altering expression of tight junction (TJ) proteins. SPRY4-IT1 silencing led to dysfunction of the epithelial barrier in cultured cells by decreasing the stability of mRNAs encoding TJ proteins claudin-1, claudin-3, occludin, and JAM-1 and repressing their translation. In contrast, increasing the levels of SPRY4-IT1 in the intestinal mucosa protected the gut barrier in mice exposed to septic stress by increasing the abundance of TJ proteins. SPRY4-IT1 directly interacted with TJ mRNAs, and this process was enhanced through the association with the RNA-binding protein HuR. Of interest, the intestinal mucosa from patients with increased gut permeability exhibited a decrease in the levels of SPRY4-IT1. These findings highlight a novel role for SPRY4-IT1 in controlling the intestinal epithelial barrier and define a mechanism by which SPRY4-IT1 modulates TJ expression by altering the stability and translation of TJ mRNAs.

Serum interleukin 17 as an early prognostic biomarker of severe acute pancreatitis receiving continuous blood purification

BACKGROUND

Severe acute pancreatitis (SAP) is associated with systemic inflammation, immunoparalysis, and sepsis, and may lead to vital organ failure and death. We evaluated the efficacy of serum interleukin 17 (IL-17) concentration for predicting eventual SAP severity and the clinical benefits of removing IL-17 by continuous veno-venous hemofiltration (CVVH).

METHODS

Patients were divided into 2 groups according to severity: Grade 1 (n = 18, SAP without organ dysfunction) and Grade 2 (n = 18, SAP with organ dysfunction). 20 healthy volunteers served as controls. All patients underwent 24-h CVVH and blood samples were taken at 0, 6, 12, and 24 h for measurement of bacterial load and serum IL-17, IL-6, and endotoxin. Clinical condition was graded by the sequential organ failure assessment (SOFA) score.

RESULTS

Baseline IL-17, IL-6, endotoxin, and bacterial load were higher in Grade 2 patients. SOFA scores improved significantly, and serum IL-17, IL-6, endotoxin, and bacterial load decreased significantly in all patients after CVVH. Serum IL-17 was significantly and positively correlated with IL-6, bacterial load, and endotoxin during CVVH treatment. In addition, post-CVVH serum IL-17 was directly correlated with SOFA scores on days 1 and 7, and with duration of hospital stay. Non-survivors showed both higher SOFA scores on day 1 and higher baseline IL-17 than survivors.

CONCLUSIONS

Earlier and higher serum IL-17 elevation predicted prolonged hospitalization, organ failure, and death, possibly by disrupting gut barrier function. CVVH can remove inflammatory cytokines from serum, including IL-17 and IL-6, thereby attenuating the inflammatory response and diminishing associated systemic complications.

Hypotension in the first week of acute pancreatitis and APACHE II score predict development of infected pancreatic necrosis

BACKGROUND

Hypotension and intestinal mucosal ischemia lead to bacterial translocation from the gut lumen into systemic circulation.

AIM

The purpose of this study was to determine the strength of association between different types of organ failure (OF): hypotension (cardiovascular system failure), renal failure, respiratory failure, CNS failure and coagulopathy in the first week of acute pancreatitis (AP) and the subsequent development of infected pancreatic necrosis (IN).

METHODS

Consecutive patients with AP were evaluated for OF and its severity in the first week of hospital admission. Modified multiple organ failure score (MOFS) was used to identify and grade severity of OF. MOFS of ≥2, lasting for more than 48 h was defined as OF. Occurrence of IN (isolation of bacteria in necrosectomy specimen or image guided fine needle aspiration of pancreatic necrosis) was compared between groups with and without OF.

RESULTS

Of the 81 patients, mean age was 40.1 ± 14.4 years and 55 were males; 60 (74 %) patients had OF and 13 (16 %) patients had IN. Occurrence of IN was not significantly different between patients with OF (18.3 %) and without OF (14.3 %), p = 0.48. However IN occurred in 10 % of patients without and 33.7 % patients with hypotension, p = 0.01. The rest of the organ systems analyzed did not show any significant difference in occurrence of infected necrosis. On multivariate analysis independent predictors of occurrence of IN were hypotension (odds ratio, OR 2.5, p < 0.001) and APACHE II score at 24 h of hospital admission (OR 4.77, p < 0.001).

CONCLUSION

Hypotension in the first week of AP and APACHE II score predict development of IN.

Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis

BACKGROUND

The gut is implicated in the pathogenesis of acute pancreatitis but there is discrepancy between individual studies regarding the prevalence of gut barrier dysfunction in patients with acute pancreatitis. The aim of this study was to determine the prevalence of gut barrier dysfunction in acute pancreatitis, the effect of different co-variables, and changes in gut barrier function associated with the use of various therapeutic modalities.

METHODS

A literature search was performed using PRISMA and MOOSE guidelines. Summary estimates were presented as pooled prevalence of gut barrier dysfunction and the associated 95 per cent c.i.

RESULTS

A total of 44 prospective clinical studies were included in the systematic review, of which 18 studies were subjected to meta-analysis. The pooled prevalence of gut barrier dysfunction was 59 (95 per cent c.i. 48 to 70) per cent; the prevalence was not significantly affected by disease severity, timing of assessment after hospital admission or type of test used, but showed a statistically significant association with age. Overall, nine of 13 randomized clinical trials reported a significant improvement in gut barrier function following intervention compared with the control group, but only three of six studies that used standard enteral nutrition reported a statistically significant improvement in gut barrier function after intervention.

CONCLUSION

Gut barrier dysfunction is present in three of five patients with acute pancreatitis, and the prevalence is affected by patient age but not by disease severity. Clinical studies are needed to evaluate the effect of enteral nutrition on gut function in acute pancreatitis.

Application of bedside continuous blood purification in patients with multiple organ dysfunction syndromes

BACKGROUND

The complications of systemic inflammatory response syndrome (SIRS) include acute lung injury, acute kidney injury, shock, and multiple organ dysfunction syndrome (MODS). In recent years, how to clear inflammatory mediators has become a hot topic in critical care medicine. Researchers hypothesize that continuous blood purification (CBP) can effectively eliminate a variety of inflammatory mediators which participate in the occurrence of MODS and adjust the immune imbalance. This study aimed to observe the effects of CBP in MODS patients.

METHODS

In this retrospective clinical study, a total of 38 MODS patients, 18 males and 20 females, were enrolled. After conventional therapy, all the patients received CBP. Biochemistry, blood gas analysis, oxygenation index, mean arterial blood pressure (MAP), acute physiology and chronic health evaluation (APACHE) II scores were monitored.

RESULTS

After CBP, the vital signs of patients were rapidly stable, and electrolyte disorders and acid-base imbalance were corrected. Renal function, blood gas, oxygenation index were all improved. MAP was increased, and APACHE II score was significantly decreased. All patients had good tolerance, stable hemodynamics, and no obvious adverse reaction on CBP compared with pre-CBP.

CONCLUSION

CBP can effectively clean toxins, correct electrolyte acid-base balance, and improve systemic inflammatory response syndrome and the organ function of MODS patients.

Is continuous venovenous hemofiltration effective against severe acute pancreatitis?

Our aim was to investigate the efficacy of continuous venovenous hemofiltration (CVVH) in treating severe acute pancreatitis (SAP). A literature search was performed using PubMed (1992-present), and all studies investigating the efficacy of CVVH in treating SAP were included. Four comparative studies and seven case series comprising a total of 354 patients were included. The overall mortality rate of patients receiving CVVH was 20% (55/275). A decreased mortality rate and decreased serum cytokine levels were reported in the CVVH groups in only two studies. The starting time point, substitution fluid flow rate, filter membrane type, hemofilter change interval, anticoagulation, and sustaining times of CVVH varied among the studies, and the impact of these parameters on the efficacy of CVVH was poorly reported. High-volume CVVH, when started early, was demonstrated to be more effective in eliminating cytokines in only one study. After the application of CVVH, the patient conditions started to improve between the 6th and 72nd hours. In conclusion, no solid clinical evidence has proven the efficacy of CVVH in treating SAP. High-volume CVVH that is started early and sustained for at least 72 h may be adopted to investigate the efficacy of CVVH for treating SAP.

Coupled plasma filtration adsorption combined with continuous veno-venous hemofiltration treatment in patients with severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis (SAP) still has a high mortality rate. Coupled plasma filtration adsorption (CPFA) and continuous veno-venous hemofiltration (CVVH) are 2 extracorporeal blood purification techniques. We hypothesized that CPFA combined with CVVH could preferentially improve prognosis and suppress clinical manifestations of SAP.

METHODS

In this observational cohort study, 25 patients with SAP were enrolled, in which 12 received CPFA plus CVVH treatment (group 1), and 13 received CVVH therapy (group 2). All the patients underwent a successive 10-day intervention. Clinical indicators were detected before or after the intervention and the results were compared between the 2 groups. The feasibility and the survival rate were evaluated on day 28.

RESULTS

Compared with group 2, oxygenation index (PaO(2)/FiO(2)), mean arterial pressure, serum amylase, and blood urine nitrogen showed significant differences (all P<0.01) and serum TNF-α, IL-1β, IL-6 were reduced and IL-10 was elevated with time in group 1 (all P<0.01). Liver functions, electrolyte, and acid-base balance did not show significant difference before and after the 10-day treatment with CPFA plus CVVH compared with CVVH (P>0.05). No therapy-related adverse reactions were noted in both groups. Twenty-eight-day survival rate of group 1 was higher than that in group 2 [91.7% (11/12) vs. 53.8% (7/13), P<0.05].

CONCLUSIONS

CPFA combined with CVVH was an effective and safe method for treatment of SAP patients, the mechanism being related to its effect on regulating the level of cytokines and serum amylase.

High-volume hemofiltration reduces the expression of myocardial tumor necrosis factor-alpha in septic shock pigs

Increasing evidence indicates that the expression of tumor necrosis factor-α (TNF-α) in myocardium correlates with the severity of cardiac dysfunction in septic shock. The aim of this study was to investigate the impact of high-volume hemofiltration (HVHF) on the expression of TNF-α in myocardium in septic shock pigs. Sixteen male Landrace pigs weighing 31 ± 5 kg were randomly assigned to control group (n = 4), septic shock group (n = 6), and HVHF group (septic shock + HVHF, n = 6). All animals were anesthetized and mechanically ventilated. After baseline examinations, septic shock group and HVHF group underwent induction of peritonitis. One hour later, the animals in HVHF group received treatment with HVHF and the treatment was continued for 12 h. As the control of HVHF group, the animals in septic shock group received the same support but hemofiltration. Twelve hours after HVHF therapy, all the animals were sacrificed. TNF-α and nitric oxide (NO) levels in both circulation and myocardium were measured. Compared with those of septic shock animals, the levels of cardiac output, stroke volume, and mean arterial pressure were better maintained in HVHF group. The expression of TNF-α in myocardium in HVHF group was lower than that in septic shock group (44.17 ± 18.70 vs. 92.50 ± 33.89 pg/mg protein, P = 0.015). The difference of TNF-α in circulation between HVHF group and septic shock group was no significance at different time. However, circulating NO in HVHF group was lower than that in septic shock group. These results suggest that HVHF improves hemodynamics and heart dysfunction in septic shock pigs, which may be attributed to reduction of TNF-α in myocardium but not in circulation.

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.