Granulocyte Colony-Stimulating Factor to Prevent the Progression of Systemic Nonresponsiveness in Systemic Inflammatory Response Syndrome and Sepsis

Polymer conjugation of proteins as a synthetic post-translational modification to impact their stability and activity

For more than 40 years, protein-polymer conjugates have been widely used for many applications, industrially and biomedically. These bioconjugates have been shown to modulate the activity and stability of various proteins while introducing reusability and new activities that can be used for drug delivery, improve pharmacokinetic ability, and stimuli-responsiveness. Techniques such as RDRP, ROMP and "click" have routinely been utilized for development of well-defined bioconjugate and polymeric materials. Synthesis of bioconjugate materials often take advantage of natural amino acids present within protein and peptide structures for a host of coupling chemistries. Polymer modification may elicit increased or decreased activity, activity retention under harsh conditions, prolonged activity in vivo and in vitro, and introduce stimuli responsiveness. Bioconjugation has resulted to modulated thermal stability, chemical stability, storage stability, half-life and reusability. In this review we aim to provide a brief state of the field, highlight a wide range of behaviors caused by polymer conjugation, and provide areas of future work.

Neutrophils in Tissue Trauma of the Skin, Bone, and Lung: Two Sides of the Same Coin

Following severe tissue injury, patients are exposed to various danger- and microbe-associated molecular patterns, which provoke a strong activation of the neutrophil defense system. Neutrophils trigger and modulate the initial posttraumatic inflammatory response and contribute critically to subsequent repair processes. However, severe trauma can affect central neutrophil functions, including circulation half-life, chemokinesis, phagocytosis, cytokine release, and respiratory burst. Alterations in neutrophil biology may contribute to trauma-associated complications, including immune suppression, sepsis, multiorgan dysfunction, and disturbed tissue regeneration. Furthermore, there is evidence that neutrophil actions depend on the quality of the initial stimulus, including trauma localization and severity, the micromilieu in the affected tissue, and the patient's overall inflammatory status. In the present review, we describe the effects of severe trauma on the neutrophil phenotype and dysfunction and the consequences for tissue repair. We particularly concentrate on the role of neutrophils in wound healing, lung injury, and bone fractures, because these are the most frequently affected tissues in severely injured patients.

Inflammatory markers, oxidative stress, and antioxidant capacity in healthy allo-HSCT donors during hematopoietic stem cell mobilization

The aim of this study is to investigate the impact of mobilization with granulocyte colony stimulating factor (G-CSF) and apheresis procedure on inflammatory and oxidative stress markers, and antioxidant capacity in healthy allo-HSCT donors. The study was conducted in the Stem Cell Transplantation Unit of Gazi University Hospital between October 2010 and March 2011, and 25 consecutive allo-HSCT donors were included. The alteration in the serum levels of iron, iron binding capacity, albumin, ferritin, IL-6, hs-CRP, TAC, MDA, and AOPP were determined at five different time points. (1) Prior to the first dose of G-CSF (T0), (2) preapheresis (on the fourth day of G-CSF before the apeheresis procedure) (T1), (3) immediately postapheresis (T2), (4) 24 h postapheresis (T3), and (5) a week after apheresis (T4). Serum ferritin levels increased steadily after administration of G-CSF and remained high up toT4. Both serum IL-6 and hs-CRP levels began to increase in the T1 sampling and reached to a maximum level at T3 and decreased even below the basal levels at T4. Serum AOPP levels decreased at preapheresis and postapheresis time points, while they increased at T3 and T4 samples. Serum MDA levels decreased at T1, T2, T3, and T4 samples. Serum TAC increased significantly and steadily at all time points post G-CSF. In conclusion; mobilization with G-CSF and apheresis caused a transient inflammatory reaction and a protein limited oxidative stress in healthy allo-HCT donors.

Immunomodulatory adjuvant therapy in severe community-acquired pneumonia

Severe pneumonia has a high mortality (38.2%) despite evidence-based therapy. Rising rates of antimicrobial resistance increase the urgency to develop new treatment strategies. Multiple adjuvant therapies for pneumonia have been investigated but none are currently licensed. Profound immune dysregulation occurs in patients with severe infection. An initial hyper-inflammatory response is followed by a secondary hypo-inflammatory response with 'immune-paralysis'. There is focus on the development of immunostimulatory agents to improve host ability to combat primary infection and reduce secondary infections. Successful treatments must be targeted to immune response; promising biomarkers exist but have not yet reached common bedside practice. We explore evidence for adjuvant therapies in community-acquired pneumonia. We highlight novel potential treatment strategies using a broad-based search strategy to include publications in pneumonia and severe sepsis. We explore reasons for the failure to develop effective adjuvant therapies and highlight the need for targeted therapy specific to immune activity.

Cannabinoid receptor activation leads to massive mobilization of myeloid-derived suppressor cells with potent immunosuppressive properties

Cannabinoid receptor activation by agents such as Δ(9)-tetrahydrocannabinol (THC) is known to trigger immune suppression. Here, we show that administration of THC in mice leads to rapid and massive expansion of CD11b(+)Gr-1(+) myeloid-derived suppressor cells (MDSC) expressing functional arginase and exhibiting potent immunosuppressive properties both in vitro and in vivo. The induction of MDSC by THC was associated with a significant increase in granulocyte CSF. Moreover, administration of anti-granulocyte CSF Ab inhibited the induction of MDSC by THC. THC was able to induce MDSC in TLR4 mutant C3H and C57BL10/ScN mice and hence acted independently of TLR4. Accumulation of MDSC in the periphery with a corresponding decrease in the proportion of CD11b(+)Gr-1(+) cells in the bone marrow, as well as in vivo BrdU labeling and cell-cycle analysis, showed that THC induced mobilization of these cells from bone marrow and their expansion in the periphery. Use of selective antagonists SR141716A and SR144528 against cannabinoid receptors 1 and 2, respectively, as well as receptor-deficient mice showed that induction of MDSC was mediated through activation of both cannabinoid receptors 1 and 2. These studies demonstrate that cannabinoid receptor signaling may play a crucial role in immune regulation via the induction of MDSC.

Phagocytosis and digestion of pH-sensitive fluorescent dye (Eos-FP) transfected E. coli in whole blood assays from patients with severe sepsis and septic shock

The function of phagocytic and antigen presenting cells is of crucial importance to sustain immune competence against infectious agents as well as malignancies. We here describe a reproducible procedure for the quantification of phagocytosis by leukocytes in whole blood. For this, a pH-sensitive green-fluorescent protein- (GFP) like dye (Eos-FP) is transfected into infectious microroganisms. After UV-irradiation, the transfected bacteria emit green (≈5160 nm) and red (≈581 nm) fluorescent light at 490 nm excitation. Since the red fluorescent light is sensitive to acidic pH, the phagocytosed bacteria stop emitting red fluorescent light as soon as the phagosomes fuse with lysosomes. The green fluorescence is maintained in the phagolysosome until pathogen degradation is completed. Fluorescence emission can be followed by flow cytometry with filter settings documenting fluorescence 1 (FL 1, FITC) and fluorescence 2 (FL 2, phycoerythrin, PE). Eos-FP transfected bacteria can also be traced within phagocytes using microscopical techniques. A standardized assay has been developed which is suitable for clinical studies by providing clinicians with syringes pre-filled with fixed and appropriately UV-irradiated Eos-FP E. coli (TruCulture™). After adding blood or body fluids to these containers and starting the incubation at 37°C, phagocytosis by granulocytes proceeds over time. Cultures can be terminated at a given time by lysing red blood cells followed by flow cytometry. A pilot study demonstrated that Eos-FP E. coli phagocytosis and digestion was up-regulated in the majority of patients with either severe sepsis or septic shock as compared to healthy donors (p < 0.0001 after o/n incubation). Following treatment with recombinant human granulocyte colony-stimulating factor (rhG-CSF) in selected patients with sepsis, phagolysosome fusion appeared to be accelerated.

Use of granulocyte colony-stimulating factor in patients with severe sepsis or septic shock

PURPOSE

The efficacy and safety of granulocyte colony-stimulating factor (G-CSF) in critically ill patients with severe sepsis or septic shock were evaluated.

SUMMARY

The medical literature was reviewed to identify published trials, case reports, and case series on the use of G-CSF in critically ill patients for treatment of severe sepsis or septic shock. G-CSF has been evaluated as an adjunct to standard care for critically ill patients. Initial studies involving critically ill patients with severe sepsis or septic shock found mortality benefits with G-CSF therapy; however, these findings are limited by factors such as small sample sizes, selection bias, and lack of an appropriate control group. Prospective, randomized, multicenter, double-blind studies failed to confirm the benefits in mortality for patients receiving G-CSF for the treatment of severe sepsis and septic shock. Due to the limitations in the design of the studies that report a mortality benefit and prospective, randomized, multicenter, double-blind studies that report the lack of a mortality benefit, a recommendation to add G-CSF as an adjunctive therapy in critically ill patients with severe sepsis and septic shock cannot be made at this time.

CONCLUSION

The available data, especially those from large, prospective, randomized, double-blind studies, do not support the use of G-CSF as an adjunct therapy to standard care for critically ill patients with severe sepsis or septic shock. Data from prospective, large, randomized, controlled, well-designed studies are needed to define the optimal G-CSF dosing regimen, the safety of this therapy, and the effects of G-CSF on patient morbidity and survival.

Plasma granulocyte colony-stimulating factor levels correlate with clinical outcomes in patients with acute lung injury

OBJECTIVES

To evaluate the association between plasma granulocyte colony-stimulating factor (G-CSF) levels and clinical outcomes including mortality in patients with acute lung injury (ALI), and to determine whether lower tidal volume ventilation was associated with a more rapid decrease in plasma G-CSF over time in patients with ALI.

DESIGN

Retrospective measurement of G-CSF levels in plasma samples that were collected prospectively as part of a large multicenter clinical trial.

SETTING

Intensive care units in ten university centers.

PATIENTS

The study included 645 patients enrolled in the National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Clinical Network trial of lower tidal volumes compared with traditional tidal volumes for ALI.

MEASUREMENTS AND MAIN RESULTS

Baseline plasma levels of G-CSF were associated with an increased risk of death and a decrease in ventilator-free days and organ failure-free days in multivariate analyses controlling for ventilation strategy, age, and sex (Odds ratio death 1.2/log10 increment G-CSF, 95% confidence interval 1.01 to 1.4). Stratification of G-CSF levels into quartiles revealed a strong association between the highest levels of G-CSF and an increased risk of death and decreased ventilator-free days and organ failure-free days in multivariate analyses controlling for ventilation strategy, Acute Physiology and Chronic Health Evaluation III score, Pao2/Fio2 ratio, creatinine, and platelet count (p < 0.05). Subgroup multivariate analysis of patients with sepsis as their risk factor for ALI revealed a U-shaped association between mortality and G-CSF levels such that risk increased linearly from the second through fourth (highest) quartiles, yet also increased in the first (lowest) quartile. G-CSF levels decreased over time in both tidal volume groups, and there was no statistical difference in the extent of decrease between ventilator strategies.

CONCLUSIONS

In patients with ALI, plasma G-CSF levels are associated with morbidity and mortality, but these levels are not influenced by tidal volume strategy. In patients with sepsis-related ALI, a bimodal association between baseline plasma G-CSF levels and subsequent morbidity and mortality from this disease was found.

Interacting neuroendocrine and innate and acquired immune pathways regulate neutrophil mobilization from bone marrow following hemorrhagic shock

Polymorphonuclear neutrophils (PMN) are critical innate immune effector cells that either protect the host or exacerbate organ dysfunction by migrating to injured or inflamed tissues. Resuscitated hemorrhagic shock following major trauma promotes the development of organ inflammation by priming PMN migration and activation in response to a second, often trivial, stimulus (a so-called "two hit" phenomenon). PMN mobilization from bone marrow supports a sustained, hemorrhagic shock/resuscitation (HS/R)-primed migration of PMN. We addressed the role and mechanism of HS/R in regulating PMN egress from bone marrow. We demonstrate that HS/R through the alarmin HMGB1 induces IL-23 secretion from macrophages in an autocrine and TLR4 signaling-dependent manner. In turn IL-23, through an IL-17 G-CSF-mediated mechanism, induces PMN egress from bone marrow. We also show that beta-adrenergic receptor activation by catecholamine of macrophages mediates the HS/R-induced release of HMGB1. These data indicate that HS/R, a global ischemia/reperfusion stimulus, regulates PMN mobilization through a series of interacting pathways that include neuroendocrine and innate and acquired immune systems. Blocking this novel signaling axis may present a novel therapeutic target for posttrauma inflammation.

Effects and safety of granulocyte colony-stimulating factor in healthy volunteers

PURPOSE OF REVIEW

Recombinant human granulocyte colony-stimulating factor (rhG-CSF) is now widely used in normal donors for collection of peripheral blood progenitor cells for allogeneic transplantation and granulocytes for transfusion. Currently available data on biologic and molecular effects, and safety of rhG-CSF in normal healthy volunteers are reviewed.

RECENT FINDINGS

In addition to its known activating role on neutrophil kinetics and functional status, rhG-CSF administration can affect monocytes, lymphocytes and the hemostatic system. Granulocyte colony-stimulating factor receptors were identified in a variety of nonmyeloid tissues, although their role and functional activity have not always been well defined. Moreover, rhG-CSF is capable of modulating complex cytokine networks and can impact the inflammatory response. In addition to its known mobilizing role for peripheral blood progenitor cells, rhG-CSF can mobilize dendritic and endothelial progenitor cells as well. On a clinical level, serious rhG-CSF-related adverse events are well described (e.g. splenic rupture) but remain rare.

SUMMARY

rhG-CSF effects in healthy volunteers, although normally transient and self-limiting, are now believed to be more complex and heterogeneous than previously thought. Although rhG-CSF administration to healthy volunteers continues to have a favorable risk-benefit profile, these new findings have implications for safeguarding the safety of normal individuals.

A comparison of monocyte counts and ex vivo and in vitro monocyte cytokine production after major surgical trauma

BACKGROUND

Impaired function of cluster of differentiation 14-positive (CD14+) monocytes (MOs) after major surgical trauma is believed to predispose to infectious complications. Postoperative decreases in human leukocyte antigen (HLA)-DR expression, tumor necrosis factor-alpha (TNF-alpha) production and interleukin (IL)-12 synthesis have been reported. There are no studies comparing absolute MO counts and MO cytokine synthesis in peripheral blood and stimulated cultures.

METHODS

The study group included 10 low-risk patients undergoing elective cardiac surgery with extracorporeal circulation. Preoperatively (d0) and on the first (d1) and third (d3) postoperative d, we analyzed leukocyte counts, CD14+ MO absolute counts, HLA-DR expression, and stimulated IL-12 and TNF-alpha synthesis using flow cytometry. In addition, IL-12 and TNF-alpha release in stimulated whole blood cultures was assayed.

RESULTS

Whereas the absolute numbers of leukocytes and CD14+ MOs were significantly elevated, HLA-DR expression was suppressed postoperatively. The proportion of TNF-alpha- and IL-12-producing MOs was reduced after surgery. This, however, led to a significant postoperative decrease only in the absolute numbers of peripheral blood IL-12+ MOs. IL-12 secretion was postoperatively reduced in whole blood cultures. The IL-12-synthesizing capacity of IL-12+ MOs was significantly reduced only on d1.

CONCLUSIONS

The immediate postoperative period is associated with an increase in the absolute MO numbers and an impairment of MO function, which is reflected in a reduced capacity to synthesize IL-12 and TNF-alpha and a decreased ability to express HLA-DR and present antigens. Whereas the cytokine-producing capacity returns to normal levels on d3, the suppression of HLA-DR expression persists.

Randomized, double-blind, placebo-controlled trial of granulocyte colony-stimulating factor in patients with septic shock

OBJECTIVE

To investigate the effect of early administration of granulocyte colony-stimulating factor (G-CSF) on hospital mortality in nonneutropenic patients with septic shock, excluding patients with melioidosis.

DESIGN

A randomized, placebo-controlled, double-blinded clinical trial.

SETTING AND PATIENTS

Adult patients with septic shock admitted to the Royal Darwin Hospital Intensive Care Unit.

INTERVENTIONS

Patients were randomized to receive G-CSF or placebo intravenously daily for 10 days, in addition to routine management of septic shock.

MEASUREMENTS

Primary outcome was hospital mortality. Secondary outcomes included intensive care unit mortality, intensive care unit and hospital length of stay, ventilator hours, and time to resolution of shock. Patient comorbidities, baseline and daily physiology, and organ function were collected.

RESULTS

Of 166 patients enrolled, 83 were allocated to receive G-CSF (81 included in analysis) and 83 were allocated to receive placebo. At baseline, 30% of patients had diabetes, 18% were known to have renal impairment or failure, and 38% had a history of hazardous alcohol use. The two groups had similar comorbidities at baseline and a similar severity of illness. The in-hospital mortality was 27% in the G-CSF group and 25% in the placebo group. Secondary end points were not different between groups. There was a higher rate of new organ failure in G-CSF-treated patients than placebo-treated patients (50% vs. 33%, p = .03), most of which was accounted for by new liver dysfunction (11% vs. 1%, p = .007). There was no significant difference in the proportion of patients with troponin I of >0.08 mg/L (78% vs. 66%, p = .09), and the prevalence of acute myocardial infarction (6% vs. 4%, p = .55) was not different during the study. The median peak troponin I level was higher in the G-CSF group (0.5 vs. 0.14 mg/L, p = .007), but baseline levels were not available.

CONCLUSION

G-CSF does not improve outcomes in patients with septic shock, excluding melioidosis. Increased hepatic dysfunction and higher peak troponin levels in patients receiving G-CSF have not been reported in previous clinical trials and warrant further investigation.

A randomized controlled trial of granulocyte colony-stimulating factor for the treatment of severe sepsis due to melioidosis in Thailand

BACKGROUND

Melioidosis is a tropical infectious disease associated with significant mortality. Most deaths occur early and are caused by fulminant sepsis.

METHODS

In this randomized, placebo-controlled trial, we assessed the efficacy of lenograstim (granulocyte colony-stimulating factor [G-CSF], 263 mu g per day administered intravenously) in ceftazidime-treated patients with severe sepsis caused by suspected melioidosis in Thailand.

RESULTS

Over a 27-month period, 60 patients were enrolled to receive either G-CSF (30 patients, 18 of whom had culture-confirmed melioidosis) or placebo (30 patients, 23 of whom had culture-confirmed melioidosis). Mortality rates were similar in both groups (G-CSF group, 70%; placebo group, 87%; risk ratio, 0.81; 95% confidence interval, 0.61-1.06; P=.2), including among patients with confirmed melioidosis (83% vs. 96%; P=.3). The duration of survival was longer for patients who received G-CSF than for patients who received placebo (33 h vs. 18.6 h; hazard ratio, 0.56; 95% confidence interval, 0.31-1.00; P=.05).

CONCLUSIONS

Receipt of G-CSF is associated with a longer duration of survival but is not associated with a mortality benefit in patients with severe sepsis who are suspected of having melioidosis in Thailand. We hypothesize that G-CSF may "buy time" for severely septic patients, but survival is more likely to be improved by management of associated metabolic abnormalities and organ dysfunction associated with severe sepsis.

Effects of granulocyte-colony stimulating factor on the polymorphonuclear leukocyte activity and the course of sepsis in rats with experimental peritonitis

PURPOSE

Polymorphonuclear leucocytes (PML) play an essential role in the host immune response to severe infections. The effects of granulocyte-colony stimulating factor (G-CSF) on the PML immune functions during serious abdominal infection and course of sepsis, and on the survival in rats with peritonitis are the main subjects of this study.

METHODS

The first phase of the study was carried out on 30 Wistar-albino rats equally divided into three groups; Group 1 (control) sham laparotomy; Group 2 (peritonitis); and Group 3 (peritonitis+G-CSF) with fecal peritonitis created by a cecal puncture. At postoperative hours 3, 12, and 24, 0.5 ml normal saline was injected subcutaneously in groups 1 and 2, and 0.5 ml solution containing 50 microg/kg of G-CSF in group 3. The phagocytic and chemotactic activities of neutrophils and monocytes were evaluated by a flow cytometry analysis. The plasma lactate concentrations were assessed as a marker of tissue perfusion during sepsis. The second phase was a survival analysis, which was observed during 10 days on 20 rats equally divided into two groups; group 1 (peritonitis) and group 2 (peritonitis+G-CSF). 0.5 ml normal saline in group 1 and 50 microg/kg of G-CSF in group 2 was injected subcutaneously at the 3rd hour and twice daily.

RESULTS

Both the neutrophil- (1.636 vs 2.236) and monocyte-related (1.789 vs 2.465) phagocytic activities significantly (P < 0.001) improved after the G-CSF administration in the rats with peritonitis. In addition, the G-CSF treatment significantly (P < 0.0014) improved the chemotactic activity (1.18 vs 2.75) of neutrophils, and partly supported (P < 0.0952) the chemotactic activity (1.69 vs 2.37) of monocytes. The plasma lactate level (1.86 vs 4.9 mmol/l) was significantly (P < 0.0001) increased after septic changes due to experimental peritonitis. On the other hand, the lactate concentration was significantly (P < 0.001) decreased (4.9 vs 2.63 mmol/l) after the G-CSF administration. The survival was 20% at the 4th day and 0 at the 6th day in peritonitis, and 90% at the 4th day (P = 0.0055) and 80% at the 6th day (P = 0.0007) days in the peritonitis+G-CSF groups.

CONCLUSION

G-CSF enhances the immune functions of neutrophils and monocytes. The increased activities of these cells have a beneficial effect on the enhancement of the host immune response during severe infections. The improved immune function of PML due to the G-CSF treatment thus ameliorates the survival and the courses of sepsis, which is also defined by tissue perfusion and the cellular oxygen balance, which is affected by septic changes.

Granulocyte-colony stimulating factor (G-CSF) as an adjunct to antibiotics in the treatment of pneumonia in adults

BACKGROUND

Granulocyte colony stimulating factor (G-CSF) is a naturally-occurring cytokine that has been shown to increase neutrophil function and number. Exogenous administration of recombinant G-CSF (filgrastim, pegfilgrastim or lenograstim) has found extensive use in the treatment of febrile neutropenia, but its role in the treatment of infection in non-neutropenic hosts is less well defined.

OBJECTIVES

We explored the role of G-CSF as an adjunct to antibiotics in the treatment of pneumonia in non-neutropenic adults.

SEARCH STRATEGY

For this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2006); MEDLINE (1950 to January 2007); EMBASE (1988 to January 2007); and online databases of clinical trials (www.controlled-trials.com, updated 10 November, 2006).

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) which included hospitalized adult patients with either community-acquired pneumonia or hospital-acquired pneumonia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. The primary outcome measure was 28-day mortality. Secondary outcome measures included other markers of mortality as well as markers of adverse events, including organ dysfunction. An assessment of methodological quality was made for each study.

MAIN RESULTS

Six studies with a total of 2018 people were identified. G-CSF use appeared to be safe with no increase in the incidence of total serious adverse events (pooled odds ratio (OR) 0.91; 95% confidence interval (CI): 0.73 to 1.14) or organ dysfunction. However, the use of G-CSF was not associated with improved 28-day mortality (pooled OR 0.81; 95% CI: 0.52 to 1.27).

AUTHORS' CONCLUSIONS

There is no current evidence supporting the routine use of G-CSF in the treatment of pneumonia. Studies in which G-CSF is administered prophylactically or earlier in therapy may be of interest.

The preterm parturition syndrome

The implicit paradigm that has governed the study and clinical management of preterm labour is that term and preterm parturition are the same processes, except for the gestational age at which they occur. Indeed, both share a common pathway composed of uterine contractility, cervical dilatation and activation of the membranes/decidua. This review explores the concept that while term labour results from physiological activation of the components of the common pathway, preterm labour arises from pathological signalling and activation of one or more components of the common pathway of parturition. The term "great obstetrical syndromes" has been coined to reframe the concept of obstetrical disease. Such syndromes are characterised by: (1) multiple aetiology; (2) long preclinical stage; (3) frequent fetal involvement; (4) clinical manifestations that are often adaptive in nature; and (5) gene-environment interactions that may predispose to the syndromes. This article reviews the evidence indicating that the pathological processes implicated in the preterm parturition syndrome include: (1) intrauterine infection/inflammation; (2) uterine ischaemia; (3) uterine overdistension; (4) abnormal allograft reaction; (5) allergy; (6) cervical insufficiency; and (7) hormonal disorders (progesterone related and corticotrophin-releasing factor related). The implications of this conceptual framework for the prevention, diagnosis, and treatment of preterm labour are discussed.

Effect of granulocyte colony-stimulating factor on IL-12 p40 production during chemotherapy for B-cell lineage non-Hodgkin's lymphoma patients

Interleukin (IL)-12 is a 70-kDa cytokine comprised of two disulfide-linked proteins (p35 and p40) and is essential for the initiation of effective immune response. Granulocyte-colony stimulating factor (G-CSF) affects the balance in the production of anti-inflammatory cytokines. We investigated the serum IL-12 p40 and IL-12 Mix (p40 and p70) production in 28 patients with B-cell lineage non-Hodgkin's lymphoma (NHL) treated with chemotherapy (e.g., CHOP regimen) with or without G-CSF administration and eight healthy volunteers. We found that serum levels of IL-12 p40 (191.2 +/- 150.0 pg/mL) and IL-12 Mix (277.4 +/- 274.5 pg/mL) in the patients before chemotherapy were higher than those in the healthy volunteers (IL-12 p40: 76.4 +/- 25.3 pg/mL, IL-12 Mix: 48.5 +/- 33.4 pg/mL) (P = 0.04 and 0.02, respectively). Next, we examined the serum IL-12 p40 and IL-12 Mix levels in nine patients receiving chemotherapy with administration of G-CSF (CG group, n = 9) and without G-CSF (C group, n = 9). Serum IL-12 p40 and IL-12 Mix levels were decreased on 10 d after chemotherapy in both groups, and those in CG groups were significantly lower than those in C group. These results indicated that administration of G-CSF decreased serum IL-12 p40 and IL-12 Mix levels. Overall survival (OS) at 24 months was not significantly different in the two groups (58.3% in group C vs. 80.0% in group CG, P = 0.67). However, the survival rate of patients at clinical stages III and IV in CG group (n = 6, 66.0%) was significantly better than that of patients in C group (n = 4, 25.0%) (P = 0.02). Long-term administration of G-CSF appears to influence the survival rate by reducing immunosuppressive IL-12 p40 production.

Prolonged intestinal mucosal acidosis is associated with multiple organ failure in human acute pancreatitis: Gastric tonometry revisited

AIM: To evaluate whether multiple determinations of intramucosal pH (pHi) in acute pancreatitis (AP) patients could provide additional information of the disease severity during early hospitalization.

METHODS: Twenty-one patients suffering from acute pancreatitis were monitored by gastric tonometry in the first 72 h after hospital admission.

RESULTS: In the survivor group (n = 15) the initially low pHi values returned to normal level (pHi ≥ 7.32) within 48 h (median pHi: d 1: 7.21; d 2: 7.32; d 3: 7.33). In contrast, pHi values in the non-survivor group n = 6) were persistently either below or in the low normal range (median pHi 7.12; 7.12; 7.07 respectively), but pHi differences between the two groups reached significance only after 24 h (P < 0.01). Mucosal acidosis detected at any time during the monitored period was associated with the emergence of single or multiple organ dysfunction (P < 0.01).

CONCLUSION: Prolonged gastric mucosal acidosis was associated with remote organ dysfunction and failure in Acute Pancreatitis, however, correlation with the fatal outcome became significant only 24 h after admission. Due to its non-invasive nature gastric tonometry may supplement the pro-inflammatory markers to achieve a multi-faceted monitoring of the disease.

Treatment with granulocyte colony-stimulating factor increases interleukin-1 receptor antagonist levels during engraftment following allogeneic stem-cell transplantation

BACKGROUND

The effect of treatment with granulocyte colony-stimulating factor (G-CSF) on interleukin-1 receptor antagonist (IL-1ra) plasma concentrations as well as the role of IL-1ra on leucocyte recovery and parameters of infection within the first 30 days after haematopietic stem-cell transplantation (HSCT) are not well known.

MATERIAL AND METHODS

Twenty-seven patients undergoing myeloablative therapy followed by allogeneic SCT for various haematological disorders were either treated with (n = 18) or without (n = 9) G-CSF. IL-1ra plasma levels were serially determined by ELISA starting at day - 1 and continued until patients were engrafted.

RESULTS

Patients receiving G-CSF had significantly shorter neutropenic periods and significantly lower mean C-reactive protein serum levels during the first 3 weeks succeeding bone marrow transplantation (BMT). Importantly, starting at day + 11 and paralleling the rise of peripheral blood leucocytes, increasing IL-1ra plasma concentrations were observed in both treatment groups. However, the magnitude of the IL-1ra surge was far greater in the G-CSF treatment group. Peak IL-1ra plasma level observed on day + 19 was 882.3 +/- 879.2 pg mL(-1) (mean +/- SD) in patients receiving G-CSF compared with 285.8 +/- 175.2 pg mL(-1) (mean +/- SD) in patients not receiving G-CSF (P = 0.0130). Furthermore, a direct correlation of IL-1ra with peripheral blood leucocytes was verified by the Spearman rank test (P = 0.0025).

CONCLUSION

Granulocyte colony-stimulating factor-mediated acceleration of neutrophil recovery following myeloablative therapy correlated with increased IL-1ra plasma concentrations. Our data suggest that IL-1ra constitutes an intrinsic component of the anti-inflammatory and neutrophil differentiating efficacy of G-CSF and, thus, IL-1ra may be required for the in vivo activity of G-CSF.

Effect of granulocyte colony-stimulating factor in experimental methicillin resistant Staphylococcus aureus sepsis

Background

Methicillin resistant Staphylococcus aureus (MRSA) is the leading pathogenic cause of nosocomial infections, especially in bacteraemia and sepsis. The essential therapy for MRSA infection is glycopeptides. Therapeutic failure can be seen with this therapy and the mortality is still high. The aim of this study was to evaluate the additional effect of G-CSF on the traditional antibiotic treatment in an experimental MRSA sepsis.

Methods

Experimental sepsis was performed in mice by intraperitoneal injection of MRSA isolate. Inoculum dose was estimated as 6 × 10⁹/ml. Mice were randomised for the study into four group; control group (not receive any therapy), G-CSF group (1000 ng/daily, subcutaneously for 3 d), antibiotic group (vancomycin 25 or 50 mg/kg intraperitoneally every 12 hours for 7 d), and vancomycin+G-CSF group (at the same concentrations and duration). Autopsy was done within one hour after mice died. If mice was still alive at the end of seventh day, they were sacrificed, and autopsy was done. In all groups, the effect of G-CSF therapy on the survival, the number of the MRSA colonies in the lung, liver, heart, spleen, and peritoneal cultures, the histopathology of the lung, liver, heart and spleen was investigated.

Results

One hundred and six mice were used. There were no significant differences in survival rates and bacterial eradication in G-CSF group compared with control group, and also in antibiotic +G-CSF group compared with antibiotic alone group. These parameters were all significantly different in antibiotic alone group compared with control group. Histopathologically, inflammation of the lung and liver were significantly reduced in vancomycin (25 mg/kg)+G-CSF and vancomycin (50 mg/kg)+G-CSF subgroups, respectively (p < 0.01). The histopathological inflammation of the other organs was not significantly different in antibiotic+G-CSF group compared with antibiotic group and, also G-CSF group compared with control group.

Conclusion

G-CSF treatment had no additional effect on survival and bacterial eradication in MRSA sepsis in nonneutropenic mice; and only a little effect on histopathology. G-CSF treatment is very expensive, likewise glycopeptides. The more interest in infection control measures, and prevent the spread of MRSA infections is more rational.

G-CSF modulates LPS-induced apoptosis and IL-8 in human microvascular endothelial cells: involvement of calcium signaling

Microvascular endothelial cells (mECs) circulate at higher numbers in patients with severe sepsis and hemophagocytic syndromes. Although these blood mECs might stem from damaged microvasculature, they are perfectly viable and lead to the establishment of cell lines. Such mECs were cultured in low-dose human serum pools (0.5%) and MEM-alpha medium. Antigenic profiling revealed the expression of CD36, factor VIIIa, CD95-ligand, and CD44, but also CD146. We studied the antioxidative effect of the hematopoietic growth factor G-CSF(1) after in vitro stimulation with LPS from E. coli 0111:B4; the growth factor appeared to exhibit a protective effect on organ function in patients with SIRS. mECs were stimulated with 1 micro g/mL of LPS for 24 h and 48 h with and without G-CSF (3x10(3) U/mL) preincubation. After 24 h, supernatants of the stimulated mEC were tested for IL-8 by ELISA, and cells were tested for hemoxygenase-1 (HO-1, Hsp32) by immunohistochemistry and flow cytometry using OSA110 (mAb, Stressgene). Stimulation with LPS upregulated IL-8 by a factor of 2 to 10 in mEC. Preincubation with G-CSF markedly downregulated the LPS-induced IL-8 secretion (20-50%), but IL-6 production was not affected. Upon 48 h of LPS stimulation, mECs developed massive signs of apoptosis and concomitant caspase 3 activation. Caspase 3 activity induced by LPS (24 h) or by staurosporin (6 h) was found to be dramatically downregulated by the G-CSF preincubation protocol.

Pretreatment with granulocyte-colony stimulating factor decreases lipopolysaccharide-induced interferon-γ production in mice in association with the production of interleukin-18

We studied the effects of pretreatment with granulocyte-colony stimulating factor (G-CSF) on the production of pro- and anti-inflammatory cytokines induced by lipopolysaccharide (LPS). Mice received G-CSF or control saline once a day for 7 days or once at 1 h before the injection of LPS. Cytokines were measured by enzyme-linked immunosorbent assay or antibody-based electrochemiluminescence assay and cytokine mRNA was measured by RNAse protection assay. Mice pretreated with G-CSF for 7 days before LPS had lower serum levels of LPS-induced interferon-gamma (IFN-gamma) and higher levels of interleukin (IL)-6 and IL-10 than controls. G-CSF-pretreated mice also had lower mRNA levels of IFN-gamma and higher mRNA levels of IL-6 and IL-10 in the spleen and/or liver than controls. G-CSF-pretreated mice had serum levels of tumor necrosis factor, IL-12 p70 and IL-12 p40 similar to controls. G-CSF-pretreated mice had lower levels of spleen IL-18 than controls-serum IL-18 being undetectable in mice after LPS-and lower levels of IL-18 mRNA in the spleen. Mice pretreated with G-CSF 1 h before LPS had lower levels of serum IFN-gamma and spleen IL-18 than controls. G-CSF pretreatment alters the expression of LPS-induced cytokines with a decrease in pro-inflammatory IFN-gamma and an increase in anti-inflammatory IL-6 and IL-10. G-CSF decrease of IL-18 production may be a major mechanism explaining the effects of G-CSF on the production of IFN-gamma.

Granulocyte-Colony Stimulating Factor (G-CSF) as an adjunct to antibiotics in the treatment of pneumonia in adults

BACKGROUND

Granulocyte colony stimulating factor (G-CSF) is a naturally-occurring cytokine that has been shown to increase neutrophil function and number. Exogenous administration of recombinant G-CSF (filgrastim, pegfilgrastim or lenograstim) has found extensive use in the treatment of febrile neutropaenia, but its role in the treatment of infection in non-neutropaenic hosts is less well defined.

OBJECTIVES

We explored the role of G-CSF as an adjunct to antibiotics in the treatment of pneumonia in non-neutropaenic adults.

SEARCH STRATEGY

We searched the following electronic databases in 2003 and updated the search in 2004: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2004); MEDLINE (January 1966 to March Week 1, 2004); EMBASE (1998 to December 2003); online databases of clinical trials; and reference lists of articles. We also contacted study authors, manufacturers and distributors of G-CSF.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) which included hospitalised adult patients with either community acquired pneumonia or hospital-acquired pneumonia.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. The primary outcome measure was 28 day mortality. Secondary outcome measures included other markers of mortality as well as markers of adverse events, including organ dysfunction. An assessment of methodological quality was made for each study.

MAIN RESULTS

Six studies with a total of 1984 people were identified. G-CSF use appeared to be safe with no increase in the incidence of total serious adverse events (pooled odds ratio (OR) 0.91; 95% confidence interval (CI): 0.73 to 1.14) or organ dysfunction. However, the use of G-CSF was not associated with improved 28 day mortality (pooled OR 0.86; 95% CI: 0.56 to 1.31).

REVIEWERS' CONCLUSIONS

There is no current evidence supporting the routine use of G-CSF in the treatment of pneumonia. Studies in which G-CSF is administered prophylactically or earlier in therapy may be of interest.

Is there a place for granulocyte colony-stimulating factor in non-neutropenic critically ill patients?

Immunoparalysis, characterised by impairments in neutrophil and monocyte/macrophage function, is common in critically ill patients. The theoretical ability of granulocyte colony-stimulating factor (G-CSF) to improve the functions of both neutrophils and monocytes/macrophages provides a rationale for G-CSF therapy in non-neutropenic critically ill patients with infection or a high risk of nosocomial infection. The expression of the receptors that mediate G-CSF effects in neutrophils and monocytes/macrophages is regulated by bacterial products, cytokines and endogenous G-CSF levels, accounting for the variables effects of G-CSF on the neutrophil functions of critically ill patients. This variability should be taken into account when designing studies on the use of G-CSF in ICU-patients. Studies are still needed to identify the subset of patients who may benefit from G-CSF therapy.

Adjunctive granulocyte colony-stimulating factor for treatment of septic shock due to melioidosis

Melioidosis, caused by the intracellular pathogen Burkholderia pseudomallei, is endemic in northern Australia and Southeast Asia. Risk factors for this infection have also been associated with functional neutrophil defects. Because of this, granulocyte colony-stimulating factor (G-CSF) was adopted for use in patients with septic shock due to melioidosis in December 1998. We compared the mortality rates from before and after the introduction of G-CSF therapy at the Royal Darwin Hospital (Darwin, Australia) during the period of 1989-2002. The mortality rate decreased from 95% to 10% after the introduction of G-CSF. Risk factors, the duration of illness before presentation, and the severity of illness were similar in both groups. A smaller decrease in mortality among patients in the intensive care unit who did not have melioidosis was observed, suggesting that other changes in management did not account for the magnitude of the benefit seen. We conclude that G-CSF may have contributed to the reduction in the mortality rate among patients with septic shock due to melioidosis.

Effects of exogenous recombinant human granulocyte colony-stimulating factor (filgrastim, rhG-CSF) on neutrophils of critically ill patients with systemic inflammatory response syndrome depend on endogenous G-CSF plasma concentrations on admission

OBJECTIVE

To investigate the effects of exogenous recombinant human granulocyte colony-stimulating factor (rhG-CSF; filgrastim) application on the neutrophils of patients at risk of sepsis following major trauma or operation.

DESIGN

Randomized controlled trial.

SETTING

Surgical intensive care unit and research laboratory of a university hospital.

PATIENTS

Twenty-seven patients with systemic inflammatory response syndrome (SIRS).

INTERVENTIONS

Thirteen patients were treated with filgrastim (1 micro g.kg.24 h) for 10 days as a continuous infusion. Fourteen patients served as controls.

MEASUREMENTS AND RESULTS

Surface expression of FcgammaR type I (CD64), phagocytosis of E. coli, and the E. coli-induced oxidative burst of neutrophils were tested by flow cytometry. On the first postoperative/posttraumatic day, endogenous G-CSF plasma concentrations were <300 pg/ml in seven controls (subgroup 1) and nine filgrastim patients (subgroup 3), and were already elevated with >500 pg/ml in seven controls (subgroup 2) and four filgrastim patients (subgroup 4). G-CSF values ( P=0.0026, subgroup 1/3; P=0.0167, 2/4), neutrophil counts ( P=0.0026, 1/3; P=0.0167, 2/4), and CD64 expression ( P=0.0013, 1/3) were higher in filgrastim-treated than non-treated subgroups, but not phagocytic and burst activities. From day zero to day 1, phagocytosis decreased in subgroups 1 (5/7 patients) and 3 (5/9), but increased in subgroups 2 (5/7) and 4 (3/4), and respiratory burst activity decreased in subgroup 3 (8/9).

CONCLUSIONS

Besides activation of neutrophil maturation, low-dose rhG-CSF application in postoperative patients with SIRS has different effects on neutrophil functions, in part depending on already endogenously produced G-CSF.

An audit of the use of granulocyte colony-stimulating factor in septic shock

BACKGROUND

Granulocyte colony-stimulating factor (G-CSF) stimulates the production of neutrophils and modulates the function and activity of developing and mature neutrophils. In septic shock, the immune system can be considered one of the failing organ systems. G-CSF improves immune function and may be a useful adjunctive therapy in patients with septic shock.

AIM

To evaluate the introduction of G-CSF as an adjunct to our standard treatment for community-acquired septic shock.

METHODS

We performed a prospective data collection and analysis to determine whether the addition of G-CSF to our standard treatment for community-acquired septic shock was associated with improved hospital outcome, compared with an historical cohort of similar patients. We included all patients admitted to the Intensive Care Unit (ICU) with community-acquired septic shock between December 1998 and March 2000. Patients received 300 microg G-CSF intravenously daily for 10 days in addition to our standard treatment for community-acquired septic shock. G-CSF was discontinued early if the patient was discharged from ICU before 10 days or if the absolute neutrophil count exceeded 75 x 10(6)/mL.

RESULTS

A total of 36 patients with community-acquired septic shock, an average Apache 2 score of 26.7, and a predicted mortality of 0.79, were treated with G-CSF from December 1998 to March 2000. Hospital mortality was 31% compared with an historical cohort of 11 similar patients with a hospital mortality of 73% (P = 0.018). In the subgroup of patients with melioidosis septic shock, the hospital survival improved from 5% to 100% (P < 0.0001). No significant adverse events occurred as a result of the administration of G-CSF.

CONCLUSION

G-CSF is a safe adjunctive therapy in community-acquired septic shock and may be associated with improved outcome. The use of G-CSF in septic shock should undergo further investigation to define subgroups of patients who may benefit from G-CSF. The use of G-CSF in patients with septic shock due to Burkholderia pseudomallei is recommended.

Peaks of endogenous G-CSF serum concentrations are followed by an increase in respiratory burst activity of granulocytes in patients with septic shock

The relationship between peaks of G-CSF serum concentrations and respiratory burst activity of polymorphonuclear cells (PMN) was investigated in patients with postoperative or post-traumatic severe sepsis and septic shock. Over a 12 month period, a longitudinal analysis of G-CSF, TNF-alpha and IFN-gamma serum concentrations, burst activity of PMN, and expression of CD64 on the surface of PMN, were performed by ELISA technique and flow cytometric analysis, respectively, in 58 patients admitted to the intensive care unit (ICU) on a daily basis until discharge from the ICU or death. Out of these 58 patients, 27 with proven infections were in septic shock for at least 4 days' duration. Seventeen of these patients survived, whereas ten died. In 15 out of these 27 patients, 26 episodes of G-CSF peaks were observed, which were followed in most patients (13/15) by an increase in PMN burst activity, from 28% up to 540% (median 188%). Following the G-CSF peaks, CD64 expression on PMN remained at an increased level, followed by a marked decline 3 days later. TNF-alpha serum concentrations were elevated in most episodes (22/26), whereas IFN-gamma serum concentrations were below the detection level in 23/26 episodes. Taken together, peaks in G-CSF serum concentrations are followed by enhanced CD64 expression and increased burst activity of PMN in most patients with severe sepsis and septic shock. Thus, endogenous G-CSF increases neutrophil function in patients with severe sepsis and septic shock, necessary for resolution of bacterial infections in these patients.

Activated polymorphonuclear leukocytes enhance production of leukocyte microparticles with increased adhesion molecules in patients with sepsis

BACKGROUND

Leukocyte microparticles (MPs) derived from polymorphonuclear leukocytes (PMNLs) have been recently found to be activators of vascular endothelium in vitro. The precise role of leukocyte MPs has not been clarified in patients suffering severe insult. The objective of this study was to evaluate production of leukocyte MPs and expression of adhesion molecules on the MP surface in patients with sepsis.

METHODS

Twenty-one patients with severe infection (fulfilling the criteria of sepsis with serum C-reactive protein > 10 mg/dL) and 21 healthy volunteers were included as study subjects. Production of leukocyte MPs, expression of CD11b on the MPs, and oxidative activity of PMNLs were measured by flow cytometry in the presence and absence of formyl-methionyl-leucyl-phenylalanine. CD11b expression was evaluated according to the MP size (more than, equal to, or less than 1.0 microm). Soluble E-selectin, thrombomodulin, and PMNL elastase were also measured in blood.

RESULTS

Production of leukocyte MPs and superoxide production in PMNLs with and without formyl-methionyl-leucyl-phenylalanine increased significantly in patients with sepsis in comparison with production in normal volunteers. In patients with sepsis, expression of CD11b was also markedly enhanced on MPs less than 1.0 microm in diameter in comparison with expression in control subjects. Levels of soluble E-selectin, thrombomodulin, and PMNL elastase in blood were significantly increased in patients with sepsis. We succeeded in detecting leukocyte MPs visually by fluorescence microscopy.

CONCLUSION

Activated PMNLs enhance production of leukocyte MPs with increased adhesion molecules in patients with sepsis. Activated leukocyte MPs may play a role in the pathogenesis of endothelial activation and leukocyte-endothelium interaction in the presence of sepsis.

Innovative therapies for sepsis

Sepsis and septic shock continue to be a major cause of morbidity and mortality. Despite numerous advances in the supportive care of patients with sepsis, the overall mortality has changed little in the past 20 years. Many innovative therapies have been attempted in the field of sepsis, primarily aimed at stopping the cycle of cytokine activation which is part of the systemic inflammatory response. Therapies have also targeted other molecular mediators of inflammation and coagulation. Despite encouraging preliminary preclinical results, most of the early trials in sepsis research have failed to offer hope of improving survival with the use of these innovative therapies. Postulated reasons for the failure of clinical trials include the disparity between animal models and clinical reality, the heterogeneous nature of patient populations and sepsis, and the complexity of the inflammatory cascade. On a more hopeful note, three recent trials assessing corticosteroids, anti-tumour necrosis factor strategy and drotrecogin alfa (rhAPC), respectively, have proclaimed positive results. However, only the drotrecogin alfa trial has been peer reviewed and published.

Granulocyte colony-stimulating factor (G-CSF) stiffens leukocytes but attenuates inflammatory response without lung injury in septic patients

OBJECTIVE

To determine whether granulocyte colony-stimulating factor (G-CSF) administration changes leukocyte deformability resulting in lung injury in patients with sepsis.

METHODS

Twenty-five consecutive septic patients were divided randomly into two groups. Twelve patients were given recombinant human G-CSF subcutaneously at 2 microg/kg once a day for 5 days (group G). The remaining 13 patients were given sterilized saline as placebo (group N). Leukocyte count; concentrations of C-reactive protein (CRP) and thrombomodulin (TM); respiratory index (RI) and lung injury score (LIS); and APACHE II score and Goris MOF index were determined before and after G-CSF or placebo administration. Leukocyte deformability was observed in a microchannel array etched on a single-crystal silicon tip, which simulates the microvasculature. The number of microchannels obstructed (NOM) by stiffened leukocytes was counted. Transit time (TT), that is, the time taken for 100 microL of whole blood to pass through the microchannel, was determined.

RESULTS

G-CSF administration significantly increased leukocyte count and decreased CRP concentration. In group G, both NOM and TT increased significantly 5 days after G-CSF administration; they did not change in group N. However, RI, LIS, and TM did not change, suggesting that no patient developed lung injury.

CONCLUSION

G-CSF causes leukocyte stiffness but attenuates inflammatory response without inducing lung injury in septic patients.

Pilot trial of interleukin-2 with granulocyte colony-stimulating factor for the mobilization of progenitor cells in advanced breast cancer patients undergoing high-dose chemotherapy: expansion of immune effectors within the stem-cell graft and post-stem-cell infusion

PURPOSE

To evaluate whether administration of interleukin-2 (IL-2) with granulocyte colony-stimulating factor (G-CSF) improves mobilization of immune effector cells into the stem-cell graft of patients undergoing high-dose chemotherapy and autografting.

PATIENTS AND METHODS

We performed a trial of stem-cell mobilization with IL-2 and G-CSF in advanced breast cancer patients receiving high-dose chemotherapy with cyclophosphamide, thiotepa, and carboplatin and stem cells followed by IL-2. The trial defined immune, hematologic, and clinical effects of IL-2 in this setting.

RESULTS

Of 32 patients enrolled, nine received G-CSF alone for mobilization. Twenty-one of 23 patients mobilized with IL-2 plus G-CSF had stem cells collected with more mononuclear cells than those receiving G-CSF (19.3 v 10.4 x 10(8)/kg; P =.006), but fewer CD34(+) progenitor cells (6.9 v 22.0 x 10(6)/kg; P =.049). The IL-2 plus G-CSF-mobilized patients had greater numbers of activated T (CD3(+)/CD25(+)) cells (P =.009), natural killer (NK; CD56(+)) cells (P =.007), and activated NK (CD56 bright(+)) cells (P: =.039) than those patients mobilized with G-CSF. NK (P =.042) and lymphokine-activated killer (LAK) (P =.016) activity was increased in those mobilized with IL-2 + G-CSF, whereas G-CSF-mobilized patients had a decline in cytolytic activity. In the third week posttransplantation, immune reconstitution was superior in those mobilized with IL-2 plus G-CSF based on greater numbers of activated T cells (P =.003), activated NK cells (P =.04), and greater LAK activity (P =.003). The 16 of 21 IL-2 + G-CSF-mobilized patients with adequate numbers of stem cells (> 1.5 x 10(6) CD34(+) cells/kg) collected engrafted rapidly posttransplantation.

CONCLUSION

The results demonstrate that G-CSF + IL-2 can enhance the number and function of antitumor effector cells in a mobilized autograft without impairing the hematologic engraftment, provided that CD34 cell counts are more than 1.5 x 10(6) cells/kg. Mobilization of CD34(+) stem cells does seem to be adversely affected. In those mobilized with IL-2 and G-CSF, post-stem-cell immune reconstitution of antitumor immune effector cells was enhanced.

Dissociation of LPS-induced monocytic ex vivo production of granulocyte colony-stimulating factor (G-CSF) and TNF-alpha in patients with septic shock

Over a 6 month period, in 192 patients admitted to the intensive care unit (ICU), a longitudinal analysis of whole blood lipopolysaccharide (LPS)-induced ex vivo cytokine production was performed on a daily basis until discharge from the ICU or death. Twenty-one patients with proven infections were in septic shock for the first time and for at least 3 days' duration. Ex vivo LPS-inducible release of granulocyte colony-stimulating factor (G-CSF) was upregulated and that of TNF-alpha was downregulated in patients with septic shock, regardless whether they survived or died. In conclusion, LPS-induced ex vivo TNF-alpha and G-CSF cytokine release by monocytes is regulated differentially in patients with septic shock. Since upregulation of LPS-induced production of G-CSF occurred earlier in survivors than in non-survivors, rapidly elevated and sustained G-CSF responsiveness may contribute to survival in septic shock.

Effect of granulocyte colony-stimulating factor treatment on ex vivo neutrophil functions in nonneutropenic surgical intensive care patients

Granulocyte colony-stimulating factor (G-CSF) preferentially stimulates growth and differentiation of neutrophil precursors and activates neutrophil functions. The aim of the present study was to investigate the functional response of the neutrophil to exogenous recombinant human G-CSF (rHuG-CSF) in nonneutropenic patients. In 30 surgical intensive care unit patients with severely impaired wound healing, leukocyte differential count, plasma G-CSF level, and a broad spectrum of neutrophil functions were monitored before (day 0), throughout (days 1 and 5), and at days 1 and 5 after stopping G-CSF treatment. G-CSF application resulted in a 3.5-fold increase in peripheral blood granulocyte count at day 5 of treatment. The mean plasma G-CSF level rose from 48 to a maximum of 2314 pg/ml at day 1 of G-CSF therapy. Neutrophil chemotaxis and stimulated lysozyme release were decreased throughout G-CSF treatment, whereas respiratory burst activity, phagocytic activity, and intracellular calcium concentration were enhanced by G-CSF. Neutrophil membrane depolarization remained unaffected. The increased count and activation state of neutrophils were associated with clinical improvement in most of these patients. Thus, G-CSF may be a useful adjuvant treatment for nonneutropenic patients with severely impaired wound healing.

Safety of granulocyte colony-stimulating factor (filgrastim) in intubated patients in the intensive care unit: interim analysis of a prospective, placebo-controlled, double-blind study

OBJECTIVE

To investigate the safety of the granulocyte colony-stimulating factor filgrastim in the prevention of nosocomial infections in intubated patients in the intensive care unit (ICU), with special emphasis on the possible deleterious effect on acute respiratory distress syndrome (ARDS) and the development of multiple organ dysfunction (MOD).

DESIGN

Predetermined, interim analysis of a prospective, randomized, placebo-controlled, double-blind trial.

SETTING

University hospital medical-surgical ICU.

PATIENTS

A total of 59 consecutive ICU patients, aged >18 yrs, admitted to the ICU no more than 12 hrs before the study, intubated because of ventilatory insufficiency no more than 48 hrs before the study, expected to stay in the ICU for >48 hrs, and had informed consent from the next relative.

INTERVENTIONS

Patients were randomized to receive either placebo or 300 microg of filgrastim subcutaneously once daily for 7 days.

MEASUREMENTS AND MAIN RESULTS

No significant differences were found in the number of patients developing ARDS (2 of 20 in the placebo group vs. 0 of 22 in the filgrastim group), disseminated intravascular coagulation (3 of 27 vs. 3 of 29), acute renal failure (1 of 27 vs. 1 of 23), or change in MOD. Data analysis showed nosocomial infections in 11 of 29 patients in the placebo group and in 7 of 30 patients in the filgrastim group (p = .266). The median (range) length of ICU stay was 8 (1-34) days in the placebo group and 6 days (1-28) in the filgrastim group. The day 28 mortality rate was 17% (5 of 29) in the placebo group and 13% (4 of 30) in the filgrastim group. No drug-related adverse events occurred.

CONCLUSION

Filgrastim is safe in intubated ICU patients, with no excess risk for development of ARDS or MOD.

Strategies to evaluate metabolic stress and catabolism by means of immunological variables

In this article, we outline how metabolic stress and catabolism are set off and influenced by the neuroendocrine network that interacts intensely with the immune system. When evaluating metabolic stress in individuals, the vast ocean of mediators, cell-surface markers and intracellular components that participate in metabolism and catabolic or anabolic changes make it necessary to focus on specific entities that may best mirror all these events. T cell responsiveness and factors that orchestrate the T helper type 1 and type 2 balance form an immunological mirror that can competently reflect catabolism and metabolic stress.

Ex vivo expansion of mature human neutrophils with normal functions from purified peripheral blood CD34+ haematopoietic progenitor cells

Purified CD34+ haematopoietic progenitor cells were cultivated with stem cell factor, interleukin 3 (IL-3), granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte CSF (G-CSF) for 7 d, and thereafter non-adherent cells were divided into two groups. Cells in one group (group A) were further cultivated for 7 d with four cytokines, and cells in the other group (group B) were further cultivated for 7 d with G-CSF alone. On day 14, 220-fold and 130-fold increases in the numbers of non-adherent cells were achieved for groups A and B respectively. These cell preparations contained 65% granulocytes for group A and 95% granulocytes for group B. These cells gained the ability to respond effectively with chemotaxis, phagocytosis and superoxide (O2-) release. Cells in group B were appropriately primed by G-CSF, GM-CSF, tumour necrosis factor alpha and IL-1beta for enhanced release of O2 -. The responsiveness of these cells was identical to that of peripheral blood neutrophils, indicating that cells in group B may be in the resting state. In contrast, cells in group A were not primed by these cytokines for enhanced release of O2- and released a large amount of O2- spontaneously, indicating that cells in group A may be in the activated state. These findings indicate that mature neutrophils with normal functions were expanded ex vivo in group B and suggest that these cells could be used for possible autologous neutrophil transfusion to prevent bacterial infections during severe neutropenia after cytotoxic chemotherapy.

Difference in the responses after administration of granulocyte colony-stimulating factor in septic patients with relative neutropenia

OBJECTIVE

The objective of this study was to classify the clinical responses after administration of granulocyte colony-stimulating factor (G-CSF) in septic patients with relative neutropenia.

PATIENTS AND METHODS

We administered recombinant human G-CSF (2 microg/kg) subcutaneously once a day for 5 days to 30 septic patients with white cell counts below 5,000 cells/mm3. Absolute neutrophil count (ANC), neutrophil differentiation, and serum concentration of G-CSF were determined serially. Bone marrow also was analyzed before and after treatment.

RESULTS

Neutrophil responses to G-CSF varied from good (ANC > 10,000/mm3, group G, n = 20) to moderate (ANC < 10,000/mm3, group M, n = 5) to poor (no increase in ANC, group P, n = 5). Before G-CSF administration, the three groups showed no differences in ANC but did show significant differences in serum concentration of G-CSF. G-CSF concentration was 0.16 +/- 0.03 ng/mL in group G, 7.0 +/- 3.0 ng/mL in group M, and 270 +/- 90 ng/mL in group P. Immature neutrophils accounted for 35.0 +/- 3.7% of peripheral leukocytes in group P but only 5.1 +/- 0.6% in group G. Although bone marrow was depressed in all groups before G-CSF treatment, nucleated cell count increased significantly after rhG-CSF treatment in groups G and M. Survival rate after 4 weeks was 90% in group G and 100% in group M; no patient in group P survived.

CONCLUSION

G-CSF administration was effective in septic patients with a low percentage of immature neutrophils and insufficient endogenous G-CSF. It had little effect on patients with a high percentage of immature neutrophils whose G-CSF production was up-regulated and whose bone marrow was severely depressed.

Hematopoietic cell transplantation for primary systemic amyloidosis: what have we learned

Dose-intensive therapy with hematopoietic cell transplantation is effective at reversing AL amyloidosis but is not without risk. Guidelines have been developed for patient selection in order to maximize benefit and minimize treatment-related mortality. Identification of a patient's clonal germline light chain variable region gene may become relevant to patient selection, and development of less morbid approaches to stem cell mobilization and collection would be helpful. While there is room for discussion regarding the design of future therapeutic trials, it is reasonable to attempt to improve the complete response rate for good risk patients by continuing efforts on the phase II level. Attempts to improve outcomes for patients with symptomatic cardiac or advanced multisystem disease may require serial solid organ and stem cell transplantation as well as the development of less toxic approaches using lower doses of melphalan, improved supportive care measures and specific organ-system prophylaxis. If outcomes can be improved, issues related to clonotypic contamination of stem cells will need to be revisited.

Inflammation-induced systemic proteolysis of inter-alpha-inhibitor in plasma from patients with sepsis

Inter-alpha-inhibitor (IalphaI) is a human plasma serine proteinase inhibitor. It contains one light peptide chain called bikunin that exerts antiproteinase activity and other antiinflammatory functions. Bikunin is covalently linked to two heavy chains that, after tissular diffusion, stabilize the extracellular matrix. Owing to its negative acute-phase reactant character and its susceptibility to proteolysis, IalphaI has been implicated in the pathophysiology of sepsis. Moreover, IalphaI has been shown to exert a protective effect on a pig model of endotoxic shock. Twenty patients admitted to the intensive care unit (ICU) for a septic syndrome were included in the present study. IalphaI and antithrombin III (ATIII) levels were measured on admission. Sequential measurements of IalphaI could be done in 4 patients. We demonstrate that IalphaI levels are significantly decreased in plasma samples collected on admission from patients with sepsis (59 +/- 32 mg/L vs 241 +/- 70 mg/L; P < .0001). This decrease was greater in severe sepsis and septic shock than in sepsis. Death was not predictable from initiol IalphaI levels. In 2 patients with a favorable course, IalphaI values regularly increased during the ICU stay. By sodium dodecyl sulfate-polyacrylamide gel electrophoresis followed by immunoblot analysis and microsequencing, we characterized IalphaI-related components in plasma from several patients; they obviously arise from IalphaI through proteolytic cleavage. Thus, systemic proteolysis and decreased biosynthesis both contribute to the fall in the plasma level of IalphaI. Because IalphaI is very sensitive to proteolysis by polymorphonuclear granulocytes (PMNs) that are stimulated during sepsis, we suggest that IalphaI plasma level would be a useful marker for neutrophil proteinase activity. ATIII, as well as IalphaI, is considered a negative acute phase protein. Because in vitro ATIII is less susceptible than IalphaI to proteolysis by PMNs and because their relative levels weakly correlated, we suggest that an unspecific systemic proteolysis is not significantly involved in the ATIII deficiency occurring in sepsis.