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Fan Y, Moser J, van Meurs M, Kiers D, Sand JMB, Leeming DJ, Pickkers P, Burgess JK, Kox M, Pillay J. Neo-epitope detection identifies extracellular matrix turnover in systemic inflammation and sepsis: an exploratory study. Crit Care 2024; 28:120. [PMID: 38609959 PMCID: PMC11010428 DOI: 10.1186/s13054-024-04904-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/06/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Sepsis is associated with high morbidity and mortality, primarily due to systemic inflammation-induced tissue damage, resulting organ failure, and impaired recovery. Regulated extracellular matrix (ECM) turnover is crucial for maintaining tissue homeostasis in health and in response to disease-related changes in the tissue microenvironment. Conversely, uncontrolled turnover can contribute to tissue damage. Systemic Inflammation is implicated to play a role in the regulation of ECM turnover, but the relationship between the two is largely unclear. METHODS We performed an exploratory study in 10 healthy male volunteers who were intravenously challenged with 2 ng/kg lipopolysaccharide (LPS, derived from Escherichia coli) to induce systemic inflammation. Plasma samples were collected before (T0) and after (T 1 h, 3 h, 6 h and 24 h) the LPS challenge. Furthermore, plasma was collected from 43 patients with septic shock on day 1 of ICU admission. Circulating neo-epitopes of extracellular matrix turnover, including ECM degradation neo-epitopes of collagen type I (C1M), type III (C3M), type IV (C4Ma3), and type VI (C6M), elastin (ELP-3) and fibrin (X-FIB), as well as the ECM synthesis neo-epitopes of collagen type III (PRO-C3), collagen type IV (PRO-C4) and collagen type VI (PRO-C6) were measured by ELISA. Patient outcome data were obtained from electronic patient records. RESULTS Twenty-four hours after LPS administration, all measured ECM turnover neo-epitopes, except ELP-3, were increased compared to baseline levels. In septic shock patients, concentrations of all measured ECM neo-epitopes were higher compared to healthy controls. In addition, concentrations of C6M, ELP-3 and X-FIB were higher in patients with septic shock who ultimately did not survive (N = 7) compared to those who recovered (N = 36). CONCLUSION ECM turnover is induced in a model of systemic inflammation in healthy volunteers and was observed in patients with septic shock. Understanding interactions between systemic inflammation and ECM turnover may provide further insight into mechanisms underlying acute and persistent organ failure in sepsis.
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Affiliation(s)
- YiWen Fan
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- University Medical Center Groningen, Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - Jill Moser
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Dorien Kiers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Centre for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janette K Burgess
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- University Medical Center Groningen, Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Centre for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janesh Pillay
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- University Medical Center Groningen, Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands.
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Wang D, Wang J, Zheng X, Diao S, Li W, Ma W. Bone homeostasis disorders increased the mortality of sepsis patients: A preliminary retrospective cohort study. Front Med (Lausanne) 2022; 9:1017411. [DOI: 10.3389/fmed.2022.1017411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022] Open
Abstract
IntroductionSepsis is a common clinical syndrome and nearly 20% of all deaths are related to sepsis. As an important part of the body, bone homeostasis disorders are closely related to inflammatory response, but the correlation between bone homeostasis and sepsis, sepsis shock was unknown. The objective of this study was to explore the relation of bone homeostasis on sepsis and sepsis shock.MethodsIn this retrospective cohort study, patients were enrolled between April 2018 and May 2022 from Beijing Chaoyang hospital. Primary outcomes were serum indicators reflected bone homeostasis, such as cross-linked carboxy-terminal telopeptide of type I collagen (CTX-I), tartrate-resistant acid phosphatase 5b (TRACP-5b) and piezo-type mechanosensitive ion channel component 1 (PIEZO1).ResultsThe data were analyzed retrospectively. among 88 evaluable patients, 45 were sepsis (19 were sepsis shock) and 43 were non-sepsis. There was no significant difference in age, gender, BMI, combination diseases, operation time, intraoperative blood loss, and hospital stay. Patients with sepsis or sepsis shock had higher serum CTX-I, TRACP-5b, PIEZO1 (p < 0.05). Spearman’s rank correlation test showed that CTX-I, TRACP-5b, PIEZO1 and the three together (CTX-I + TRACP-5b + PIEZO1) had strong correlation with sepsis or sepsis shock (p < 0.05). The receiver operating characteristic curve (ROC) and precision-recall curve (PRC) showed that these indicators could predict the occurrence of sepsis or sepsis shock (p < 0.05). Besides, decision curve analysis (DCA) and interventions avoided curve (IAC) displayed a high net benefit of bone homeostasis disorders indicators on sepsis or sepsis shock. Kaplan–Meier survival curves revealed that sepsis or shock patients with high value indicators (>0.47227) had a higher mortality (p < 0.05).ConclusionBone homeostasis disorders could increase the mortality of sepsis and sepsis shock patients.
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Jaurila H, Koskela M, Koivukangas V, Gäddnäs F, Salo T, Ala-Kokko TI. Growth factor expression is enhanced and extracellular matrix proteins are depressed in healing skin wounds in septic patients compared with healthy controls. APMIS 2021; 130:155-168. [PMID: 34939229 PMCID: PMC9305760 DOI: 10.1111/apm.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/28/2022]
Abstract
Sepsis manifests as a dysregulated immune response to infection, damaging organs. Skin has a critical role in protecting the body. In sepsis, skin wound healing is impaired. The mechanisms behind it have been poorly studied. In this study, suction blister wounds were induced on intact abdominal skin in 15 septic patients. A single blister wound was biopsied from each patient and from 10 healthy controls. Immunohistochemical staining of growth factors and extracellular matrix (ECM) proteins was performed. Significance (p < 0.05) of the differences was calculated. The following growth factors were overexpressed in the skin of septic patients compared with healthy controls: epithelial growth factor (intact epithelium p = 0.007, migrating epithelium p = 0.038), vascular epithelial growth factor (intact epithelium p < 0.001, migrating epithelium p = 0.011) and transforming growth factor beta (migrating epithelium p = 0.002). The expression of syndecan‐1 was upregulated in the skin of septic patients compared with healthy controls (intact epithelium p = 0.048, migrating epithelium p = 0.028). The following ECM proteins had lower expression in the epithelium in septic patients than in healthy controls: tenascin‐C (migrating epithelium p = 0.03) and laminin‐332 (intact epithelium p = 0.036). In sepsis, growth factor and syndecan expression was enhanced, while ECM and basement membrane proteins were mostly depressed.
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Affiliation(s)
- Henna Jaurila
- ¹Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, Oulu, Finland, Medical Research Center Oulu, University of Oulu, Finland.,Cancer and Translational Medicine Research Unit, Faculty of Medicine, Medical Research Center Oulu, University of Oulu, Finland
| | - Marjo Koskela
- ¹Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, Oulu, Finland, Medical Research Center Oulu, University of Oulu, Finland
| | - Vesa Koivukangas
- ¹Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, Oulu, Finland, Medical Research Center Oulu, University of Oulu, Finland
| | - Fiia Gäddnäs
- ¹Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, Oulu, Finland, Medical Research Center Oulu, University of Oulu, Finland
| | - Tuula Salo
- Cancer and Translational Medicine Research Unit, Faculty of Medicine, Medical Research Center Oulu, University of Oulu, Finland.,Research Group of Oral Health Sciences, Oulu University Hospital, Medical Research Center Oulu, University of Oulu, Finland
| | - Tero I Ala-Kokko
- ¹Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, Oulu, Finland, Medical Research Center Oulu, University of Oulu, Finland
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Jaurila H, Koivukangas V, Koskela M, Gäddnäs F, Salo S, Korvala J, Risteli M, Karhu T, Herzig KH, Salo T, Ala-Kokko TI. Inhibitory effects of serum from sepsis patients on epithelial cell migration in vitro: a case control study. J Transl Med 2017; 15:11. [PMID: 28086962 PMCID: PMC5237124 DOI: 10.1186/s12967-016-1110-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/14/2016] [Indexed: 12/05/2022] Open
Abstract
Background Sepsis delays wound re-epithelialization. In this study we explored the effect of human sepsis sera as well as the effects of cytokines, growth factors and exosomes of sepsis sera treated normal fibroblasts (NF) on keratinocyte migration and proliferation in vitro. Methods Serum samples were taken on days 1, 4, and 9 from 44 patients diagnosed with severe sepsis, and from 14 matching healthy controls. We evaluated the effects of sepsis serum with or without TNF-α, EGF, EGF receptor inhibitor or exosomes of sepsis sera treated NF on human keratinocyte (HaCaT) proliferation (BrdU assay), viability (MTT assay), and migration (horizontal wound healing model). Cytokine levels of sepsis and healthy sera were measured by multiplex assay. Comparisons between groups were carried out using SPSS statistics and P < 0.05 was considered significant. Results Severe-sepsis sera collected on days 1, 4, and 9 reduced keratinocyte proliferation by 6% (P = 0.005), 20% (P = 0.001), and 18% (P = 0.002), respectively, compared to control sera. Cell viability in cultures exposed to sepsis sera from days 4 and 9 was reduced by 38% (P = 0.01) and 58% (P < 0.001), respectively. Open-surface wounds exposed to sepsis sera from days 1 and 4 were larger than those exposed to sera from healthy controls (60 vs. 31%, P = 0.034 and 66 vs. 31%, P = 0.023, respectively). Exosomes of sepsis or healthy sera treated NF inhibited keratinocyte migration. We detected higher serum levels of cytokines TNF-α (5.7 vs. 0.7 pg/ml, P < 0.001), IL-6 (24.8 vs. 3.8 pg/ml, P < 0.001), IL-10 (30.0 vs. 11.9 pg/ml, P = 0.040), and VEGF (177.9 vs. 48.1 pg/ml, P = 0.018) in sepsis sera. Levels of EGF were significantly lower in sepsis sera than in that of healthy controls (6.5 vs. 115.6 pg/ml, P < 0.001). Sepsis serum supplemented with EGF 5 ng/ml and TNF-α in all concentrations improved keratinocyte migration. Conclusions Keratinocyte viability, proliferation and migration were reduced in severe sepsis in vitro. Exosomes from NF added in healthy or sepsis serum media inhibited keratinocyte migration. Decreased levels of EGF in sepsis sera may partially explain the delay of wound healing with severe-sepsis patients. Increased levels of TNF-α in sepsis sera do not explain diminished keratinocyte migration.
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Affiliation(s)
- Henna Jaurila
- Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, P. O. Box 21, 90029, Oulu, Finland. .,Cancer and Translational Medicine Research Unit, Faculty of Medicine, Medical Research Center Oulu, University of Oulu, P.O. Box 5281, 90014, Oulu, Finland.
| | - Vesa Koivukangas
- Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, P. O. Box 21, 90029, Oulu, Finland
| | - Marjo Koskela
- Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, P. O. Box 21, 90029, Oulu, Finland
| | - Fiia Gäddnäs
- Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, P. O. Box 21, 90029, Oulu, Finland
| | - Sirpa Salo
- Research Group of Biomedicine, Faculty of Biochemistry and Molecular Medicine, University of Oulu, P. O. Box 5000, Oulu, 90014, Finland
| | - Johanna Korvala
- Cancer and Translational Medicine Research Unit, Faculty of Medicine, Medical Research Center Oulu, University of Oulu, P.O. Box 5281, 90014, Oulu, Finland
| | - Maija Risteli
- Cancer and Translational Medicine Research Unit, Faculty of Medicine, Medical Research Center Oulu, University of Oulu, P.O. Box 5281, 90014, Oulu, Finland
| | - Toni Karhu
- Research Unit of Biomedicine, Faculty of Medicine and Biocenter of Oulu, University of Oulu, P.O. Box 5000, Oulu, 90014, Finland
| | - Karl-Heinz Herzig
- Research Unit of Biomedicine, Faculty of Medicine and Biocenter of Oulu, University of Oulu, P.O. Box 5000, Oulu, 90014, Finland.,Department of Gastroenterology and Metabolism, Poznan University of Medical Sciences, Collegium Maius, Fredry 10, 61-701, Poznan, Poland
| | - Tuula Salo
- Cancer and Translational Medicine Research Unit, Faculty of Medicine, Medical Research Center Oulu, University of Oulu, P.O. Box 5281, 90014, Oulu, Finland.,Research Group of Oral Health Sciences, Oulu University Hospital, Medical Research Center Oulu, University of Oulu, P. O. Box 5000, Oulu, 90014, Finland
| | - Tero I Ala-Kokko
- Research Group of Surgery, Anesthesia and Intensive Care, Oulu University Hospital, P. O. Box 21, 90029, Oulu, Finland
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Koskela M, Ala-Kokko TI, Gäddnäs F, Herzig KH, Karhu T, Oikarinen A, Koivukangas V. Blister fluid and serum cytokine levels in severe sepsis in humans reflect skin dysfunction. Acta Anaesthesiol Scand 2017; 61:53-61. [PMID: 27514616 DOI: 10.1111/aas.12771] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 05/16/2016] [Accepted: 06/12/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Knowledge of sepsis-related end-organ inflammation in vivo is limited. We investigated the cytokine response in skin and in serum in sepsis and its relation to multiorgan failure (MOF) and survival. METHODS Cytokines were analysed in serum and in suction blister fluid of intact skin of 44 patients with severe sepsis and 15 healthy controls. Blister fluid and serum samples were collected within 48 h of the first sepsis-induced organ failure. This is a substudy of a larger follow-up study on wound healing in sepsis. RESULTS Cytokine levels were higher in patients with sepsis vs. controls (interleukin [IL]-10, blisters: 65.9 vs. 4.3 pg/ml, P < 0.001, serum: 25.7 vs. 4.5 pg/ml, P = 0.004; IL-6, blisters: 41.9 vs. 0.03 pg/ml, P < 0.001, serum: 45.5 vs. 2.1 pg/ml, P < 0.001). Patients with MOF had higher levels of IL-10 (116.4 vs. 21.3 pg/ml, P = 0.015), IL-4 (0.7 vs. 0.07 pg/ml, P = 0.013) and basic fibroblast growth factor (bFGF) (25.9 vs. 9.5 pg/ml, P = 0.027) in blister fluid than patients without MOF. In blister fluid, survivors had lower levels of IL-10 (43.3 vs. 181.9 pg/ml, P = 0.024) and bFGF (15.8 vs. 31.9 pg/ml, P = 0.006) than non-survivors. In serum, survivors had higher levels of vascular endothelial growth factor (VEGF) (152.2 vs. 14.7 pg/ml, P = 0.012) and lower levels of IL-6 (38.5 vs. 91.1 pg/ml, P = 0.011) than non-survivors. The blister fluid levels of bFGF, TNF and VEGF did not correlate with the serum levels. CONCLUSIONS Cytokine responses in skin blister fluid in patients with sepsis differed from those in healthy controls.
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Affiliation(s)
- M. Koskela
- Department of Anesthesiology; Division of Intensive Care Medicine; Oulu University Hospital; Oulu Finland
- Department of Surgery; Oulu University Hospital; Oulu Finland
- Medical Research Center; Oulu University Hospital; Oulu Finland
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine; University of Oulu; Oulu Finland
| | - T. I. Ala-Kokko
- Department of Anesthesiology; Division of Intensive Care Medicine; Oulu University Hospital; Oulu Finland
- Department of Surgery; Oulu University Hospital; Oulu Finland
- Medical Research Center; Oulu University Hospital; Oulu Finland
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine; University of Oulu; Oulu Finland
| | - F. Gäddnäs
- Department of Anesthesiology; Division of Intensive Care Medicine; Oulu University Hospital; Oulu Finland
- Medical Research Center; Oulu University Hospital; Oulu Finland
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine; University of Oulu; Oulu Finland
| | - K.-H. Herzig
- Institute of Biomedicine and Biocenter of Oulu; University of Oulu; Oulu Finland
- Clinical Research Center; University of Oulu; Oulu Finland
| | - T. Karhu
- Institute of Biomedicine and Biocenter of Oulu; University of Oulu; Oulu Finland
| | - A. Oikarinen
- Department of Dermatology; Oulu University Hospital; Oulu Finland
| | - V. Koivukangas
- Department of Anesthesiology; Division of Intensive Care Medicine; Oulu University Hospital; Oulu Finland
- Department of Surgery; Oulu University Hospital; Oulu Finland
- Institute of Biomedicine and Biocenter of Oulu; University of Oulu; Oulu Finland
- Clinical Research Center; University of Oulu; Oulu Finland
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Zakynthinos S, Papanikolaou S, Mentzelopoulos S, Konstandelou E, Psachoulia C, Mavrommatis A. Procollagen type III aminoterminal propeptide as biomarker of host response in severe sepsis. J Crit Care 2013; 28:577-85. [PMID: 23683562 DOI: 10.1016/j.jcrc.2013.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 03/04/2013] [Accepted: 04/02/2013] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study is to test the hypothesis that procollagen type III aminoterminal propeptide (PIIINP) is early elevated in septic episodes and can indicate the acute organ dysfunction/failure characterizing severe sepsis. MATERIALS AND METHODS This prospective study included 107 consecutive septic patients (44 with sepsis, 13 with severe sepsis, and 50 with septic shock) and 45 controls. After blood sampling (within 48 hours after onset of septic episodes), serum was assayed. Patients were followed up, and their disease severity was daily evaluated. RESULTS Procollagen type III aminoterminal propeptide (median [range]) increased in patients with sepsis (9.4 [2.2-42.4] ng/mL) compared with controls (3.6 [1.9-4.9] ng/mL; P<.001), exhibiting further significant increase in patients with severe sepsis and septic shock (19.5 [6.0-52.4] and 20.2 [1.8-89.2] ng/mL, respectively; P<.01-.001 vs sepsis). Among biomarkers of host response severity, PIIINP was the sole that was independently associated with severe sepsis/septic shock (P=.01). The area under the receiver operating characteristic curve for PIIINP to predict which patients with sepsis would eventually develop severe sepsis/septic shock was 0.87; the cutoff of 12 ng/mL had sensitivity 82% and specificity 89%. CONCLUSIONS Increased serum PIIINP can signify severe sepsis/septic shock and predict which patients with sepsis will eventually develop severe sepsis/septic shock, thus representing a biomarker of risk stratification of patients with sepsis.
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Affiliation(s)
- Spyros Zakynthinos
- First Department of Critical Care Medicine and Pulmonary Services, Medical School of Athens University, Evaggelismos Hospital, GR-10675, Athens, Greece.
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Borthwick HA, Brunt LK, Mitchem KL, Chaloner C. Does lactate measurement performed on admission predict clinical outcome on the intensive care unit? A concise systematic review. Ann Clin Biochem 2012; 49:391-4. [PMID: 22715295 DOI: 10.1258/acb.2011.011227] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background There is a need for practical, efficient and effective prognostic markers for patients admitted to the intensive care unit (ICU) with sepsis, to identify patients at highest risk and guide and monitor treatment. Although many biomarkers and scoring systems have been advocated, none have yet achieved this elusive combination. Most ICUs already use blood lactate concentrations to monitor patients but the evidence base for this application is unclear. Methods A systematic review of the last five years of evidence of effectiveness of lactate measurement in prediction of outcome in ICUs was performed. Results It was found that there is a lack of high-quality evidence, and no specific studies of prognostic accuracy. d- or l-Lactate concentrations measured in plasma, serum, whole blood or colonic washings were raised at admission in almost all patient groups, and were higher in patient groups who had the worst outcomes (in-hospital mortality, sequential organ failure). However, there was significant overlap in individual concentrations measured in those who died within 28 days of admission, or who developed multiple organ failure, and those who did not. For serum l-lactate concentrations, no specific cut-off value capable of predicting in-hospital mortality or sequential organ failure could be recommended. Conclusions The evidence reviewed suggested that whole blood, plasma or serum lactate measurement could not provide specific prognostic information for individual patients. There may be a role for monitoring for normalization of serum d- or l-lactate concentrations during goal-directed therapy in the ICU but further good-quality studies are needed. Measurement of the d-lactate stereoisomer shows promise, such that further studies are warranted.
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Affiliation(s)
- Hazel-Ann Borthwick
- Department of Clinical Biochemistry, Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust, Hollyhurst Road, Durham DL3 6HX
| | - Lorraine K Brunt
- Clinical Chemistry, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield S10 2JF
| | - Kelly L Mitchem
- Prince Charles Hospital, Cwm Taf NHS Health Board, Merthyr Tydfil CF47 9DT
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