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Ge J, Pan W, Feeney NJ, Ott L, Anderson E, Alessandrini A, Zanoni I, Markmann JF, Cuenca AG. Adjuvant conditioning induces an immunosuppressive milieu that delays alloislet rejection through the expansion of myeloid-derived suppressor cells. Am J Transplant 2023; 23:935-945. [PMID: 37080464 PMCID: PMC10330215 DOI: 10.1016/j.ajt.2023.04.015] [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: 03/23/2023] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
Advances in immunosuppression have been relatively stagnant over the past 2 decades, and transplant recipients continue to experience long-term morbidity associated with immunosuppression regimens. Strategies to reduce or eliminate the dosage of immunosuppression medications are needed. We discovered a novel administration strategy using the classic adjuvant alum to condition murine islet transplant recipients, known as adjuvant conditioning (AC), to expand both polymorphonuclear and monocytic myeloid-derived suppressive cells (MDSCs) in vivo. These AC MDSCs potently suppress T cell proliferation when cultured together in vitro. AC MDSCs also facilitate naïve CD4+ T cells to differentiate into regulatory T cells. In addition, we were able to demonstrate a significant delay in alloislet rejection compared with that by saline-treated control following adjuvant treatment in a MDSC-dependent manner. Furthermore, AC MDSCs produce significantly more interleukin (IL)-10 than saline-treated controls, which we demonstrated to be critical for the increased T cell suppressor function of AC MDSCs as well as the observed protective effect of AC against alloislet rejection. Our data suggest that adjuvant-related therapeutics designed to expand MDSCs could be a useful strategy to prevent transplant rejection and curb the use of toxic immunosuppressive regimens currently used in transplant patients.
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Affiliation(s)
- Jifu Ge
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Urology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weikang Pan
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Noel J Feeney
- Division of Transplant Surgery, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leah Ott
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Emily Anderson
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alessandro Alessandrini
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Massachusetts, USA; Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivan Zanoni
- Division of Gastroenterology/Immunology, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - James F Markmann
- Division of Transplant Surgery, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Massachusetts, USA
| | - Alex G Cuenca
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Massachusetts, USA.
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Dong X, Tu H, Qin S, Bai X, Yang F, Li Z. Insights into the Roles of B Cells in Patients with Sepsis. J Immunol Res 2023; 2023:7408967. [PMID: 37128298 PMCID: PMC10148744 DOI: 10.1155/2023/7408967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 05/03/2023] Open
Abstract
Sepsis is a life-threatening yet common disease, still posing high mortality worldwide. Sepsis-related deaths primarily occur during immunosuppression; the disease can hamper the numbers and function of B cells, which mediate innate and adaptive immune responses to maintain immune homeostasis. Dysfunction of B cells, along with aggravated immunosuppression, are closely related to poor prognosis. However, B cells in patients with sepsis have garnered little attention. This article focuses on the significance of B-cell subsets, including regulatory B cells, in sepsis and how the counts and function of circulating B cells are affected in patients with sepsis. Finally, potential B-cell-related immunotherapies for sepsis are explored.
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Affiliation(s)
- Xijie Dong
- Trauma Center/Department of Emergency and Traumatic Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hao Tu
- Trauma Center/Department of Emergency and Traumatic Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shuang Qin
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangjun Bai
- Trauma Center/Department of Emergency and Traumatic Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Fan Yang
- Trauma Center/Department of Emergency and Traumatic Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhanfei Li
- Trauma Center/Department of Emergency and Traumatic Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Wang N, Lu Y, Zheng J, Liu X. Of mice and men: Laboratory murine models for recapitulating the immunosuppression of human sepsis. Front Immunol 2022; 13:956448. [PMID: 35990662 PMCID: PMC9388785 DOI: 10.3389/fimmu.2022.956448] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Prolonged immunosuppression is increasingly recognized as the major cause of late phase and long-term mortality in sepsis. Numerous murine models with different paradigms, such as lipopolysaccharide injection, bacterial inoculation, and barrier disruption, have been used to explore the pathogenesis of immunosuppression in sepsis or to test the efficacy of potential therapeutic agents. Nonetheless, the reproducibility and translational value of such models are often questioned, owing to a highly heterogeneric, complex, and dynamic nature of immunopathology in human sepsis, which cannot be consistently and stably recapitulated in mice. Despite of the inherent discrepancies that exist between mice and humans, we can increase the feasibility of murine models by minimizing inconsistency and increasing their clinical relevance. In this mini review, we summarize the current knowledge of murine models that are most commonly used to investigate sepsis-induced immunopathology, highlighting their strengths and limitations in mimicking the dysregulated immune response encountered in human sepsis. We also propose potential directions for refining murine sepsis models, such as reducing experimental inconsistencies, increasing the clinical relevance, and enhancing immunological similarities between mice and humans; such modifications may optimize the value of murine models in meeting research and translational demands when applied in studies of sepsis-induced immunosuppression.
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Affiliation(s)
- Ning Wang
- West China Biopharm Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yongling Lu
- Medical Research Center, Southwest Hospital, Army Military Medical University, Chongqing, China
| | - Jiang Zheng
- Medical Research Center, Southwest Hospital, Army Military Medical University, Chongqing, China
- *Correspondence: Jiang Zheng, ; Xin Liu,
| | - Xin Liu
- Medical Research Center, Southwest Hospital, Army Military Medical University, Chongqing, China
- *Correspondence: Jiang Zheng, ; Xin Liu,
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Gao YL, Liu YC, Zhang X, Shou ST, Chai YF. Insight Into Regulatory T Cells in Sepsis-Associated Encephalopathy. Front Neurol 2022; 13:830784. [PMID: 35370925 PMCID: PMC8965708 DOI: 10.3389/fneur.2022.830784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/18/2022] [Indexed: 01/09/2023] Open
Abstract
Sepsis-associated encephalopathy (SAE) is a diffuse central nervous system (CNS) dysfunction during sepsis, and is associated with increased mortality and poor outcomes in septic patients. Despite the high incidence and clinical relevance, the exact mechanisms driving SAE pathogenesis are not yet fully understood, and no specific therapeutic strategies are available. Regulatory T cells (Tregs) have a role in SAE pathogenesis, thought to be related with alleviation of sepsis-induced hyper-inflammation and immune responses, promotion of T helper (Th) 2 cells functional shift, neuroinflammation resolution, improvement of the blood-brain barrier (BBB) function, among others. Moreover, in a clinical point of view, these cells have the potential value of improving neurological and psychiatric/mental symptoms in SAE patients. This review aims to provide a general overview of SAE from its initial clinical presentation to long-term cognitive impairment and summarizes the main features of its pathogenesis. Additionally, a detailed overview on the main mechanisms by which Tregs may impact SAE pathogenesis is given. Finally, and considering that Tregs may be a novel target for immunomodulatory intervention in SAE, different therapeutic options, aiming to boost peripheral and brain infiltration of Tregs, are discussed.
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Affiliation(s)
- Yu-lei Gao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
- Yu-lei Gao
| | - Yan-cun Liu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiang Zhang
- Department of Emergency Medicine, Rizhao People's Hospital of Shandong Province, Rizhao, China
| | - Song-tao Shou
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan-fen Chai
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
- *Correspondence: Yan-fen Chai
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Gao YL, Yao Y, Zhang X, Chen F, Meng XL, Chen XS, Wang CL, Liu YC, Tian X, Shou ST, Chai YF. Regulatory T Cells: Angels or Demons in the Pathophysiology of Sepsis? Front Immunol 2022; 13:829210. [PMID: 35281010 PMCID: PMC8914284 DOI: 10.3389/fimmu.2022.829210] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a syndrome characterized by life-threatening organ dysfunction caused by the dysregulated host response to an infection. Sepsis, especially septic shock and multiple organ dysfunction is a medical emergency associated with high morbidity, high mortality, and prolonged after-effects. Over the past 20 years, regulatory T cells (Tregs) have been a key topic of focus in all stages of sepsis research. Tregs play a controversial role in sepsis based on their heterogeneous characteristics, complex organ/tissue-specific patterns in the host, the multi-dimensional heterogeneous syndrome of sepsis, the different types of pathogenic microbiology, and even different types of laboratory research models and clinical research methods. In the context of sepsis, Tregs may be considered both angels and demons. We propose that the symptoms and signs of sepsis can be attenuated by regulating Tregs. This review summarizes the controversial roles and Treg checkpoints in sepsis.
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Affiliation(s)
- Yu-lei Gao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
- *Correspondence: Yan-fen Chai, ; Yu-lei Gao,
| | - Ying Yao
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiang Zhang
- Department of Emergency Medicine, Rizhao People’s Hospital of Shandong Province, Rizhao, China
| | - Fang Chen
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiang-long Meng
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Xin-sen Chen
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao-lan Wang
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan-cun Liu
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Xin Tian
- Department of Medical Research, Beijing Qiansong Technology Development Company, Beijing, China
| | - Song-tao Shou
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan-fen Chai
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, China
- *Correspondence: Yan-fen Chai, ; Yu-lei Gao,
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Rana M, La Bella A, Lederman R, Volpe BT, Sherry B, Diamond B. Follicular dendritic cell dysfunction contributes to impaired antigen-specific humoral responses in sepsis-surviving mice. J Clin Invest 2021; 131:146776. [PMID: 33956665 DOI: 10.1172/jci146776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/29/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis survivors exhibit impaired responsiveness to antigen (Ag) challenge associated with increased mortality from infection. The contribution of follicular dendritic cells (FDCs) in the impaired humoral response in sepsis-surviving mice is investigated in this study. We demonstrated that mice subjected to sepsis from cecal ligation and puncture (CLP mice) have reduced NP-specific high-affinity class-switched Ig antibodies (Abs) compared with sham-operated control mice following immunization with the T cell-dependent Ag, NP-CGG. NP-specific germinal center (GC) B cells in CLP mice exhibited reduced TNF-α and AID mRNA expression compared with sham-operated mice. CLP mice showed a reduction in FDC clusters, a reduced binding of immune complexes on FDCs, and reduced mRNA expression of CR2, ICAM-1, VCAM-1, FcγRIIB, TNFR1, IKK2, and LTβR compared with sham-operated mice. Adoptive transfer studies showed that there was no B cell-intrinsic defect. In summary, our data suggest that the reduced Ag-specific Ab response in CLP mice is secondary to a disruption in FDC and GC B cell function.
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Affiliation(s)
- Minakshi Rana
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases
| | - Andrea La Bella
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases
| | - Rivka Lederman
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases
| | | | - Barbara Sherry
- Center for Immunology and Inflammation, Feinstein Institutes for Medical Research, New York, New York, USA
| | - Betty Diamond
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases
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Population-Specific Metabolic Alterations in Professional Antigen-Presenting Cells Contribute to Sepsis-Associated Immunosuppression. Shock 2021; 53:5-15. [PMID: 31738315 DOI: 10.1097/shk.0000000000001337] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sepsis is a complex host response triggered by an infection, with the patient's immune system between hyper- and hypo-responsiveness being the main reason for the syndromes' development and propagation. Studies conducted in peripheral blood mononuclear cells uncovered an association between an impaired immunometabolism and the severity and outcome of the disease. With this prospective observational study, we aimed to evaluate the immunometabolic phenotype of monocytes and B cells and its association with the cell function.Monocytes and B cells were isolated from patients with sepsis (n = 10; onset, days 4 and 8) and healthy volunteers (n = 10) and subsequently analyzed for metabolic changes and human leukocyte antigen-DR (HLA-DR) expression. Contemporaneously, immune checkpoints on monocytes and the ex vivo cytokine responses (interleukins 6 and 8) upon lipopolysaccharide or zymosan stimulation were analyzed. The distribution of B cell subsets was assessed, and plasma levels of immunoglobulins and tricarboxylic acid cycle intermediates were quantified.Both monocytes and B cells exhibited decreased HLA-DR expression in patients with sepsis. Monocytes displayed a stable upregulated glycolysis while B cells augmented glycolysis and respiration over time. The monocytes' ability to respond to stimulation was stimuli-dependently reduced but recovered over time. The B cell compartment shifted toward antibody-producing subsets and elevated immunoglobulins within the first days.Our results provide evidence for the induction of a state of trained immunity in monocytes and an early but transient immunosuppressive phenotype accounting for peripheral sepsis-induced vulnerability to infections. B cells exhibit an unsustainable activation contributing to adaptive immunosuppression.
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Abstract
Immunosuppression is the most commonly used concept to qualify the immune status of patients with either sterile systemic inflammatory response syndrome (SIRS) or sepsis. In this review we attempt to demonstrate that the concept of immunosuppression is an oversimplification of the complex anti-inflammatory response that occurs in patients dealing with a severe sterile or infectious insult. Particularly, the immune status of leukocytes varies greatly depending on the compartment from where they are derived from. Furthermore, although certain functions of immune cells present in the blood stream or in the hematopoietic organs can be significantly diminished, other functions are either unchanged or even enhanced. This juxtaposition illustrates that there is no global defect. The mechanisms called reprogramming or trained innate immunity are probably aimed at preventing a generalized deleterious inflammatory reaction, and work to maintain the defense mechanisms at their due levels.
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Nicolai O, Pötschke C, Schmoeckel K, Darisipudi MN, van der Linde J, Raafat D, Bröker BM. Antibody Production in Murine Polymicrobial Sepsis-Kinetics and Key Players. Front Immunol 2020; 11:828. [PMID: 32425951 PMCID: PMC7205023 DOI: 10.3389/fimmu.2020.00828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/14/2020] [Indexed: 12/16/2022] Open
Abstract
Although antigen-specific priming of antibody responses is impaired during sepsis, there is nevertheless a strong increase in IgM and IgG serum concentrations. Using colon ascendens stent peritonitis (CASP), a mouse model of polymicrobial abdominal sepsis, we observed substantial increases in IgM as well as IgG of all subclasses, starting at day 3 and peaking 2 weeks after sepsis induction. The dominant source of antibody-secreting cells was by far the spleen, with a minor contribution of the mesenteric lymph nodes. Remarkably, sepsis induction in splenectomized mice did not change the dynamics of the serum IgM/IgG reaction, indicating that the marginal zone B cells, which almost exclusively reside in the spleen, are dispensable in such a setting. Hence, in systemic bacterial infection, the function of the spleen as dominant niche of antibody-producing cells can be compensated by extra-splenic B cell populations as well as other lymphoid organs. Depletion of CD4+ T cells did not affect the IgM response, while it impaired IgG generation of all subclasses with the exception of IgG3. Taken together, our data demonstrate that the robust class-switched antibody response in sepsis encompasses both T cell-dependent and -independent components.
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Affiliation(s)
- Oliver Nicolai
- Immunology Department, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Christian Pötschke
- Immunology Department, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Katrin Schmoeckel
- Immunology Department, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Murthy N Darisipudi
- Immunology Department, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Julia van der Linde
- Department of General Surgery, Visceral, Thoracic and Vascular Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Dina Raafat
- Immunology Department, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany.,Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Barbara M Bröker
- Immunology Department, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
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Bachler M, Hell T, Schausberger L, Schlömmer C, Schäfer V, Liebensteiner M, Schäffler K, Schenk B, Fries D, Innerhofer P, Niederwanger C. Response patterns of routinely measured inflammatory and coagulatory parameters in sepsis. PeerJ 2019; 7:e7147. [PMID: 31275752 PMCID: PMC6590445 DOI: 10.7717/peerj.7147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/19/2019] [Indexed: 12/13/2022] Open
Abstract
Background Sepsis is characterized by a pro-inflammatory and pro-coagulatory shift which can induce life-threatening complications. Close monitoring and risk stratification of sepsis patients is crucial for proper treatment and consequently patient outcome. Therefore, this study focuses on the response patterns of inflammatory and coagulatory parameters used in clinical routines to estimate the course of sepsis. Methods A total of 1,110 patients diagnosed with sepsis were retrospectively analyzed to identify response patterns for risk stratification of routine parameters measured at the peak level of C-reactive protein. Cluster analysis was used and the differences in the patient characteristics and 28-day survival were assessed. Cox proportional hazards regression model for survival stratified by the clusters was performed. Results The analyses revealed the parameters to have five distinct response patterns. These clusters reflect the etiology as well as the course of sepsis associated with different mortalities. Here, impairment of the liver plays a crucial role in the ability to appropriately respond to sepsis. Of the routinely measured parameters, C-reactive protein and antithrombin seem to be unspecific for stratification of septic patients. Adjusted for the individual clusters, survival was associated with an increase in fibrinogen (p = 0.0042), platelets (p = 0.0003) and PT (p = 0.001) as well as a decrease in leukocytes (p = 0.034). Conclusions This study reveals that patients have distinct response patterns of inflammatory and coagulatory parameters depending on disease etiology. These patterns are associated with different mortalities although the patients have similar levels of C-reactive protein. Independently of the type of response, good coagulatory capacity seems to be crucial for patient survival.
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Affiliation(s)
- Mirjam Bachler
- University for Health Sciences, Medical Informatics and Technology, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Hall, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Innsbruck, Austria
| | - Lukas Schausberger
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christine Schlömmer
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Volker Schäfer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Marlies Liebensteiner
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Schäffler
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Schenk
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Petra Innerhofer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics, Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
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