Serum Soluble Fms-Like Tyrosine Kinase 1 (sFlt-1) Predicts the Severity of Acute Pancreatitis

Value of soluble fms-like tyrosine kinase 1 for predicting acute pancreatitis severity: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to explore the relationship between serum soluble fms-like tyrosine kinase 1 and the severity of acute pancreatitis and its diagnostic utility.

METHODS

This study was carried out by searching Chinese and English literature from the establishment of the database to July 9, 2023, systematically, and assessing the quality and heterogeneity of the articles included.

RESULTS

Thirteen studies with a total of 986 patients were included. Patients with severe acute pancreatitis showed higher levels of soluble fms-like tyrosine kinase 1 compared with mild acute pancreatitis [weighted mean difference=76.64 pg/mL, 95% confidence interval (95%CI 50.39-102.89, p<0.001)]. Soluble fms-like tyrosine kinase 1 predicted pooled sensitivity, specificity, and area under the curve were 79%, 74%, and 0.85 for severe acute pancreatitis, with some heterogeneity (I2>50% or p<0.05). In the subgroup analysis, cutoff >150 pg/mL was found to be a heterogeneous factor.

CONCLUSION

Soluble fms-like tyrosine kinase 1 is a reliable tool for identifying acute pancreatitis severity, but only as a screening tool.

sFlt-1 Levels as a Predicting Tool in Placental Dysfunction Complications in Multiple Pregnancies

BACKGROUND

several studies have demonstrated that angiogenic markers can improve the clinical management of hypertensive disorders (HDs) and fetal growth restriction (FGR) in singleton pregnancies, but few studies have evaluated the performance of these tests in multiple pregnancies. Our aim was to investigate the role of soluble fms-like tyrosine kinase 1 (sFlt-1) in predicting adverse obstetric outcomes in hospitalized multiple pregnancies with HD (preeclampsia/gestational hypertension/uncontrolled chronic hypertension) and/or FGR in one or more fetuses.

METHODS

A retrospective analysis of multiple pregnancies with HD/FGR occurring after the 20th gestational week. Pregnant women were divided into two groups: women with high levels of sFlt-1 and those with low levels of sFlt-1. A value of sFlt-1 greater than or equal to 15,802 pg/mL was considered arbitrarily high, as it is equivalent to two times the 90th percentile expected in an uncomplicated full-term singleton pregnancy based on data from a prospective multicenter study (7901 pg/mL).

RESULTS

The cohort included 39 multiple pregnancies. There were no cases of birth <34 weeks, HELLP syndrome, ICU admission, and urgent cesarean sections for HD/FGR complications reported among women with low levels of sFlt-1.

CONCLUSIONS

A cut-off value of sFlt-1 ≥ 15,802 pg/mL could represent a valuable tool for predicting adverse obstetric outcomes in multiple pregnancies hospitalized for HD/FGR disorders, regardless of gestational age and chorionicity.

A prospective and comparative investigation of blood sFlt-1, P1GF, and niacin concentrations in women with premature ovarian insufficiency

OBJECTIVE

Endothelial dysfunction is an important component of preeclampsia like premature ovarian insufficiency (POI), and it is reported that placental growth factor (P1GF) and soluble fms-like tyrosine kinase receptor-1 (sFlt-1) levels are important in preeclampsia. Extra-placental sources for P1GF and sFlt-1 have also been identified, including various cell types. In animal models of POI, niacin treatment inhibited follicular apoptosis under hazardous conditions while significantly reducing cumulus cell apoptosis. The number of developing follicles also increased after niacin was given. This study was designed to determine blood sFlt-1, P1GF, and niacin concentrations in women with idiopathic POI (iPOI) compared with those of healthy women.

METHODS

The study comprised 45 women with iPOI and 45 healthy women. Blood was obtained and analyzed at the early follicular phase of the menstrual cycle and sFlt-1, P1GF, and niacin levels were measured using a commercially available enzyme-linked immunosorbent assay kit.

RESULTS

No significant differences were observed in the two groups according to the gravidity numbers, parity, abortion, live births, and menarche ages (p ≥ 0.05). In the iPOI group, the mean anti-mullerian hormone value was 0.03 ± 0.04 (min-max, 0.00-0.21) ng/ml. sFlt-1, P1GF, niacin levels, and also the sFlt-1/P1GF ratio were lower in the iPOI group (p < 0.01). A significant discriminative role of sFlt-1, P1GF, niacin levels, and the sFlt-1/P1GF ratio for the presence of iPOI, with cut-off values of 5.13, 10.28, 37.17, and 0.61 ng/ml, respectively, were reported in the receiver operating characteristics curve analysis.

CONCLUSIONS

Lower levels of P1GF, sFlt-1, niacin, and sFlt-1/P1GF ratios may be associated with the development of POI/iPOI. Further studies are required to better understand the etiopathogenesis of POI/iPOI.

CLINICAL TRIAL NUMBER

NCT04641624 (clinicaltrials.gov).

Acute Changes in Serum Creatinine and Kinetic Glomerular Filtration Rate Estimation in Early Phase of Acute Pancreatitis

In patients with acutely changing kidney function, equations used to estimate glomerular filtration rate (eGFR) must be adjusted for dynamic changes in the concentrations of filtration markers (kinetic eGFR, KeGFR). The aim of our study was to evaluate serum creatinine-based KeGFR in patients in the early phase of acute pancreatitis (AP) as a marker of changing renal function and as a predictor of AP severity. We retrospectively calculated KeGFR on day 2 and 3 of the hospital stay in a group of 147 adult patients admitted within 24 h from the onset of AP symptoms and treated in two secondary-care hospitals. In 34 (23%) patients, changes in serum creatinine during days 1-3 of the hospital stay exceeded 26.5 µmol/L; KeGFR values almost completely differentiated those with increasing and decreasing serum creatinine (area under receiver operating characteristic curve, AUROC: 0.990 on day 3). In twelve (8%) patients, renal failure was diagnosed during the first three days of the hospital stay according to the modified Marshall scoring system, which was associated with significantly lower KeGFR values. KeGFR offered good diagnostic accuracy for renal failure (area under receiver operating characteristic-AUROC: 0.942 and 0.950 on days 2 and 3). Fourteen (10%) patients developed severe AP. KeGFR enabled prediction of severe AP with moderate diagnostic accuracy (AUROC: 0.788 and 0.769 on days 2 and 3), independently of age, sex, comorbidities and study center. Lower KeGFR values were significantly associated with mortality. Significant dynamic changes in renal function are common in the early phase of AP. KeGFR may be useful in the assessment of kidney function in AP and the prediction of AP severity.

Diagnostic Significance of Serum Galectin-3 in Hospitalized Patients with COVID-19-A Preliminary Study

Severe coronavirus disease 2019 (COVID-19) is associated with hyperinflammation leading to organ injury, including respiratory failure. Galectin-3 was implicated in innate immunological response to infections and in chronic fibrosis. The aim of our preliminary study was the assessment of the diagnostic utility of serum galectin-3 in patients with COVID-19. The prospective observational study included adult patients admitted with active COVID-19 and treated in tertiary hospital between June and July 2020. The diagnosis was confirmed by the quantitative detection of nucleic acid of severe acute respiratory syndrome coronavirus 2 in nasopharyngeal swabs. Galectin-3 was measured by enzyme immunoassay in serum samples obtained during the first five days of hospital stay. We included 70 patients aged 25 to 73 years; 90% had at least one comorbidity. During the hospital stay, 32.9% were diagnosed with COVID-19 pneumonia and 12.9% required treatment in the intensive care unit (ICU). Serum galectin-3 was significantly increased in patients who developed pneumonia, particularly those who required ICU admission. Positive correlations were found between galectin-3 and inflammatory markers (interleukin-6, C-reactive protein, ferritin, pentraxin-3), a marker of endothelial injury (soluble fms-like tyrosine kinase-1), and a range of tissue injury markers. Serum galectin-3 enabled the diagnosis of pneumonia with moderate diagnostic accuracy and the need for ICU treatment with high diagnostic accuracy. Our findings strengthen the hypothesis that galectin-3 may be involved in severe COVID-19. Further studies are planned to confirm the preliminary results and to verify possible associations of galectin-3 with long-term consequences of COVID-19, including pulmonary fibrosis.

Accuracy of angiopoietin-2 for predicting organ failure in patients with acute pancreatitis: a systematic review and meta-analysis

Objective

Our aim was to assess the accuracy of angiopoietin-2 (Ang-2) as a prognostic marker for acute pancreatitis (AP) with organ failure (OF).

Methods

We undertook a systematic search of the PubMed, Cochrane Library, Embase, Chinese Journals Full-text, Wanfang, China Biology Medicine disc, and Weipu databases to identify eligible cohort studies on the predictive value of Ang-2 for AP with OF. The main outcome measures were sensitivity and specificity. The effects were pooled using a bivariate mixed-effects model.

Results

Six articles with seven case-control studies (n = 650) were included. Pooled sensitivity, specificity, and positive and negative likelihood ratios with 95% confidence intervals (CI) for AP with OF were 0.93 (95%CI: 0.75–0.99), 0.85 (95%CI: 0.75–0.92), 6.40 (95%CI: 3.36–12.19), and 0.08 (95%CI: 0.02–0.36), respectively. The area under the summary receiver operating characteristic curve was 0.95 (95%CI: 0.92–0.96), and the diagnostic odds ratio was 83.18 (95%CI: 11.50–623.17). Subgroup analysis showed that admission time of AP onset (< or ≥24 hours) was a source of overall heterogeneity. Sensitivity analysis supported this finding.

Conclusion

Ang-2 had high diagnostic accuracy for AP with OF; the best prediction of Ang-2 may be 24 to 72 hours after onset of AP.

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

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

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Value of soluble fms-like tyrosine 1 in early prediction of severity of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

Biomarkers for the early prediction of the severity of acute pancreatitis (AP) are urgently needed for clinical management of this disease. Soluble fms-like tyrosine 1 (sFlt-1), one of the vascular endothelial growth factor receptors, has been found to be associated with various diseases, including AP.

AIM

To summarize all the relevant literature to determine the overall clinical value of sFlt-1 in the early diagnosis of severity of AP by meta-analysis.

METHODS

CNKI, Wanfang Database, Chinese BioMedicine Database, WEIPU database, PubMed, Cochrane Library, and EMBASE database were searched systematically. The time range was from the inception of the database to 15 February 2020. Eligible cohort studies on the early predictive value of sFlt-1 for AP of different severities were collected. Quality assessment and data extraction were performed in those clinical trials in line with the inclusion criteria. Stata software was applied to carry out meta-analysis.

RESULTS

A total of 7 articles reporting 8 case-control studies were included in the analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for early prediction of AP severity were 0.65 (95%CI: 0.57-0.72), 0.88 (95%CI: 0.81-0.92), 5.36 (95%CI: 3.30-8.69), 0.40 (95%CI: 0.32-0.51), and 13.35 (95%CI: 6.88-25.88), respectively. The area under the receiver operating characteristic curve was 0.81 (95%CI: 0.78-0.84). Subgroup analysis showed that geographical location (Asia, Europe, and America), time of onset (≥ 24 h or < 24 h), and severity assessment method (the Atlanta classification or others) were probably the sources of overall heterogeneity.

CONCLUSION

SFlt-1 has only moderate value for early prediction of the severity of AP, with a low sensitivity. Therefore, it needs to be combined with other relevant examinations and clinical indicators for early prediction of the severity of AP.

A Rare Case of Acquired Thrombotic Thrombocytopenic Purpura Triggered by Acute Pancreatitis

Acquired thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy with varied etiology and manifestations. It is uncommon for acute pancreatitis to trigger TTP. A 59-year-old man hospitalized with acute pancreatitis developed fever, acute kidney injury, thrombocytopenia, and microangiopathic hemolytic anemia (MAHA) on his second day in the hospital. Based on clinical suspicion and a high PLASMIC score indicating a severe deficiency in ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type 1 motif no. 13) activity, a presumptive diagnosis of TTP was made. He was treated with plasmapheresis with improvement in his hemoglobin and platelet count. Severely deficient ADAMTS13 activity causing accumulation of large von Willebrand factor (VWF) multimers and subsequent formation of platelet rich microthrombi are thought to be the mechanisms of development of TTP. Proinflammatory mediators released during the systemic inflammatory response seen in acute pancreatitis can promote VWF activity and inhibit ADAMTS13 activity. Diffuse endothelial injury as a result of the inhibition of vascular endothelial growth factor (VEGF)-mediated endothelial protection as well as production of excessive reactive oxygen species during an episode of acute pancreatitis also contributes to the pathogenesis of TTP. Thrombocytopenia and MAHA in a systemic inflammatory state should raise the suspicion for TTP. The PLASMIC score can further aid in the diagnosis and early initiation of plasmapheresis, which is key to the outcome.

Does Beta-Trace Protein (BTP) Outperform Cystatin C as a Diagnostic Marker of Acute Kidney Injury Complicating the Early Phase of Acute Pancreatitis?

Acute pancreatitis (AP) belongs to the commonest acute gastrointestinal conditions requiring hospitalization. Acute kidney injury (AKI) often complicates moderately severe and severe AP, leading to increased mortality. Among the laboratory markers proposed for early diagnosis of AKI, few have been studied in AP, including cystatin C and neutrophil gelatinase-associated lipocalin (NGAL). Beta-trace protein (BTP), a low-molecular-weight glycoprotein proposed as an early marker of decreased glomerular filtration, has never been studied in AP. We investigated the diagnostic usefulness of serum BTP for early diagnosis of AKI complicating AP in comparison to previously studied markers. BTP was measured in serum samples collected over the first three days of hospital stay from 73 adult patients admitted within 24 h of mild to severe AP. Thirteen patients (18%) developed AKI in the early phase of AP. Serum BTP was higher in patients who developed AKI, starting from the first day of hospitalization. Strong correlations were observed between BTP and serum cystatin C but not serum or urine NGAL. On admission, BTP positively correlated with endothelial dysfunction. The diagnostic usefulness of BTP for AKI was similar to cystatin C and lower than NGAL. Increased BTP is an early predictor of AKI complicating AP. However, it does not outperform cystatin C or NGAL.

Potential Prognostic Markers of Acute Kidney Injury in the Early Phase of Acute Pancreatitis

Acute kidney injury (AKI) is a serious complication of acute pancreatitis (AP), which occurs in up to 70% of patients with severe AP and significantly increases the risk of mortality. At present, AKI is diagnosed based on dynamic increase in serum creatinine and decreased urine output; however, there is a need for earlier and more accurate biomarkers. The aim of the study was to review current evidence on the laboratory tests that were studied as the potential biomarkers of AKI in AP. We also briefly summarized the knowledge coming from the studies including sepsis or ICU patients since severe acute pancreatitis is associated with systemic inflammation and organ failure. Serum cystatin C and serum or urine NGAL have been shown to predict or diagnose AKI in AP; however, this evidence come from the single center studies of low number of patients. Other markers, such as urinary kidney injury molecule-1, cell cycle arrest biomarkers (tissue inhibitor metalloproteinase-2 and urine insulin-like growth factor-binding protein 7), interleukin-18, liver-type fatty acid-binding protein, or calprotectin have been studied in other populations suffering from systemic inflammatory states. In AP, the potential markers of AKI may be significantly influenced by either dehydration or inflammation, and the impact of these factors may be difficult to distinguish from kidney injury. The subject of AKI complicating AP is understudied. More studies are needed, for both exploratory (to choose the best markers) and clinical (to evaluate the diagnostic accuracy of the chosen markers in real clinical settings).

Serum D-dimer levels at admission for prediction of outcomes in acute pancreatitis

BACKGROUND

Systemic alterations in coagulation are associated with complications of acute pancreatitis (AP). D-dimer, a fibrin degradation product, was recently described as a marker of pancreatitis outcome. Early prediction is essential for reducing mortality in AP. The present study aims to assess the relationship between elevated serum D-dimer levels and the severity of AP.

METHODS

We performed an observational retrospective study with data from 3451 enrolled patients with AP. Serum D-dimer levels were measured upon admission, after 24 h and during the week after admission by immunoturbidimetry. Univariate and multivariate analyses were used to determine whether elevated D-dimer levels were independently associated with the severity of AP.

RESULTS

Of the 3451 AP patients, 2478 (71.8%) had serum D-dimer levels measured within 24 h of hospital admission; 1273 of these patients had D-dimer levels ≤2.5 mg/L, and 1205 had D-dimer levels > 2.5 mg/L (934 patients had mild AP (MAP); 1086, moderately severe AP (MSAP); and 458, severe AP (SAP)). Patients with D-dimer levels > 2.5 mg/L (n = 1205) had higher incidences of SAP (75.5% vs. 24.5%), acute peripancreatic fluid collection (APFC) (53.3% vs. 46.7%), acute necrotic collection (ANC) (72.4% vs. 27.6%), pancreatic necrosis (PN) (65.2% vs. 34.8%), infected pancreatic necrosis (IPN) (77.7% vs. 22.8%), organ failure (OF) (68.5% vs. 31.5%), persistent organ failure (POF) (75.5% vs. 24.5%), ICU requirement (70.2% vs. 29.8%), and mortality (79.2% vs. 20.8%) than did patients with D-dimer levels ≤2.5 mg/L (n = 1273). The multivariate analysis showed that patients with higher serum D-dimer levels had poorer prognoses that worsened over time.

CONCLUSION

The measurement of D-dimer levels at admission may be useful for risk stratification of AP.

Increased soluble fms-like tyrosine kinase 1 after ischemia reperfusion contributes to adverse clinical outcomes following kidney transplantation

Renal ischemia reperfusion injury (IRI) adversely affects clinical outcomes following kidney transplantation. Understanding the cellular mechanisms and the changes in gene/protein expression following IRI may help to improve these outcomes. Serum soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein, is increased in the first week following kidney transplantation. We evaluated the casual relationship of elevated sFlt-1 levels with renal microvascular dysfunction following IRI in a longitudinal study of 93 kidney transplant recipients and in several animal models. Transplant recipients with higher sFlt-1 levels had higher odds of delayed graft function, graft rejection, impaired graft function, and death. In a subgroup of 25 participants who underwent kidney biopsy within 4 months of kidney transplantation, peritubular capillary area was lower in those with elevated serum sFtl-1 levels. The administration of recombinant sFlt-1 into rodents resulted in significant structural and functional changes of the renal microvasculature, including reduced peritubular capillary density and intracapillary blood volume, and lead to increased expression of inflammatory genes and increased fibrosis. In a murine model of IRI, the kidney was a site of sFlt-1 production, and systemic neutralization of sFlt-1 preserved peritubular capillary density and alleviated renal fibrosis. Our data indicate that high sFlt-1 levels after IRI play an important role in the pathogenesis of microvascular dysfunction, thereby contributing to adverse clinical outcomes following kidney transplantation.

Biology of preeclampsia: Combined actions of angiogenic factors, their receptors and placental proteins

Although massive efforts have been undertaken to elucidate the etiology of the pregnancy syndrome preeclampsia, its developmental origin remains a mystery. Most efforts of the last decade have focused on biomarkers to predict and/or diagnose preeclampsia, including the anti-angiogenic factor sFlt-1 (soluble fms-like tyrosin kinase-1), the angiogenic factor PGF (placental growth factor) and PP13 (placental protein 13). The origins of these marker proteins are still under debate, and so far their actions have only been describe separate from each other. This study will focus on the origins and actions of all three markers during pregnancy and outside pregnancy and will describe a scenario where all three markers act synergistically to rescue the mother from the deleterious effects of the debris that is released from the placenta during preeclampsia. This more holistic approach may open new avenues to think about maternal-fetal interactions and putative therapies.

Evaluation of the effects of different treatment modalities on angiogenesis in heart failure patients with reduced/mid-range ejection fraction via VEGF and sVEGFR-1

OBJECTIVES

To investigate the clinical significance of VEGF, sVEGFR-1 in heart failure reduced ejection fraction (HFrEF) and heart failure mid-range ejection fraction (HFmrEF) patients. Methods: A total of 104 people consisting of HFrEF and HFmrEF patients (n=54) and healthy (n=50) subjects were included in this comparative cross-sectional study. The study took place in Gulhane Training and Research Hospital, Ankara, Turkey, between  2011 and 2013. Serum VEGF, sVEGFR-1, plasma pro-BNP analysis and transthoracic echocardiography were performed.  Results: The average sVEGFR-1 level of the HFrEF and HFmrEF patients was significantly higher than the control group (0.185±0.122; 0.141±0.120; p=0.013). The average sVEGFR-1 level of the HFrEF and HFmrEF patients using beta-blocker was significantly higher than the HFrEF and HFmrEF patients not using it (p=0.015). There was a significant and positive correlation between sVEGFR-1 and N-terminal pro-brain natriuretic peptide (pro-BNP)  levels in the group with HF (r=0.211, p=0.044). Conclusion: It increases awareness about the role of sVEGFR-1 in HFrEF anf HFmrEF patients and the need for further studies. Beta-blocker may have a negative effect on angiogenesis in HFrEF and HFmrEF via increasing sVEGFR-1 levels. Additionally, Pro-BNP may contribute to inhibiting angiogenesis by increasing sVEGFR-1 levels and sVEGFR-1 may be an important biomarker in HFrEF and HFmrEF.

Serum Urokinase-Type Plasminogen Activator Receptor Does Not Outperform C-Reactive Protein and Procalcitonin as an Early Marker of Severity of Acute Pancreatitis

Severe acute pancreatitis (SAP) concerns 10–20% of acute pancreatitis (AP) patients and is associated with a poor prognosis and high mortality. An early prognosis of the unfavorable outcome, transfer to an intensive care unit (ICU) and the introduction of an adequate treatment are crucial for patients’ survival. Recently, the elevated circulating urokinase-type plasminogen activator receptor (uPAR) has been reported to predict SAP with a high diagnostic accuracy among patients in a tertiary center. The aim of the study was to compare the diagnostic utility of uPAR and other inflammatory markers as the predictors of the unfavorable course of AP in patients admitted to a secondary care hospital within the first 24 h of the onset of AP. The study included 95 patients, eight with a SAP diagnosis. Serum uPAR was measured on admission and in the two subsequent days. On admission, uPAR significantly predicted organ failure, acute cardiovascular failure, acute kidney injury, the need for intensive care, and death. The diagnostic accuracy of the admission uPAR for the prediction of SAP, organ failure, and ICU transfer or death was low to moderate and did not differ significantly from the diagnostic accuracy of interleukin-6, C-reactive protein, procalcitonin, D-dimer and soluble fms-like tyrosine kinase-1. In the secondary care hospital, where most patients with AP are initially admitted, uPAR measurements did not prove better than the currently used markers.

Does the Automatic Measurement of Interleukin 6 Allow for Prediction of Complications during the First 48 h of Acute Pancreatitis?

Acute pancreatitis (AP) in most patients takes a course of self-limiting local inflammation. However, up to 20% of patients develop severe AP (SAP), associated with systemic inflammation and/or pancreatic necrosis. Early prediction of SAP allows for the appropriate intensive treatment of severe cases, which reduces mortality. Serum interleukin-6 (IL-6) has been proposed as a biomarker to assist early diagnosis of SAP, however, most data come from studies utilizing IL-6 measurements with ELISA. Our aim was to verify the diagnostic usefulness of IL-6 for the prediction of SAP, organ failure, and need for intensive care in the course of AP using a fully automated assay. The study included 95 adult patients with AP of various severity (29 mild, 58 moderately-severe, 8 severe) admitted to a hospital within 24 h from the onset of symptoms. Serum IL-6 was measured using electochemiluminescence immunoassay in samples collected on admission and on the next day of hospital stay. On both days, patients with SAP presented the highest IL-6 levels. IL-6 correlated positively with other inflammatory markers (white blood cell and neutrophil counts, C-reactive protein, procalcitonin), the markers of renal injury (kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin), and the markers of endothelial dysfunction (angiopoietin-2, soluble fms-like tyrosine kinase-1). IL-6 on admission significantly predicted SAP, vital organ failure, and the need for intensive care or death, with areas under the receiver operating curve between 0.75 and 0.78, not significantly different from multi-variable prognostic scores. The fully automated assay allows for fast and repeatable measurements of serum IL-6, enabling wider clinical use of this valuable biomarker.

Predictors of acute pancreatitis with low elevation of serum amylase

Background and aims

Serum amylase is a traditional measure used to establish the diagnosis of acute pancreatitis (AP). The current study aimed to assess the predictors and clinical outcome of AP with low serum amylase.

Methods

All patients were divided into two groups, based on their serum amylase level within the first 2 days after hospital admission: group 1 (amylase ≥300 U/L) and group 2 (amylase <300 U/L). Clinical outcomes were compared between the two groups before and after 1:1 propensity score matching. Clinical and biochemical parameters were collected and evaluated as potential predictors of AP with low serum amylase.

Results

A total of 464 patients were enrolled. After propensity score matching according to age, gender, time interval before admission, hematocrit, blood urea nitrogen and creatinine, 108 matched pairs of patients were selected. There was no significant statistical difference between group 2 and group 1 with respect to severity of AP, median days of stay in hospital and death. Multivariate analysis indicated that biliary etiology (odds ratio [OR]: 0.499; 95% confidence interval [CI]: 0.265-0.942; P=0.003), low-density lipoprotein cholesterol (LDL-C) (OR: 1.009; 95% CI: 1.002-1.017; P=0.017) and triglyceride levels (OR: 1.001; 95% CI: 1.0001-1.001; P=0.015) were independently associated with development of AP along with low serum amylase.

Conclusion

Serum amylase level was not related to the severity of AP, median hospital stay (days) and death. Biliary etiology, LDL-C and triglyceride levels were independently associated with the development of AP with lower elevation of serum amylase.

Plasma Sphingolipids in Acute Pancreatitis

Acute pancreatitis (AP) is a prevalent gastrointestinal disorder associated with systemic inflammatory response syndrome and, in the case of severe AP, a mortality rate ranging from 36% to 50%. Standard clinical treatment of AP includes intensive hydration, analgesia, and management of complications. Unfortunately, the direct treatment of AP at the level of its molecular pathomechanism has not yet been established. Recent studies indicate that the sphingolipid signaling pathway may be one of the important factors contributing to the development of inflammation in pancreatic diseases. In the current study, we sought to investigate this promising route. We examined the plasma sphingolipid profile of 44 patients with acute pancreatitis, dividing them into three groups: mild, moderate and severe AP. Samples were collected from these groups at days 1, 3 and 7 following their hospital admission. We demonstrated significant changes in blood plasma sphingolipids in relation to the time course of AP. We also found an inhibition of de novo ceramide synthesis in mild and moderate AP. However, the most important and novel finding was a significant elevation in sphingosine-1-phosphate (S1P) (a downstream metabolite of ceramide) in mild AP, as well as a dramatic reduction in the lipid molecule content in the early stage (days 1 and 3) of severe AP. This strongly indicates that plasma S1P could serve as a prognostic marker of AP severity.

Serum Uromodulin Levels in Prediction of Acute Kidney Injury in the Early Phase of Acute Pancreatitis

In health, uromodulin is the main protein of urine. Serum uromodulin concentrations (sUMOD) have been shown to correlate with kidney function. Acute kidney injury (AKI) is among the main complications of severe acute pancreatitis (AP). No reports exist on sUMOD in patients with AP, including the diagnostic usefulness for early prediction of AP severity. We measured sUMOD during first 72 h of AP. Sixty-six adult patients with AP were recruited at the surgical ward of the District Hospital in Sucha Beskidzka, Poland. AP was diagnosed according to the Revised Atlanta Classification. Blood samples were collected at 24, 48 and 72 h of AP, and sUMOD concentrations were measured with enzyme-linked immunosorbent test. sUMOD decreased non-significantly during the study. Patients with severe AP had non-significantly lower sUMOD concentrations than those with mild disease. Significant positive correlation was observed between sUMOD and estimated glomerular filtration rate on each day of the study and negative correlations were shown between sUMOD and age, serum creatinine, cystatin C and urea. Patients with AKI tended to have lower sUMOD. Although sUMOD correlated significantly with kidney function in the early phase of AP, measuring sUMOD did not allow to reliably predict AP severity or development of AKI.

Serum Concentrations of Angiopoietin-2 and Soluble fms-Like Tyrosine Kinase 1 (sFlt-1) Are Associated with Coagulopathy among Patients with Acute Pancreatitis

In severe acute pancreatitis (SAP), systemic inflammation leads to endothelial dysfunction and activation of coagulation. Thrombotic disorders in acute pancreatitis (AP) include disseminated intravascular coagulation (DIC). Recently, angiopoietin-2 and soluble fms-like tyrosine kinase 1 (sFlt-1) were proposed as markers of endothelial dysfunction in acute states. Our aim was to assess the frequency of coagulation abnormalities in the early phase of AP and evaluate the relationships between serum angiopoietin-2 and sFlt-1 and severity of coagulopathy. Sixty-nine adult patients with AP were recruited: five with SAP, 15 with moderately severe AP (MSAP) and 49 with mild AP. Six patients were diagnosed with DIC according to International Society on Thrombosis and Haemostasis (ISTH) score. All patients had at least one abnormal result of routine tests of hemostasis (low platelet count, prolonged clotting times, decreased fibrinogen, and increased D-dimer). The severity of coagulopathy correlated with AP severity according to 2012 Atlanta criteria, bedside index of severity in AP and duration of hospital stay. D-dimers correlated independently with C-reactive protein and studied markers of endothelial dysfunction. Angiopoietin-2, D-dimer, and ISTH score were best predictors of SAP, while sFlt-1 was good predictor of MSAP plus SAP. In clinical practice, routine tests of hemostasis may assist prognosis of AP.

The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications

Acute pancreatitis (AP) is an inflammatory disease with varied severity, ranging from mild local inflammation to severe systemic involvement resulting in substantial mortality. Early pathologic events in AP, both local and systemic, are associated with vascular derangements, including endothelial activation and injury, dysregulation of vasomotor tone, increased vascular permeability, increased leukocyte migration to tissues, and activation of coagulation. The purpose of the review was to summarize current evidence regarding the interplay between inflammation, coagulation and endothelial dysfunction in the early phase of AP. Practical aspects were emphasized: (1) we summarized available data on diagnostic usefulness of the markers of endothelial dysfunction and activated coagulation in early prediction of severe AP; (2) we reviewed in detail the results of experimental studies and clinical trials targeting coagulation-inflammation interactions in severe AP. Among laboratory tests, d-dimer and angiopoietin-2 measurements seem the most useful in early prediction of severe AP. Although most clinical trials evaluating anticoagulants in treatment of severe AP did not show benefits, they also did not show significantly increased bleeding risk. Promising results of human trials were published for low molecular weight heparin treatment. Several anticoagulants that proved beneficial in animal experiments are thus worth testing in patients.