Iron deficiency in sepsis patients based on reticulocyte hemoglobin and hepcidin concentration: a prospective cohort study

Introduction

Iron tests are deranged in sepsis; therefore new biomarkers should be used for diagnosis of iron deficiency (ID)/ID anemia (IDA).

Methods

Diagnosis of ID/IDA was based on reticulocyte (Ret) hemoglobin (Hb) equivalent (Ret-He) and Hb concentration, with hepcidin (Hep) determined retrospectively.

Results

The prevalence of ID and IDA was 7% and 47%, respectively. The AUROCs for Rets number and Hep in prediction of ID/IDA were 0.69 and 0.62, respectively.

Conclusions

Approximately half of sepsis patients are iron-deficient. Number of Rets may be a predictor of ID/IDA when Ret-He is not available. Hepcidin is a poor IDA predictor.

Iron deficiency in sepsis patients managed with divided doses of iron dextran: a prospective cohort study

Iron deficiency (ID) impairs hemoglobin (Hb) synthesis and immune function, both crucial for sepsis patients. We assessed the impact of iron dextran on reticulocyte (Ret) Hb equivalent (Ret-He) and Ret subpopulations in iron-deficient sepsis patients. In this prospective clinical study we enrolled patients with sepsis or septic shock with procalcitonin concentration > 0.5 ng/mL, diagnosed with ID based on Ret-He. Study subjects received divided doses of iron dextran until normalization of Ret-He. The study population included 35 subjects. The median Ret-He increase after 2 doses of iron dextran was 3.0 (IQR 1.9-6.1) pg (p < 0.01) with median time to normalization 4 (IQR 3-5) days. Although no change in Ret percentage [Me 1.5 (IQR 1.1-2.1) vs. Me 1.4 (IQR 1.1-2.4) %, p = 0.39] and number [Me 0.05 (IQR 0.04-0.07) vs. Me 0.05 (IQR 0.03-0.06) 10⁶/µL, p = 0.88] was noted, Ret subpopulations changed significantly (p for all < 0.01). Divided doses of iron dextran relatively quickly normalize Ret-He in iron-deficient sepsis patients. Changes in Ret subpopulations suggest increased erythropoietic activity. Further research is needed to explore the role of intravenous iron in this clinical setting.

Comparison of Standard and New Iron Status Biomarkers: A Prospective Cohort Study in Sepsis Patients

Both iron deficiency (ID) and iron overload can have negative effects on the risk and course of infection. Therefore, the ability to accurately assess iron status in these patients is of the utmost importance. Systemic inflammation in sepsis patients affects the results of standard iron biomarkers and makes accurate diagnosis of ID problematic. The aim of our study was to analyze the association between widely available standard iron biomarkers and selected new iron biomarkers in various iron status subgroups among sepsis patients. Consecutive patients diagnosed with sepsis or septic shock and procalcitonin concentration > 0.5 ng/mL were enrolled. The following iron biomarkers were determined: iron, ferritin, transferrin, transferrin saturation, reticulocyte (Ret) number and percentage, Ret hemoglobin equivalent, Ret fluorescence subpopulations, and hepcidin concentration. The study group comprised 90 study subjects. There were 42 (47%) patients with normal iron status, 6 (6%) with ID without anemia, and 42 (47%) with ID anemia. No meaningful correlation exists between standard and new iron biomarkers in various iron status subgroups among sepsis patients. Therefore, standard iron biomarkers cannot be used to diagnose ID in this cohort.

Association between Functional Parameters of Coagulation and Conventional Coagulation Tests in the Setting of Fluid Resuscitation with Balanced Crystalloid or Gelatine: A Secondary Analysis of an In Vivo Prospective Randomized Crossover Study

Functional point-of-care tests (POCTs) have evolved into useful tools for diagnosing disorders of blood coagulation and fibrinolysis. We aimed to describe the in vivo association between standard and functional parameters of coagulation and fibrinolysis in the setting of acute hemodilution induced by an infusion of balanced crystalloid or synthetic gelatine solutions. This prospective randomized crossover in vivo study included healthy male volunteers aged 18–30 years. Enrolled participants were randomly assigned to receive either the Optilyte^® or Geloplasma^® infusion. Laboratory analysis included conventional coagulation parameters and rotational thromboelastometry (ROTEM) assays. A total of 25 healthy Caucasian males were included. ROTEM viscoelastic assays presented moderate to strong correlations with conventional coagulation tests, regardless of the fluid type utilized. Irrespectively of the extent of hemodilution, significant correlations remained unaffected. The strongest associations were found between the ROTEM clot formation and clot strength and the fibrinogen concentration and platelet count, and between the ROTEM clotting time and the APTT and PT. This in vivo experimental study in healthy male volunteers demonstrated that ROTEM may be used as a credible alternative to standard laboratory tests to assess blood coagulation and fibrinolysis in the setting of fluid resuscitation with both crystalloid and colloid solutions. The study was registered online in the ClinicalTrials.gov database (NCT05148650).

Efficacy and safety of therapeutic plasma exchange in stiff person syndrome

The stiff person syndrome (SPS) is an extremely rare neurological disorder with primarily immune-mediated etiology. The cardinal symptoms are progressive, fluctuating axial/proximal limb muscle stiffness and spasms. The diagnosis is based on the clinical picture, electromyography examination and detection of antibodies to glutamic acid decarboxylase (anti-GAD). Adverse effects of medications might preclude its use or increase in dosing, therefore symptomatic and/or immunomodulatory medical therapy might be ineffective in acute exacerbation of the disease. We present a case of a 49-year-old female with exacerbation of SPS, in whom some standard pharmacotherapy could not be introduced (clonazepam, baclofen used in the past) and doses of existing standard medications could not be increased (diazepam, gabapentin, and levetiracetam) due to adverse effects. Moreover, a newly introduced medication (methylprednisolone) also led to a serious adverse effect (severe hyperglycemia). The patient underwent therapeutic plasma exchange (TPE) with good effect and no complications. We review the literature regarding the efficacy and safety profile of TPE in exacerbation of SPS unresponsive to medical therapy. The procedure seems to have a good safety profile as an adjunct therapy for exacerbation of SPS not responding to standard medical therapy in this patient population.

Hyperosmolar Treatment for Patients at Risk for Increased Intracranial Pressure: A Single-Center Cohort Study

Treatment with osmoactive agents such as mannitol or hypertonic saline (HTS) solutions is widely used to manage or prevent the increase of intracranial pressure (ICP) in central nervous system (CNS) disorders. We sought to evaluate the variability and mean plasma concentrations of the water and electrolyte balance parameters in critically ill patients treated with osmotic therapy and their influence on mortality. This cohort study covered patients hospitalized in an intensive care unit (ICU) from January 2017 to June 2019 with presumed increased ICP or considered to be at risk of it, treated with 15% mannitol (G1, n = 27), a combination of 15% mannitol and 10% hypertonic saline (HTS) (G2, n = 33) or 10% HTS only (G3, n = 13). Coefficients of variation (Cv) and arithmetic means (mean) were calculated for the parameters reflecting the water and electrolyte balance, i.e., sodium (NaCv/NaMean), chloride (ClCv/ClMean) and osmolality (mOsmCv/mOsmMean). In-hospital mortality was also analyzed. The study group comprised 73 individuals (36 men, 49%). Mortality was 67% (n = 49). Median NaCv (G1: p = 0.002, G3: p = 0.03), ClCv (G1: p = 0.02, G3: p = 0.04) and mOsmCv (G1: p = 0.001, G3: p = 0.02) were higher in deceased patients. NaMean (p = 0.004), ClMean (p = 0.04), mOsmMean (p = 0.003) were higher in deceased patients in G3. In G1: NaCv (AUC = 0.929, p < 0.0001), ClCv (AUC = 0.817, p = 0.0005), mOsmCv (AUC = 0.937, p < 0.0001) and in G3: NaMean (AUC = 0.976, p < 0.001), mOsmCv (AUC = 0.881, p = 0.002), mOsmMean (AUC = 1.00, p < 0.001) were the best predictors of mortality. The overall mortality prediction for combined G1+G2+G3 was very good, with AUC = 0.886 (p = 0.0002). The mortality of critically ill patients treated with osmotic agents is high. Electrolyte disequilibrium is the independent predictor of mortality regardless of the treatment method used. Variations of plasma sodium, chloride and osmolality are the most deleterious factors regardless of the absolute values of these parameters.

Biomarkers Facilitate the Assessment of Prognosis in Critically Ill Patients with Primary Brain Injury: A Cohort Study

Primary injuries to the brain are common causes of hospitalization of patients in intensive care units (ICU). The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system is widely used for prognostication among critically ill subjects. Biomarkers help to monitor the severity of neurological status. This study aimed to identify the best biomarker, along with APACHE II score, in mortality prediction among patients admitted to the ICU with the primary brain injury. This cohort study covered 58 patients. APACHE II scores were assessed 24 h post ICU admission. The concentrations of six biomarkers were determined, including the C-reactive protein (CRP), the S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neutrophil gelatinase-associated lipocalin (NGAL), matrix metalloproteinase 9 (MMP-9), and tissue inhibitor of metalloproteinase 1 (TIMP-1), using commercially available ELISA kits. The biomarkers were specifically chosen for this study due to their established connection to the pathophysiology of brain injury. In-hospital mortality was the outcome. Median APACHE II was 18 (IQR 13–22). Mortality reached 40%. Median concentrations of the CRP, NGAL, S100B, and NSE were significantly higher in deceased patients. S100B (AUC = 0.854), NGAL (AUC = 0.833), NSE (AUC = 0.777), and APACHE II (AUC = 0.766) were the best independent predictors of mortality. Combination of APACHE II with S100B, NSE, NGAL, and CRP increased the diagnostic accuracy of mortality prediction. MMP and TIMP-1 were impractical in prognostication, even after adjustment for APACHE II score. S100B protein and NSE seem to be the best predictors of compromised outcome among critically ill patients with primary brain injuries and should be assessed along with the APACHE II calculation after ICU admission.