|
1
|
Jantunen E, Hämäläinen S, Pulkki K, Juutilainen A. Novel biomarkers to identify complicated course of febrile neutropenia in hematological patients receiving intensive chemotherapy. Eur J Haematol 2024; 113:392-399. [PMID: 38961525 DOI: 10.1111/ejh.14264] [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: 04/17/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 07/05/2024]
Abstract
Febrile neutropenia (FN) is a common consequence of intensive chemotherapy in hematological patients. More than 90% of the patients with acute myeloid leukemia (AML) develop FN, and 5%-10% of them die from subsequent sepsis. FN is very common also in autologous stem cell transplant recipients, but the risk of death is lower than in AML patients. In this review, we discuss biomarkers that have been evaluated for diagnostic and prognostic purposes in hematological patients with FN. In general, novel biomarkers have provided little benefit over traditional inflammatory biomarkers, such as C-reactive protein and procalcitonin. The utility of most biomarkers in hematological patients with FN has been evaluated in only a few small studies. Although some of them appear promising, much more data is needed before they can be implemented in the clinical evaluation of FN patients. Currently, close patient follow-up is key to detect complicated course of FN and the need for further interventions such as intensive care unit admission. Scoring systems such as q-SOFA (Quick Sequential Organ Failure Assessment) or NEWS (National Early Warning Sign) combined with traditional and/or novel biomarkers may provide added value in the clinical evaluation of FN patients.
Collapse
Affiliation(s)
- Esa Jantunen
- Institute of Clinical Medicine/Internal Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Kuopio University Hospital, Wellbeing Services County of North Savo, Kuopio, Finland
| | - Sari Hämäläinen
- Department of Medicine, Kuopio University Hospital, Wellbeing Services County of North Savo, Kuopio, Finland
| | - Kari Pulkki
- Diagnostic Center, Helsinki University Hospital and Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
- Institute of Clinical Medicine/Clinical Chemistry, University of Eastern Finland, Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine/Internal Medicine, University of Eastern Finland, Kuopio, Finland
| |
Collapse
|
|
2
|
Zhu B, Zhou R, Qin J, Li Y. Hierarchical Capability in Distinguishing Severities of Sepsis via Serum Lactate: A Network Meta-Analysis. Biomedicines 2024; 12:447. [PMID: 38398049 PMCID: PMC10886935 DOI: 10.3390/biomedicines12020447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Blood lactate is a potentially useful biomarker to predict the mortality and severity of sepsis. The purpose of this study is to systematically review the ability of lactate to predict hierarchical sepsis clinical outcomes and distinguish sepsis, severe sepsis and septic shock. Methods: We conducted an exhaustive search of the PubMed, Embase and Cochrane Library databases for studies published before 1 October 2022. Inclusion criteria mandated the presence of case-control, cohort studies and randomized controlled trials that established the association between before-treatment blood lactate levels and the mortality of individuals with sepsis, severe sepsis or septic shock. Data was analyzed using STATA Version 16.0. Results: A total of 127 studies, encompassing 107,445 patients, were ultimately incorporated into our analysis. Meta-analysis of blood lactate levels at varying thresholds revealed a statistically significant elevation in blood lactate levels predicting mortality (OR = 1.57, 95% CI 1.48-1.65, I2 = 92.8%, p < 0.00001). Blood lactate levels were significantly higher in non-survivors compared to survivors in sepsis patients (SMD = 0.77, 95% CI 0.74-0.79, I2 = 83.7%, p = 0.000). The prognostic utility of blood lactate in sepsis mortality was validated through hierarchical summary receiver operating characteristic curve (HSROC) analysis, yielding an area under the curve (AUC) of 0.72 (95% CI 0.68-0.76), accompanied by a summary sensitivity of 0.65 (95% CI 0.59-0.7) and a summary specificity of 0.7 (95% CI 0.64-0.75). Unfortunately, the network meta-analysis could not identify any significant differences in average blood lactate values' assessments among sepsis, severe sepsis and septic shock patients. Conclusions: This meta-analysis demonstrated that high-level blood lactate was associated with a higher risk of sepsis mortality. Lactate has a relatively accurate predictive ability for the mortality risk of sepsis. However, the network analysis found that the levels of blood lactate were not effective in distinguishing between patients with sepsis, severe sepsis and septic shock.
Collapse
Affiliation(s)
| | | | | | - Yifei Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu 610041, China; (B.Z.); (R.Z.); (J.Q.)
| |
Collapse
|
|
3
|
Tojo K, Yamamoto N, Tamada N, Mihara T, Abe M, Nishii M, Takeuchi I, Goto T. Early alveolar epithelial cell necrosis is a potential driver of COVID-19-induced acute respiratory distress syndrome. iScience 2022; 26:105748. [PMID: 36507222 PMCID: PMC9722615 DOI: 10.1016/j.isci.2022.105748] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/30/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) with COVID-19 is aggravated by hyperinflammatory responses even after the peak of the viral load has passed; however, its underlying mechanisms remain unclear. In the present study, analysis of the alveolar tissue injury markers and epithelial cell death markers in patients with COVID-19 revealed that COVID-19-induced ARDS was characterized by alveolar epithelial necrosis at an early disease stage. Serum levels of HMGB-1, one of the DAMPs released from necrotic cells, were also significantly elevated in these patients. Further analysis using a mouse model mimicking COVID-19-induced ARDS showed that the alveolar epithelial cell necrosis involved two forms of programmed necrosis, namely necroptosis, and pyroptosis. Finally, the neutralization of HMGB-1 attenuated alveolar tissue injury in the mouse model. Collectively, necrosis, including necroptosis and pyroptosis, is the predominant form of alveolar epithelial cell death at an early disease stage and subsequent release of DAMPs is a potential driver of COVID-19-induced ARDS.
Collapse
Affiliation(s)
- Kentaro Tojo
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan,Corresponding author
| | - Natsuhiro Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Nao Tamada
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan,Department of Paramedic, Kyorin University Faculty of Health Sciences, Mitaka, Tokyo, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Kanagawa, Japan
| | - Miyo Abe
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Mototsugu Nishii
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| |
Collapse
|
|
4
|
Henry BM, Cheruiyot I, Benoit SW, Sanchis-Gomar F, Lippi G, Benoit J. Cytokeratin 18 cell death assays as biomarkers for quantification of apoptosis and necrosis in COVID-19: a prospective, observational study. J Clin Pathol 2022; 75:410-415. [PMID: 33789919 PMCID: PMC8025250 DOI: 10.1136/jclinpath-2020-207242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/21/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The mechanism by which SARS-CoV-2 triggers cell damage and necrosis are yet to be fully elucidated. We sought to quantify epithelial cell death in patients with COVID-19, with an estimation of relative contributions of apoptosis and necrosis. METHODS Blood samples were collected prospectively from adult patients presenting to the emergency department. Circulating levels of caspase-cleaved (apoptosis) and total cytokeratin 18 (CK-18) (total cell death) were determined using M30 and M65 enzyme assays, respectively. Intact CK-18 (necrosis) was estimated by subtracting M30 levels from M65. RESULTS A total of 52 COVID-19 patients and 27 matched sick controls (with respiratory symptoms not due to COVID-19) were enrolled. Compared with sick controls, COVID-19 patients had higher levels of M65 (p = 0.046, total cell death) and M30 (p = 0.0079, apoptosis). Hospitalised COVID-19 patients had higher levels of M65 (p= 0.014) and intact CK-18 (p= 0.004, necrosis) than discharged patients. Intensive care unit (ICU)-admitted COVID-19 patients had higher levels of M65 (p= 0.004), M30 (p= 0.004) and intact CK-18 (p= 0.033) than hospitalised non-ICU admitted patients. In multivariable logistic regression, elevated levels of M65, M30 and intact CK-18 were associated with increased odds of ICU admission (OR=22.05, p=0.014, OR=19.71, p=0.012 and OR=14.12, p=0.016, respectively). CONCLUSION Necrosis appears to be the main driver of hospitalisation, whereas apoptosis and necrosis appear to drive ICU admission. Elevated levels CK-18 levels are independent predictors of severe disease, and could be useful for risk stratification of COVID-19 patients and in assessment of therapeutic efficacy in early-phase COVID-19 clinical trials.
Collapse
Affiliation(s)
- Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Ohio, Cincinnati, USA
| | - Fabian Sanchis-Gomar
- Department of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Justin Benoit
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
|
5
|
High Serum Caspase-Cleaved Cytokeratin-18 Levels and Mortality of Traumatic Brain Injury Patients. Brain Sci 2019; 9:brainsci9100269. [PMID: 31658711 PMCID: PMC6826452 DOI: 10.3390/brainsci9100269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 01/28/2023] Open
Abstract
Objective: Apoptosis increases in traumatic brain injury (TBI). Caspase-cleaved cytokeratin (CCCK)-18 in blood during apoptosis could appear. At the time of admission due to TBI, higher blood CCCK-18 levels were found in non-surviving than in surviving patients. Therefore, the objective of our study was to analyze whether serum CCCK-18 levels determined during the first week after TBI could predict early mortality (at 30 days). Methods: Severe TBI patients were included (considering severe when Glasgow Coma Scale < 9) in this observational and multicentre study. Serum CCCK-18 levels were determined at day 1 of TBI, and at days 4 and 8 after TBI. Results: Serum CCCK-18 levels at day 1 of TBI, and in the days 4 and 8 after TBI were higher (p < 0.001) in non-surviving than in surviving patients (34 and 90 patients, respectively) and could predict early mortality (p < 0.001 in the area under the curve). Conclusions: The new findings from our study were that serum CCCK-18 levels at any moment of the first week of TBI were higher in non-surviving patients and were able to predict early mortality.
Collapse
|
|
6
|
Plasma Fibrinogen-Like 1 as a Potential Biomarker for Radiation-Induced Liver Injury. Cells 2019; 8:cells8091042. [PMID: 31489941 PMCID: PMC6770824 DOI: 10.3390/cells8091042] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022] Open
Abstract
Liver damage upon exposure to ionizing radiation, whether accidental or because of therapy can contribute to liver dysfunction. Currently, radiation therapy is used for various cancers including hepatocellular carcinoma; however, the treatment dose is limited by poor liver tolerance to radiation. Furthermore, reliable biomarkers to predict liver damage and associated side-effects are unavailable. Here, we investigated fibrinogen-like 1 (FGL1)-expression in the liver and plasma after radiation exposure. We found that 30 Gy of liver irradiation (IR) induced cell death including apoptosis, necrosis, and autophagy, with fibrotic changes in the liver occurring during the acute and subacute phase in mice. Moreover, FGL1 expression pattern in the liver following IR was associated with liver damage represented by injury-related proteins and oxidative stress markers. We confirmed the association between FGL1 expression and hepatocellular injury by exposing human hepatocytes to radiation. To determine its suitability, as a potential biomarker for radiation-induced liver injury, we measured FGL1 in the liver tissue and the plasma of mice following total body irradiation (TBI) or liver IR. In TBI, FGL1 showed the highest elevation in the liver compared to other major internal organs including the heart, lung, kidney, and intestine. Notably, plasma FGL1 showed good correlation with radiation dose by liver IR. Our data revealed that FGL1 upregulation indicates hepatocellular injury in response to IR. These results suggest that plasma FGL1 may represent a potential biomarker for acute and subacute radiation exposure to the liver.
Collapse
|
|
7
|
Li X, Zhang W, Huang M, Ren Z, Nie C, Liu X, Yang S, Zhang X, Yang N. Selection of potential cytokeratin-18 monoclonal antibodies following IGH repertoire evaluation in mice. J Immunol Methods 2019; 474:112647. [PMID: 31421082 DOI: 10.1016/j.jim.2019.112647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/12/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022]
Abstract
Cytokeratin 18 (CK18), the main scaffold protein of keratinocyte, is distributed in epithelial cells. This structural protein maintains the integrity and continuity of epithelial tissue. Cytokeratin is also frequently used as an immunohistochemical marker of tumor growth. In recent years, immune repertoire (IR) evaluation using next-generation sequencing (NGS) have become increasingly efficient. Here we deep sequenced the mouse IR of the immunoglobulin heavy chain (IGH) after CK18 immunization. We comprehensively analyzed the IR based on complementarity determining region 3 (CDR3) abundance, germline gene usage polarization, clone diversity, and lineage. We found many convergence characteristics after CK18 immunization. Convergence represents a phenomenon that antigen stimulation or pathogen exposure induces the antigen specific clone expansion and enrichment. The convergence could be used for the immune evaluation and antibody screen. After immunization, the IGHV5 gene clusters became preponderant. The abundance and length of the most frequent CDR3 both increased, nevertheless the IR diversity level decreased. From the convergent IGH repertoires, we selected and expressed six antibodies with the most frequent CDR3s and IGH V-J combinations. The ELISA results suggested all screened six antibodies bound CK18 specifically. The most potential antibody had 9.424E-10M M affinity for the interaction with the CK18. Therefore, this is the NGS platform has been first used for anti-CK18 monoclonal antibodies (MAbs) discovery. These analyses methods could also be used for vaccine evaluation.
Collapse
Affiliation(s)
- Xinyang Li
- BGI Education Center, University of Chinese Academy of Sciences, Shenzhen 518083, China; BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Wei Zhang
- BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Mi Huang
- BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Zhe Ren
- BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Chao Nie
- BGI Education Center, University of Chinese Academy of Sciences, Shenzhen 518083, China; BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Xiao Liu
- BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Shuang Yang
- BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Xiuqing Zhang
- BGI Education Center, University of Chinese Academy of Sciences, Shenzhen 518083, China; BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China
| | - Naibo Yang
- BGI-Shenzhen, Shenzhen 518083, China; China National GeneBank, BGI-Shenzhen, Shenzhen 518120, China; Complete Genomics, Inc., 2904 Orchard Parkway, San Jose, CA 95134, USA.
| |
Collapse
|
|
8
|
Subacute Elevation of Plasma Level of Caspase-Cleaved Cytokeratin-18 is Associated with Hemorrhagic Transformation and Functional Outcome in Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 28:719-727. [PMID: 30528602 DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/17/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Caspase-cleaved cytokeratin-18 (CCCK-18) is an apoptosis marker. Here, we analyzed the relationship between plasma level of CCCK-18 in the acute and subacute stage of ischemic stroke and early and late functional outcome. Besides, correlation among CCCK-18 and complications, such as hemorrhagic transformation (HT) were also explored. METHODS Plasma concentration of CCCK-18 was investigated in 54 patients at admission and poststroke 72 hours. HT was evaluated by CT scans on 24 poststroke hours. Outcome measures were assessed by modified Rankin scale at hospital discharge and 6-month later. Receiver operating characteristics (ROC) analysis was used to determine the best cut-off values of CCCK-18 as a predictor of unfavorable functional outcome. RESULTS Significantly elevated CCCK-18 level was observed at 72 hours after onset of stroke, in nonsurviving compared to surviving patients (331 ± 191 ng/L versus 251 ± 164 ng/L, P = .01). Based on ROC analysis, the cut-off value of plasma CCCK-18 levels >223 ng/L at 72 poststroke hours predicted 6-month unfavorable stroke outcome with a sensitivity of 84.4% and a specificity of 77.3% (area under the curve: .851, 95% confidence interval = .745-.955, P < .001). The rate of complications such as HT and in-hospital infection was significantly higher in patients presented with a plasma CCCK-18 level above the cut-off value. CONCLUSIONS The association between high serum CCCK-18 levels and unfavorable early and late stroke outcome in an unselected study population was first described here. Besides, the apoptosis marker CCCK-18 might be a predictor of further complication such as HT and in-hospital infection.
Collapse
|
|
9
|
Lorente L. New prognostic biomarkers of mortality in patients undergoing liver transplantation for hepatocellular carcinoma. World J Gastroenterol 2018; 24:4230-4242. [PMID: 30310256 PMCID: PMC6175764 DOI: 10.3748/wjg.v24.i37.4230] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/18/2018] [Accepted: 08/24/2018] [Indexed: 02/06/2023] Open
Abstract
The outcome prediction of hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT) was classically established using various macromorphological factors and serum alpha-fetoprotein levels prior to LT. However, other biomarkers have recently been reported to be associated with the prognosis of HCC patients undergoing to LT. This review summarizes clinical data on these new biomarkers. High blood levels of malondialdehyde, total antioxidant capacity, caspase-cleaved cytokeratin-18, soluble CD40 ligand, substance P, C-reactive protein, and vascular endothelial growth factor, increased neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in blood, high peripheral blood expression of human telomerase reverse transcriptase messenger ribonucleic acid, and high HCC expression of dickkopf-1 have recently been associated with decreased survival rates. In addition, high blood levels of des-gamma-carboxy prothrombin, and high HCC expression of glypican-3, E-cadherin and beta-catenin have been associated with increased HCC recurrence. Additional research is necessary to establish the prognostic role of these biomarkers in HCC prior to LT. Furthermore, some of these biomarkers are also interesting because their potential modulation could help to create new research lines for improving the outcomes of those patients.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Santa Cruz de Tenerife 38320, Spain
| |
Collapse
|
|
10
|
High Circulating Caspase-Cleaved Keratin 18 Fragments (M30) Indicate Short-Term Mortality in Critically Ill Patients. DISEASE MARKERS 2018; 2018:8583121. [PMID: 30069276 PMCID: PMC6057335 DOI: 10.1155/2018/8583121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/06/2018] [Indexed: 12/25/2022]
Abstract
Caspase-cleaved fragments of the intermediate filament protein keratin 18 (cytokeratin-18 (CK18)) can be detected in serum as M30 levels and may serve as a circulating biomarker indicating apoptosis of epithelial and parenchymal cells. In order to evaluate M30 as a biomarker in critical illness, we analyzed circulating M30 levels in 243 critically ill patients (156 with sepsis, 87 without sepsis) at admission to the medical intensive care unit (ICU), in comparison to healthy controls (n = 32). M30 levels were significantly elevated in ICU patients compared with healthy controls. Circulating M30 was closely associated with disease severity but did not differ between patients with sepsis and ICU patients without sepsis. M30 serum levels were correlated with biomarkers of inflammation, cell injury, renal failure, and liver failure in critically ill patients. Patients that died at the ICU showed increased M30 levels at admission, compared with surviving patients. A similar trend was observed for the overall survival. Regression analyses confirmed that M30 levels are associated with mortality, and patients with M30 levels above 250.8 U/L displayed an excessive short-term mortality. Thus, our data support the utility of circulating levels of the apoptosis-related keratin fragment M30 as a prognostic biomarker at ICU admission.
Collapse
|
|
11
|
Oweira H, Sadeghi M, Volker D, Mieth M, Zidan A, Khajeh E, Ghamarnejad O, Fonouni H, Weiss KH, Schmidt J, Lahdou I, Mehrabi A. Serum Caspase-Cleaved Cytokeratin (M30) Indicates Severity of Liver Dysfunction and Predicts Liver Outcome. Ann Transplant 2018; 23:393-400. [PMID: 29880786 PMCID: PMC6248295 DOI: 10.12659/aot.908031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The Model for End-Stage Liver Disease (MELD) score is a well-established tool for assessing hepatic failure. The present retrospective study investigated whether serum keratin 18 (M65) and caspase-cleaved cytokeratin (M30) were associated with liver dysfunction and post-transplant graft failure. MATERIAL AND METHODS A total of 147 patients with liver cirrhosis were categorized into 2 groups according to their baseline MELD score (group I: MELD score <20, n=87, and group II: MELD score ≥20, n=60). Serum M65 and M30 levels were measured by ELISA. RESULTS Cirrhotic patients had significantly higher serum M65 and M30 levels than healthy controls (p<0.0001). Serum M65 was correlated with the MELD score and serum bilirubin (p≤0.007) and serum M30 was correlated with the MELD score, international normalized ratio, and serum bilirubin (p≤0.001). Group II had significantly higher serum M65 and M30 levels than group I (M65, p=0.025 and M30, p<0.001). Patients who lost the allograft during the first post-transplant year had significantly higher serum M30 levels than patients with a graft survival of >1 year (p=0.004). In the regression analysis, serum M30 was associated with the MELD score (odds ratio [OR]=2.545, p=0.005), serum bilirubin (OR=2.605, p=0.005) and 1-year graft loss (OR=3.61, p=0.006). CONCLUSIONS Our data indicate that serum M30 levels reflect the degree of liver dysfunction and can predict 1-year graft loss.
Collapse
Affiliation(s)
- Hani Oweira
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Switzerland.,Surgical Center Zürich, Hirslanden Hospital, Zürich, Switzerland
| | - Mahmoud Sadeghi
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Daniel Volker
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ahmed Zidan
- Department of Hepato-Pancreato-Biliary (HPB) and Liver Transplantation Surgery, Rajhy Liver Hospital, Assiut University Hospital, Assuit, Egypt
| | - Elias Khajeh
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Hamidreza Fonouni
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University of Heidelberg, Heidelberg, Germany
| | - Jan Schmidt
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Switzerland.,Surgical Center Zürich, Hirslanden Hospital, Zürich, Switzerland
| | - Imad Lahdou
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
|
12
|
Th’ng F, Vliegenthart B, Lea JD, Antoine DJ, Dear JW, Mole DJ. Evaluation of plasma microRNA-122, high-mobility group box 1 and keratin-18 concentrations to stratify acute gallstone disease: a pilot observational cohort study in an emergency general surgery unit. BMJ Open 2018; 8:e020061. [PMID: 29703854 PMCID: PMC5922517 DOI: 10.1136/bmjopen-2017-020061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/08/2018] [Accepted: 03/23/2018] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To obtain pilot data to evaluate the discriminatory power of biomarkers microRNA-122 (miR-122), high-mobility group box 1 (HMGB1), full-length keratin-18 (flk-18) and caspase-cleaved keratin-18 (cck-18) in plasma to identify potential biliary complications that may require acute intervention. DESIGN An observational biomarker cohort pilot study. SETTING In a Scottish University teaching hospital for 12 months beginning on 3 September 2014. PARTICIPANTS Blood samples were collected from adults (≥16 years old) referred with acute biliary-type symptoms who have presented to hospital within 24 hours prior were recruited. Patients unable or refused to give informed consent or were transferred from a hospital outside the National Health Service regional trust were excluded. PRIMARY OUTCOME MEASURES To evaluate whether circulating miR-122, HMGB1, flk-18 and cck-18 can discriminate between people with and without gallstone disease and uncomplicated from complicated gallstone disease during the first 24 hours of hospital admission. RESULTS 300 patients were screened of which 285 patients were included. Plasma miR-122, cck-18 and flk-18 concentrations were increased in patients with gallstones compared with those without (miR-122: median: 2.89×104 copies/mL vs 0.90×104 copies/mL (p<0.001); cck-18: 121.2 U/L vs 103.5 U/L (p=0.031); flk-18: 252.4 U/L vs 145.1 U/L (p<0.001)). Uncomplicated gallstone disease was associated with higher miR-122 and cck-18 concentrations than complicated disease (miR-122: 5.72×104 copies/mL vs 2.26×104 copies/mL (p=0.023); cck-18: 139.7 U/L vs 113.6 U/L (p=0.047)). There was no significant difference in HMGB1 concentration between patients with and without gallstones (p=0.559). Separation between groups for all biomarkers was modest. CONCLUSION miR-122 and keratin-18 plasma concentrations are elevated in patients with gallstones. However, this result is confounded by the association between biomarker concentrations, age and gender. In this pilot study, miR-122 and keratin-18 were not sufficiently discriminatory to be progressed as clinically useful biomarkers in this context.
Collapse
Affiliation(s)
- Francesca Th’ng
- Clinical Surgery, School of Clinical Sciences and Community Health, University of Edinburgh, Edinburgh, UK
| | | | - Jonathan D Lea
- MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
| | - Daniel J Antoine
- MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
| | - James W Dear
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Damian J Mole
- Clinical Surgery, School of Clinical Sciences and Community Health, University of Edinburgh, Edinburgh, UK
- MRC Centre for Inflammation Research, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
- General Surgery, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| |
Collapse
|
|
13
|
Lorente L, Martín MM, Pérez-Cejas A, Ramos L, Argueso M, Solé-Violán J, Cáceres JJ, Jiménez A, García-Marín V. Association between serum levels of caspase-cleaved cytokeratin-18 and early mortality in patients with severe spontaneous intracerebral hemorrhage. BMC Neurosci 2018; 19:23. [PMID: 29661155 PMCID: PMC5902924 DOI: 10.1186/s12868-018-0424-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Apoptotic changes after cerebral hemorrhage in brain samples of humans have been found. Caspase-cleaved cytokeratin (CCCK)-18 could be detected in the bloodstream during apoptosis. Higher circulating CCCK-18 levels have been associated with 6-month mortality in patients with basal ganglia hemorrhage. The aim of our study was to determine whether there is an association between serum CCCK-18 levels and early mortality of spontaneous intracerebral hemorrhage (SIH) patients. We performed an observational, prospective and multicentre study. There were included patients with severe SIH defined as Glasgow Coma Scale (GCS) lower than 9. We determined serum CCCK-18 levels at the severe SIH diagnosis moment. RESULTS We found that non-surviving SIH patients (n = 46) showed lower GCS, and higher serum CCCK-18 levels and APACHE-II score than survivor ones (n = 54). In ROC analysis was found that the area under the curve of serum CCCK-18 levels for 30-day mortality prediction was 90% (95% CI 82-95%; p < 0.001). In the multiple logistic regression analysis, we found an association between serum CCCK-18 levels and 30-day mortality (OR 1.034; 95% CI 1.013-1.055; p = 0.002). CONCLUSIONS The novel finding of our study was that there is an association between high serum CCCK-18 levels and 30-day mortality in severe SIH patients.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, 38010, Santa Cruz de Tenerife, Spain
| | - Antonia Pérez-Cejas
- Laboratory Department, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320, Santa Cruz de Tenerife, Spain
| | - Luis Ramos
- Intensive Care Unit, Hospital General La Palma, Buenavista de Arriba s/n, Breña Alta, 38713, La Palma, Spain
| | - Mónica Argueso
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibáñez no 17-19, 46004, Valencia, Spain
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, CIBERES, Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Juan J Cáceres
- Intensive Care Unit, Hospital Insular, Plaza Dr. Pasteur s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320, Santa Cruz de Tenerife, Spain
| | - Victor García-Marín
- Department of Neurosurgery, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320, Santa Cruz de Tenerife, Spain
| |
Collapse
|
|
14
|
Schmitt FCF, Salgado E, Friebe J, Schmoch T, Uhle F, Fleming T, Zemva J, Kihm L, Nusshag C, Morath C, Zeier M, Bruckner T, Mehrabi A, Nawroth PP, Weigand MA, Hofer S, Brenner T. Cell cycle arrest and cell death correlate with the extent of ischaemia and reperfusion injury in patients following kidney transplantation - results of an observational pilot study. Transpl Int 2018; 31:751-760. [PMID: 29505681 DOI: 10.1111/tri.13148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 06/26/2017] [Accepted: 02/28/2018] [Indexed: 01/11/2023]
Abstract
A prolonged cold ischaemia time (CIT) is suspected to be associated with an increased ischaemia and reperfusion injury (IRI) resulting in an increased damage to the graft. In total, 91 patients were evaluated for a delayed graft function within 7 days after kidney transplantation (48 deceased, 43 living donors). Blood and urine samples were collected before, immediately after the operation, and 1, 3, 5, 7 and 10 days later. Plasma and/or urine levels of total keratin 18 (total K18), caspase-cleaved keratin 18 (cc K18), the soluble receptor for advanced glycation end products (sRAGE), tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein-7 (IGFBP7) were measured. As a result of prolonged CIT and increased IRI, deceased donor transplantations were shown to suffer from a more distinct cell cycle arrest and necrotic cell death. Plasmatic total K18 and urinary TIMP-2 and IGFBP7 were therefore demonstrated to be of value for the detection of a delayed graft function (DGF), as they improved the diagnostic performance of a routinely used clinical scoring system. Plasmatic total K18 and urinary TIMP-2 and IGFBP7 measurements are potentially suitable for early identification of patients at high risk for a DGF following kidney transplantation from deceased or living donors.
Collapse
Affiliation(s)
- Felix C F Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Eduardo Salgado
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Janina Friebe
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Schmoch
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Fleming
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany.,German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Johanna Zemva
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - Lars Kihm
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter P Nawroth
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany.,German Center for Diabetes Research (DZD), Neuherberg, Germany.,Joint Division Molecular Metabolic Control, German Cancer Research Center (DKFZ) Heidelberg Center for Molecular Biology (ZMBH) and University Hospital Heidelberg University, Heidelberg, Germany Institute for Diabetes and Cancer IDC Helmholtz Center Munich and Joint Heidelberg-IDC Translational Diabetes Program, Neuherberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anesthesiology, Kaiserslautern Westpfalz Hospital, Kaiserslautern, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
|
15
|
Lorente L, Martín MM, Pérez-Cejas A, Ramos L, Argueso M, Solé-Violán J, Cáceres JJ, Jiménez A, García-Marín V. High serum levels of caspase-cleaved cytokeratin-18 are associated with malignant middle cerebral artery infarction patient mortality. BMC Neurol 2018; 18:32. [PMID: 29573748 PMCID: PMC5866523 DOI: 10.1186/s12883-018-1038-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 03/15/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There have been found apoptotic changes in brain tissue samples from humans after cerebral ischemia. Caspase-cleaved cytokeratin (CCCK)-18 could appears in blood during apoptosis. High circulating levels of CCCK-18 have been associated with a poor prognosis in patients with cerebral process, such as traumatic brain injury and spontaneous cerebral hemorrhage. However, they have not been explored in patients with ischemic stroke. Thus, the aim of this study was to determine whether there is an association between serum CCCK-18 levels and mortality in patients with severe malignant middle cerebral artery infarction (MMCAI). METHODS This was an observational, prospective and multicentre study. We included patients with severe MMCAI. We considered MMCAI as severe when Glasgow Coma Scale (GCS) was lower than 9. We measured serum CCCK-18 levels at the diagnosis moment of the severe MMCAI. RESULTS We found that non-surviving severe MMCAI patients (n = 33) showed lower GCS and platelet count, and higher serum CCCK-18 levels than survivor ones (n = 33). We found an area under the curve (AUC) of serum CCCK-18 levels to predict 30-day mortality of 82% (95% CI = 71%-91%; p < 0.001). In the multiple logistic regression analysis was found that serum CCCK-18 levels were associated with 30-day mortality (OR = 1.023; 95% CI = 1.010-1.037; p = 0.001) after to control for platelet count and GCS. CONCLUSIONS To our knowledge, this is the first series reporting data on serum CCCK-18 levels in ischemic stroke patients. The novel findings of our study were that non-surviving severe MMCAI patients had higher serum CCCK-18 levels than surviving patients, and that there is an association between high serum CCCK-18 levels and MMCAI patients mortality.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra s/n, La Laguna, -38320, Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, -38010, Santa Cruz de Tenerife, Spain
| | - Antonia Pérez-Cejas
- Laboratory Deparment, Hospital Universitario de Canarias, Ofra, s/n., La Laguna -, 38320, Tenerife, Spain
| | - Luis Ramos
- Intensive Care Unit, Hospital General La Palma, Buenavista de Arriba s/n, -38713, Breña Alta, La Palma, Spain
| | - Mónica Argueso
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda Blasco Ibáñez n°17-19, -46004, Valencia, Spain
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, CIBERES, Barranco de la Ballena s/n, -35010, Las Palmas de Gran Canaria, Spain
| | - Juan J Cáceres
- Intensive Care Unit, Hospital Insular, Plaza Dr. Pasteur s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra s/n. La Laguna, -38320, Santa Cruz de Tenerife, Spain
| | - Victor García-Marín
- Deparment of Neurosurgery, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain
| |
Collapse
|
|
16
|
Higher serum caspase-cleaved cytokeratin-18 levels during the first week of sepsis diagnosis in non-survivor patients. ACTA ACUST UNITED AC 2017; 55:1621-1629. [DOI: 10.1515/cclm-2016-1034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
AbstractBackground:Caspase-cleaved cytokeratin (CCCK)-18 is a protein released into the blood during apoptosis. Higher circulating CCCK-18 concentrations have been found in non-survivor than in survivor septic patients at moment of sepsis diagnosis. The following questions arise now: (1) How are serum CCCK-18 levels during the first week of sepsis? (2) Is there an association between sepsis severity and mortality and serum CCCK-18 levels during the first week? The aims of this study were to answer these questions.Methods:Multicenter study with 321 severe septic patients from eight Spanish intensive care units. We determined serum concentration of CCCK-18, tumor necrosis factor (TNF)-α, and interleukin (IL)-10 during the first week. Our end-point study was 30-day mortality.Results:Non-survivor (n=108) compared to survivor patients (n=213) showed higher serum CCCK-18 levels at days 1, 4 and 8 (p<0.001). ROC curve analyses showed that serum CCCK-18 levels at days 1 (AUC=0.77; 95% CI=0.72–0.82), 4 (AUC=0.81; 95% CI=0.76–0.85) and 8 (AUC=0.83; 95% CI=0.78–0.88) could predict mortality at 30 days (p<0.001). Logistic regression analyses showed that serum CCCK-18 levels at days 1 (OR=4.367; 95% CI=2.491–7.659), 4 (OR=10.137; 95% CI=4.741–21.678) and 8 (OR=8.781; 95% CI=3.626–21.268) were associated with 30-day mortality (p<0.001). We found a positive correlation between CCCK-18, SOFA, and lactic acid at days 1, 4 and 8.Conclusions:Non-survivor septic patients showed persistently during the first week higher serum CCCK-18 levels than survivor patients, and there is an association between sepsis severity and mortality and serum CCCK-18 levels during the first week.
Collapse
|
|
17
|
Hünkerler Z, Köken T, Koca B, Kahraman A. Role of Uremic Toxins on Apoptosis With Varying Periods of Hemodialysis. Ther Apher Dial 2017; 21:38-42. [PMID: 28067473 DOI: 10.1111/1744-9987.12504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/03/2016] [Accepted: 09/09/2016] [Indexed: 11/28/2022]
Abstract
Increased apoptotic cell death in uremic patients has been confirmed by a variety of studies. The present study aimed to investigate the effect of uremic toxins and duration of hemodialysis (HD) therapy on apoptosis by means of measuring serum caspase cleaved CK18 (CCCK-18) levels. Seventy chronic HD patients were recruited and divided into three groups with differing periods of HD, from 6 months to 10 years. Twelve healthy subjects served as controls. Serum CCCK-18 level was found significantly higher in HD patient groups (Group 2; 189 ± 71 IU/L, Group 3; 182 ± 65 IU/L, Group 4; 204 ± 111 IU/L) as compared to the control group (122 ± 20 U/L) (P < 0.05). When all hemodialysis patients considered together serum CCCK-18 showed positive correlation with serum uric acid and phosphorus (P < 0.05). In conclusion, our results suggest that apoptosis is enhanced in HD patients, phosphorus and uric acid might play a role in this increment, but duration of HD therapy has no effect on apoptosis.
Collapse
Affiliation(s)
- Zeynep Hünkerler
- Department of Clinical Biochemistry, School of Medicine, Afyon Kocatepe University, Afyon, Turkey
| | - Tülay Köken
- Department of Clinical Biochemistry, School of Medicine, Afyon Kocatepe University, Afyon, Turkey
| | - Buğra Koca
- Department of Clinical Biochemistry, School of Medicine, Afyon Kocatepe University, Afyon, Turkey
| | - Ahmet Kahraman
- Department of Clinical Biochemistry, School of Medicine, Afyon Kocatepe University, Afyon, Turkey
| |
Collapse
|
|
18
|
Abstract
Sepsis and septic shock are characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The liver has a central role during sepsis, and is essential to the regulation of immune defence during systemic infections by mechanisms such as bacterial clearance, acute-phase protein or cytokine production and metabolic adaptation to inflammation. However, the liver is also a target for sepsis-related injury, including hypoxic hepatitis due to ischaemia and shock, cholestasis due to altered bile metabolism, hepatocellular injury due to drug toxicity or overwhelming inflammation, as well as distinct pathologies such as secondary sclerosing cholangitis in critically ill patients. Hence, hepatic dysfunction substantially impairs the prognosis of sepsis and serves as a powerful independent predictor of mortality in the intensive care unit. Sepsis is particularly problematic in patients with liver cirrhosis (who experience increased bacterial translocation from the gut and impaired microbial defence) as it can trigger acute-on-chronic liver failure - a syndrome with high short-term mortality. Here, we review the importance of the liver as a guardian, modifier and target of sepsis, the factors that contribute to sepsis in patients with liver cirrhosis and new therapeutic strategies.
Collapse
|
|
19
|
Lorente L, Martín MM, Pérez-Cejas A, Barrios Y, Solé-Violán J, Ferreres J, Labarta L, Díaz C, Jiménez A. Association between Interleukin-6 Promoter Polymorphism (-174 G/C), Serum Interleukin-6 Levels and Mortality in Severe Septic Patients. Int J Mol Sci 2016; 17:ijms17111861. [PMID: 27834822 PMCID: PMC5133861 DOI: 10.3390/ijms17111861] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/01/2016] [Accepted: 11/04/2016] [Indexed: 12/29/2022] Open
Abstract
The association between interleukin (IL)-6 promoter polymorphism (-174 G/C), circulating IL-6 levels and mortality in septic patients has scarcely been addressed, and then only in studies of small sample size, and a direct association among them has not been previously reported. Therefore, the purpose of our study was to determine whether this association exists. An observational, prospective and multicenter study including severe septic patients was undertaken and serum IL-6 levels at severe sepsis diagnosis and IL-6 promoter polymorphism (-174 G/C) were determined. The end-point of the study was 30-day mortality. The study included 263 patients with the following genotypes of IL-6 promoter polymorphism (-174 G/C): 123 (46.8%) GG, 110 (41.8%) GC and 30 (11.4%) CC. CC homozygous patients showed lower sepsis-related organ failure assessment (SOFA) score, serum IL-6 levels and mortality at 30 days compared to those with other genotypes (GC or GG). On regression analysis, CC homozygous patients showed lower 30-day mortality than those with genotype GG (odds ratio = 0.21; 95% CI = 0.053−0.838; p = 0.03) or GC (hazard ratio = 0.28; 95% CI = 0.074−1.037; p = 0.06). The most important results of our study were that CC might be a favorable genotype in septic patients showing lower serum IL-6 levels and lower risk of death within 30 days.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320 Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora Candelaria, Crta Rosario s/n, 38010 Santa Cruz de Tenerife, Spain.
| | - Antonia Pérez-Cejas
- Laboratory Deparment, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320 Santa Cruz de Tenerife, Spain.
| | - Ysamar Barrios
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna, 38320 Santa Cruz de Tenerife, Spain.
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 35010 Las Palmas de Gran Canaria, Spain.
| | - José Ferreres
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda, Blasco Ibáñez nº17, 46004 Valencia, Spain.
| | - Lorenzo Labarta
- Intensive Care Unit, Hospital San Jorge de Huesca, Avenida Martínez de Velasco nº36, 22004 Huesca, Spain.
| | - César Díaz
- Intensive Care Unit, Hospital Insular, Plaza Dr. Pasteur s/n, 35016 Las Palmas de Gran Canaria, Spain.
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n, La Laguna-38320, 38320 Santa Cruz de Tenerife, Spain.
| |
Collapse
|
|
20
|
Prognostic Value of Serum Caspase-Cleaved Cytokeratin-18 Levels before Liver Transplantation for One-Year Survival of Patients with Hepatocellular Carcinoma. Int J Mol Sci 2016; 17:ijms17091524. [PMID: 27618033 PMCID: PMC5037799 DOI: 10.3390/ijms17091524] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/01/2016] [Accepted: 09/05/2016] [Indexed: 12/30/2022] Open
Abstract
Cytokeratin (CK)-18 is the major intermediate filament protein in the liver and during hepatocyte apoptosis is cleaved by the action of caspases; the resulting fragments are released into the blood as caspase-cleaved cytokeratin (CCCK)-18. Higher circulating levels of CCCK-18 have been found in patients with hepatocellular carcinoma (HCC) than in healthy controls and than in cirrhotic patients. However, it is unknown whether serum CCCK-18 levels before liver transplantation (LT) in patients with HCC could be used as a prognostic biomarker of one-year survival, and this was the objective of our study with 135 patients. At one year after LT, non-survivors showed higher serum CCCK-18 levels than survivors (p = 0.001). On binary logistic regression analysis, serum CCCK-18 levels >384 U/L were associated with death at one year (odds ratio = 19.801; 95% confidence interval = 5.301–73.972; p < 0.001) after controlling for deceased donor age. The area under the receiver operating characteristic (ROC) curve of serum CCCK-18 levels to predict death at one year was 77% (95% CI = 69%–84%; p < 0.001). The new finding of our study was that serum levels of CCCK-18 before LT in patients with HCC could be used as prognostic biomarker of survival.
Collapse
|
|
21
|
Lorente L, Martín MM, Ferreres J, Solé-Violán J, Labarta L, Díaz C, Jiménez A, Borreguero-León JM. Serum caspase 3 levels are associated with early mortality in severe septic patients. J Crit Care 2016; 34:103-6. [DOI: 10.1016/j.jcrc.2016.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/05/2016] [Accepted: 04/05/2016] [Indexed: 12/26/2022]
|
|
22
|
Lorente L. New Prognostic Biomarkers in Patients With Traumatic Brain Injury. ARCHIVES OF TRAUMA RESEARCH 2015; 4:e30165. [PMID: 26848476 PMCID: PMC4733516 DOI: 10.5812/atr.30165] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/15/2015] [Indexed: 01/02/2023]
Abstract
CONTEXT Traumatic brain injury (TBI) is a leading cause of death, disability, and resource consumption per year. There are two kinds of brain injury in TBI, primary and secondary injuries. Primary injury refers to the initial physical forces applied to the brain at the moment of impact. Secondary injury occurs over a period of hours or days following the initial trauma and results from the activation of different pathways such as inflammation, coagulation, oxidation, and apoptosis. EVIDENCE ACQUISITION This review focuses on new prognostic biomarkers of mortality in TBI patients related to inflammation, coagulation, oxidation, and apoptosis. RESULTS Recently circulating levels of substance P (SP), soluble CD40 ligand (sCD40L), tissue inhibitor of matrix metalloproteinases (TIMP)-1, malondialdehyde (MDA), and cytokeratin (CK)-18 fragmented have been found to be associated with mortality in TBI patients. Substance P is a neuropeptide of the tachykinin family, mainly synthesized in the central and peripheral nervous system, with proinflammatory effects when binding to their neurokinin-1 receptor (NK1R). Soluble CD40 ligand, a member of the tumor necrosis factor (TNF) family that is released into circulation from activated platelets, exhibit proinflamatory, and procoagulant properties on binding to their cell surface receptor CD40. Matrix metalloproteinases (MMPs) are a family of zinc-containing endoproteinases involved neuroinflammation and TIMP-1 is the inhibitor of some of them. Malondialdehyde is an end-product formed during lipid peroxidation due to degradation of cellular membrane phospholipids, that is released into extracellular space and finally into the blood. Cytokeratin -18 is cleaved by the action of caspases during apoptosis, and CK-18 fragmented is released into the blood. CONCLUSIONS Circulating levels of some biomarkers, such as SP, sCD40L, TIMP-1, MDA, and CK-18 fragmented, related to inflammation, coagulation, oxidation, and apoptosis have been recently associated with mortality in patients with TBI. These biomarkers could help in the prognostic classification of the patients and open new research lines in the treatment of patients with TBI.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| |
Collapse
|
|
23
|
Yuan ZG, Wang JL, Jin GL, Yu XB, Li JQ, Qiu TL, Dai RX. Serum caspase-cleaved cytokeratin-18 levels and outcomes after aneurysmal subarachnoid hemorrhage. J Neurol Sci 2015; 359:298-304. [PMID: 26671131 DOI: 10.1016/j.jns.2015.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/03/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Cell apoptosis is involved in acute brain injury after aneurysmal subarachnoid hemorrhage (aSAH). The protein cytokeratin-18 (CK-18) is cleaved by the action of caspases during apoptosis, and the resulting fragments are released into the blood as caspase-cleaved CK (CCCK)-18. Our study examined the relationship between circulating CCCK-18 levels and long-term clinical outcomes among aSAH patients. METHODS We recruited 128 aSAH patients and 128 controls (matched on age and sex). Serum was collected at admission to the emergency department. Unfavorable outcome was defined as the Glasgow Outcome Score scores of 1-3. After a 6-month follow-up period, outcomes were assessed using a logistic regression analyses. The prognostic predictive values were evaluated according to receiver operating curves analysis. RESULTS aSAH patients had higher plasma CCCK-18 levels compared to controls (235.1 ± 86.8 U/L vs. 25.6 ± 23.4 U/L, P<0.001). CCCK-18 was independently associated with World Federation of Neurological Surgeons (WFNS) scores (t=4.460, P<0.001) and modified Fisher scores (t=3.781, P<0.001). Furthermore, CCCK-18 levels were markedly higher among patients with an unfavorable outcome and among non-survivors. CCCK-18 was yet identified as an independent prognostic predictor for mortality (odds ratio, 5.769; 95% confidence interval, 1.196-27.832; P=0.029) and unfavorable outcome (odds ratio, 4.909; 95% confidence interval, 1.521-15.838; P=0.008), as well as had similar predictive values for them compared with WFNS scores and modified Fisher scores. CONCLUSIONS High circulating CCCK-18 levels were associated with injury severity and a poor clinical outcome after aSAH and CCCK-18 had the potential to be a good prognostic biomarker for aSAH.
Collapse
Affiliation(s)
- Zi-Gang Yuan
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China
| | - Jian-Li Wang
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China.
| | - Guo-Liang Jin
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China
| | - Xue-Bin Yu
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China
| | - Jin-Quan Li
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China
| | - Tian-Lun Qiu
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China
| | - Rong-Xiao Dai
- Department of Neurosurgery, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, 568 Zhongxing North Road, Shaoxing 312000, Zhejiang Province, China
| |
Collapse
|
|
24
|
Gu SJ, Lu M, Xuan HF, Chen XZ, Dong WF, Yan XF, Si Y, Gao GL, Hu DX, Miao JQ. Predictive value of serum caspase-cleaved cytokeratin-18 concentrations after acute intracerebral hemorrhage. Clin Chim Acta 2015; 452:124-8. [PMID: 26569346 DOI: 10.1016/j.cca.2015.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 11/06/2015] [Accepted: 11/09/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Caspase-cleaved Cytokeratin-18 (CCCK-18) is released during apoptosis. Serum CCCK-18 concentrations are associated with prognosis of some critical illness. We investigated the potential relationships between serum CCCK-18 concentrations and disease severity and long-term clinical outcomes after intracerebral hemorrhage. METHODS Serum CCCK-18 concentrations were determined in a total of 102 patients and 102 controls. Multivariate models were used to predict high concentration of CCCK-18 and 6-month clinical outcomes. The predictive values were evaluated based on areas under receiver operating curve. RESULTS Compared with controls, serum CCCK-18 concentrations were increased in patients (245.8±108.3U/l vs. 23.6±18.1U/l, P<0.001). National Institute of Health Stroke Scale scores [odds ratio (OR), 1.164; 95% confidence interval (CI), 1.027-1.320; P=0.003] and hematoma volumes (OR, 1.079; 95% CI, 1.018-1.205; P=0.008) were independent predictors of high concentration of CCCK-18. CCCK-18 was identified as an independent predictor of 6-month mortality (OR, 1.019; 95% CI, 1.010-1.038; P=0.013) and 6-month unfavorable outcome (OR, 1.017; 95% CI, 1.008-1.029; P=0.032) and possessed high predictive values. CONCLUSION Increased serum CCCK-18 concentrations are associated with disease severity and clinical outcomes, suggesting that CCCK represent a novel prognostic predictive biomarker after intracerebral hemorrhage.
Collapse
Affiliation(s)
- Shui-Jun Gu
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Ming Lu
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China.
| | - Hong-Fei Xuan
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Xin-Zhi Chen
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Wei-Feng Dong
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Xiao-Feng Yan
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Yun Si
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Guo-Liang Gao
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Dian-Xiang Hu
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| | - Jian-Qing Miao
- Department of Neurosurgery, The first people's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou 311200, China
| |
Collapse
|
|
25
|
Lorente L, Martín MM, Abreu-González P, de la Cruz T, Ferreres J, Solé-Violán J, Labarta L, Díaz C, Jiménez A, Borreguero-León JM. Serum melatonin levels are associated with mortality in severe septic patients. J Crit Care 2015; 30:860.e1-6. [PMID: 25869726 DOI: 10.1016/j.jcrc.2015.03.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 03/17/2015] [Accepted: 03/19/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Melatonin in septic patients has been scarcely explored and only in studies of small sample size (maximum 20 patients). Thus, the objective of this study was to determine whether serum melatonin levels are associated with severity, oxidant and inflammatory state, and mortality in a large series of septic patients. METHODS A prospective, observational, multicenter study was performed in 6 Spanish intensive care units with 201 severe septic patients. Serum levels of melatonin were measured at moment of severe sepsis diagnosis. The end point was 30-day mortality. RESULTS Non-surviving patients (n = 71) showed higher serum melatonin levels (P < .001) than survivors (n = 130). Multiple logistic regression analysis showed that serum melatonin levels were associated with 30-day mortality (odds ratio, 1.022; 95% confidence interval, 1.001-1.043; P = .04), controlling for serum tumor necrosis factor-α levels, serum interleukin 6 levels and age. Serum melatonin levels were positively associated with serum levels of malondialdehyde as biomarker of oxidative stress, interleukin-6 and lactate, and with SOFA score. CONCLUSIONS The novel finding of our study was that serum melatonin levels are associated with mortality in septic patients.
Collapse
Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora Candelaria, Crta Rosario s/n. Santa Cruz Tenerife, 38010, Spain.
| | - Pedro Abreu-González
- Deparment of Phisiology, Faculty of Medicine, University of the La Laguna, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - Thais de la Cruz
- Faculty of Pharmacy, University of the La Laguna, Avda. Astrofísico Francisco Sánchez s/n, La Laguna, Tenerife, 38071, Spain.
| | - José Ferreres
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibáñez n°17-19, Valencia, 46004, Spain.
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n. Las Palmas de Gran Canaria, 35010, Spain.
| | - Lorenzo Labarta
- Intensive Care Unit, Hospital San Jorge de Huesca, Avenida Martínez de Velasco n°36, Huesca, 22004, Spain.
| | - César Díaz
- Intensive Care Unit, Hospital Insular, Plaza Dr. Pasteur s/n. Las Palmas de Gran Canaria, 35016, Spain.
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - Juan M Borreguero-León
- Laboratory Department, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain.
| |
Collapse
|
|
26
|
Chondrogiannis K, Hadziyannis E, Fassoulaki A. Propofol or sevoflurane anaesthesia does not affect hepatic integrity as assessed by the M30 & M65 cell death markers & liver enzymes. Indian J Med Res 2014; 140:630-6. [PMID: 25579144 PMCID: PMC4311316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND & OBJECTIVES General anaesthetics may induce apoptosis. The pro-apoptotic/necrotic markers M30 (caspase-cleaved cytokeratin-18) and M65 (intact cytokeratin-18) have been used to identify early apoptosis in liver disease. The aim of this study was to detect the effect of propofol and sevoflurane anaesthesia on these markers and blood transaminase levels in female patients undergoing elective surgery. METHODS Sixty-seven women undergoing mastectomy or thyroidectomy under general anaesthesia were randomly allocated to the propofol or sevoflurane groups. Venous blood samples for measuring the apoptotic and necrotic markers M30 and M65 as well as for measuring the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST) liver enzymes were collected before induction of anaesthesia, immediately after completion of surgery, and 24 and 48 h postoperatively. RESULTS The M30 values preoperatively and 0, 24 and 48 h postoperatively were 280±229, 300±244, 267±198 and 254±189 U/l in the propofol group and 237±95, 242±109, 231±94 and 234±127 U/l in the sevoflurane group, respectively. The M30 values did not differ within or between the groups. The M65 levels at the same time intervals were 470±262, 478±271, 456±339 and 485±273 in the propofol group and 427±226, 481±227, 389±158 and 404±144 U/l in the sevoflurane group, respectively. No significant changes were found in the M65 either within or between the propofol and the sevoflurane groups. The ALT and AST levels did not change at these time intervals. INTERPRETATION & CONCLUSIONS Under the present study design propofol or sevoflurane anaesthesia did not induce apoptosis or affected the liver function as assessed by the M30, M65 markers and liver enzymes in patients undergoing mastectomy or thyroidectomy under general anaesthesia.
Collapse
Affiliation(s)
| | - Emilia Hadziyannis
- Department of Medicine, Immunology, Hippokratio Hospital, University of Athens, Athens, Greece
| | - Argyro Fassoulaki
- Department of Anaesthesia, Aretaieio Hospital, University of Athens, Athens, Greece,Reprint requests: Dr Argyro Fassoulaki, Department of Anaesthesia, Aretaieio Hospital, University of Athens, 76 Vasilisis Sofias Ave, 11528, Athens, Greece e-mail: ,
| |
Collapse
|