Effect of sepsis and cardiac surgery with cardiopulmonary bypass on plasma level of nitric oxide metabolites, neopterin, and procalcitonin: correlation with mortality and postoperative complications.

OBJECTIVES: To examine the hypothesis that nitrite/nitrate, neopterin, and procalcitonin (PCT) levels can be useful predictors of sepsis-associated mortality and predictors of the postoperative complications after cardiopulmonary bypass (CPB). DESIGN: Prospective clinical study. SETTING: Intensive care unit of the Medical University Hospital. PATIENTS: 41 patients with sepsis, 42 patients subjected to open heart surgery with CPB, and 30 healthy volunteers. MEASUREMENTS AND RESULTS: Nitrite/nitrate, neopterin, and PCT levels were measured in septic patients as soon as sepsis was recognized and then on the 2nd, 3rd, and 5th days of treatment. Statistically significant differences between survivors and nonsurvivors were found for neopterin and PCT. The area under receiver operating characteristic curve (AUC) for both parameters as predictors of mortality was above 0.8. The nitrite/nitrate level was also higher in nonsurvivors, but the AUC remained below 0.8, which indicates poor predictive power. The same parameters were measured in patients undergoing cardiac surgery before, during and after CPB establishment. The development of post-operative complications was correlated with increased postoperative neopterin and PCT levels. Additionally, neopterin was found as an early marker for the prognosis of postoperative complications, since patients who developed organ dysfunction had had elevated concentration of this parameter even before surgery (AUC 0.83). Measurement of NO metabolite levels was less specific and less sensitive. CONCLUSIONS: Our results confirm the value of PCT and neopterin measurement as diagnostic tools in monitoring the clinical course of patients in intensive care units.

Immunological status of septic and trauma patients. II. Proliferative response and production of interleukin 6 and tumor necrosis factor alpha by peripheral blood mononuclear cells from septic survivor, nonsurvivor and trauma patients: a correlation with the survival rate.

We have studied proliferative response to phytohemagglutinin (PHA) and bacterial lipopolysaccharide (LPS) of peripheral blood mononuclear cells (PBMC) and their ability to produce IL-6 and TNF-alpha in vitro in: septic survivors, nonsurvivors and with multiple injury patients. Blood samples for determination of PBMC reactivity were taken upon admission and after 1, 2 and 5 days later. The proliferative response of lymphocytes, both spontaneous as well as PHA- and LPS-induced, was generally higher in septic nonsurvivor patients comparing to other groups. Markedly elevated LPS-induced proliferation (particularly on day 3) was a bad prognostic sign for survival. The ability of PBMC from the patients to produce IL-6 in culture was depressed in nonsurvivor septic patients and elevated in trauma patients, comparing to control donors. More profound differences were found with respect to TNF-alpha production which was deeply depressed (both spontaneous and induced) in septic nonsurvivors. In contrast, TNF-alpha production in septic survivors was significantly higher with a peak response on day 3. Trauma patients, on the other hand, had significantly increased ability to produce TNF-alpha on day 1 and 2, declining thereafter. The data presented in this report reveal that low production (or even anergy) with respect to synthesis of proinflammatory cytokines in vitro, as well as increased spontaneous proliferation of PBMC and proliferation in response to LPS, are significantly correlated with the fatal outcome of the septic shock.

Immunological status of septic and trauma patients. I. High tumor necrosis factor alpha serum levels in septic and trauma patients are not responsible for increased mortality; a prognostic value of serum interleukin 6.

The aim of this study was to monitor plasma interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-alpha), levels in patients with sepsis, septic shock and multiple organ dysfunction syndrome admitted to the intensive care unit. The patients obtained adequate supportive therapy. Plasma samples were taken upon admission, then on days 1, 2, and 5 following admission. IL-6 and TNF-alpha levels were determined using bioassays (7TD1 and WEHI-164.13 indicator cell lines, respectively). The results showed that the kinetics of the cytokine release in septic patients differed significantly between survivors and nonsurvivors. In survivors IL-6 concentrations were initially high, fell down rapidly on day 1 after admission, and persisted very low throughout the monitoring time. In contrast, relatively low IL-6 levels in the nonsurvivors, registered upon admission, rose significantly with peak values on day 3 of observation, declining thereafter. TNF-alpha levels were initially higher in survivors than in nonsurvivors, declined on day 1 following admission, and on day 5 they were higher than the initial values. In nonsurvivors, on the other hand, the starting concentrations of TNF-alpha were much lower than in survivors with a peak on day 3 with a tendency to fall on day 7. The profiles of cytokine production by traumatic patients (90% survivors) revealed low and progressively diminishing levels of IL-6, contrasting with constantly increasing concentrations of TNF-alpha within the monitoring period. We conclude that high IL-6 levels in septic patients accompanied by high TNF-alpha levels may indicate bad prognosis. In contrast, rapidly diminishing serum IL-6 levels, even in the presence of high TNF-alpha levels, could indicate a very good chance for survival. Similar conclusion can be drawn from the monitoring of cytokine production in traumatic, nonseptic patients since almost all of them recovered. We also speculate that TNF-alpha presence in circulating blood is essential for regeneration of tissues and wound healing.

Lactoferrin effects on the in vitro immune response in critically ill patients.

The aim of the study was to investigate whether lactoferrin can improve the immune competence of cells from patients with systemic inflammatory response syndrome (SIRS). We studied the effect of lactoferrin (LF) on the proliferative response of peripheral blood mononuclear cells (PBMC) to lipopolisaccharide (LPS) in vitro and its influence on production of 2 proinflammatory cytokines: interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha). Three groups of patients: septic survivors, septic nonsurvivors and multiple trauma patients, were investigated. Blood samples were taken upon admission to intensive care unit and after 2, 3 and 5 days. The proliferative response of PBMC in vitro was tested using 3-day culture with LPS. Cell proliferation/death was measured using MTT colorimetric method. The spontaneous and LPS-induced activity of TNF-alpha and IL-6 were measured with bioassays using indicator cell lines WEHI-164.13 and 7TD1, respectively. We demonstrated that LF inhibited the proliferative response, both spontaneous and LPS-induced, in all groups of patients. Lactoferrin alone was a good inducer of IL-6 and TNF-alpha production by monoclear cells in vitro. Addition of LF to the cultures of LPS-activated mononuclear cells stimulated IL-6 production, most markedly in the group of septic survivor patients (mean 1479, 1452, 1728, 1980 pg/ml on day 1, 2, 3 and 6 respectively). Lactoferrin also upregulated TNF-alpha production. That effect was very significant in the septic survivor patients (mean 7407, 6739, 7498 and 8509 pg/ml on day 1, 2, 3 and 5 respectively) and less pronounced in the group of trauma patients. We conclude that lactoferrin exhibited regulatory actions on the altered reactivity of PBMC from patients with sepsis and multiple injury. Lactoferrin is a good inducer of IL-6 and TNF-alpha production. However, in most cases of septic nonsurvivors LF could not abolish low reactivity of cells with regard to cytokine production.

Immunological status of patients subjected to cardiac surgery: effect of lactoferrin on proliferation and production of interleukin 6 and tumor necrosis factor alpha by peripheral blood mononuclear cells in vitro.

The aim of this investigation was to monitor proliferation and cytokine production by peripheral blood mononuclear cells (PBMC) of patients subjected to cardiac surgery. Another goal was to establish regulatory effects of lactoferrin (LF) on these immune reactions in vitro. PBMC were tested before, during surgery and on day 1 and day 8-10 following operation. In control donors, low spontaneous and phytohemagglutinin (PHA)-induced proliferation of PBMC, as well as lipopolysaccharide (LPS)-induced TNF-alpha secretion was stimulated by LF, but high production of this cytokine was inhibited. In patients, the proliferation of PBMC and the ability to produce IL-6 TNF-alpha by these cells underwent characteristic changes depending on preoperative immune reactivity of patients. In general, low, preoperative reactivity of PBMC showed a tendency to increase within the monitoring period whereas moderate/high responsiveness was diminishing. LF had, in majority of cases, a down-regulatory effect on the proliferative response, best pronounced in patients of high/moderate preoperative response. Similarly, LF exhibited, in general, an inhibitory effect on LPS-induced IL-6 production. In terms of TNF-alpha production, a considerable up-regulatory effect of LF, particularly in low responding patients was of a special interest. In summary, we suggest that LF may play a role in lowering the immune response of patients to surgery and promoting tissue regeneration.

Immunological status of patients subjected to cardiac surgery: serum levels of interleukin 6 and tumor necrosis factor alpha and the ability of peripheral blood mononuclear cells to proliferate and produce these cytokines in vitro.

The aim of this study was to monitor plasma interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) levels in patients subjected to cardiac surgery under general anesthesia. In addition, proliferation of peripheral blood mononuclear cells (PBMC) to phytohemagglutinin (PHA) and the ability of these cells to secrete lipopolysaccharide-induced IL-6 and TNF-alpha during the observation period was investigated. IL-6 and TNF-alpha levels were measured using bioassays. We found that despite high variability in the postoperative response of the patients, characteristic kinetics in the appearance of the cytokines in plasma could be demonstrated. Most significant phenomenon was an increase of IL-6 level 1 day after operation associated with an inhibition of TNF-alpha concentration. Relatively high, preoperative concentrations of these cytokines were probably elicited by stress. Control, healthy donors, did not exhibit measurable levels of these cytokines. In terms of proliferative response of PBMC to PHA and of cytokine production in vitro, the patients could be classified into low and high responding. The proliferative response of PBMC from low responders was progressively increasing and the response of high responders did not exhibit meaningful changes throughout the observation period. PBMC from low producers of IL-6 showed also an increased ability to secrete this cytokine during the monitoring time while the cells from high producers yielded less IL-6 on the last day of the follow up. Regarding TNF-alpha production, PBMC from low responders reacted strongly by secretion of this cytokine on day 1 after surgery in contrast to high responders whose cells yielded less TNF-alpha after surgery. In majority of cases TNF-alpha production had a tendency to diminish on the last day of observation. We conclude that the changes in cytokine levels as well as an altered reactivity of PBMC in vitro reflect the immune response to the postoperative trauma and are desirable for a normal course of the immune response and wound healing.

[Lactoferrin--its role in defense against infection and immunotropic properties]. / Laktoferyna--rola w obronie ustroju przed infekcja i wlasciwosci immunotropowe.

Lactoferrin (LF) is an iron-binding protein found in milk and other secretory fluids of mammals as well as in secondary granules of neutrophils. Receptors for LF were detected and isolated on activated T and B cells, monocytes, intestinal brush border cells, platelets and neoplastic cells. Very low physiologic serum levels of LF increase significantly upon infection. Serum concentration of LF is also elevated in rheumatoid patients. It is suggested that the ability of LF to bind an excess of Fe() ions, needed for growth of microorganisms and tumors, represents an important defence mechanism in humans. LF, in addition, may contribute to the protection against pathogens and their metabolites by enhancing phagocytosis, cell adherence and controlling release of proinflammatory cytokines such as IL-1, IL-6 and TNF-alpha. The protein diminishes also damaging effects of free radical release. LF possesses interesting immunotropic properties with regard to immature T and B cells by promoting phenotypic and functional maturation of these cells. LF also controls the effector phase of cellular immune response and inhibits manifestations of autoimmune response in mice. One molecular form of LF with a ribonuclease activity may have a prognostic value in breast cancer. Lactoferrin may be potentially applied in neutropenic patients or in patients with bleeding disorders as a preoperative immunomodulator.

[Prognostic markers of sepsis and septic shock]. / Wskazniki prognostyczne posocznicy i wstrzasu septycznego.

The first stage of systemic inflammatory response during sepsis and septic shock is the massive production of proinflammatory cytokines. Numerous clinical trials were done investigating various agents that were thought to stop this reaction. The results, however, were disappointing. Then it was realised that massive production of antiinflammatory cytokines could also be delirious. Persistent immunosuppression in the course of sepsis increased the risk of death. Therefore the proper balance between pro- and antiinflammatory mediators is extremely important and the methodologies available for monitoring immunological status in patients with sepsis and septic shock are currently of great interest.

Nitric oxide and inflammatory response in simulated extracorporeal circulation.

BACKGROUND: Simulated extracorporeal circulation (SECC) induces inflammatory reaction. Nitric oxide (NO) has pro-and anti-inflammatory properties. NO role in SECC-related inflammatory response is unclear. The aim of this study was to clarify if NO affects the foreign-surface induced leukocyte activation during SECC. METHODS: Human blood was circulated through SECC during 3 hours. Control group C was ventilated with oxygen/air mixture and the study group with oxygen/air mixture and NO. Leukocyte activation was measured as serum levels of myeloperoxidase (MPO), human neutrophil lipocalin (HNL), lactoferrin (LF), interleukin-1-beta (IL-1 beta) and interleukin-10 (IL-10). Oxygen free radical production capacity was evaluated with chemiluminescence. NO metabolites nitrite/nitrate were estimated in serum. RESULTS: Leukocyte granule release increased over time. Addition of NO significantly increased MPO, HNL and LF release. The average difference increased with SECC duration. NO addition did not significantly affect measured interleukins concentration or oxygen free radical production capacity. NO metabolites increased significantly in the NO circuits. CONCLUSIONS: Results indicate that NO addition during SECC is pro-inflammatory and has no effect on oxygen free radical production and interleukin release.