Diagnostic value of plasma NGAL and intraoperative diuresis for AKI after major gynecological surgery in patients treated within an intraoperative goal-directed hemodynamic algorithm: A substudy of a randomized controlled trial.

Data on early markers for acute kidney injury (AKI) after noncardiovascular surgery are still limited. This study aimed to determine the diagnostic value of plasma neutrophil-gelatinase-associated lipocalin (pNGAL) and intraoperative diuresis for AKI in patients undergoing major abdominal surgery treated within a goal-directed hemodynamic algorithm.This study is a post-hoc analysis of a randomized controlled pilot trial comparing intravenous solutions within a hemodynamic goal-directed algorithm based on the esophageal Doppler in patients undergoing epithelial ovarian cancer surgery. The diagnostic value of plasma NGAL obtained at ICU admission and intraoperative diuresis was determined with respect to patients already meeting AKI criteria 6 hours after surgery (AKI6h) and to all patients meeting AKI criteria at least once during the postoperative course (AKItotal). AKI was diagnosed by the definition of the Kidney Disease Improving Global Outcome (KDIGO) group creatinine criteria and was screened up to postoperative day 3. Receiver operating characteristic curves including a gray zone approach were performed.A total of 48 patients were analyzed. None of the patients had increased creatinine levels before surgery and 14 patients (29.2%) developed AKI after surgery. Plasma NGAL was predictive for AKI6h (AUCAKI6h 0.832 (95% confidence interval [CI], 0.629-0.976), P = .001) and AKItotal (AUCAKItotal 0.710 (CI 0.511-0.878), P = .023). The gray zones of pNGAL calculated for AKI6h and AKItotal were 210 to 245 and 207 to 274 ng mL, respectively. The lower cutoffs of the gray zone at 207 and 210 ng mL had a negative predictive value (NPV) (i.e., no AKI during the postoperative course) of 96.8% (CI 90-100) and 87.1% (CI 78-97), respectively. Intraoperative diuresis was also predictive for AKI6h (AUCAKI6h 0.742 (CI 0.581-0.871), P = .019) with a gray zone of 0.5 to 2.0 mL kg h. At the lower cutoff of the gray zone at 0.5 mL kg h, corresponding to the oliguric threshold, the NPV was 84.2% (78-92).This study indicates that pNGAL can be used as an early marker to rule out AKI occurring within 3 days after major abdominal surgery. Intraoperative diuresis can be used to rule out AKI occurring up to 6 hours after surgery. TRIAL REGISTRATION: ISRCTN 53154834.

Delta-He, Ret-He and a New Diagnostic Plot for Differential Diagnosis and Therapy Monitoring of Patients Suffering from Various Disease-Specific Types of Anemia.

BACKGROUND: The present study was aimed to prove the usefulness of a new diagnostic plot (Hema-Plot), illustrating the relationship between the hemoglobin content of reticulocytes (Ret-He) as a marker of functional iron deficiency and the difference between the reticulocyte and erythrocyte hemoglobin content (Delta-He) as a marker of an impaired hemoglobinization of newly formed reticulocytes occurring during inflammatory processes, to differentiate between various disease-specific types of anemia. METHODS: A complete blood and reticulocyte count was performed on routine EDTA blood samples from 345 patients with and without various disease-specific types of anemia using the Sysmex XN-9000 hematology analyzer: blood healthy newborns (n = 23), blood healthy adults (n = 31), patients suffering from anemia of chronic disease (ACD) due to diverse oncological, chronic inflammatory, or autoimmune diseases (total n = 138) with (n = 65) and without therapy (n = 73), patients with thalassemia and/or hemoglobinopathy (n = 18), patients with iron deficiency anemia (IDA) (n = 35), patients with a combination of ACD and IDA (n = 17), as well as patients suffering from sepsis (total n = 83) with (n = 32) and without therapy (n = 51). The results for Ret-He, Delta-He, and C-reactive protein (CRP) were statistically compared (Mann-Whitney U Test) between the particular patient groups and the diagnostic plots were drawn. RESULTS: Delta-Hemoglobin showed a statistically significant difference between blood healthy newborns and blood healthy adults (p ≤ 0.05), while Ret-He and C-reactive protein did not. In addition, of all three biomarkers only Delta-He showed a statistically significant difference (p ≤ 0.05) between the ACD/IDA and IDA cohort. Delta-He, Ret-He, and CRP showed a statistically significant difference between patient cohorts with and without therapy suffering from ACD, ACD/IDA, and sepsis before and after medical therapy (p ≤ 0.05). The Hema-Plot illustrated the dynamic character of Ret-He and Delta-He, notably in inflammation-based types of anemia like ACD or ACD/ IDA. CONCLUSIONS: Delta-He is a new biomarker clearly distinguishing between inflammation-based types of anemia before and after medical therapy, as well as between ACD/IDA and IDA. The new Hema-Plot is a helpful tool for differential diagnosis and disease-monitoring in various types of disease-specific anemia, especially in ACD and ACD/IDA. The Hema-Plot can be used to identify non-adherent patients or an insufficient therapy.

Detection and quantification of hypo- and hypergranulated neutrophils on the new Sysmex XN hematology analyzer: establishment of an adapted reference interval for the neutrophil-granularity-intensity compared to XE-technology in adult patients.

BACKGROUND: Since the recent introduction of Sysmex hematology analyzers of the XN-series it can be expected that the values of individual hematological parameters might differ between the new XN and the well-established XE platform. One such parameter is called Neutrophil-Granularity-Intensity or NEUT-GI on the XN-series and NEUT-X on the XE-series. Both parameters are used by clinicians to calculate the Granularity-Index (GI-Index), an important tool to detect hypo- or hypergranulated neutrophils occurring during myelodysplasia or inflammation. The aims of this study were to determine if previously reported reference intervals for NEUT-X can be used for NEUT-GI as well and if the GI-Indices on both analyzer platforms correlate with each other. METHODS: NEUT-GI and NEUT-X were assessed in a set of 789 blood samples (n = 543 samples from adult intensive care units and n = 246 samples from adult "blood-healthy" control patients) and the corresponding Granularity-Indices were calculated for all samples using data obtained from XE-5000 and XN-1000 hematology analyzers. RESULTS: NEUT-GI and NEUT-X correlated significantly with each other (r2: 0.6512; p < 0.0001) with statistically significant higher values for NEUT-GI compared to NEUT-X in the control group (p < 0.0001) as well as in the ICU patients (p < 0.0001). This indicated that previously established reference intervals for NEUT-X cannot be used for NEUT-GI. In contrast, the GI-Indices showed no statistically significant difference between the analyzers in both groups. The GI-Indices were higher in the ICU patients compared to the control group on both analyzer platforms (p < 0.0001), as would be expected. CONCLUSIONS: Our study revealed the emphatic need for a new reference interval for NEUT-GI on the XN platform. The resulting 95% reference intervals were 140.91 - 160.46 channels for NEUT-GI and 129.20 - 142.33 channels for NEUT-X. The GI-Indices showed no significant statistical difference between the XN- and XE-series in both cohorts.

Soluble CEACAM8 interacts with CEACAM1 inhibiting TLR2-triggered immune responses.

Lower respiratory tract bacterial infections are characterized by neutrophilic inflammation in the airways. The carcinoembryonic antigen-related cell adhesion molecule (CEACAM) 8 is expressed in and released by human granulocytes. Our study demonstrates that human granulocytes release CEACAM8 in response to bacterial DNA in a TLR9-dependent manner. Individuals with a high percentage of bronchial lavage fluid (BALF) granulocytes were more likely to have detectable levels of released CEACAM8 in the BALF than those with a normal granulocyte count. Soluble, recombinant CEACAM8-Fc binds to CEACAM1 expressed on human airway epithelium. Application of CEACAM8-Fc to CEACAM1-positive human pulmonary epithelial cells resulted in reduced TLR2-dependent inflammatory responses. These inhibitory effects were accompanied by tyrosine phosphorylation of the immunoreceptor tyrosine-based inhibitory motif (ITIM) of CEACAM1 and by recruitment of the phosphatase SHP-1, which could negatively regulate Toll-like receptor 2-dependent activation of the phosphatidylinositol 3-OH kinase-Akt kinase pathway. Our results suggest a new mechanism by which granulocytes reduce pro-inflammatory immune responses in human airways via secretion of CEACAM8 in neutrophil-driven bacterial infections.

In vitro cytotoxicity of the novel antimyeloma agents perifosine, bortezomib and lenalidomide against different cell lines.

The novel AKT inhibitor perifosine, a synthetic alkylphospholipid, is currently being investigated in clinical trials for the treatment of different hematological and oncological malignancies. The in vitro cytotoxicity of perifosine, bortezomib and lenalidomide against 6 cell lines derived from hematological malignancies was investigated using trypan blue staining, flow cytometry-based detection of activated caspases, Annexin V assays, immunohistochemistry studies (KI-67 and caspase-3 staining) and the immature-myeloid-information (IMI) technique. Perifosine and bortezomib induced concentration- and time-dependent cytotoxicity in all cell lines tested. Perifosine together with bortezomib largely exerted additive or synergistic effects with combination indices ranging from 1.13 to 0.22 for combined efficacies of 25% to 75% after 24-hour incubation. Lenalidomide-triggered cytotoxicity was low in all cell lines tested with any assay (less than 10% compared to the negative control). Finally, perifosine, but not bortezomib or lenalidomide, significantly increased the number of cells detected in the IMI channel. Perifosine and bortezomib- but not lenalidomide- trigger substantial cytotoxicity by caspase activation and mainly act additively or synergistically. The IMI technique might be a useful tool for studying cytotoxicity of agents like perifosine that interact mainly with the cellular membrane.

Immature platelet count: a simple parameter for distinguishing thrombocytopenia in pediatric acute lymphocytic leukemia from immune thrombocytopenia.

BACKGROUND: Platelet counts below normal values define thrombocytopenia. However, platelet counts alone do not reveal the underlying pathomechanism. New blood cell counters provide additional information on platelet size and volume, and enable the distinction of sub-populations. In this preliminary study, we evaluate whether one of these markers can be used for diagnosis of isolated thrombocytopenia in children. PROCEDURE: We provide normal values for mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (PCT), platelet large cell ratio (P-LCR), platelet mean-frequent volume (P-MFV), relative immature platelet fraction (IPF%), and absolute IPF (IPF#) for 100 healthy children and analyzed 87 children with thrombocytopenia. RESULTS: In children with platelet production defects, IPF% was low, while in acute immune thrombocytopenia (ITP), IPF% was markedly increased (median 25.2%, P < 0.01), representing accelerated platelet turnover. Interestingly, children diagnosed with acute lymphocytic leukemia (ALL) also had elevated IPF% (median 10%, P < 0.01), suggesting that thrombopoiesis is stimulated despite virtual absence of bone marrow progenitors. Low IPF# was only found in patients with acute ITP. CONCLUSIONS: IPF% is a marker for thrombocytopenia due to defective platelet production while IPF#, representing the immature platelet count, might become a practical parameter to distinguish acute ITP from thrombocytopenia in children with newly diagnosed ALL (P < 0.01).

Comparison of six immunohistochemical markers for the histologic diagnosis of neoplasia in Barrett's esophagus.

In esophageal neoplasms, the histopathologic differentiation between Barrett's esophagus with or without intraepithelial neoplasia and adenocarcinoma is often challenging. Immunohistochemistry might help to differentiate between these lesions. The expression of CDX2, LI-cadherin, mucin 2 (MUC2), blood group 8 (BG8, Lewis(y)), claudin-2, and villin was investigated in normal gastroesophageal (n = 23) and in Barrett's (n = 17) mucosa, in low-grade (n = 12) and high-grade (n = 9) intraepithelial neoplasia (IEN) as well as in esophageal adenocarcinoma (n = 16), using immunohistochemistry. For CDX2 and LI-cadherin, the immunoreactivity score was highest in IEN while for MUC2, BG8, and villin, it dropped gradually from Barrett's via IEN to adenocarcinoma, and expression of Claudin-2 was only weak and focal in all lesions. The expression of MUC2 and LI-cadherin differed significantly between all examined lesions except between low-grade and high-grade IEN. MUC2 and LI-cadherin are useful immunohistochemical markers for the differentiation between normal glandular mucosa, Barrett's mucosa, IEN, and invasive carcinoma of the esophagus; however, none of the examined markers was helpful for the differentiation between low-grade and high-grade IEN.

CDX2 and LI-cadherin expression in esophageal mucosa: use of both markers can facilitate the histologic diagnosis of Barrett's esophagus and carcinoma.

BACKGROUND: Barrett's mucosa is a risk factor for esophageal adenocarcinoma and should be detected at an early stage. CDX2 and liver-intestine (LI)-cadherin are intestine-specific markers. Aberrant CDX2 expression has been demonstrated in Barrett's metaplasia, esophagitis, and intestinal metaplasia of the stomach. METHODS: The relationship between CDX2 and LI-cadherin expression was investigated in normal gastroesophageal (n = 24) and in Barrett's (n = 20) mucosa, in low-grade (n = 15) and high-grade (n = 13) intraepithelial neoplasia (IEN) as well as in esophageal adenocarcinoma (n = 16), using immunohistochemistry. RESULTS: Nuclear positivity for CDX2 coupled with membranous expression of LI-cadherin was observed in about 70% of the epithelial cells of Barrett's mucosa. The intensity of staining and the percentage of positive cells increased within the sequential steps of low-grade to high-grade IEN, whereas the normal cylindric epithelium lacked the expression of both. In adenocarcinoma, the expression of LI-cadherin and CDX2 was significantly weaker or absent. CONCLUSIONS: CDX2 and LI-cadherin are sensitive markers of intestinal metaplasia with or without dysplasia in the upper gastrointestinal tract. Both can be helpful for the early histologic diagnosis of Barrett's esophagus and its subsequent lesions; however, they do not significantly discern between different grades of dysplasia.

Is there a role for mannan-binding lectin in the diagnosis of inflammatory bowel disease?

Mannan-binding lectin (MBL) activates the lectin-complement pathway as part of the innate immune defence by binding to the surface of microorganisms. Therefore, MBL2 presents an interesting candidate gene for the inflammatory bowel diseases, ulcerative colitis (UC) and Crohn's disease (CD). In our study, we evaluated the MBL serum concentrations and genotypes for diagnostic and classification purposes of patients with CD and UC. The MBL serum concentration was analysed in 98 CD patients and in 83 UC patients. In total, 82 patients with inflammatory rheumatic disorders and 189 healthy individuals served as controls. All study subjects were genotyped for the MBL2 polymorphisms G54D, G57E and R52C and the NOD2 (CARD15) mutations R702W, G908R and L1007fsinsC. Neither the median MBL serum concentration nor the MBL2 genotype distribution differed significantly between cohorts. Measurement of MBL serum concentrations offers no benefit for the diagnosis of CD or UC.

Boy with pseudohypoparathyroidism type 1a caused by GNAS gene mutation (deltaN377), Crouzon-like craniosynostosis, and severe trauma-induced bleeding.

We report on a 6-month-old boy with craniosynostosis, pseudohypoparathyroidism type 1a (PHP1A), and a GNAS gene mutation. He had synostoses of the coronal, frontal, and sagittal sutures, brachyturricephaly, and hydrocephaly. He also had congenital hypothyroidism, round face, full cheeks, shortness of limbs, mild developmental delay, and muscular hypotonia. Because of progressive hydrocephaly, the synostosis was corrected surgically but circulatory decompensation led to disseminated intravascular coagulation and cerebral infarctions. Our patient died 8 days later. Postmortem molecular studies of GNAS, the gene for guanine nucleotide-binding protein, alpha-stimulating activity polypeptide (gene for PHP1A), identified a de novo heterozygous 3 bp in frame deletion predicting a deletion of the asparagine residue at position 377 (deltaN377). This is the second report of this mutation. Results of molecular studies of craniosynostosis genes (FGFR2, FGFR3) and of numerous genetic variants predisposing to bleeding disorders were normal. We question whether craniosynostosis and trauma-induced bleeding disorder may be manifestations of PHP1A, or if our patient had two or three different congenital disorders.

Mayo risk score for primary biliary cirrhosis: a useful tool for the prediction of course after liver transplantation?

BACKGROUND: Survival after orthotopic liver transplantation (OLT) for primary biliary cirrhosis (PBC) is excellent. In order to define the optimal time point for OLT, the Mayo risk score (MRS) was developed and a score of 7.8 was identified for transplantation. However, in reality most recipients are in a bad condition with a MRS above 7.8. So far it is still unknown if a higher score is associated with more complications after OLT perioperatively and in a long-term follow-up. Therefore, this study was designed to investigate the association of the MRS score with postoperative survival and complications. MATERIAL/METHODS: Between 1989 and 2006, 115 patients were transplanted for histologically proven PBC at the Charité Campus Virchow Clinic. In 98 of these patients, MRS data was available and retrospectively analyzed. Median age of 87 women and 11 men was 54 years (25 to 66 years). RESULTS: The median follow-up after liver transplantation was 109 months (0.5-205 months). Actuarial patient survival after 5, 10 and 15 years was 90%, 88%, and 83%. Calculated survival by MRS without transplantation after 1, 5 and 7 years was 20%, 2% and 1% for these patients. Twelve patients (12%) died and histological recurrence of PBC was detected in 14 patients (14%). Seven patients underwent retransplantation (7%) and 58 patients developed an acute rejection episode (59%). Mean MRS was in all patients 9.54+/-1.35 and did not differ between patients with lethal course, retransplantations, PBC recurrence, rejection episodes and duration of hospital stay. Classification of all patients into a low (<8.5), middle (8.5-10) and high MRS score (>10) did not show a significant difference in long-term survival. Univariate analysis for identifying the level of MRS as risk for death, PBC-recurrence, retransplantation, acute rejection episodes and hospital stay only showed a significant increased risk for acute rejection episodes (1 episode = 0.04; 2 episodes = 0.01) for patients with a MRS above 8.5. CONCLUSIONS: The Mayo risk score is an approved mathematical model predicting survival in non-transplanted patients suffering from PBC. However, the score did not predict the course of our liver transplanted patients in a long-term follow-up. We could not demonstrate a reduced patient survival at a median MRS of 9.4 and about 10.0. Therefore, it is, from our point of view, questionable if the optimal time point for OLT is still 7.8.