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To investigate the value of renal resistive index (RRI) in early predictor and discriminator of severe acute pancreatitis (SAP)-related acute kidney injury (AKI). Methods A retrospective observational study was conducted. SAP patients complicated with AKI (within 1 week of onset) and admitted to intensive care unit (ICU) of Ruijin Hospital Shanghai Jiaotong University School of Medicine from January 2016 to June 2019 were enrolled. The RRI within 24 hours admission was measured. Clinical data such as acute physiology and chronic health evaluation Ⅱ(APACHEⅡ), heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), intra-abdominal pressure (IAP), arterial blood lactate (Lac), oxygenation index (PaO2/FiO2), base excess (BE), serum creatinine (SCr), urine output, norepinephrine (NE) and RRI were collected. Within 24 hours and 7 days after ICU admission, patients were grouped according to AKI classification criteria of Kidney Disease: Improving Global Outcomes (KDIGO), and the differences of relevant parameters were statistically analyzed. Influence factors of AKI grading were screened by Logistic regression analysis. Pearson correlation analysis was used to analyze the correlation between RRI and other parameters. The predictive value of RRI for AKI classification was analyzed by receiver operating characteristic (ROC) curve. Results A total 57 patients were included, with an average age of (54.6±13.5) years old, and APACHEⅡscore of 21.8±5.6. Within 24 hours, the number of patients suffered from stage 1-3 AKI were 19 (33.3%), 18 (31.6%) and 20 (35.1%), respectively. On day 7, the number of patients suffered from stage 0-3 AKI were 21 (36.9%), 8 (14.0%), 9 (15.8%) and 19 (33.3%), respectively. The higher APACHEⅡ score, CVP, IAP, Lac, NE dosage and RRI were found in the group with higher AKI grades, especially in the group with stage 3 AKI on day 7. RRI of patients with stage 3 AKI was significantly higher than that of patients with stage 1 and 2 AKI within 24 hours (0.74±0.04 vs. 0.65±0.05, 0.68±0.05, both P < 0.05). Similarly, RRI of patients with stage 2 and 3 AKI were significantly higher than that of patients with stage 0 and 1 AKI on day 7 (0.70±0.04, 0.74±0.04 vs. 0.65±0.05, 0.66±0.05, all P < 0.05). Multivariate Logistic regression analysis showed that RRI was an independent factor of AKI classification [odds ratio (OR) = 3.15, 95% confidence interval (95%CI) = 1.09-9.04, P < 0.05], and IAP and CVP also had significant impacts on AKI grading [OR value was 2.11 (95%CI = 1.16-4.22), 3.78 (95%CI = 1.21-12.90), both P < 0.05]. ROC curve analysis showed that the area under curve (AUC) of RRI for predicting AKI ≥2 stage was 0.87 (P < 0.05); the cut-off ﹥ 0.71, sensitivity was 71% and specificity was 83%. The correlation analysis showed that RRI was positively correlated to a certain extent with IAP and lactic acid (r1 = 0.49, r2 = 0.39, both P < 0.05). Conclusion High RRI on ICU admission was a significant predictor for development of severe AKI during the first week, and RRI can help predict the tendency of AKI in SAP.
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Objective To evaluate an effective and feasible quantitative evaluation table of traditional Chinese medicine (TCM) syndrome differentiation, and to observe the effect of combination of TCM syndrome differentiation and standard bundle therapy in patients with septic shock. Methods A prospective randomized controlled trial was conducted. The septic shock patients with acute deficiency syndrome admitted to department of critical care medicine of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from January 1st, 2016 to December 31st, 2017 were enrolled. The patients were randomly divided into control group and Shenfu group. The patients in both groups received early application of standardized bundle therapy; those in Shenfu group received 60 mL Shenfu injection infusion in addition for 7 days. The TCM syndrome score was evaluated by classification and scoring method of TCM symptoms. The circulation and tissue perfusion, severity of disease, organ function, inflammation response, adjuvant treatment and 28-day mortality were compared between the two groups. Results A total of 50 patients with septic shock were enrolled in the analysis, 25 in control group and 25 in Shenfu group. The markedly effective rate of TCM symptoms score in Shenfu group was significantly higher than that in control group [60.0% (15/25) vs. 16.0% (4/25), P < 0.01]. There was no significant difference in all parameters before treatment between the two groups. After treatment, the observation indexes of both groups were improved. Compared with control group, the mean arterial pressure (MAP) in Shenfu group increased more significantly [mmHg (1 mmHg = 0.133 kPa): 13.0 (2.5, 28.5) vs. 6.0 (0, 13.5)], the lactate (Lac) and procalcitonin (PCT) decreased more significantly [Lac (mmol/L): 0.8 (0.1, 3.7) vs. 0.5 (-0.6, 1.7), PCT (μg/L): 2.0 (0.7, 32.3) vs. 0 (-1.8, 3.8)], activated partial thromboplastin time (APTT) was shortened more significantly [s: 8.5 (0, 12.9) vs. 0 (-7.2, 10.0)], and interleukins (IL-2 receptor and IL-6) levels decreased more significantly [IL-2 receptor (ng/L):1 031.0 (533.0, 1 840.0) vs. 525.5 (186.0, 1 166.8), IL-6 (ng/L): 153.1 (21.4, 406.8) vs. 35.1 (16.3, 110.1)] with significant differences (all P < 0.05). There was no significant difference in the use time of vasoactive drugs, duration of mechanical ventilation, severity of the disease or 28-day mortality between the two groups. However, the use time of vasoactive drugs in Shenfu group was shorter than that in control group (days: 5.48±4.81 vs. 8.28±7.83), and the 28-day mortality was decreased [8.0% (2/25) vs. 20.0% (5/25)]. Conclusions TCM syndrome score is helpful to evaluate the effect of TCM syndrome differentiation and treatment, and it is effective and feasible in clinical application. Septic shock patients treated with TCM syndrome differentiation and treatment combined with standard bundle therapy were significantly improved in circulation, tissue perfusion, coagulation function and inflammation reaction.
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Objective To investigate the diagnostic value of serum proadrenomedullin( pro-ADM)in catheter related blood stream infection( CRBSI). Methods Prospective diagnostic test was performed with 76 cases patients with clinically suspected diagnosis of CRBSI,and the patients were divided into CRBSI group( n=25)and non-CRBSI group. Serum pro-ADM,procalcitonin( PCT),C-reactive protein( CRP)and white blood cell( WBC)levels were measured at the study entry and on the day of CRBSI suspicion. Results On the day of CRBSI suspicion,the levels of pro-ADM,PCT,CRP and WBC in the CRBSI group were(5. 17 ± 1. 28)nmol/L, 2. 29(1. 47-4. 28)μg/L,(102. 04 ± 51. 00)μg/L and(14. 66 ± 5. 09)× 109/L respectively,significantly higher than those in the non-CRBSI group((2. 83 ± 1. 25)nmol/L,2. 29(1. 4-4. 28)μg/L,(61. 43 ± 53. 52) mg/L and(11. 78 ± 3. 52)× 109/L respectively;t or Z=7. 636,-4. 777,3. 156,2. 882;P﹤0. 05). For the diagnosis of CRBSI,the area under the curve(AUC)of pro-ADM,PCT,CRP and WBC were 0. 89(95%CI 0. 82-0. 97),0. 84(95%CI 0. 75-0. 93),76(95%CI 0. 65-0. 86)and 0. 68(0. 54-0. 81)respectively. Taking pro-ADM with 4. 31 nmol/L as the cutoff value,the sensitivity,specificity,positive predictive value and negative predictive value were 76. 0%,84. 3%,70. 4% and 87. 8% respectively. Simultaneously,taking procalcitonin with 1. 52 μg/L as the cutoff value, the sensitivity and specificity was 81. 8% and 87. 0%respectively. Conclusion Serum level of pro-ADM in the diagnosis of CRBSI has good specificity. Simultaneous surveillance of serum pro-ADM and PCT may be helpful for the diagnosis of CRBSI in the early stage.
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Objective To investigate the prevalence and main genotypes of carbapenemases in carbepenem‐resistant Enterobacteriaceae (CRE) .Methods A total of 114 strains of CRE were isolated in Shanghai Ruijin Hospital from May 2011 to June 2013 .The diameter of inhibition zone of imipemen or meropenem for these strains was not larger than 22 mm .PCR method was used to screen for the main carbapenemase genes (blaKPC ,blaIMP ,blaVIM ,blaOXA‐48 and blaNDM ) with previously described primers followed by nucleotide sequencing analysis . Conjugation experiments were performed to examine the transferability of plasmids .Pulsed‐field gel electrophoresis (PFGE) was used to show the relatedness of KPC‐2‐producing Enterobacteriaceae .Results Most of the 114 isolates were K lebsiella pneumoniae and Escherichia coli .Of the 114 isolates ,98 was positive for carbapenemases ,specifically ,78 blaKPC‐2‐positive ,15 blaIMP‐4‐positive ,2 blaIMP‐8‐positive ,1 positive for both blaKPC‐2 and blaIMP‐4 and 4 blaNDM‐1‐positive .None of the strains was positive for blaOXA‐48 or blaVIM .About 21 .4% (21/98) of the isolates were conjugated successfully .The 49 blaKPC‐2‐positive K .pneumoniae isolates were grouped into 12 types according to PFGE patterns .Majority (34/49) of these isolates belonged to the same type A .Conclusions BlaKPC‐2 was the primary epidemic genotype of Enterobacteriaceae in Ruijin Hospital ,followed by blaIMP‐4 .NDM‐1 carbapenemase was produced in 4 strains of CRE . Meanwhile , clonal spread of KPC‐2‐producing K . pneumoniae was observed in some departments of our hospital , such as surgical ICU , respiratory medicine and thoracic surgery . Appropriate measures should be taken timely and effectively to prevent the in‐hospital spread of resistant genes .
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Objective To explore the mRNA expressions of NLRP1 (NOD-like receptor 1 ) and NLRP3 inflammasomescomponents and related pro-inflammation cytokines in peripheral blood mononuclear cells (PBMCs).Methods A total of 21 septic patients,20 non-infectious SIRS patients and 20 health subjects were enrolled in this study.The mRNA expressions of inflammasomes components and related proinflammation cytokines were measured by using RT-PCR,and serum levels of IL-1β and IL-18 were measured using ELISA.One-way ANOVA was usedd to compare the data of all three groups,and SNK-q was employed to compare thedata among different groups.Spearman correlation analysis was used to analyze the correlation between these biomarkers and the severity of septic patients.Results ①The mRNA expression of NLRP1 in PBMCs of septic patients in early stage and non-infectious SIRS patients was down-regulated in comparison with healthy subjects (P ＜0.01 ).The expression of NLRP3 in septic patients was not differentfrom that in healthy subjects ( P ＞ 0.05 ),but NLRP3 mRNA expression in non-infectious SIRS patients was significantly higher than that in septic patients and in healthy subjects ( P ＜ 0.01 ).ASC ( apoptosis associated speck like protein containing a CARD) and caspase-1 mRNA expressions in septic patients and non-infectious SIRS patients were higher than those in healthy subjects ( P ＜ 0.01 ).There was no difference in level of IL-1β found among all groups.IL-18 mRNA expression in septic patients and non-infectious SIRS patients was higher than that in healthy subjects ( P ＜ 0.01 ),and that in non-infectious SIRS patients was highest.②)Serum protein level of IL-1β in septic patients was lower than that in healthy subjects (P ＜0.05 ),and serum level of IL-18 in septic patients was significantly higher than that in non-infectious SIRS patients and in healthy subjects ( P ＜ 0.01 ).③NLRP1 was negatively related to SOFA ( sepsis-related organ failure assessment) score (r =-0.44,P ＜ 0.05 ) and negatively related to APACHE Ⅱ score as well ( r =- 0.52,P ＜ 0.05 ).Conclusions NLRP1 mRNA expression was down regulated in patients with early sepsis and its expression was negatively correlated to the severity of septic patients,indicating the lower NLRP1 mRNA expression the severer illness.
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Objective To explore the CD4 + CD25 + Foxp3 + regulatory T cell percentage and plasma levels of soluble CD25 molecules in peripheral blood of septic patients and their clinical value through prospective study. Method A total of 37 septic patients and 15 non-infectious SIRS patients, who conformed to the criteria of SIRS and sepsis which proposed by American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference ( ACCP/SCCM ) in 1997, were collected in ICU of Ruijin Hospital ( Shanghai Jiaotong University) from February 2009 to February 2010. Twenty-four health people were from Medical Center of Ruijin Hospital, who were excluded infection and (or) autoimmune diseases. There were 26 male and 11 female in sepsis group, average age ( 61.67 ± 11.87 ) years old; 8 male and 7 female in SIRS group, average age (67.06 ± 12.57)years old; 14 male and 10 female in health control, average age (56.54 ± 6.37 )years old. All selected patrents were excluded the autoimmune diseases and (or) patients within recent (30 days) had used or now used immunosuppressive agents. We therefore measured the Treg cell percentage in peripheral blood by Flow Cytometry and the plasma levels of IL-2sRa, IL-4, IFN-γ by ELISA. The data were analyzed by analysis of variance or nonparametric Kruskal-Wallis H test. Results ① The percentage of CD4 + CD25 + Foxp3 + regulatory T cells among septic patients, SIRS patients, and control group was: ( 66.82 ± 21.79 ) %, ( 51.79 ± 21.79 ) %, ( 56.45 ± 10. 68 ) %, respectively. septic patients showed the highest percentages of CD4 + CD25 + Foxp3 + regulatory T cell among CD4 + CD25 + T cells(P ＜ 0.05 ). ② The plasma levels of soluble CD25 in septic patients (425. 619 ± 270.12 ) were significantly higher than SIRS patients (381. 664 ± 189.83) and the control group ( 164. 1 32 ± 56.37 ) ( P ＜ 0.05 ). ③ The correlation analysis between the concentration of soluble CD25 molecules in plasma and the ratio of CD4 + CD25 + Foxp3 + regulatory T cells to CD4 + CD25 + T cells showed Spearman correlation coefficient =0.390, P = 0.003 ( P ＜ 0.05 ). Conclusion: the expression of natural regulatory T cells characteristically increased in septic patients. And the levels of soluble CD25 in peripheral blood were related to the percentages of natural regulatory T cells, which simplified the assessment of the immune status in Septic patients.
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Objective To evaluate antibiotic therapy for the treatment of intraabdominal infection secondary to severe acute pancreatitis.Methods 39 SAP patients with intraabdominal infection were devided into 2 groups: early infection group (early group) and late infection group (late group) according to the onset time of infection. All patients received imipenem and or surgical treatment, and results were compared between the two groups. Results 83 strains of pathogen were isolated among which Gram negative bacteria accounting for 84%, with a ratio of sensitivity to imipenem of 80%; Gram positive bacteria taking up 16%, all were resistant to imipenem. The cure rate was 53% in eraly group and 86% in late group(P=0.02); The rate of bacteria clearance was 47% in early group and 82% in late group(P=0.02). The survival rate of patients in early group was 77% and in late group was 95%(P=0.08); The reinfection rate in early group was 58% and in late group was 37%(P=0.16). Conclusion Imipenem is effective in the treatment of intraabdominal infection secondary to severe acute pancreatitis,and repeated surgical intervention is still necessary for patietns in early infection group.