Sepsis hastalarında inflamasyon ilişkili prognostik skorlar CRP/albumin, LDH/albumin ve laktat/albumin oranlarının değerlendirilmesi

Öz

Amaç: Septik hastalarda C-reaktif protein (CRP), laktat dehidrogenaz (LDH) ve laktat gibi inflamasyona dayalı parametrelerin klinik yararlılığı ve tahmin doğruluğuna ilişkin sonuçlar çelişkilidir. Çalışmamızda bu inflamatuvar parametrelerin albumin ile kombinasyonunun, hastalık şiddeti ve prognoz ile ilişkilerini değerlendirmeyi amaçladık. Gereç ve yöntem: Sepsis tanısı konulan 98 hasta, yoğun bakım ünitesi (YBÜ) mortalitelerine göre yaşayanlar (n=68) ve ölenler (n=30) olarak sınıflandırıldı. Prognostik faktörler receiver operating characteristic curve ve Cox proportional hazard regression model ile değerlendirildi. Sağ kalım Kaplan-Meier methodu ile analiz edildi. Bulgular: Yaşayan hastalarla karşılaştırıldığında, ölen hastalarda CRP ve laktat düzeyleri artmıştı (sırasıyla 13,5'e karşı 10,0, p=0,044; 2,2'ye karşı 1,7, p=0,006), ancak LDH ve albumin düzeyleri anlamlı derecede farklı değildi (sırasıyla 246,0'ya karşı 245,0, p=0,624; 2,9'a karşı 3,0, p=0,061). Kombine faktörler değerlendirildiğinde, CRP/albumin ve laktat/albumin ölen hastalarda anlamlı derecede yüksek iken (sırasıyla 4,9'a karşı 3,0, p=0,018; 0,8'e karşı 0,5, p=0,001), LDH/albumin ise her iki grupta benzerdi (93,1'e karşı 78,9, p=0,148). Laktat/albumin 0,709 ile en yüksek AUC'ye sahipken (p=0,001), CRP 0,628 ile en düşük AUC'ye sahipti (p=0,044). YBÜ mortalitesinin olası belirleyicilerinin çok değişkenli analizinde, yalnızca laktat kötü sonucun bağımsız bir belirleyicisi olabilirken (HR:1,998; p=0,020), diğer değişkenler bağımsız olarak ilişkili değildi. Sonuç: Septik hastalarda CRP, laktat, CRP/albumin ve laktat/albumin düzeylerindeki artış kötü sonuçlarla ilişkilidir. Laktat düzeyi mortalitenin bağımsız bir belirleyicisidir.

Anahtar Kelimeler

• Albumin
• C-reaktif protein
• laktat
• prognoz
• sepsis

Evaluation of inflammation-related prognostic scores, CRP/albumin, LDH/albumin and lactate/albumin ratios in patients with sepsis

Öz

Purpose: Results regarding the clinical usefulness and predictive accuracy of inflammation-based parameters, including C-reactive protein (CRP), lactate dehydrogenase (LDH), and lactate in septic patients are conflicting. In our study, we aimed to evaluate the relationships of the combination of these inflammatory parameters with albumin, disease severity and prognosis. Materials and methods: 98 patients diagnosed with sepsis were categorised as survivors (n=68) and nonsurvivors (n=30) according to their intensive care unit (ICU) mortality. Prognostic factors were evaluated with the receiver operating characteristic curve and Cox proportional hazard regression model. Survival was analyzed with the Kaplan-Meier method. Results: Compared to survivors, nonsurvivors had increased CRP and lactate (13.5 vs 10.0, p=0.044; 2.2 vs 1.7, p=0.006, respectively), while LDH and albumin levels were not significantly different (246.0 vs 245.0, p=0.624; 2.9 vs 3.0, p=0.061, respectively). When combined factors were evaluated, CRP/albumin and lactate/albumin were significantly higher in nonsurvivors (4.9 vs 3.0, p=0.018; 0.8 vs 0.5, p=0.001, respectively), while LDH/albumin was similar in both groups (93.1 vs 78.9, p=0.148). Lactate/albumin had the highest AUC of 0.709 (p=0.001), while CRP had the lowest AUC of 0.628 (p=0.044). In a multivariate analysis of possible predictors of ICU mortality, only lactate could be an independent predictor of poor outcome (HR:1.998; p=0.020), while other variables were not independently associated. Conclusion: Increased CRP, lactate, CRP/albumin and lactate/albumin levels in septic patients were associated with poor outcomes. Lactate level was an independent predictor of mortality.

Anahtar Kelimeler

• Albumin
• C-reactive protein
• lactate
• prognosis
• sepsis

Kaynakça

1. Harrison C. Sepsis: calming the cytokine storm. Nat Rev Drug Discov. 2010;9(5):360-361. doi:10.1038/nrd3162
2. Surbatovic M, Veljovic M, Jevdjic J, Popovic N, Djordjevic D, Radakovic S. Immunoinflammatory response in critically ill patients: severe sepsis and/or trauma. Mediators Inflamm. 2013;2013:362793. doi:10.1155/2013/362793
3. Pierrakos C, Velissaris D, Bisdorff M, Marshall JC, Vincent JL. Biomarkers of sepsis: time for a reappraisal. Crit Care. 2020;24(1):287. doi:10.1186/s13054-020-02993-5
4. Duman A, Akoz A, Kapci M, et al. Prognostic value of neglected biomarker in sepsis patients with the old and new criteria: predictive role of lactate dehydrogenase. Am J Emerg Med. 2016;34(11):2167-2171. doi:10.1016/j.ajem.2016.06.012
5. Mendoza D, Ascuntar J, Rosero O, Jaimes F. Improving the diagnosis and prognosis of sepsis according to the sources of infection. Emerg Med J. 2022;39(4):279-283. doi:10.1136/emermed-2021-211910
6. Bou Chebl R, Geha M, Assaf M, et al. The prognostic value of the lactate/albumin ratio for predicting mortality in septic patients presenting to the emergency department: a prospective study. Ann Med. 2021;53(1):2268-2277. doi:10.1080/07853890.2021.2009125
7. Dugar S, Choudhary C, Duggal A. Sepsis and septic shock: Guideline-based management. Cleve Clin J Med. 2020;87(1):53-64. doi:10.3949/ccjm.87a.18143
8. Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268-281. doi:10.1111/j.1469-0691.2011.03570.x

9. European Committee on Antimicrobial Susceptibility Testing (EUCAST). European Society of Clinical Microbiology and Infectious Diseases. Clinical Breakpoints 2023
10. DeLong ER, DeLong DM, Clarke Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837-845.
11. Ali SB, Cecchin A, Lucchesi C, et al. Can C-reactive protein be used as a surrogate marker of IL-6 in a broad array of clinical entities? Biomark Med. 2023;17(24):1001-1010. doi:10.2217/bmm-2023-0708
12. Yao Y, Hua Q, Liu S, Yang Z, Shen H, Gao W. Efficacy of multi-groove silicone drains in single-port video-assisted thoracoscopic lung cancer surgery and their effect on c-reactive protein: a single-center experience. J Thorac Dis. 2021;13(12):6885-6896. doi:10.21037/jtd-21-1801
13. Ye Z, Zou H, Liu S, et al. Diagnostic performance of neutrophil CD64 index in patients with sepsis in the intensive care unit. J Int Med Res. 2019;47(9):4304-4311. doi:10.1177/0300060519860677
14. Zhang Y, Feng Q, Zhou S, Chen H. Downregulation of serum survivin correlates with increased inflammation, enhanced disease severity and worse prognosis in sepsis patients. Medicine (Baltimore). 2020;99(28):e20272. doi:10.1097/MD.0000000000020272
15. Yin M, Si L, Qin W, et al. Predictive Value of Serum Albumin Level for the Prognosis of Severe Sepsis Without Exogenous Human Albumin Administration: A Prospective Cohort Study. J Intensive Care Med. 2018;33(12):687-694. doi:10.1177/0885066616685300
16. Artero A, Zaragoza R, Camarena JJ, Sancho S, González R, Nogueira JM. Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock. J Crit Care. 2010;25(2):276-281. doi:10.1016/j.jcrc.2009.12.004
17. Gharipour A, Razavi R, Gharipour M, Mukasa D. Lactate/albumin ratio: An early prognostic marker in critically ill patients. Am J Emerg Med. 2020;38(10):2088-2095. doi:10.1016/j.ajem.2020.06.067
18. Basile Filho A, Lago AF, Menegueti MG, et al. The use of APACHE II, SOFA, SAPS 3, C-reactive protein/albumin ratio, and lactate to predict mortality of surgical critically ill patients: A retrospective cohort study. Medicine (Baltimore). 2019;98(29):e16675. doi: 10.1097/MD.0000000000016675].
19. Ranzani OT, Zampieri FG, Forte DN, Azevedo LC, Park M. C-reactive protein/albumin ratio predicts 90-day mortality of septic patients. PLoS One. 2013;8(3):e59321. doi:10.1371/journal.pone.0059321
20. Winters BD, Eberlein M, Leung J, Needham DM, Pronovost PJ, Sevransky JE. Long-term mortality and quality of life in sepsis: a systematic review. Crit Care Med. 2010;38(5):1276-1283. doi:10.1097/CCM.0b013e3181d8cc1d
21. Araújo I, Gonçalves-Pereira J, Teixeira S, et al. Assessment of risk factors for in-hospital mortality after intensive care unit discharge. Biomarkers. 2012;17(2):180-185. doi:10.3109/1354750X.2012.654407
22. Erez A, Shental O, Tchebiner JZ, et al. Diagnostic and prognostic value of very high serum lactate dehydrogenase in admitted medical patients. Isr Med Assoc J. 2014;16(7):439-443.
23. Miglietta F, Faneschi ML, Lobreglio G, et al. Procalcitonin, C-reactive protein and serum lactate dehydrogenase in the diagnosis of bacterial sepsis, SIRS and systemic candidiasis. Infez Med. 2015;23(3):230-237.
24. Gibot S. On the origins of lactate during sepsis. Crit Care. 2012;16(5):151. doi:10.1186/cc11472
25. Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3(1):12. doi:10.1186/2110-5820-3-12
26. Kushimoto S, Akaishi S, Sato T, et al. Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients. Acute Med Surg. 2016;3(4):293-297. doi:10.1002/ams2.207
27. Haas SA, Lange T, Saugel B, et al. Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients. Intensive Care Med. 2016;42(2):202-210. doi:10.1007/s00134-015-4127-0
28. Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2009;37(5):1670-1677. doi:10.1097/CCM.0b013e31819fcf68
29. Wang B, Chen G, Cao Y, Xue J, Li J, Wu Y. Correlation of lactate/albumin ratio level to organ failure and mortality in severe sepsis and septic shock. J Crit Care. 2015;30(2):271-275. doi:10.1016/j.jcrc.2014.10.030
30. Lichtenauer M, Wernly B, Ohnewein B, et al. The Lactate/Albumin Ratio: A Valuable Tool for Risk Stratification in Septic Patients Admitted to ICU. Int J Mol Sci. 2017;18(9):1893. doi:10.3390/ijms18091893
31. Arina P, Singer M. Pathophysiology of sepsis. Curr Opin Anaesthesiol. 2021;34(2):77-84. doi:10.1097/ACO.0000000000000963