Tanta Medical Journal

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 44  |  Issue : 4  |  Page : 135--140

Receptor for advanced glycation endproducts in pediatric sepsis: A pilot study


Ahmed A Abo-Elezz1, Samir M Hasan1, Shimaa A Mashaly1, Mohamed A Saad2, Maaly M Mabrouk2,  
1 Department of Pediatric, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt

Correspondence Address:
Ahmed A Abo-Elezz
Pediatric Intensive Care Unit, Pediatric Department, Faculty of Medicine, Tanta University, Tanta 31512
Egypt

Abstract

Background Sepsis in pediatric patients is still a leading cause of morbidity and mortality. Aim The aim of the study was to determine whether the serum level of receptor for advanced glycation endproducts (RAGEs) can be used as a potential diagnostic and prognostic marker in septic children. Patients and methods A pilot study was conducted on pediatric intensive care unit patients who had clinical evidence of sepsis over a 1-year period. Forty patients were enrolled in the study within the first 24 h after onset of sepsis; they were classified according to 28-day mortality into survivors and nonsurvivors. Complete blood count, erythrocyte sedimentation rate, C-reactive protein, and soluble form of RAGE (sRAGE) were measured. Bacterial cultures from suitable body fluids were prepared. Results There was a significantly higher mean serum sRAGE level among septic patients compared with controls (P=0.001); the level was higher in nonsurvivors compared with survivors (P=0.001). A cutoff value of 1325 pg/ml for serum sRAGE showed a sensitivity of 89.2% and a specificity of 78.3%. There were positive correlations with C-reactive protein and Pediatric Risk of Mortality III, and no correlation with bacterial culture. Multivariate logistic regression analysis showed that sRAGE level and leukocytic count were significant markers in the diagnosis of sepsis (P=0.047 and 0.001, respectively). sRAGE level and Pediatric Risk of Mortality III score were significant parameters in sepsis prognosis (P=0.019 and 0.043, respectively). Conclusion Serum sRAGE can be used as a diagnostic and prognostic marker in pediatric sepsis, especially in those with a negative blood culture.



How to cite this article:
Abo-Elezz AA, Hasan SM, Mashaly SA, Saad MA, Mabrouk MM. Receptor for advanced glycation endproducts in pediatric sepsis: A pilot study.Tanta Med J 2016;44:135-140


How to cite this URL:
Abo-Elezz AA, Hasan SM, Mashaly SA, Saad MA, Mabrouk MM. Receptor for advanced glycation endproducts in pediatric sepsis: A pilot study. Tanta Med J [serial online] 2016 [cited 2017 Dec 12 ];44:135-140
Available from: http://www.tdj.eg.net/text.asp?2016/44/4/135/201722


Full Text

 Introduction



Sepsis is a serious medical condition that presents a management challenge to those who care for infants and children [1].

Clinical experience and various studies have shown that the most important measure for reducing mortality from sepsis is early diagnosis and initiation of therapy. Diagnosis of sepsis in children is difficult as the clinical signs in children vary at the start of the infection; microbiological culture results are expected only after 48–72 h, and false negatives are common [2].

The receptor for advanced glycation endproducts (RAGE), a member of the immunoglobulin superfamily of cell surface molecules, is expressed by endothelial cells, smooth muscle cells, monocytes, and lymphocytes [3].

A soluble form of RAGE (sRAGE) also exists and consists of both shed membrane-bound RAGE ectodomain and released endogenous secretory RAGE [4]. RAGE initiates inflammatory signaling, which stimulates proinflammatory mechanisms. Previous experimental studies with different RAGE inhibitors proposed that blocking the RAGE receptor decreases many proinflammatory mediators associated with sepsis pathogenesis [5],[6],[7],[8].

Many researchers evaluated the relationship between different inflammatory markers and pediatric sepsis; however, the relation between RAGE and sepsis has not been studied in children.

 Patients and methods



The study was approved by the Ethics Committee of the Faculty of Medicine, Tanta University, and conducted in accordance with the Helsinki Declaration. Written informed consent was obtained from each child’s guardian before any study procedure, with assurance of patient privacy.

This study was conducted on 60 infants and children: 40 of them were critically ill patients fulfilling the criteria for sepsis according to International Pediatric Sepsis Consensus Conference criteria [9] who were admitted to the Pediatric Intensive Care Unit (PICU), Children Hospital, Tanta University, which is a 10-bed PICU with an annual admission rate of about 700 cases per year. The study was conducted over a period of 12 months, from May 2012 to April 2013.

The mean age of the patients was 13.05±7.68 months, ranging from 6 to 30 months. Twenty-four (60%) of them were male.

The children with primary inflammatory kidney disease, rheumatoid arthritis, diabetes mellitus, or chronic renal failure were excluded from the study. Pediatric Risk of Mortality III (PRISM III) [10] was evaluated in the first 24 h.

Septic patients were classified into survivors and nonsurvivors according to 28-day survival. The enrolled septic patients who died from any cause within the follow-up time were considered nonsurvivors.

Twenty healthy infants and children of matched age and sex served as controls. Their ages ranged from 3 to 24 months (range: 10.4±6.36 months). Ten (50%) of them were male.

Data collection

Patient data including name, age, sex, past medical history, and vital signs were recorded at enrollment. Local examination included the whole body to determine the primary site of infection.

Laboratory examinations, including complete blood count, blood gas analysis, erythrocyte sedimentation rate, blood biochemistry, cultures from suitable body fluids, and radiographic scans, were carried out within 24 h.

C-reactive protein (CRP) was measured with the CRP Human SimpleStep ELISA Kit (Abcam 181416; Abcam, UK).

RAGE was measured once the diagnosis of sepsis was suspected clinically, usually within 24 h after admission into the PICU. It was measured in the serum using enzyme immunoassay supplied by RayBio Human RAGE ELISA (catalog #ELH-RAGE, Norcross, USA) (intra-assay CV%: <10% and interassay CV%: <12%).

Statistical analysis

The relation between different values of RAGE and various sepsis parameters was determined and statistically analyzed. Numerical variables were presented as mean and SD; categorical variables were described as numbers and percentages. Comparisons of continuous variables were made using the unpaired Student t-test. Correlations of RAGE with various sepsis parameters were examined with Pearson’s correlation analysis. Significance was defined as a P-value less than 0.05. Analyses were carried out using the SPSS program (version 17; SPSS Inc., Chicago, Illinois, USA), and GraphPad Prism software (GraphPad Prism Software Inc., San Diego, California, USA).

 Results



The vital signs and laboratory data of cases and controls are listed in [Table 1].{Table 1}

There was a statistically significantly higher mean sRAGE in cases than in controls.

The original medical diagnoses of the patients were as follows: 28 (70%) patients had pneumonia; six (15%) patients had gastroenteritis; four (10%) patients had meningitis; and two (5%) patients had urinary tract infection. The culture was positive in 16 (40%) cases. The distribution of organisms was as follows: Klebsiella spp. was the most frequently detected organism at 43.8%, followed by Pseudomonas spp. at 31.3%, Escherichia coli at 18.6%, and Gram-positive cocci at 6.3%.

Mortality rates were 60% (24/40) after 28 days. The vital signs and laboratory data on survivors and nonsurvivors are listed in [Table 2].{Table 2}

Platelet counts were significantly lower in nonsurvivors than in survivors. There was a statistically significantly higher mean serum sRAGE among nonsurvivors when compared with survivors (P=0.001).

The bacterial growth in cultures increased among nonsurvivors when compared with survivors. The culture was positive in six (37.5%) survivors and 10 (41.7%) nonsurvivors; however, it did not reach a significance level (P=0.07), and there was no correlation with serum sRAGE (r=0.023, P=0.886).

A weak positive correlation between serum sRAGE and CRP (r=0.455, P<0.003) ([Figure 1]) and a strong positive correlation between serum sRAGE and PRISM III were observed (r=0.831, P<0.001) ([Figure 2]).{Figure 1}{Figure 2}

A cutoff of 1325 pg/ml for serum sRAGE showed a sensitivity of 89.2%, specificity of 78.3%, positive predictive value of 84.1%, negative predictive value of 83.9%, and accuracy of 86.7% ([Figure 3]).{Figure 3}

Multivariate logistic regression analysis showed that sRAGE level and leukocytic count were significant markers in sepsis diagnosis (P=0.047 and 0.001, respectively) ([Table 3]). sRAGE level and PRISM III score were significant parameters in sepsis prognosis (P=0.019 and 0.043, respectively) ([Table 4]).{Table 3}{Table 4}

 Discussion



Despite the progress made in antimicrobial treatment and intensive care medicine, the incidence of sepsis remains high, and severe sepsis still carries high mortality [11].

Sepsis is a systemic response to infection with bacteria, fungi, viruses, protozoa, etc. It is therefore one of the causes of systemic inflammatory response syndrome, which may manifest as hyperthermia, hypothermia, tachypnea, tachycardia, and increased or decreased white blood cell count. Sepsis can progress to severe sepsis, septic shock, and multiple organ dysfunction syndrome [12].

Early detection of sepsis is still the most important factor in the prognosis of these patients. One of the emerging factors that can contribute to the diagnosis of sepsis is RAGE.

To our knowledge, this is the first study to evaluate the diagnostic and prognostic values of RAGE in pediatric sepsis worldwide.

Our cohort included 40 children who were admitted with different infections that were progressing to sepsis. Our patients were classified according to 28-day mortality into survivors (n=16) and nonsurvivors (n=24). Pneumonia was the most common diagnosis at admission. Nikolaou et al. [13] found pneumonia to be the most common infection progressing to sepsis in their study. Ozdemir et al. [14] found ventilation-associated pneumonia to be the most common cause of sepsis, followed by catheter-associated infection. These results imply that patients admitted with pneumonia should be carefully evaluated for early detection of sepsis.

In our study, we found serum sRAGE to be significantly higher in septic patients compared with controls when measured within 24 h after the onset of sepsis, reflecting the diagnostic value of sRAGE.

These results were similar to those of Bopp et al. [15], whose observational pilot study included 28 adult septic patients. A cutoff value of 1569 pg/ml showed a specificity of 75% and sensitivity of 84.6%, whereas in our study the cutoff value was 1325 pg/ml, with specificity of 78.3% and sensitivity of 89.2%, respectively.

Hudson et al. [16] also found that sRAGE levels may denote an early marker of sepsis, which may indicate the acute inflammatory state as splice variants of RAGE.

Another similar study by Matsumoto et al. [17] demonstrated that the serum level of sRAGE increased in adult septic patients compared with that in nonseptic healthy volunteers.

The increased measured serum sRAGE indicates RAGE signaling pathway activity, which stimulates the extreme inflammatory response implicated in endothelial injury, and its measurement may be useful as a biomarker of sepsis.

Serum sRAGE also had good prognostic value, as we found serum sRAGE levels to be statistically significantly higher among nonsurvivors when compared with survivors. This was in agreement with the study by Bopp et al. [15], who found sRAGE concentrations of nonsurvivors (n=16) to be significantly higher than levels in survivors (n=13) (2302±189 vs. 1326±112 pg/ml, respectively; P<0.001). The difference in cutoff level and mean serum sRAGE levels between our study and that of Bopp et al. [15] may be attributed to the smaller number of patients in their study and the difference in ethnic groups and in the diagnoses of patients; however, still in agreement with our study was the fact that sRAGE levels were significantly higher in nonsurvivors compared with that in survivors.

Brodska et al. [18] in their study on 54 adult septic patients assessed plasma levels of sRAGE on days 1 and 3. On day 1, nonsurvivors showed increased sRAGE levels compared with survivors. On day 3, the association of increased sRAGE levels in nonsurvivors was even stronger when compared with that in survivors (P=0.0004).

Narvaez-Rivera et al. [19] found an association between elevated sRAGE and fatal outcome in their study on 30 community-acquired pneumonia adult patients.

We observed no statistically significant correlation between mean serum RAGE levels and positive culture.

These data were similar to that reported by Rogers et al. [20], who found no correlation between sRAGE levels and culture positivity.

In our study there was a positive correlation between mean serum sRAGE level and CRP. It agreed with the study of Brodska et al. [18], who reported that sRAGE showed a significant positive correlation with CRP.

We observed a significant positive correlation between mean serum RAGE levels and PRISM III (P<0.001).

Hamasaki et al. [21] reported no changes in sRAGE levels among patients with different degrees of sepsis; however, the septic shock group showed increased level compared with the other groups. A positive correlation with all the inflammatory mediators was reported in the septic shock group. Furthermore, the increased levels are associated with worse outcomes in patients with septic shock; similarly, reduced sRAGE levels are also associated with increased mortality. The correlation analysis suggested that the pathways leading to death that are associated with increased or decreased sRAGE plasma levels are different. They recommended future studies to explain the pathophysiological mechanisms triggered by sRAGE in septic models for the safe handling of this biomarker.

As regards the prognostic significance of receptor for advanced glycation end products (RAGE) , it may be involved in diverse cellular mechanisms that to a lesser or greater degree contribute to the septic process, modifying its function could favorably affect outcome. Activation RAGE may lead to regulating proinflammatory cytokine release or controlling apoptosis.

It is obvious from multivariate logistic regression analysis of the diagnostic power of different sepsis markers that sRAGE level and leukocytic count were the only significant parameters in the diagnosis of sepsis, and sRAGE level and PRISM III score were the only significant parameters in the prognosis of sepsis.

 Conclusion



From our study we can conclude that measurement of sRAGE in pediatric patients with suspected sepsis can be used as an early diagnostic marker and has a prognostic value with high sensitivity and specificity.

We recommend more research on a larger scale on pediatric patients to confirm the results of our study and clarify the functional role of sRAGE in sepsis and its putative role as a new sepsis marker.

Acknowledgements

The authors thank the staff members of the Pediatric Intensive Care Unit, Clinical Pathology Department, for their help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Larosa SP. Sepsis: menu of new approaches replaces one therapy for all. Cleve Clin J Med 2002; 69:65–73.
2Randolph AG. The purpose of the 1st international sepsis forum on sepsis in infants and children. Pediatr Crit Care Med 2005; 6(Suppl):S1–S2.
3Raucci A, Cugusi S, Antonelli A, Barabino SM, Monti L, Bierhaus A et al. A soluble form of the receptor for advanced glycation end products (RAGE) is produced by proteolytic cleavage of the membrane-bound form by the sheddase a disintegrin and metalloprotease 10 (ADAM10). FASEB J 2008; 22:3716–3727.
4Yamagishi S, Matsui T. Soluble form of a receptor for advanced glycation end products (sRAGE) as a biomarker. Front Biosci (Elite Ed) 2010; 2: 1184–1195.
5Van Zoelen MA, van der Poll T. Targeting RAGE in sepsis. Crit Care 2008; 12:103.
6Bopp C, Bierhaus A, Hofer S, Bouchon A, Nawroth PP, Martin E, Weigand MA. Bench-to-bedside review: the inflammation-perpetuating pattern-recognition receptor RAGE as a therapeutic target in sepsis. Crit Care 2008; 12:201.
7Bierhaus A, Stern DM, Nawroth PP. RAGE in inflammation: a new therapeutic target? Curr Opin Invest Drugs 2006; 7:985–991.
8Liliensiek B, Weigand MA, Bierhaus A, Nicklas W, Kasper M, Hofer S et al. Receptor for advanced glycation end products (RAGE) regulates sepsis but not the adaptive immune response. J Clin Invest 2004; 113:1641–1650.
9Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2–8.
10Pollack MM, Patel KM, Ruttiman UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24:743–752.
11Raghavan M, Marik PE. Management of sepsis during the early ‘golden hours’. J Emerg Med 2006; 31:185–199.
12Nwadioha I, Nwokedi EOP, Kashibu E, Odimayo MS, Okwori EE. A review of bacterial isolates in blood cultures of children with suspected septicaemia in a Nigerian tertiary Hospital. African J Microbiol Res 2010; 4:222–225.
13Nikolaou NI, Goritsas C, Dede M, Paissios NP, Papavasileiou M, Rombola AT, Ferti A. Brain natriuretic peptide increases in septic patients without severe sepsis or shock. Eur J Intern Med 2007; 18:535–541.
14Ozdemir H, Kendirli T, Ergün H, Ciftçi E, Tapisiz A, Güriz H et al. Nosocomial infections due to Acinetobacter baumannii in a pediatric intensive care unit in Turkey. Turk J Pediatr 2011; 53:255–260.
15Bopp C, Hofer S, Weitz J, Bierhaus A, Nawroth PP, Martin E et al. sRAGE is elevated in septic patients and associated with patients outcome. J Surg Res 2008; 147:79–83.
16Hudson BI, Harja E, Moser B, Schmidt AM. Soluble levels of receptor for advanced glycation endproducts (sRAGE) and coronary artery disease: the next C-reactive protein? Arterioscler Thromb Vasc Biol 2005; 25:879–882.
17Matsumoto H, Matsumoto N, Ogura H, Shimazaki J, Yamakawa K, Yamamoto K, Shimazu T. The clinical significance of circulating soluble RAGE in patients with severe sepsis. J Trauma Acute Care Surg 2015; 78:1086–1094.
18Brodska H, Malickova K, Valenta J, Fabio A, Drabek T. Soluble receptor for advanced glycation end products predicts 28-day mortality in critically ill patients with sepsis. Scand J Clin Lab Invest 2013; 73:650–660.
19Narvaez-Rivera RM, Rendon A, Salinas-Carmona MC, Rosas-Taraco AG. Soluble RAGE as a severity marker in community acquired pneumonia associated sepsis. BMC Infect Dis 2012; 12:15.
20Rogers LK, Graf AE, Bhatia A, Leonhart KL, Oza-Frank R. Associations between maternal and infant morbidities and sRAGE within the first week of life in extremely preterm infants. PLoS One 2013; 8:e82537.
21Hamasaki MY, Barbeiro HV, de Souza HP, Machado MC, da Silva FP. sRAGE in septic shock: a potential biomarker of mortality. Rev Bras Ter Intensiva 2014; 26:392–396.