Sepsis Induced Red Cell Dysfunction (SiRD): Physiology and Mechanisms

Parenteral glutamine supplementation in combination with enteral nutrition improves intestinal immunity in septic rats

Background:Due to the floating of the guideline, there is no evidence-based evaluation index on when to start the blood transfusion for patients with hemoglobin (Hb) level between 7 and 10 g/dl. As a result, the trigger point of blood transfusion may be different in the emergency use of the existing transfusion guidelines. The present study was designed to evaluate whether the scheme can be safely and effectively used for emergency patients, so as to be supported by multicenter and large sample data in the future.Methods:From June 2013 to June 2014, patients were randomly divided into the experimental group (Peri-operative Transfusion Trigger Score of Emergency [POTTS-E] group) and the control group (control group). The between-group differences in the patients’ demography and baseline information, mortality and blood transfusion-related complications, heart rate, resting arterial pressure, body temperature, and Hb values were compared. The consistency of red blood cell (RBC) transfusion standards of the two groups of patients with the current blood transfusion guideline, namely the compliance of the guidelines, utilization rate, and per-capita consumption of autologous RBC were analyzed.Results:During the study period, a total of 72 patients were recorded, and 65 of them met the inclusion criteria, which included 33 males and 32 females with a mean age of (34.8 ± 14.6) years. 50 underwent abdomen surgery, 4 underwent chest surgery, 11 underwent arms and legs surgery. There was no statistical difference between the two groups for demography and baseline information. There was also no statistical differences between the two groups in anesthesia time, intraoperative rehydration, staying time in postanesthetic care unit, emergency hospitalization, postoperative 72 h Acute Physiologic Assessment and Chronic Health Evaluation II scores, blood transfusion-related complications and mortality. Only the POTTS-E group on the 1st postoperative day Hb was lower than group control, P < 0.05. POTTS-E group was totally (100%) conformed to the requirements of the transfusion guideline to RBC infusion, which was higher than that of the control group (81.25%), P < 0.01. There were no statistical differences in utilization rates of autologous blood of the two groups; the utilization rates of allogeneic RBC, total allogeneic RBC and total RBC were 48.48%, 51.5%, and 75.7% in POTTS-E group, which were lower than those of the control group (84.3%, 84.3%, and 96.8%) P < 0.05 or P < 0.01. Per capita consumption of intraoperative allogeneic RBC, total allogeneic RBC and total RBC were 0 (0, 3.0), 2.0 (0, 4.0), and 3.1 (0.81, 6.0) in POTTS-E groups were all lower than those of control group (4.0 [2.0, 4.0], 4.0 [2.0, 6.0] and 5.8 [2.7, 8.2]), P < 0.05 or P < 0.001.Conclusions:Peri-operative Transfusion Trigger Score-E evaluation scheme is used to guide the application of RBC. There are no differences in the recent prognosis of patients with the traditional transfusion guidelines. This scheme is safe; Compared with doctor experience-based subjective assessment, the scoring scheme was closer to patient physiological needs for transfusion and more reasonable; Utilization rate and the per capita consumption of RBC are obviously declined, which has clinical significance and is feasible. Based on the abovementioned three points, POTTS-E scores scheme is safe, reasonable, and practicable and has the value for carrying out multicenter and large sample clinical researches.

A New Tool for HbF Quantification Demonstrates That Hydroxyurea Decreases Mostly RBCs Containing Very Low Amounts of HbF

Trial in Progress: A Phase 2, Open-Label Study Evaluating the Safety and Efficacy of the PKR Activator Etavopivat (FT-4202) in Patients with Thalassemia or Sickle Cell Disease

Venetoclax, FLT3 Inhibitor and Decitabine in FLT3mut Acute Myeloid Leukemia: Subgroup Analysis of a Phase II Trial

The role of signal transducer and activator of transduction (STAT) 4 vs. 6 has been assessed thus far only in a model of high mortality strongly driven by proinflammation alone. Their role in a low-mortality (LD25) model of sepsis remains unclear. Prospective controlled animal study in a research laboratory. STAT4 and STAT6 knockout mice. We induced sepsis by cecal ligation and puncture (CLP) or sham CLP in three groups of mice: (a) STAT4-/-, (b) STAT6-/-, (c) BALB/c. Splenic T cells or macrophages were then harvested 24 h after CLP, and their ability to produce cytokines was assessed. Following CLP T-cells from BALB/c mice were suppressed in the ability to release the Th1 cytokines interleukin (IL) 2 and interferon gamma. The release of Th2 cytokine IL-10 was increased. The Th1 response of STAT4-deficient animals was not only markedly lower in shams but was further suppressed by CLP. The Th2 cytokine response was elevated even more than that of the septic BALB/c. This was associated with lower survival than in the BALB/c. STAT6 deficiency resulted in a stronger Th1 response and a suppressed Th2 response to CLP. A similar difference between IL-12 and IL-10 release was seen in macrophages from these mice. Interestingly, while this resulted in improved survival, compared to STAT4-/- mice, the STAT6-/- animals still had a higher mortality than the BALB/c. These data suggest that contributions from both STAT4 driven processes as well as STAT6 responses are needed in a balanced fashion to maximize the animals' ability to survive septic challenge.

To investigate the role of Nrf2 on hydrogen treatment for intestinal injury caused by severe sepsis. 152 male ICR mice were randomly divided into four groups: sham operation group, hydrogen control group, sepsis group, and hydrogen treatment group, each n=38. Sepsis model was reproduced by cecal ligation and puncture (CLP). The mice in sham operation group and hydrogen control group did not receive CLP, and the operative procedure was the same as follows. The mice in hydrogen control group and hydrogen treatment group received 1-hour inhalation of 2% hydrogen 1 hour and 6 hours after sham operation or CLP. Twenty animals in each group were selected and observed for 7-day survival rate.Eighteen animals in each group were selected and sacrificed at 6, 12 and 24 hours after CLP. The intestinal tissues were obtained to determine the expression of Nrf2 and high mobility group B1 (HMGB1) protein by Western Blot, and the expression of Nrf2 mRNA by reverse transcription-polymerase chain reaction (RT-PCR). The middle portion of jejunum was obtained to evaluate the degree of septic injury by light microscope after hematoxylin and eosin (HE) staining. There was no statistical significance in variables between sham operation group and hydrogen control group. Compared with sham operation group, the 7-day survival rate was significantly decreased in sepsis group (0 vs. 100%, P<0.05); compared with sepsis group, the 7-day survival rate was significantly increased in hydrogen treatment group (55% vs. 0, P<0.05). Compared with sham operation group, the expression of Nrf2 protein (gray value) and Nrf2 mRNA were up-regulated in sepsis group at 6, 12 and 24 hours after CLP (Nrf2 protein 6 hours: 1.973 ± 0.350 vs. 1.000 ± 0.000, t=4.411, P=0.002; 12 hours: 2.367 ± 0.186 vs. 1.000 ± 0.000, t=10.210, P=0.000; 24 hours: 2.517 ± 0.280 vs. 1.000 ± 0.000, t=9.521, P=0.000; Nrf2 mRNA 6 hours: 1.606 ± 0.271 vs. 1.000 ± 0.000, t=3.631, P=0.002; 12 hours: 1.692 ± 0.399 vs. 1.000 ± 0.000, t=3.233, P=0.005; 24 hours: 1.784 ± 0.341 vs. 1.000 ± 0.000, t=3.894, P=0.001), and it was also the expression of HMGB1 (gray value) at 24 hours after CLP operation (1.507 ± 0.220 vs. 1.000 ± 0.000, t=3.948, P=0.004). Compared with sepsis group, the expression of Nrf2 protein and Nrf2 mRNA in intestines were up-regulated at 6, 12 and 24 hours after CLP in hydrogen treatment group (Nrf2 protein 6 hours: 2.583 ± 0.395 vs. 1.973±0.350, t=2.765, P=0.024; 12 hours: 2.725 ± 0.235 vs. 2.367 ± 0.186, t=2.674, P=0.028; 24 hours: 2.930 ± 0.212 vs. 2.517 ± 0.280, t=2.595, P=0.032; Nrf2 mRNA 6 hours: 2.008 ± 0.400 vs. 1.606±0.271, t= 2.405, P=0.029; 12 hours: 2.188 ± 0.475 vs. 1.692 ± 0.399, t= 2.317, P=0.034; 24 hours: 2.333 ± 0.406 vs. 1.784 ± 0.341, t= 2.728, P=0.015). Compared with sepsis group, the expression of HMGB1 was down-regulated significantly at 24 hours after CLP in hydrogen treatment group (1.147 ± 0.152 vs. 1.507 ± 0.220, t=2.805, P=0.023). HE staining showed that there was significantly aggravated intestinal pathological injury in the mice of sepsis group; compared with sepsis group, the pathology was significantly less marked in hydrogen treatment group. Through activation of Nrf2-antioxidant response element (ARE) pathway, hydrogen may increase the level of Nrf2, which is a kind of protective protein, in the intestine of mice, thus decreases the level of late pro-inflammatory factor, HMGB1, and it may protect the intestinal tissues in septic mice and increase the survival rate significantly.

In patients with advanced CKD the lifespan of red blood cells (RBCs) is often shortened, a condition attributed to the 'uremic milieu.' We reported recently that the uremic solute 3-carboxy-4-methyl-5-propyl-2-furanpropionate (CMPF) shares structural similarities with Jedi1, a chemical activator of the mechanosensitive cation channel PIEZO1, whose activation increases calcium influx into cells. Against this backdrop, we hypothesized that CMPF may induce premature RBC death (eryptosis) through prolonged CMPF-induced activation of PIEZO1 located on RBCs. To test this hypothesis, we explored if CMPF, at concentrations found in uremia, interacts with PIEZO1 located on RBCs, increases intracellular calcium (icCa2+), and induces eryptosis. RBCs from healthy individuals were incubated with CMPF or Jedi1 (both at a concentration of 87µM), in the presence or absence of the PIEZO1 inhibitor GsMTx-4 (2µM). We challenged RBCs osmotically through incubation in solutions of NaCl at concentrations between 3.0 and 9.0g/L and determined their osmotic fragility. Using flow cytometry, we quantified in incubated RBCs icCa2+ levels and phosphatidylserine exposure, a cellular marker of eryptosis. Incubation of RBCs with CMPF and Jedi1 significantly increased RBC osmotic fragility, an effect prevented by GsMTx-4. At 6.0g/L NaCl, incubation with CMPF and Jedi1 increased exposure of phosphatidylserine and elevated icCa2+ levels of RBCs, indicating increased eryptosis. Notably, at an isotonic NaCl concentration of 9.0g/L, CMPF-but not Jedi1-significantly increased RBC phosphatidylserine exposure and icCa2+ levels; both effects were diminished by GsMTx-4. Our findings support the hypothesis that CMPF may function as an endogenous activator of PIEZO1, increase icCa2+ levels, trigger eryptosis, and, through this pathway, possibly shorten the RBC lifespan. To what extent these in vitro findings are operative in advanced CKD warrants clinical studies.

Prognostic Value of Measurable Residual Disease after Venetoclax and Decitabine in Acute Myeloid Leukemia

To explore the mechanism of complement 5a (C5a) in the pathogenesis of sepsis. SPF male C57BL/6J mice were selected and divided into sham operation group (Sham group), cecal ligation and puncture (CLP) group and CLP+anti-C5A monoclonal antibody intervention group (CLP+anti-C5a group) according to random number table with 20 mice in each group. A CLP model was reproduced to induce sepsis, and those in the Sham group only underwent laparotomy without ligation and perforation. In the CLP+anti-C5a group, 0.15 mg of anti-C5a monoclonal antibody was injected intraperitoneally immediately after CLP, and in the Sham group and CLP group were given equal amount of normal saline. The cumulative survival rate was analyzed by Kaplan-Meier method. Serum levels of tumor necrosis factor-α (TNF-α), interleukins (IL-12, IL-4), and interferon-γ (IFN-γ) were measured 24, 48 and 72 hours after operation by enzyme linked immunosorbent assay (ELISA). Immunohistochemical staining was used to observe the expression of C5a receptor (C5aR) in lung and kidney tissues 48 hours after operation. The proportions of dendritic cell (DC), regulatory T cell (Treg) and helper T cell 17 (Th17) in splenic mononuclear cells 48 hours after operation were analyzed by flow cytometry. The 7-day cumulative survival rate of mice in the CLP group was significantly lower than that in the Sham group (30.00% vs. 100.00%; Log-Rank test: χ2 = 47.470, P < 0.001), and the peripheral blood inflammatory mediators TNF-α, IL-12 and IL-4 were increased 24 hours after operation, followed by a significant decreasing at 48 hours, and then gradually increased at 72 hours. IFN-γ gradually increased 24 hours after operation and lasted for 72 hours. Immunohistochemistry showed that a large number of C5aR was expressed in pulmonary and renal endothelial cells 48 hours after operation in the CLP group. Compared with the Sham group, the proportion of DC [(1.80±0.30)% vs. (6.90±1.20)%, P < 0.05] and Treg [(0.38±0.02)% vs. (4.00±0.50)%, P < 0.05] in splenic mononuclear cells was down-regulated in the CLP group, the proportion of Th17 was up-regulated [(0.83±0.08)% vs. (0.32±0.03)%, P < 0.05], and disorder of immune function was found. After anti-C5A monoclonal antibody intervention, the 7-day cumulative survival rate increased significantly compared with the CLP group (54.54% vs. 30.00%; Log-Rank test: χ2 = 28.090, P < 0.001); TNF-α, IL-12 and IFN-γ were further increased, while IL-4 was significantly decreased; the expression of C5aR in lung and kidney tissues were significantly decreased, and the expression of mature DC cells [(5.10±1.20)% vs. (1.80±0.30)%, P < 0.05] and Treg [(2.58±0.05)% vs. (0.38±0.02)%, P < 0.05] in spleen were significantly increased compared with the CLP group, and Th17 was significantly decreased [(0.54±0.05)% vs. (0.83±0.08)%, P < 0.05]. It is preliminarily concluded that anti-C5A monoclonal antibody may improve the prognosis of sepsis by improving the polarization of mature DC and T cells in the spleen, and C5a plays an important role in the immune regulation of sepsis cells.

Sepsis predisposes the host to a number of infectious sequelae, particularly the development of nosocomial pneumonia. Mechanisms by which sepsis results in impairment of lung antibacterial host defense have not been well defined. Alveolar macrophages (AM) represent important immune effector cells of the lung airspace. In this study, we examined the effects of cecal ligation and puncture (CLP) on murine AM function ex vivo, including the expression of proinflammatory cytokines and AM phagocytic activity. AM were harvested from mice subjected to a sham operation and CLP 24 h after laparotomy, adherence purified, and challenged with lipopolysaccharide (LPS) or left unstimulated. Both unstimulated and LPS-stimulated AM from mice subjected to CLP (CLP mice) produced significantly smaller amounts of proinflammatory cytokines tumor necrosis factor alpha and interleukin (IL-12) and C-X-C chemokines KC and macrophage inflammatory protein 2 than similarly treated AM from animals subjected to a sham operation. Furthermore, AM isolated from CLP mice displayed a marked impairment in phagocytic activity, as determined by flow cytometry, with this defect persisting to 48 h post-CLP. Induction of peritoneal sepsis syndrome resulted in a time-dependent increase in IL-10 in plasma and peritoneal fluid. Interestingly, the impairment in AM proinflammatory-cytokine production and phagocytic activity observed in AM from CLP mice was partially reversed by the in vivo neutralization of IL-10 prior to AM harvest. These observations suggest that abdominal sepsis syndrome results in significant impairment in AM effector cell function, which is mediated, in part, by sepsis-induced expression of IL-10.

Results of a Clinical Trial of H3B-8800, a Splicing Modulator, in Patients with Myelodysplastic Syndromes (MDS), Acute Myeloid Leukemia (AML) or Chronic Myelomonocytic Leukemia (CMML)

This paper describes relationships between osmotic fragility (OF) of red blood cells and various hematologic data in 32 male workers exposed to lead and 30 controls. The examination included measurements of OF determined by the coil planet centrifuge system, red blood cell (RBC) count, hematocrit, hemoglobin, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), water of RBC, sodium and potassium of RBC, blood and urine lead, urine coproporphyrin, and urine delta-aminolevulinic acid. The results were: 1) OF was lower in lead workers at all three hemolytic points compared with the controls (P less than 0.05). 2) A difference in hemolysis pattern between the two groups was observed (P less than 0.05). 3) A close relationship was observed in both groups between OF and MCV (P less than 0.05), although the results were contrasting. Also a close relationship was observed in lead workers between OF and hematocrit, OF and hemoglobin, OF and MCH, and OF and intracellular potassium (P less than 0.05) but not in the controls. In the controls a close relationship was found between OF and RBC (P less than 0.05) but this was not observed in the lead workers. No significant relationship was observed in either group between OF and MCHC, OF and intracellular sodium, and OF and intracellular water. 4) No difference in RBC, hematocrit, hemoglobin, MCV, MCH, MCHC, and intracellular water, sodium and potassium was observed between both groups.

Oral Administration of FT-4202, an Allosteric Activator of Pyruvate Kinase-R, Has Potent Anti-Sickling Effects in a Sickle Cell Anemia (SCA) Mouse Model, Resulting in Improved RBC Survival and Hemoglobin Levels

Healthcare Resource Utilization (HCRU) in Patients (pts) with Newly Diagnosed (ND) Acute Myeloid Leukemia (AML) Treated in the Connect® MDS/AML Disease Registry