The aim of the present study was to investigate the increase in serum and urine levels of high mobility group box protein 1 (HMGB1) during sepsis and the effect of blood purification treatments on HMGB1 levels and patient prognosis. A total of 40 intensive care patients with sepsis were randomly assigned to different groups (n=10 per group): A control group (sepsis group), a continuous renal replacement treatment (CRRT) group, a hemoperfusion (HP) group and an HP+CRRT group. The blood purification treatments using HP and/or CRRT were performed immediately after the diagnosis of sepsis. HMGB1 levels were measured using ELISA, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and 30-day survival rates were evaluated. Relative to a healthy control group (n=10), HMGB1 levels were observed to be significantly upregulated during sepsis (P<0.05). Following the initiation of sepsis, serum HMGB1 continued to increase in the sepsis group and was significantly elevated at 24 h (P<0.05), whereas urine HMGB1 levels decreased significantly at 12 and 24 h (P<0.05). Serum HMGB1 levels were significantly positively correlated with APACHE II scores (r=0.7284, P<0.01) and significantly negatively correlated with urine HMGB1 levels (r=−0.5103, P=0.026). Serum HMGB1 levels were significantly reduced in the HP and HP+CRRT groups by 12 and 24 h following the initiation of treatment (both P<0.05). Changes in the urine HMGB1 level differed in each group. Relative to the sepsis group, the APACHE II scores of all blood purification groups were significantly reduced (P<0.05) and the 30-day survival rate of the HP+CRRT group was significantly increased (P=0.0107). The results of the present study indicate that blood purification initiated at the point of diagnosis in patients with sepsis may attenuate serum HMGB1 upregulation, promote urinary excretion of HMGB1 and improve the prognosis of sepsis.
Sepsis is a systematic inflammatory response to infection and is the leading cause of death in intensive care units (ICUs) (
As techniques improve, blood purification methods, including continuous renal replacement therapy (CRRT) and hemoperfusion (HP), are becoming more commonly used as treatment methods for sepsis (
Previous studies have suggested that increased levels of serum HMGB1 may be associated with a poorer outcome in sepsis patients (SPs), and that clinical treatments that reduce HMGB1 may be effective for the treatment of sepsis (
A total of 40 adult SPs with different sepsis severities, who were admitted to the ICU of Union Hospital (Fujian Medical University, Fuzhou, China) between January and December 2015, were enrolled in the present study. Informed consent was obtained from all patients or their legal representatives, and all study protocols were approved by the Ethics Committee of Fujian Medical University and followed regulations in accordance with the Declaration of Helsinki. Sepsis was defined according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (
The exclusion criteria were as follows: Patients <18 years old, patients with life-threatening water electrolyte/acid-base balance disorder within the first 24 h of the ICU stay, patients with end stage renal disease receiving any type of blood purification therapy, pregnancy, receipt of immunosuppressive therapy or human immunodeficiency virus infection, current participation in any other clinical trial and inability to be evaluated effectively during the study period.
Immediately after a diagnosis of sepsis was confirmed, patients were randomly assigned to a control (no intervention) group without any apheresis treatment (sepsis group, n=10), a CRRT group (n=10), an HP group (n=10) and an HP+CRRT group (n=10). Blood purification treatments were initiated immediately after informed consent was obtained. A 12 Fr double lumen catheter was placed in the right femoral vein of each patient to establish vascular access. All blood purification treatments were conducted using a PrismaFlex system (Baxter International, Inc., Deerfield, IL, USA). Blood purification data are presented in
Serum and urine HMGB1 levels were measured using a Human HMGB1 ELISA kit (E-EL-H1554c, Elabscience Biotechnology Co., Ltd., Wuhan, China) according to the manufacturer's protocol. Briefly, blood samples were obtained from peripheral vascular, blood and urine specimens (~2 ml) were collected at the initiation of treatment and at 12 and 24 h thereafter. Blood specimens were maintained at room temperature for 2 h, and serum samples were collected prior to centrifugation. Serum and urine samples were centrifuged at 4°C in a swinging bucket rotor at 1,000 × g for 20 min, and the supernatant was collected and measured using the ELISA kit.
Following patient enrollment, the demographic data, sepsis type (sepsis, severe sepsis or septic shock), infection sites and biological data of patients were recorded. Acute Physiology and Chronic Health Evaluation (APACHE) II (
Statistical analyses were performed using GraphPad Prism version 6 (GraphPad Software Inc., La Jolla, CA, USA). Data are presented as the mean ± standard deviation. All variables were tested for normal distribution. Differences between groups were evaluated by analysis of variance and Tukey's multiple comparison tests were performed. Correlations between the serum and urine HMGB1 levels and APACHE II scores of the SP groups at the initiation of treatment (0 h) were calculated using Pearson's correlation analysis. Time-to-event data were compared using the Gehan-Breslow-Wilcoxon test for survival analysis. P<0.05 was considered to indicate a statistically significant difference.
The serum and urine HMGB1 levels of patients in different groups were measured using ELISA. The results indicated that upon diagnosis of sepsis, both the serum and urine HMGB1 levels were significantly increased in all SP groups when compared with the healthy control group (P<0.05;
To investigate the changes in serum and urine HMGB1 levels within the first 24 h of sepsis, serum and urine HMGB1 levels of patients in the sepsis group were measured at the time of sepsis diagnosis (0 h) and at 12 and 24 h thereafter. Serum HMGB1 levels increased gradually within the first 24 h of sepsis, and the serum HMGB1 level at 24 h after diagnosis was significantly increased compared with that at 0 h (P<0.05;
Associations between serum and urine HMGB1 levels and APACHE II scores were analyzed using Pearson's correlation analysis. The results indicated a significant negative correlation between the serum HMGB1 level and urine HMGB1 level in the SP groups (r=−0.5103, P=0.026;
To investigate the effects of various treatments on serum and urine HMGB1 levels, serum and urine samples were collected from the different SP groups and measured using ELISA kits. The results indicated that serum HMGB1 was significantly increased in the sepsis group at 24 h compared with that of 0 and 12 h. Serum and urine HMGB1 levels were significantly reduced in the HP and HP+CRRT groups at 12 and 24 h following the initiation of treatment (P<0.05;
To determine the effects of different blood purification treatments on the short-term outcome of patients, the APACHE II scores of patients were measured. The APACHE II scores of the HP+CRRT group were significantly higher compared with all other SP groups at the initiation of treatment (P<0.05;
After a 30-day follow-up period, the survival rates of the different SP groups were as follows: Sepsis group, 20%; CRRT group, 60%; HP group, 60%; and HP+CRRT group, 80% (
Sepsis is a major clinical syndrome associated with a high mortality rate in hospitalized patients (
To further investigate the association between serum HMGB1 levels and the severity of sepsis, a correlation analysis of serum HMGB1 levels and APACHE II scores was performed. The results suggested that patients with more severe sepsis had higher levels of serum HMGB1. Furthermore, results of the correlation analysis indicated that the urine HMGB1 level was negatively correlated with the serum HMGB1 level. These results suggest that as the clearance of HMGB1 decreases, the accumulation of serum HMGB1 is correlated with the aggravation of sepsis.
It is important to identify an effective method that attenuates serum HMGB1 levels and enhances the clearance of HMGB1 during the early stages of sepsis. Previous studies have indicated that blood purification techniques are able to directly and indirectly reduce the levels of proinflammatory cytokines in the blood (
The effects of different blood purification treatments on the prognosis of SPs were investigated. The results indicated that although early HP+CRRT was the most effective method for reducing the APACHE II scores of patients, all three treatments effectively attenuated the APACHE II scores. These findings paralleled the reduction in serum HMGB1 levels in each group. As APACHE II score has been correlated with the short-term prognosis of SPs (
The present study was a randomized single-center clinical trial with a limited sample size; as such, multi-center studies are now warranted to verify the present findings. Future studies are also required to determine the exact mechanism underlying HMGB1 excretion, and the mechanisms by which blood purification techniques affect serum/urine HMGB1 levels and the prognosis of sepsis.
In conclusion, the present study demonstrated that serum and urine HMGB1 levels were significantly increased during sepsis, and the greatest increases in serum HMGB1 levels were positively correlated with the severity of sepsis and reduced excretion of HMGB1 in the urine. Blood purification treatments, particularly HP+CRRT, initiated immediately upon diagnosis of sepsis, effectively attenuated serum HMGB1 levels, promoted the excretion of HMGB1 via the urine and improved the prognosis of sepsis. Sepsis is a complicated clinical syndrome that lacks specific treatment methods, and the removal of common proinflammatory cytokines does not fully explain the effects of blood purification on sepsis (
Serum and urine HMGB1 levels upon diagnosis of sepsis. (A) Serum and (B) urine levels of HMGB1 were measured by ELISA in the different patient groups prior to the initiation of treatment. Data are presented as the mean ± standard deviation. #P<0.05 vs. Control. HMGB1, high mobility group box protein 1; CRRT, continuous renal replacement treatment; HP, hemoperfusion.
Changes in serum and urine HMGB1 levels over 24 h. (A) Serum and (B) urine levels of HMGB1 in the sepsis (no apheresis intervention) group at different time points. Data are presented as the mean ± standard deviation. #P<0.05 vs. 0-h value. HMGB1, high mobility group box protein 1.
Association of serum HMGB1 level with urine HMGB1 level and APACHE II score. Correlations were identified between (A) urine and serum HMGB1 levels, and (B) APACHE II score and serum HMGB1 level in the sepsis (no apheresis intervention) group. HMGB1, high mobility group box protein 1; APACHE II, Acute Physiology and Chronic Health Evaluation II.
Changes in serum and urine HMGB1 levels in the different patient groups over 24 h. (A) Serum and (B) urine levels of HMGB1 were measured by ELISA at different time points after the initiation of treatments. Data are presented as the mean ± standard deviation. #P<0.05 vs. 0-h value; *P<0.05 vs. sepsis group; ^P<0.05 vs. 12-h value. HMGB1, high mobility group box protein 1; CRRT, continuous renal replacement treatment; HP, hemoperfusion.
APACHE II scores of patients in different groups upon initiation of treatment (0 h) and 24 h thereafter. Data are presented as the mean ± standard deviation. &P<0.05 vs. all other groups at 0 h; #P<0.05 vs. 0-h value; *P<0.05 vs. sepsis group at 24 h. APACHE II, Acute Physiology and Chronic Health Evaluation II; CRRT, continuous renal replacement treatment; HP, hemoperfusion.
Survival curves demonstrating the 30-day survival rates of patients in different groups. CRRT, continuous renal replacement treatment; HP, hemoperfusion.
Baseline characteristics of patients prior to the initiation of treatment.
Group | |||||
---|---|---|---|---|---|
Variables | Sepsis | CRRT | HP | HP+CRRT | P-value |
Demographic data | |||||
Age, years | 56.60±14.16 | 61.50±13.16 | 59.10±20.34 | 57.70±15.62 | 0.91 |
Male, % | 4 (40) | 6 (60) | 6 (60) | 5 (50) | N/A |
MAP, mmHg | 51.85±9.84 | 56.45±16.27 | 54.06±14.00 | 55.77±12.57 | 0.87 |
Type of infection, n (%) | |||||
Pulmonary | 4 (40) | 6 (60) | 4 (40) | 5 (50) | N/A |
Abdominal | 1 (10) | 3 (30) | 2 (20) | 1 (10) | N/A |
Skin and soft tissue | 2 (20) | 0 (0) | 2 (20) | 3 (30) | N/A |
Other | 3 (30) | 1 (1) | 2 (20) | 1 (10) | N/A |
Biological data | |||||
WBC, ×103/mm3 | 17.07±5.06 | 22.32±9.23 | 24.03±8.56 | 19.59±6.23 | 0.14 |
HB, g/l | 83.53±5.09 | 90.32±10.74 | 83.72±6.40 | 84.09±10.06 | 0.22 |
PCT, ng/ml | 20.52±5.10 | 16.98±7.83 | 23.20±7.76 | 18.05±8.03 | 0.24 |
ALB, g/l | 28.93±6.49 | 28.05±7.32 | 27.28±7.77 | 26.72±5.31 | 0.90 |
Type of sepsis, n (%) | |||||
Sepsis | 2 (20) | 2 (20) | 3 (30) | 1 (10) | N/A |
Severe sepsis | 7 (70) | 6 (60) | 6 (60) | 5 (50) | N/A |
Septic shock | 1 (10) | 2 (20) | 1 (10) | 4 (40) | N/A |
Pathogens, n (%) | |||||
MRSA | 3 (30) | 4 (40) | 3 (30) | 4 (40) | N/A |
|
2 (20) | 4 (40) | 3 (30) | 3 (30) | N/A |
|
5 (50) | 3 (30) | 4 (40) | 4 (40) | N/A |
Other bacteria | 2 (20) | 1 (10) | 0 (0) | 2 (20) | N/A |
Organ Dysfunction, n (%) | |||||
None | 2 (20) | 2 (20) | 3 (30) | 1 (10) | N/A |
Lung | 8 (80) | 7 (70) | 7 (70) | 9 (90) | N/A |
Kidney | 1 (10) | 2 (20) | 1 (10) | 3 (30) | N/A |
Gastrointestinal | 0 (0) | 1 (10) | 0 (0) | 1 (10) | N/A |
Liver | 0 (0) | 0 (0) | 1 (10) | 1 (10) | N/A |
Demographic and biological data are presented as the mean ± standard deviation. CRRT, continuous renal replacement treatment; HP, hemoperfusion; N/A, not applicable; MAP, mean arterial pressure; WBC, white blood cells; HB, hemoglobin; PCT, procalcitonin; ALB, human serum albumin; MRSA, Methicillin-resistant
Blood purification therapy data for the different groups.
Group | Filter set | Time, h | BF, ml/min | CTD, ml/kg/h | Pre/post | Heparin, IU/kg/h |
---|---|---|---|---|---|---|
Sepsis | N/A | N/A | N/A | N/A | N/A | N/A |
CRRT | M100 Set | 24 | 180 | 35 | 2:1 | 5 |
HP | Adsorba 300 | 2.5 | 180 | N/A | N/A | 5 |
HP+ | M100 Set | HP+CRRT | 180 | 35 | 2:1 | 5 |
CRRT | +Adsorba 300 | 2.5+CRRT 21.5 |
CRRT, continuous renal replacement treatment; HP, hemoperfusion; N/A, not applicable; BF, blood flow; CTD, CRRT treatment dose; Pre, pre-substitution; Post, post-substitution.