Spannender Artikel bei nature.com (PDF-Downloadlink) vom 10.10.2019. Die Uniklinik Ulm hat in Sachen Sepsis und Cytosorb schwer geforscht.
The study design was as follows: Patients were enrolled to our study when admitted to the ICU within 48 hours after sepsis onset and presenting with high plasma interleukin (IL)-6 concentrations (>500 pg/ml) and/or kid-ney failure. When a patient was enrolled and planned to be treated with CytoSorb hemoadsorption therapy, one blood sample was taken before the treatment. During the treatment, infection markers were routinely checked. After 24 hours of treatment, another blood sample was taken. The CytoSorb adsorber cartridge was immediately processed (see below). Cytokine measurements and leukocyte antigen expression analysis were performed before and after CytoSorb hemoadsorption treatment.We here report representative results on the biochemical preparation of a single hemoadsorption device per-formed in a 76-year-old female patient after surgery for an abdominal aneurysm through Crawford access and clamping of visceral and renal arteries. Sepsis was diagnosed, according to Singer and colleagues (2016), by the presence of catecholamine-dependent septic shock, hemodynamics and a lactate concentration >2 mg/dl follow-ing the Sepsis 3 criteria on day 3 after surgery (catecholamines were administered at 0.4 μg/kg Body Weight (BW)/min, lactate was 4.9 mg/dl), and inflammatory variables were highly elevated, including C-reactive protein (CRP): 307.6 mg/l; procalcitonin (PCT): 5.68 μg/l; IL-6: 4944 pg/ml; and IL-8: 308 pg/ml; as was lactate dehydrogenase (266 U/l). The patient benefitted from CytoSorb treatment in that the catecholamine dosage was decreased to 0.05 μg/kgBW/min and most of the other inflammatory parameters declined, including CRP (235.5 mg/l), PCT (4.3 μg/l), IL-6 (107.4 pg/ml) and IL-8 (63.6 pg/ml), whereas lactate remained elevated (5.2 μg/l).
Leider bin ich nicht vom Fach und auch nicht wirklich schlau genug, aber wenn ich die Studie richtig verstehe, hat man dann 39 verschiedene Proteine aus so einem Adsorber isolieren und vier davon als zellaktiv identifizieren können.
In summary, four different protein fractions were classified as “active” (F10–F12, F24) for their significant inhibitory effect on mEC proliferation. The remaining fractions had no effect on mEC proliferation and did not increase cell death.
Es waren wohl auch nicht einheitlich immer 39 verschiedene Protein-„Fractions“ sondern auch mal 46:
The same procedure was performed with hemoadsorbed material from two other patients, one of whom benefitted from CytoSorb treatment (data not shown). A total of 46 protein fractions were obtained from the responding patient, two of which: F26-F27 impaired mEC proliferation and increased cell death. By con-trast, none of the 44 protein fractions obtained from the hemoadsorbed material of the non-responding patient affected mEC confluency or viability (data not shown). The reasons for these differences are likely related to the individual elution profile of the column fractionation and await further investigations.
Und was soll das alles?
Die Ulmer meinen erkannt zu haben, dass der Adsorber bei Sepsis hilft, ohne dass das bislang wirklich konkret erklärbar ist oder war. Um der Sache auf den Grund zu gehen, schraubt man nun einen im Sepsis-Kontext benutzten Adsorber auf, untersucht, welches Zeug der so eingesammelt hat und schaut, was von dem Zeug „zellaktiv“ ist bzw. Zellen umbringt. Macht Sinn, oder? Noch mal: was wirklich 100% genau bei Sepsis los ist, weiß bis heute keiner. Der Ansatz der Ulmer hier ist für meine Begriffe richtig gut, logisch und stringent und sowas alles.
In summary, the molecular entities fractionated from CytoSorb adsorbers of a patient with septic shock had a major impact on mEC confluency, cell layer integrity, proliferation, ATP contents mEC apoptosis. These features may contribute to the clinical observations of perfusion deficiency and organ failure in patients with septic shock.
Zitieren wir noch ein bisschen, um zu zeigen, wie komplex der ganze Kram ist:
A major pathology in septic shock occurs by endothelial cell damage, which contributes to organ failure. The pathology related to coagulation factors has been excellently reviewed by Opal and van der Poll23. Essentially, sol-uble factors and activated immune cells contribute to alterations in coagulation and cause increased endothelial permeability. William Aird drewed the following conclusion: “…it would be difficult to identify a single com-ponent whose therapeutic modulation will short-circuit the sepsis cascade and improve outcome34”, our results provide further evidence for multiple protein entities involved in different pathways to cause sepsis-related endothelial dysfunction. In vivo, additional effects are expected to occur by leukocytes interacting with mEC in an inflammatory environment. As reviewed in an excellent manuscript, the co-activation of both cytoplas-mic toll-like receptror-(TLR)4 – and TLR3-guided non-canonical inflammasome activation is a likely target to attenuate severity in septic shock models35. One reason was the fulminant beneficial effect by CytoSorb hemoad-sorption to restore endothelial function and restrict septic shock through a major reduction of catecholamine treatment within 24 hours. We first addressed inflammatory mediators removed by CytoSorb treatment, similar to previous34 investigations focusing on inflammatory cytokines (IL-6) and coagulation factors9,10, and then frac-tionated the proteins adsorbed to a CytoSorb column by classic peptide biochemistry. An unbiased approach was followed using a novel bioassay with brain-derived mEC. A total of 39 CytoSorb-derived fractions were tested by long-term video microscopy using an IncuCyteZOOM device. This assay has the advantage of being able to simultaneously analyze9,10 cell proliferation, death and morphology36. Protein fractions F10–F12 and F24 were identified as having a major effect on the integrity of endothelial-cell layers and mEC viability, proliferation, ATP content and cell death-related mechanisms, including apoptosis. We are currently attempting to identify indi-vidual protein fractions affecting mEC from hemoadsorbed material of two additional patients as well as protein fractions pooled from eight other CytoSorb columns. These results will help us identify the protein fractions that affect mEC viability and identify their contents (cf. Fig. 7). In future experiments, we will focus on the identification of the 15 kDa protein species found in F10–F12
Schon noch ein bisschen Nebel und tausend Nebenfaktoren. Sei’s drum: die Ulmer konstatieren, dass das Ding funktioniert – am Warum wird eben noch gearbeitet:
In summary, the current work describes a mEC-based bioassay to study blood-derived mediators, which were efficiently eliminated by CytoSorb hemoadsorption treatment and may explain rapid resolution from states of septic shock after CytoSorb treatment.