|Year : 2018 | Volume
| Issue : 3 | Page : 1011-1017
Diagnostic value of apolipoprotein A1 in neonatal sepsis
Fady M El-Gendy1, Dalia M El-Lahony1, Dina A R. Midan1, Wafaa M Amin Shaban2
1 Department of Pediatrics, Faculty of Medicine, Menoufyia University, Shebeen El-Kom, Egypt
2 Department of Pediatric, Tala General Hospital, Menoufia, Egypt
|Date of Submission||19-Mar-2017|
|Date of Acceptance||18-Apr-2017|
|Date of Web Publication||31-Dec-2018|
Wafaa M Amin Shaban
Source of Support: None, Conflict of Interest: None
The aim of this study is to detect the value of apolipoprotein A1 (Apo A1) in the diagnosis and prognosis of neonatal sepsis in neonatal ICU of Menoufia University Hospitals.
Neonatal sepsis is used to describe the inflammatory response to infection in neonates younger than 30 days of age. Apo A1 is the major protein component of high-density lipoprotein in plasma, which decreases during the inflammatory process.
Patients and methods
Our study was carried out on 60 neonates admitted to neonatal ICU of Menoufia University Hospitals from April 2015 to April 2016 and were divided into two groups: group I (cases) included 40 neonates with a positive clinical and hematological sepsis score and group II (controls) included 20 healthy neonates with no evidence of sepsis. The two groups were subjected to assessment of history, clinical examination, and laboratory investigations in the form of complete blood counts, blood cultures, C-reactive protein, and Apo A1 level.
Apo A1 level was lower in group I (55.33 ± 1.53 mg/dl) than in group II (85.20 ± 1.69 mg/dl) and the best cut-off point to detect sepsis is 80 mg/dl with a sensitivity of 100% and a specificity of 100%.
Apo A1 was found to be a diagnostic and prognostic factor in neonates with sepsis.
Keywords: apolipoprotein A1, lipids, lipoproteins, neonates, sepsis
|How to cite this article:|
El-Gendy FM, El-Lahony DM, R. Midan DA, Amin Shaban WM. Diagnostic value of apolipoprotein A1 in neonatal sepsis. Menoufia Med J 2018;31:1011-7
|How to cite this URL:|
El-Gendy FM, El-Lahony DM, R. Midan DA, Amin Shaban WM. Diagnostic value of apolipoprotein A1 in neonatal sepsis. Menoufia Med J [serial online] 2018 [cited 2019 Jun 16];31:1011-7. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/1011/248730
| Introduction|| |
Neonatal sepsis is the clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first 30 days of life. Neonatal sepsis is divided into the following types: early-onset sepsis (EOS), which occurs within the first 7 days of life, and late-onset sepsis, which occurs after 7 days of life.
The incidence of sepsis is considerably higher in preterm, 26/1000 born preterm neonates, because in most cases, they require resuscitation and catheterization.
Neonatal sepsis is still the main cause of morbidity and mortality in neonates. When neonatal sepsis is diagnosed early, early treatment may be possible, and hence this will decrease the complications.
Although there are many acute-phase proteins such as C-reactive protein (CRP), procalcitonin, tumor necrosis factor, and serum amyloid-A, there is no marker that can confirm the diagnosis of neonatal sepsis.
Blood culture continues to be the main method to diagnose neonatal sepsis, but at least 48 h is needed for the earliest result to be obtained, and it can show no growth despite the presence of sepsis; thus, many other methods are studied to diagnose neonatal sepsis.
Apolipoprotein A1 (Apo A1) is the major protein component of high-density lipoprotein (HDL) in plasma and chylomicrons secreted from the intestinal enterocyte.
The gene for Apo A1 is located on the long arm of chromosome 11 together with the apolipoprotein (C3 and A4) genes.
Apo A1 is also a cofactor for lecithin cholesterol acy1 transferase, the enzyme responsible for the formation of cholesteryl esters in plasma.
Apo A1 was also isolated as a prostacyclin stabilizing factor and may thus have an anticlotting effect. Defects in the gene encoding it are associated with HDL deficiencies, including Tangier disease, and with systemic non-neuropathic amyloidosis. Apo A1 is often used as a biomarker for the prediction of cardiovascular and respiratory diseases, and the ratio Apo B100/Apo A1 has been reported to be a stronger predictor for the risk of myocardial infarction compared with any other lipid measurement.
The concentration of Apo A1 decreases during an acute infection and as secretory phospholipase A2 is an acute-phase reactant protein that is upregulated during infection. secretory phospholipase A2 increases the catabolism of HDL apolipoproteins (Apo) and HDL cholesteryl esters, resulting in decreased HDL cholesterol plasma levels.
This would favor the decrease in the synthesis or the secretion of Apo A1 during inflammation. Furthermore, the decrease in HDL cholesterol during inflammation may also be attributed to a decreased lecithin cholesterol acy1 transferase activity leading to impaired cholesteryl ester formation and HDL maturation.
The study was designed to evaluate the diagnostic and prognostic value of Apo A1 in neonatal sepsis.
| Patients and Methods|| |
Our study was carried out on 60 neonates admitted to neonatal ICU (NICU) of Menoufia University Hospitals from April 2015 to April 2016 and the newborns studied were divided into two groups: group I (cases) included 40 neonates with a positive clinical sepsis score (CSS) and hematological sepsis score (HSS) and group II (controls) included 20 healthy neonates with no evidence of sepsis. Any newborn who had congenital anomalies, congenital infection, signs and symptoms of inborn errors of metabolism, hypoxic ischemic encephalopathy, and cranial trauma was excluded from the study. An informed consent was obtained from the parents of all the neonates studied.
The two groups were subjected to an assessment of history, including the prenatal and natal Apgar score the first test carried out on the baby in the delivery room. It includes appearance, pulse, grimace, activity and respiration, postnatal, and present history; a full clinical examination, including general examination, cardiovascular examination, chest examination, neurological examination, abdominal examination, and skin examination, was also carried out. Laboratory Investigations included complete blood counts with a differential count (photocitometer; Nihon Kohden, Celtac, Japan), blood culture (EDM Company, 6th October city, Egypt), and quantitative CRP (latex agglutination test) (Egy-Chem for Lab Technology, Badr, Egypt). It was considered positive when the titer was more than 6 mg/l. Apo A1 was assessed at the time of diagnosis of sepsis and after 96 h using an enzyme-linked immunosorbent assay technique (Assaypro LLC, St Charles, Missouri, USA, http://www.assaypro.com).
Two millilitre of blood was obtained from a peripheral vein in a serum separator tube. After clot formation, samples were centrifuged at 3000g for 10 min and serum was collected and stored at −80°C until the time of assay up to 3 months.
The Assay Max Human Apo A1 (South San Francisco, CA 94080 USA) enzyme-linked immunosorbent assay kit is designed for the detection of human Apo A1 in plasma and serum samples.
All data were collected, tabulated, and statistically analyzed using the statistical analysis software package (SPSS) program 19.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for Windows (MedCalc Software BVBA, Ostend, Belgium).
Two types of statistics were calculated:
Descriptive statistics (e.g., percentage), mean ± SD and analytic statistics, which included the following tests.
The χ2-test was used to study the association between two qualitative variables. Fisher's exact test was used, which is a test of statistical significance used in the analysis of 2x2 contingency tables when at least 25% of the cells have expected number less than 5.
t-Test is a test of significance used for comparison between two groups with normally distributed quantitative variables.
The Mann–Whitney U-test is a nonparametric test of significance used for comparison between two groups with non-normally distributed quantitative variables.
A P value more than 0.05 was considered statistically nonsignificant.
A P value of less than 0.05 was considered statistically significant.
A P value of less than 0.001 was considered highly statistically significant.
| Results|| |
In terms of the demographic data of the groups studied, there were no significant differences between the two groups in gestational age, sex, socioeconomic status, consanguinity, and age in days (P > 0.001) as shown in [Table 1]. In terms of the clinical data of the groups studied, there were no significant differences between the two groups in the mode of delivery and weight, whereas there was highly significant difference in the Apgar score at the first minute, the fifth minute, and the 10th minute, being lower in group I than in group II as shown in [Table 2]. Our study showed that the most common clinical findings among the patient group were weak suckling and weak moro reflex in 100% of cases (P = 0.000) and there were significant differences between the two groups in CSS and HSS, being higher in group I than group II (P < 0.001 and P > 0.05, respectively) as shown in [Table 3] and [Table 6].
|Table 6: Spearman's correlation between apolipoprotein A1 and different parameters|
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There was a decrease in Apo A1 in the patient group at the time of diagnosis, with a mean value of (55.33 ± 1.53 mg/dl) compared with that of the control group (85.20 ± 1.69 mg/dl), and the difference was statistically significant (P < 0.001) as shown in [Table 4]. Also, there was a greater decrease in Apo A1 after 96 h in the patient group as shown in [Figure 1]. Our study showed that there was a significant decrease in the Apo A1 level in both the group that survived and the group that died at diagnosis, with mean ± SD (56.36 ± 1.26 mg/dl) and (54.06 ± 0.54 mg/dl), compared with after (96 h), where it decreased, with mean ± SD (54.36 ± 1.26 mg/dl) and (51.67 ± 0.59 mg/dl), respectively (P < 0.001), as shown in [Table 5].
|Table 4: Apolipoprotein A1 (in mg/dl) among the groups studied at diagnosis|
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|Table 5: Apolipoprotein A1 (mg/dl) in relation to outcome among the cases studied|
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Our study showed that there was a positive significant correlation between Apo A1 and the Apgar score at the first minute, the fifth minute, and the 10th minute at diagnosis of neonatal sepsis and after 96 h.
Also, there was negative significant correlation between Apo A1 and immature to total leukocyte ratio, immature to mature leukocyte ratio, CSS, HSS, and CRP at diagnosis of neonatal sepsis and after 96 h as shown in [Table 6].
Our study showed that the best cut-off point of Apo A1 as an early marker to diagnose sepsis was 80 mg/dl, with a diagnostic sensitivity of 100%, a specificity of 100%, and an accuracy of 100% as shown in [Table 4].
On using the receiver operating characteristic curve of Apo A1 (at diagnosis) to diagnose the patient group from the control group, it had a sensitivity and a specificity 100% and area under the curve was 1.0 as shown in [Figure 2].
| Discussion|| |
Neonatal sepsis is one of the most important clinical problems in the neonatal period, with high morbidity and mortality despite the progress in NICU and antibiotics. A major challenge that the pediatricians face when diagnosing neonatal sepsis is that the early symptoms and signs are not clear and nonspecific and the most important method for diagnosis is a blood culture, which requires a minimum of 48 h for the first result and can show no growth despite the clinical signs of sepsis. Therefore, there is no single diagnostic test that can reliably diagnose sepsis in the newborn; therefore, a variety of diagnostic infection markers have been studied in the past few years.
Apo A1 is one of these infection markers. Apo A1 is the major protein component of HDL in plasma. The concentration of Apo A1 is decreased during an acute infection.
This study was carried out to detect the diagnostic and prognostic value of Apo A1 in neonates clinically suspected and proven to have neonatal sepsis according to CSS and HSS.
Our study was carried out on 60 neonates: 40 patients with a positive CSS, Tollner, and HSS, Rodwell et al.. There were a total of 22 males and 18 females. They were compared with a control group of 20 healthy neonates: 10 males and 10 females.
In our study, there was no significant difference in patients and controls in terms of sex. This was in agreement with Betty and Inderpreet, who did not observe any increase in the incidence of sepsis among the neonates studied.
In our study, we found that there were no significant differences in gestational age, socioeconomic status, consanguinity, and weight, and this was not in agreement with Linda and Bryan, who found that preterm infants are more susceptible to sepsis as they require invasive procedures, such as umbilical catheterization and intubation, and have less immunologic ability to resist infection.
Also, we found that there was a predominance of cesarean sections as a mode of delivery in the septic group (55%), but this was not in agreement with Stoll, who observed that babies born by vaginal delivery were more likely to have EOS than those delivered by cesarean section. This may be related to good sterilization and intrapartum chemoprophylaxis, which markedly decreased the risk of sepsis in neonates delivered by cesarean section.
In our study, we found a highly significant decrease in the Apgar score at the first minute and the fifth minute in the patient group compared with the control group. Similarly, Gonzalez et al. and Moore et al. found a significant statistical difference between the healthy group and the patient group. This may suggest that EOS presents very early in life in these neonates.
In terms of the clinical manifestations in the patient group, we found poor moro reflex (100%), poor suckling reflex (100%), tachypnea (80%), and distention (70%), intercostal retraction (65%), lethargy (52.5%), temp instability (45%), hepatomegaly (45%), hypoglycemia (37.5%), prolonged capillary refill (35%), weak pulse (20%), irritability (15%), seizure (10%), grunting (10%), cyanosis (7.5%), bloody stool (5%), and diarrhea (5%), whereas Ottolini et al. found that lethargy was present in 20% of the neonates.
The HSS was significantly higher in septic neonates and the mean value of HSS was 4.73 ± 0.99. This was in agreement with Yousef and Fergany, who reported that HSS was significantly higher in septic neonates than those with no sepsis and that HSS of the septic group was at least 4.
In terms of the types of bacteria isolated from blood cultures in the present study, 30 (75%) cases had positive culture results and 10 (25%) cases had negative culture results. In our study, we found that group B streptococci was the most frequently isolated organism (17.5%), followed by Candida spp. (15%), Klebsiella spp. (12.5%), Staphylococcus aureus (10%), Gram-negative bacilli (Escherichia coli) (7.5%), methicillin-resistant S. aureus (5%), Klebsiella spp. (2.5%), Staphylococcus epidermidis (2.5%), and Streptococcus pyogenes (2.5%). This was in agreement with Kaseb et al., who found that Gram-positive bacteria accounted for the majority of the culture growth, and was not in agreement with a study carried out by Abdelfata et al. in the NICU, Kasr El-Eini Hospital, who found that the most commonly isolated organisms were Klebsiella spp., E. coli, and Enterobacter spp. There was a significant increase in CRP at diagnosis in the group that died (6–96 g/l) than in the group that survived (6–24 g/l) and a highly significant increase in CRP after 96 h (24–96 g/l) in the group that died than in the group that survived (6–48 g/l). This was in agreement with Ipek et al., who found that there was a significant difference between the patient group and the control group in CRP at admission and after 24 h (P < 0.05).
The outcome of the diseased group showed that 22 neonates representing (55%) survived whereas 18 neonates representing (45%) had died; however, all the neonates in the control group survived. There was a decrease in the mean Apo A1 level (55.33 ± 1.53 mg/dl) in patients at the time of diagnosis compared with the control group (85.20 ± 1.69 mg/dl), and the difference was statistically significant (P < 0.001). Our study showed that the Apo A1 level was lower after 96 h than that at diagnosis in the group that survived (P < 0.001).
The Apo A1 level was lower after 96 h than that at diagnosis in the group that died (P < 0.001). Our study showed that there was no significant correlation between the level of Apo A1 and gestational age, weight, hemoglobin, hematocrit, total leukocytic count, platelets, alanine aminotransferase, aspartate aminotransferase, urea, and creatinine of neonates, but there was a positive significant correlation between Apo A1 and the Apgar score at the first minute and the fifth minute at diagnosis of neonatal sepsis and after 96 h.
Also, there was a significant negative correlation between Apo A1 and immature to total leukocyte ratio, immature to mature leukocyte ratio, CSS, HSS, and CRP at diagnosis of neonatal sepsis and after 96 h.
Our study showed that the best cut-off point of Apo A1 as an early marker of sepsis (to diagnose sepsis) was 80 mg/dl with a diagnostic sensitivity of 100%, a specificity of 100%, and an accuracy of 100%.
Our study showed that the receiver operating characteristic curve of Apo A1 (at diagnosis) to diagnose sepsis cases from controls had a sensitivity and specificity of 100%.
| Conclusion|| |
Apo A1 appeared to be a useful acute-phase reactant for the early detection and diagnosis of neonatal sepsis. The Apo A1 lipoprotein level is decreased in newborns with neonatal sepsis compared with controls and also had prognostic value.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]