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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 1  |  Page : 132-137

The role of measurement of serum mannose-binding lectin in diagnosis of sepsis and prediction of prognosis among children admitted into the pediatric intensive care unit


1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Pediatrics, Benha Children Hospital, Benha, Egypt

Date of Submission21-Aug-2019
Date of Decision12-Sep-2019
Date of Acceptance14-Sep-2019
Date of Web Publication25-Mar-2020

Correspondence Address:
Osama A.R. Diab
Shebin El-Kom, Menoufia 32717
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_260_19

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  Abstract 


Objective
To evaluate validity of serum mannose-binding lectin (MBL) measurement in diagnosis and prognosis of sepsis among critically ill children.
Background
MBL is a part of the innate immune system with a potential role in sepsis susceptibility.
Patients and methods
A prospective observational study was conducted that included 50 critically ill children admitted into the pediatric intensive care unit. Another group of 38 healthy children served as a control group. Serum MBL level was measured for all patients (within 24 h) and controls. Patients were monitored till hospital discharge to determine the diagnosis of sepsis and occurrence of morbidity and mortality.
Results
No significant difference in MBL level was noted between septic patients and controls [median and range = 2.1 (1.2–298) vs. 2.25 (1.4–134); P = 0.45] or between survivors and nonsurvivors [median and range = 2.4 (1.1–298) vs. 10.95 (1.3–244); P = 0.75]. MBL had a significant negative correlation with C-reactive protein (rs=−0.33; P = 0.021) but not with pediatric risk of mortality, pediatric index of mortality 2, or sequential organ failure assessment score. MBL had a poor area under receiver operating characteristic (area under the curve) curve for prediction of mortality compared with pediatric risk of mortality, sequential organ failure assessment, and pediatric index of mortality 2 (area under the curve = 0.54, 0.91, 0.90, and 0.75, respectively). No significant correlation was found between MBL and length of pediatric intensive care unit stay or mechanical ventilation duration.
Conclusion
MBL is neither useful for sepsis diagnosis nor prediction of mortality or morbidity. The routinely available markers and prognostic scores are much more powerful compared with an expensive marker like MBL.

Keywords: C-reactive protein, critically ill children, mannose-binding lectin, pediatric, prognosis, sepsis


How to cite this article:
El Gendy FM, El-Mekkawy MS, Sonbol AA, Diab OA. The role of measurement of serum mannose-binding lectin in diagnosis of sepsis and prediction of prognosis among children admitted into the pediatric intensive care unit. Menoufia Med J 2020;33:132-7

How to cite this URL:
El Gendy FM, El-Mekkawy MS, Sonbol AA, Diab OA. The role of measurement of serum mannose-binding lectin in diagnosis of sepsis and prediction of prognosis among children admitted into the pediatric intensive care unit. Menoufia Med J [serial online] 2020 [cited 2020 Aug 7];33:132-7. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/132/281284




  Introduction Top


Sepsis still represents a major cause of morbidity and mortality in critically ill patients despite the use of modern antibiotics and resuscitation therapies. There is a lack of early diagnosis and timely intervention for sepsis in pediatric intensive care unit (PICU), and recent interest has focused on biomarkers for early diagnosis, risk stratification, and evaluation of prognosis of sepsis[1].

Children admitted to PICU have life-threatening illnesses. They either already have infection when admitted or are at high risk of acquiring infections because of different procedures, use of invasive devices, and extended length of stay. Antibiotics are the most commonly used medicines in the ICUs. The critical nature of the illness of patients admitted to PICU often leads to the prescription of multiple and prolonged antibiotics. The use of antibiotics may be helpful in preventing health care-associated infections, but their unnecessary and irrational use has a few serious disadvantages. Prolonged and inappropriate use of antibiotics has resulted in emergence of antibiotic resistance, which is an important clinical, economic, and public health problem[2].

The innate immune system is the first line of defense against invasive pathologic organisms, and its role is essential in controlling infection in the first 24–48 h before the adaptive immune system is able to mount an adequate response. One of the primary innate immune processes is activation of the complement system for direct pathogen killing and for opsonization, which marks pathogens for destruction by phagocytes. A critical antimicrobial protein in this pathway is mannose-binding lectin (MBL) which recognizes mannose sugars on the periphery of bacteria, viruses, and fungi, and on damaged human cells. Binding of this protein to cell membranes causes conformational changes that activate directed complement deposition for the invading microbe to be opsonized and killed[3].

MBL is produced continuously in the liver; serum levels in healthy individuals have been shown to be influenced by host genetic makeup[4]. It is worth mentioning that MBL deficiency is often associated with an increased risk of infection or worse prognosis in immunocompromised patients[5].

Aim

The aim of this study was to evaluate the validity of serum MBL level in diagnosis and prognosis of sepsis in PICU of Benha Children Hospital.


  Patients and Methods Top


This was a prospective observational study conducted in Benha Children Hospital from April 2017 to March 2018. The study protocol was approved by the ethical committee of Faculty of Medicine, Menoufia University. The study was conducted from April 2017 to March 2018 in PICU of Benha Children Hospital. A total of 86 children were included. These consisted of 50 patients and 36 age-matched and sex-matched healthy children who served as a control group.

Critically ill children with an expected length of PICU stay of 48 h or more were consecutively enrolled. The exclusion criteria included (a) children younger than 1 month or older than 18 years, (b) known immune deficiency, (c) anticipated short PICU stay (>48 h), and (d) failure to obtain parental informed consent. Patients were subgrouped according to the presence of infection and systemic inflammatory response syndrome (SIRS) into the following: (a) patients with sepsis, (b) patients with noninfectious SIRS, and (c) patients without SIRS. A patient was considered as having sepsis if he or she fulfilled at least two SIRS criteria (one of which is temperature or leukocytic count change) in the presence of proven or suspected infection[6]. Another method to diagnose sepsis was based on the recent sepsis-3 adult guidelines that require the presence of sequential organ failure assessment (SOFA) score of at least two with suspected infection[7].

The diagnostic workup performed to patients included history, physical examination, and investigations. Investigations included venous blood gas, complete blood count, C-reactive protein (CRP), blood glucose, sodium, potassium, urea, creatinine, serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, blood culture, and other cultures if needed. Additionally, serum MBL level was performed for controls and patients within 24 h of PICU admission. The clinical and laboratory parameters were used to calculate two mortality predictive scores, namely, pediatric risk of mortality (PRISM) (within 24 h of PICU admission), pediatric index of mortality 2 (PIM2) (within 1 h of PICU admission) and SOFA (within 24 h of admission). Patients were closely monitored till hospital discharge.

Laboratory methods

For all patients, serum MBL was measured within 24 h of PICU admission. MBL was also measured for all controls. Two milliliters of venous blood was taken under complete aseptic conditions in sterile vacutainer tube. Serum sample was coagulated at room temperature for 10–20 min and then centrifuged at the speed of 3000 rpm for 10 min to collect supernatant. This kit was based on standard sandwich enzyme-linked immunosorbent assay technology. The purified anti-MBL antibody (Cat No. BYLK1089; Chongqing Biospes Co. Ltd, Chongqing, China) was precoated onto 96-well plates, and the HRP-conjugated anti-MBL antibody was used as detection antibodies. The standard test samples and HRP-conjugated detection antibody were added to the wells subsequently, mixed, and incubated, and then unbound conjugates were washed away with wash buffer. TMB substrates (A and B) were used to visualize HRP enzymatic reaction, and then the concentration of MBL was calculated.

Statistical analysis

The collected data were tabulated and analyzed using SPSS, version 23, software (SPSS Inc., Chicago, Illinois, USA). Categorical data were presented as number and percentages. χ2 or Fisher's exact test was used to analyze categorical variables. Quantitative data were tested for normality using Kolmogorov–Smirnov test, assuming normality at P value more than 0.05. Quantitative data were expressed as mean ± SD, median, and range. Student t test was used to analyze normally distributed quantitative variables among two independent groups, whereas Mann–Whitney U test was used for comparing the means of non-normally distributed variables. Spearman's correlation coefficient (rs) was used to assess correlation between nonparametric variables. Receiver operating characteristic curve was used to detect cutoff values with optimum sensitivity and specificity for prediction of sepsis. A P value less than 0.05 was considered statistically significant.


  Results Top


Characteristics of the study participants

A total of 86 individuals were enrolled in the study. Their demographic and clinical data are shown in [Table 1]. Patients and controls were age and sex matched. However, weight and length were significantly lower among patients compared with controls. The most frequent primary reason for PICU admission was respiratory diseases, and then neurological diseases. There was no statistically significant difference between patients and controls regarding age and male sex. There was a statistically significant decrease in weight and length among patients than controls [Table 1].
Table 1: Demographic and clinical characteristics of patients and controls

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The diagnostic value of systemic inflammatory response syndrome

There was no significant difference between patients with sepsis (based on SIRS or SOFA score) and controls regarding MBL [Table 2].
Table 2: Comparison between mannose-binding lectin in patients with sepsis (based on systemic inflammatory response syndrome and sequential organ failure assessment score) and controls

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There was no statistically significant difference between sepsis, noninfectious SIRS, and non-SIRS regarding MBL [Figure 1].
Figure 1: Median MBL in patients with sepsis, noninfectious SIRS, and non-SIRS. MBL, mannose-binding lectin; SIRS, systemic inflammatory response syndrome.

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There was no statistically significant difference between survivors and nonsurvivors regarding MBL [Figure 2].
Figure 2: Median MBL level in survivors and nonsurvivors. MBL, mannose-binding lectin.

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MBL and platelets had poor area under the curve (AUC) for prediction of sepsis, whereas white blood cells (WBCs) had the highest AUC for prediction of sepsis [Table 3].
Table 3: Receiver operating characteristic curve analysis for prediction of prediction of sepsis by mannose-binding lectin among critically ill children by mannose-binding lectin

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The prognostic value of mannose-binding lectin

MBL had a poor AUC for prediction of mortality. whereas PRISM, SOFA, and PIM were much more useful. Hemoglobin and alanine transaminase were also superior to MBL in this regard.

MBL had low sensitivity and specificity to detect mortality, whereas PIM2 and pediatric SOFA score had high sensitivity and specificity to detect mortality [Table 4].
Table 4: Receiver operating characteristic curve analysis for prediction of mortality by mannose-binding lectin among critically ill children by mannose-binding lectin

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Correlation between mannose-binding lectin and other clinical and laboratory variables

There was a significant negative weak correlation between MBL and CRP. However, there were no significant correlations between MBL and other numerical data (WBCs, platelets, hemoglobin, creatinine, age, weight, length, PRISM score, PIM2 score, and pediatric SOFA score).


  Discussion Top


In the present study, critically ill children were evaluated for the possibility of having sepsis depending on serum MBL level as well as the routine sepsis markers and prognostic scores. MBL demonstrated no diagnostic value. No significant difference in serum MBL level was found between patients with sepsis and controls. No significant difference was found among patients with sepsis, noninfectious SIRS, and non-SIRS either. Noteworthy, the lack of significant difference between septic patients and controls was demonstrated when sepsis was defined classically based on SIRS and when it was defined following the recent adult guidelines (sepsis-3). Undoubtedly, the small sample size in the present study hinders us from drawing firm conclusions about the diagnostic value of MBL, and certainly, larger studies are needed.

Although our current research provides no solid conclusions, principally owing to the small sample size, it should be borne in mind that a small study is not without value as it can be later included in a meta-analysis which can give more clear-cut answers to the questions related to the role of MBL in pediatric sepsis. In addition, a small study can serve as a stimulus for performing a larger or multicenter study which can be more conclusive.

We also noticed that there was no significant difference between patients with sepsis and controls regarding MBL and no significant difference between sepsis, noninfectious SIRS, and non-SIRS regarding MBL level.

In line with our current findings, previous studies in adults have detected no role for MBL in diagnosis of sepsis. Similarly, Madsen et al.[8] found no association between MBL level and infection status on admission or with progression from SIRS to sepsis or septic shock in pediatric patients. Although MBL haplotypes strongly influenced MBL levels in the predicted relationship, low MBL-producing haplotypes were not associated with increased risk of infection.

Likewise, another pediatric study, Liu and Ning[9], failed to detect a lower MBL level among PICU patients with infection versus PICU patients without infection.

Specifically in pediatrics, six studies have demonstrated an association between lower MBL levels, or low MBL-producing haplotypes, and increased severity of infection-related disease[10] whereas five studies have showed similar findings to ours with a lack of association[11], and two studies concluded a possible protective role for low-producing MBL genotypes or levels[12].

On the contrary, Garred et al.[13] and Gordon et al.[14] reported that MBL polymorphisms were associated with lower level of serum MBL and increasing risk of sepsis in critically ill adult populations. However, other studies in adults have not found MBL to be associated with risk for sepsis[15] or have reported a more nuanced picture that includes a mixture of both proinflammatory and anti-infection effects, which may be beneficial or detrimental in varying disease states[9].

There are likely several etiologies behind the lack of association between MBL levels, low-producing MBL haplotypes, and increased susceptibility to severe infection. The redundancy in complement activation within the innate immune system may provide relative resilience[16].

In other words, the relation between MBL and the whole immune system can be likened to the relation between one fighter and a whole army; loss of one fighter is not expected to have a significant influence on the performance of the whole army.

In contrast, Amer et al.[17] reported a significantly lower MBL levels in neonates with sepsis compared with controls.

Likewise, El Gendy et al.[18] found that the mean MBL serum level was lower in the septic neonates compared with healthy controls.

Another neonatal study[19] demonstrated that MBL level was significantly lower in infants with sepsis than in the control group. The lowest MBL levels were detected in those infants with septic shock.

Another finding in the present study was the significant weak negative correlation between CRP and MBL in addition to lack of significant correlations with other clinical and laboratory variables, including the sepsis biomarkers WBC and platelet count. These findings are in line with our previous findings showing no association of MBL with sepsis.

A further demonstration of the lack of the diagnostic power of MBL came from receiver operating characteristic curve analysis where MBL have a poor AUC, whereas WBC had a high AUC for discriminating children with sepsis from controls. In contrast, other pediatric studies reported a high AUC as well as a better sensitivity and specificity of MBL for prediction of sepsis[17],[18].

Besides the diagnostic value, we evaluated a potential prognostic value of MBL. MBL was found to have a very poor performance for prediction of mortality compared with PRISM, SOFA, PIM2, hemoglobin, and alanine transaminase. Of note, these mortality predictive scores are freely available and require parameters that are routinely obtained for all PICU patients. The excellent performance of these scores has been demonstrated in previous studies ,[20],[21],[22]. It is thus prudent to carefully evaluate new biomarkers, as routinely available prognostic tools can be much more useful.

In fact, a point of controversy that is frequently raised, particularly in resource-limited countries, is related the high cost of almost all new sepsis biomarkers. Undoubtedly, MBL is much more expensive compared with the more routinely available diagnostic (e.g. CRP) and prognostic (e.g., platelet count and WBC) markers as well as clinical severity scores, for example, PRISM and SOFA score. However, new researches are supposed to be targeting, not only national medical problems but also medical problems of concern to the whole scientific community all over the world. Moreover, if a new biomarker proves to be clinically useful, it will be inevitably produced commercially on a large scale, with a consequent fall of its price.

Limitations of the present study include the small sample which made it difficult to assess MBL role with great confidence. Furthermore, the mortality rate in the present study was high, and our result might not hold in centers with lower mortality rates.


  Conclusion Top


Our current findings suggest a lack of utility of MBL for diagnosis of sepsis or prediction of mortality and morbidity. Furthermore, the routinely available markers and prognostic scores proved to be much more powerful compared with an expensive marker like MBL. However, larger studies are required to more fully assess the true value of MBL in managing critically ill children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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