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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 655-660

Serum thrombomodulin level in neonates with septic shock


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, El Santa General Hospital, Gharbia, Egypt

Date of Submission27-Aug-2020
Date of Decision30-Sep-2020
Date of Acceptance03-Oct-2020
Date of Web Publication30-Jun-2021

Correspondence Address:
Mohamed A Mohamed Farea
Tanta, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_272_20

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  Abstract 


Objective
The aim was to assess the potential role of serum thrombomodulin level as a biochemical diagnostic marker in neonates with septic shock.
Background
Neonatal septic shock is a significant cause of morbidity and mortality. Thrombomodulin is expressed on vascular endothelial cells and is found in the body in a bound form and a soluble form.
Patients and methods
This prospective cohort study was done on 120 neonates who were divided into two groups: patients' group included 80 neonates with septic shock, and control group included 40 healthy neonates. Detailed history, thorough clinical examination, and laboratory investigations including level of serum soluble thrombomodulin were done.
Results
Neonates with septic shock had statistically significant higher level of serum soluble thrombomodulin than controls. Serum soluble thrombomodulin levels were significantly higher in patients with gram-positive bacteria in comparison with gram-negative ones. Nonsurviving septic neonates had statistically significant increase in serum soluble thrombomodulin levels than survived septic neonates. There was a statistically significant positive correlation between serum soluble thrombomodulin levels and quantitative C-reactive protein (CRP) values. The cutoff value of 20 of serum soluble thrombomodulin levels had a sensitivity of 91.5%, a specificity of 84.7%, positive predicted value of 91.9%, negative predicted value of 88.3% with accuracy 92.94% in the diagnosis of septic shock. Serum soluble thrombomodulin showed a higher accuracy in the diagnosis of septic shock than quantitative CRP values.
Conclusion
Serum soluble thrombomodulin level has a more sensitivity diagnostic role in septic shock than quantitative CRP value. Higher serum soluble thrombomodulin levels predict the prognosis of septic shock.

Keywords: C-reactive protein, marker, septic shock, soluble thrombomodulin


How to cite this article:
Mahmoud AT, Elzaiat RS, Farea MA, Midan DA. Serum thrombomodulin level in neonates with septic shock. Menoufia Med J 2021;34:655-60

How to cite this URL:
Mahmoud AT, Elzaiat RS, Farea MA, Midan DA. Serum thrombomodulin level in neonates with septic shock. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:655-60. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/655/319678




  Introduction Top


Neonatal sepsis is recognized as a leading global public health challenge and has a fulminant and fatal evolution if the treatment is not commenced promptly [1]. Diagnosis of septic shock requires several conditions to be met: first, systemic inflammatory response syndrome must be diagnosed. Second, there must be sepsis and not an alternative cause of systemic inflammatory response syndrome. Sepsis requires evidence of infection, which may include positive blood culture, signs of pneumonia on chest radiograph, or other radiological imaging or laboratory evidence of infection. Third, signs of endorgan dysfunction are required such as renal failure, liver dysfunction, changes in mental status, or elevated serum lactate. Finally, septic shock is diagnosed if there is refractory hypotension that does not respond to intravenous fluid administration alone [2].

Endothelial dysfunction plays an important role in the pathophysiology of sepsis. Thrombomodulin, a membrane glycoprotein, is expressed on vascular endothelial cells and is found in the body in a bound form and a soluble or plasmatic form. It binds to thrombin and acts as an anticoagulant. Once thrombomodulin binds to endothelial thrombin, the thrombin-thrombomodulin complex accelerates protein C activation. Soluble thrombomodulin is released from the surface of endothelial cells into the serum by proteolytic degradation [3].

As endothelial dysfunction plays an essential role in the pathogenesis of sepsis, some studies have focused on serum thrombomodulin level as a predictor of the severity of sepsis and mortality in adults [4]. However, few pediatric studies have examined the role of serum thrombomodulin as a biomarker to predict the clinical course of different pediatric sepsis syndromes, sepsis-induced disseminated intravascular coagulation (DIC), multiple organ dysfunction syndrome (MODS), and mortality [5]. Therefore, this study aimed to assess the potential role of serum thrombomodulin level as a biomarker in neonates with septic shock.


  Patients and methods Top


This cohort study was done on 120 neonates recruited from the neonatal intensive care unit (NICU), Faculty of Medicine, Menoufia University Hospitals, from November 2018 to June 2019. They were divided into two groups: patient group, which included 80 neonates in septic shock aged 1–28 days, and control group, which included 40 clinically healthy neonates, age and sex matched with the first group recruited from outpatient clinic during their follow-up visits.

Ethical consideration

The study protocol was approved by the Menoufia Faculty of Medicine Committee for Medical Research and Ethics. Informed consents were obtained from guardians of all participants included in the study.

Inclusion criteria

Preterm and full-term neonates with septic shock diagnosed according to the consensus definition of neonatal septic shock [6], of both sexes, were included.

Exclusion criteria

Cardiogenic shock, hypovolemic shock, congenital anomalies, and infants of diabetic mothers were excluded.

Methods

Detailed history

Age, sex, and consanguinity were assessed.

Thorough clinical examination

Signs of sepsis, including the application of clinical sepsis score and confirmation of selected criteria, were recorded [7].

Laboratory investigations

Complete blood count was performed using automated cell counter (Coulter, Indianapolis, Indiana, USA) with the differential count done on Leishmania-Giemsa stained peripheral blood film for I/T ratio calculation [8].

Hematological sepsis score was calculated from complete blood count [9].

Quantitative C-reactive protein (CRP) was assessed using quantitative latex agglutination test [10].

For blood cultures, sterilization was done before venipuncture from a peripheral vein not from central line, and blood was inoculated into a bottle of diphasic culture medium through the rubber liner of the bottle cap dispensing 1–2 ml of blood into culture medium bottle containing 25 ml of broth. A fresh ethanol-ether swab was used to wipe the top of each culture bottle and the tape or protective cover(s). Each bottle was clearly labeled with the name and number of the patient, and the date and time of collection [11].

Renal function test (urea and creatinine) was done using the open system autoanalyzer synchron CX5 (Beckman, Brea, California, USA). Liver function test (alanine aminotransferase, aspartate transaminase, and serum albumin) was done using a biochromatic (405–510 nm) rate technique. Arterial blood gas, electrolytes, and radiological imaging were done when needed.

Serum soluble thrombomodulin level was measured. Blood samples were collected. Serum was obtained after centrifugation, and the samples were labeled and kept at −80°C until analysis. Serum soluble thrombomodulin was quantified using an IMUBIND Thrombomodulin ELISA kit (Sekisui Diagnostics, Lexington, Massachusetts, USA), according to the manufacturer's instructions [12].

Principle of the assay

A quantitative sandwich enzyme immunoassay technique was used. A monoclonal antibody specific for human thrombomodulin has been precoated onto a microplate. Standards and samples are pipetted into the wells, and any thrombomodulin present is bound by the immobilized antibody. After washing away any unbound substances, an enzyme-linked monoclonal antibody specific for human thrombomodulin is added to the wells. Following a wash to remove any unbound antibody-enzyme reagent, a substrate solution is added to the wells and color develops in proportion to the amount of thrombomodulin bound in the initial step. The color development is stopped and the intensity of the color is measured.

Statistical analysis

The collected data were tabulated and analyzed using SPSS version 17 software (SPSS Inc., Chicago, Illinois, USA). Categorical data were presented as number and percentages. Quantitative data were expressed as mean ± SD, median and range. χ2 test, Student 't' test, Spearman's correlation coefficient (ρ), and receiver operating characteristic curve were used. P value less than 0.05 was considered significant [13].


  Results Top


In this study, there was no statistically significant difference between patient group and control group regarding demographics. Clinical sepsis score was used to confirm N-sepsis [Table 1]. Moreover, increase in white blood cells (WBCs), immature neutrophils, I/T ratio, and I/M ratio, as a component of the hematological sepsis score confirmed diagnosis of N-sepsis. Neonates with septic shock had statistically significantly higher mean serum soluble thrombomodulin levels (23.49 ± 10.51 units) than controls (16.32 ± 4.82 units). Serum soluble thrombomodulin mean levels were statistically significantly increased among nonsurvived neonates with septic shock (29.18 ± 7.93 units) than survived neonates with septic shock (12.928 ± 4.87 units) [Table 2]. Regarding blood culture, among patient group, it was seen that 70% of patients had positive culture results: 45% of them revealed gram-negative organisms, 20% revealed gram-positive ones, and 5% showed Candida. A statistically significant positive correlation was observed between serum soluble thrombomodulin level and quantitative CRP values (r = 0.123, P = 0.04) [Table 2]. At a cutoff value of serum soluble thrombomodulin levels of 20 unit, the sensitivity was 91.5%, the specificity was 84.7%, the positive predicted value (PPV) was 91.9%, the negative predicted value (NPV) was 88.3%, and the accuracy was 92.94%. Serum soluble thrombomodulin level was more accurate in diagnosis of septic shock than a CRP value. Moreover, at cutoff value of serum soluble thrombomodulin of 20.25, the sensitivity of it was 90.9%, specificity was 66.7%, PPV was 76.9%, NPV was 85.7%, and accuracy was 80% as a predictor marker of mortality in septic shock. Serum soluble thrombomodulin level was more accurate as a predictor marker of mortality in septic shock than hematological sepsis score and a CRP value [Table 3] and [Figure 1]a, [Figure 1]b.
Table 1: Demographic and clinical data of the studied groups

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Table 2: CBC and hematological sepsis score of the two studied groups as well serum soluble thrombomodulin levels in nonsurvived and survived neonates as well correlation between thrombomodulin and CRP

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Table 3: ROC curve for clinical performance of thrombomodulin in diagnosis of septic shock and prediction of mortality.

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Figure 1: (a) Receiver operating characteristics curve for clinical performance of thrombomodulin in diagnosis of patients. (b) Accuracy of thrombomodulin as a predictor marker of mortality in septic shock.

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  Discussion Top


This work showed a predominance of males among patients with septic shock (75%). This goes with previous studies like those done by Bellig [14], Baltimore [15], and Higazi et al. [16]. Edwards[17] correlated this to X-linked immune-regulatory genes. Regarding complete blood count, our results revealed that there was a significant increase in WBCs among patients than controls. This agrees with Ahmed and Mahmoud [18], who found that there was a significant increase in WBC count in neonates with septic shock when compared with a control group. This is also consistent with El-Mazary et al.[19] who found that WBCs were significantly higher among patients than controls. Mehta et al.[20] reported that increase in the total leukocyte count could possibly be owing to the release of various growth factors and cytokines such as granulocyte colony stimulating factor, granulocyte/macrophage colony stimulating factor, interleukin-3, and interleukin-6, which stimulate bone marrow. Band cells may increase owing to rapid production. This finding was comparable with that of the studies done by Srinivasan and Harris [21]. However, Laurent et al.[22] found that the total leukocytic count had little value in discriminating infection in neonates. In contrast to our result, Mostafa et al.[23] reported that there was no statistically significant difference in WBCs between septic and control groups.

This study showed that there was a statistically significant increase in I/T ratio among patient group than controls. This agrees with Ahmed and Mahmoud[18] who found that I/T ratio was significantly higher in patients with neonatal sepsis. Our study revealed low mean count of platelets in the septic neonates when compared with the controls. This agrees with Shalaby et al. [24]. Moreover, Mondal et al.[25] found that platelet count was significantly lower among patients than controls. Hemoglobin level was statistically significantly decreased among patient group than controls. This agrees with Mondal et al. [25], who stated that low hemoglobin level was due to increased hemolysis of red blood cells caused by bacterial toxins in blood. The hematological scoring system (HSS) was significantly higher in neonates with septic shock than controls as expected. Regarding the causative organisms, gram-negative organisms were detected in 45% of patients. Klebsiella represented the commonest gram-negative organisms (30%). Gram-positive organisms represented 20% of the blood culture results, with Staphylococcus aureus found in 15%. Candida was cultured in 5% of patients. Our results go with Dzwonek et al. [26], in which nearly half of the positive blood cultures grew K. pneumoniae. Moreover, De Benedetti et al.[27] studied the isolated pathogens in confirmed sepsis and found that 47.5% were K. pneumoniae, 20% were Pseudomonas aeruginosa, 10% were Escherichia coli, 10% were C. albicans, 7.5% were S. aureus, and 5% were Enterococcus spp. This variation in the type of organism detected confirms that each NICU should check its preventing organisms periodically and evaluate culture method and supportive care practice [28]. Negative blood culture in the percentage of the septic patients may be explained by low levels of bacteremia or small volumes of blood obtained from sick infants or previous antibiotics treatment [29].

In our study, there was a statistically significant increase in serum soluble thrombomodulin level among patient group than controls. This was in agreement with Lin et al. [12], who found increased serum thrombomodulin levels in different sepsis syndromes and correlated with the disease severity. In our study, there was a statistically significant increase in serum soluble thrombomodulin levels among nonsurvived than survived patients. Serum soluble thrombomodulin level may be used as an early predictor of mortality in septic neonates. Lin et al. reported that the serum thrombomodulin level predicted mortality (hazard ratio 1.19) in adults with sepsis [30].

This study showed that there was a statistically significant positive correlation between serum soluble thrombomodulin level and quantitative CRP value. This is in agreement with Han et al. [30] who found that CRP and thrombomodulin are closely linked.

The current study showed the sensitivity of serum soluble thrombomodulin levels of 20 was 91.5%, the specificity was 84.7%, the PPV was 91.9%, the NPV was 88.3%, and the accuracy 92.94%. This was in agreement with Lin et al. [12], who demonstrated that thrombomodulin is a good diagnostic marker in neonates with septic shock. This also was in agreement with Katayama et al. [31], who found that thrombomodulin is an ideal tool for diagnosis of neonates with septic shock.

Finally, a cause of the lower sensitivity of the CRP due to the qualitative assay of CRP does not offer significant advantages on the leukocyte indexes. On the contrary, quantitative CRP values, particularly when repeated, are highly specific and have good sensitivity. In addition, serial measurements can be helpful in monitoring the response to treatment. Two serial CRP values less than 1 mg/dl, excluding the investigation soon after birth, carry a 99% negative predictive value. In spite of the reduced early sensitivity, CRP still remains the preferred index in most NICUs.


  Conclusion Top


Serum soluble thrombomodulin level has a more sensitivity diagnostic role in septic shock than quantitative CRP value. Higher serum soluble thrombomodulin levels predict the prognosis of septic shock.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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