Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit

Introduction: Absolute lymphocytopenia has been reported as a predictor of bacteremia in medical emergencies. Likewise, the neutrophil-lymphocyte count ratio (NLCR) has been shown a simple promising method to evaluate systemic inflammation in critically ill patients. Methods: We retrospectively evaluated the ability of conventional infection markers, lymphocyte count and NLCR to predict bacteremia in adult patients admitted to the Emergency Department with suspected community-acquired bacteremia. The C-reactive protein (CRP) level, white blood cell (WBC) count, neutrophil count, lymphocyte count and NLCR were compared between patients with positive blood cultures (n = 92) and age-matched and gender-matched patients with negative blood cultures (n = 92) obtained upon Emergency Department admission. Results: Significant differences between patients with positive and negative blood cultures were detected with respect to the CRP level (mean +/- standard deviation 176 +/- 138 mg/l vs. 116 +/- 103 mg/l; P = 0.042), lymphocyte count (0.8 +/- 0.5 x 10(9)/l vs. 1.2 +/- 0.7 x 10(9)/l; P < 0.0001) and NLCR (20.9 +/- 13.3 vs. 13.2 +/- 14.1; P < 0.0001) but not regarding WBC count and neutrophil count. Sensitivity, specificity, positive and negative predictive values were highest for the NLCR (77.2%, 63.0%, 67.6% and 73.4%, respectively). The area under the receiver operating characteristic curve was highest for the lymphocyte count (0.73; confidence interval: 0.66 to 0.80) and the NLCR (0.73; 0.66 to 0.81). Conclusions: In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra cost

Considerable Variability Among Transplant Nephrologists in Judging Deceased Donor Kidney Offers

Introduction: Transplant clinicians may disagree on whether or not to accept a deceased donor kidney offer. We investigated the interobserver variability between transplant nephrologists regarding organ acceptance and whether the use of a prediction model impacted their decisions.Methods: We developed an observational online survey with 6 real-life cases of deceased donor kidneys offered to a waitlisted recipient. Per case, nephrologists were asked to estimate the risk of adverse outcome and whether they would accept the offer for this patient, or for a patient of their own choice, and how certain they felt. These questions were repeated after revealing the risk of adverse outcome, calculated by a validated prediction model. Results: Sixty Dutch nephrologists completed the survey. The intraclass correlation coefficient of their estimated risk of adverse outcome was poor (0.20, 95% confidence interval [CI] 0.08–0.62). Interobserver agreement of the decision on whether or not to accept the kidney offer was also poor (Fleiss kappa 0.13, 95% CI 0.129–0.130). The acceptance rate before and after providing the outcome of the prediction model was significantly influenced in 2 of 6 cases. Acceptance rates varied considerably among transplant centers. Conclusion: In this study, the estimated risk of adverse outcome and subsequent decision to accept a suboptimal donor kidney varied greatly among transplant nephrologists. The use of a prediction model could influence this decision and may enhance nephrologists’ certainty about their decision.</p

Dynamics of peripheral blood lymphocyte subpopulations in the acute and subacute phase of Legionnaires' disease

Absolute lymphocytopenia is recognised as an important hallmark of the immune response to severe infection and observed in patients with Legionnaires' disease. To explore the immune response, we studied the dynamics of peripheral blood lymphocyte subpopulations in the acute and subacute phase of LD. EDTA-anticoagulated blood was obtained from eight patients on the day the diagnosis was made through detection of L. pneumophila serogroup 1 antigen in urine. A second blood sample was obtained in the subacute phase. Multiparametric flow cytometry was used to calculate lymphocyte counts and values for B-cells, T-cells, NK cells, CD4+ and CD8+ T-cells. Expression of activation markers was analysed. The values obtained in the subacute phase were compared with an age and gender matched control group. Absolute lymphocyte count (×10⁹/l, median and range) significantly increased from 0.8 (0.4-1.6) in the acute phase to 1.4 (0.8-3.4) in the subacute phase. B-cell count showed no significant change, while T-cell count (×10⁶/l, median and range) significantly increased in the subacute phase (495 (182-1024) versus 979 (507-2708), p = 0.012) as a result of significant increases in both CD4+ and CD8+ T-cell counts (374 (146-629) versus 763 (400-1507), p = 0.012 and 119 (29-328) versus 224 (107-862), p = 0.012). In the subacute phase of LD, significant increases were observed in absolute counts of activated CD4+ T-cells, naïve CD4+ T-cells and memory CD4+ T-cells. In the CD8+ T-cell compartment, activated CD8+ T-cells, naïve CD8+ T-cell and memory CD8+ T-cells were significantly increased (p <0.05). The acute phase of LD is characterized by absolute lymphocytopenia, which recovers in the subacute phase with an increase in absolute T-cells and re-emergence of activated CD4+ and CD8+ T cells. These observations are in line with the suggested role for T-cell activation in the immune response to L

Relative expansion of lymphocyte subpopulations in the subacute phase compared to the acute phase of Legionnaires’ disease.

<p>RE, relative expansion: relative decrease or increase of the different absolute lymphocyte subpopulation counts in the acute versus the subacute phase compared to the relative increase of the absolute lymphocyte count in the same period; all data presented as mean and standard deviation; NK, natural killer cells; *Wilcoxon Signed Rank tests, significant difference p-value <0.05.</p

Baseline characteristics upon hospitalization of Legionnaires’ disease patients (n = 8).

<p>NA, not applicable; M, male, F, female; Temp, temperature (C) upon presentation to the ED; CRP, C-reactive protein (mg/l); WBC, white blood cell (10⁹/l); lymphocyte count expressed as 10⁹/l; X-ray, chest radiography results upon presentation to the ED; AB, adequate antibiotics within 12 hours after presentation; Duration of symptoms before ED presentation, ICU, Intensive Care Unit admission, LOS, length of stay.</p

CRP levels, WBC counts, absolute neutrophil -, absolute lymphocyte - and lymphocyte subpopulation counts in the acute and subacute phase of Legionnares’ disease (n = 8) and in age and gender matched healthy controls (n = 8).

<p>NA, not applicable; LD, Legionnaires’ disease; CRP, C-reactive protein (mg/l); WBC, white blood cell (10⁹/l); absolute neutrophil count expressed as 10⁹/l; NK, natural killer; absolute lymphocyte count expressed as 10⁹/l; lymphocyte subpopulation counts expressed as 10⁶/l; all data presented as median and range; *p-value Wilcoxon Signed Rank tests for differences in CRP levels, WBC counts, absolute neutrophil, absolute lymphocyte and lymphocyte subpopulation counts between the acute and subacute phase of LD; <b>^#</b>p-value Mann Whitney U tests for differences between the subacute phase of LD and healthy controls.</p

Flow cytometric analysis of activated CD4⁺ T-cells (top) and activated CD8⁺ T-cells (bottom) in the acute (left) and subacute phase (right) in one Legionnaires’ disease patient.

<p>Activated T-cells are defined as CD38+ and HLA-DR+ double positive cells and located in the upper right quadrants of each dot plot. The numbers represent the percentage of cells in the upper right quadrant.</p

Machine perfusion versus cold storage for preservation of kidneys from expanded criteria donors after brain death

P>The purpose of this study was to analyze the possible effects of machine perfusion (MP) versus cold storage (CS) on delayed graft function (DGF) and early graft survival in expanded criteria donor kidneys (ECD). As part of the previously reported international randomized controlled trial 91 consecutive heart-beating deceased ECDs - defined according to the United Network of Organ Sharing definition - were included in the study. From each donor one kidney was randomized to MP and the contralateral kidney to CS. All recipients were followed for 1 year. The primary endpoint was DGF. Secondary endpoints included primary nonfunction and graft survival. DGF occurred in 27 patients in the CS group (29.7%) and in 20 patients in the MP group (22%). Using the logistic regression model MP significantly reduced the risk of DGF compared with CS (OR 0.460, P = 0.047). The incidence of nonfunction in the CS group (12%) was four times higher than in the MP group (3%) (P = 0.04). One-year graft survival was significantly higher in machine perfused kidneys compared with cold stored kidneys (92.3% vs. 80.2%, P = 0.02). In the present study, MP preservation clearly reduced the risk of DGF and improved 1-year graft survival and function in ECD kidneys. (Current Controlled Trials number: ISRCTN83876362)