Biomarkers for Predicting the Use of Selective Hemosorption of Lipopolysaccharides in Sepsis and Septic Shock

Abstract. Sepsis and septic shock are one of the most life-threatening complications with high mortality, reaching 70% in the presence of endotoxemia. Extracorporeal removal of lipopolysaccharides (LPS) can improve treatment outcomes.

Aim. To evaluate the effectiveness of a group of biomarkers for predicting the use of selective hemosorption of lipopolysaccharides in patients with sepsis and septic shock.

Material and Methods. The study included 22 patients (12 men and 10 women) who were treated at the N.V. Sklifosovsky Research Institute for Emergency Medicine from April 2022 to November 2023. Patients were examined within 72 hours after the development of sepsis. In the case of sepsis or septic shock, with an endotoxin activity assay (EAA) ≥0.6, 11 patients underwent LPS-selective hemoperfusion (LPS-HP) procedures. The values before hemoperfusion were analyzed in Group 1 (11 points), if LPS-HP was not used — in Group 2 (22 points).

Results. The concentration of β-hydroxymyristic acid (β-HMA) in healthy volunteers was 2.95 (1.52; 5.08) ng/ml, and in patients with sepsis and septic shock 7.44 (4.50; 15.68) ng/ml (p=0.0001). The level of EAA was higher in Group 1 (0.780) compared to Group 2 (0.425), p=0.019. Differences were found between Groups 1 and 2 in the level of CRP: 290.0 and 166.5 mg/l, respectively (p=0.016). The percentage of lymphocytes (CD95+) was lower in Group 1 compared to Group 2: 24.8 and 44.2%, respectively (p=0.04). The SOFA score significantly correlated with the β-HMA level, the Spearman correlation coefficient r was 0.386, a moderate correlation was found between the β-HMA level and IL-6 (r=0.638), EAA and CRP (r=0.485), a negative correlation of CD 95+ lymphocytes with the level of IL-6 and CRP.

Conclusion. 1. The β-HMA level in patients with sepsis and septic shock is 2.5 times higher than the values in healthy volunteers (p=0.0001). In the ROC analysis, AUC was 0.817 (95% CI 0.702; 0.933, p=0.0001), the cutoff point was 3.26 ng/ml. 2. Using the threshold values EAA≥0.6 c.u. allowed us to identify patients requiring LPS-selective hemoperfusion with statistically significant differences in the level of endotoxin activity (p=0.019) and CRP (p=0.016). At the same time, in the high EAA group, there was a tendency for an increase in the absolute value of the LPS level tested by β-HMA, the SOFA score was 13 points, compared with 9.5 points in the low EAA group. 3. In the high EAA group, a decrease in CD 95+ lymphocytes was established (p=0.033), which, together with a tendency towards lower values of HLA-DR expression on monocytes, may indicate the development of immunoparalysis and immune system dysregulation in these patients. 4. The β-HMA level correlated with the severity of organ dysfunction according to the SOFA score and IL-6 levels. EAA positively correlates with the level of CRP, and negatively correlates with IL-6. A positive correlation of IL-6 with CRP and a negative correlation with the level of CD 95+ lymphocytes were established. CRP negatively correlated with CD 95+ lymphocytes.

1. Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395:200–211. PMID: 31954465 https://doi.org/10.1016/S0140-6736(19)32989-7

2. Liu YC, Yao Y, Yu MM, Gao YL, Qi AL, Jiang TY, et al. Frequency and mortality of sepsis and septic shock in China: a systematic review and meta-analysis. BMC Infectious Diseases. 2022;22(1):564. PMID: 35729526 https://doi.org/10.1186/s12879-022-07543-8

3. Vincent JL, Jones G, David S, Olariu E, Cadwell KK. Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. Crit Care. 2019;23(1):196. PMID: 31151462 https://doi.org/10.1186/s13054-019-2478-6

4. Seymour CW, Kennedy JN, Wang S, Chang CH, Elliott CF, Xu Z, et al. Derivation, Validation, and Potential Treatment Implications of Novel Clinical Phenotypes for Sepsis. JAMA. 2019;321(20):2003–2017. PMID: 31104070 https://doi.org/10.1001/jama.2019.5791

5. Kellum JA, Ronco C. The role of endotoxin in septic shock. Crit Care. 2023;27(1):400. PMID: 37858258 https://doi.org/10.1186/s13054-023-04690-5

6. Adamik B, Smiechowicz J, Jakubczyk D, Kübler A. Elevated Serum PCT in Septic Shock with Endotoxemia Is Associated with a Higher Mortality Rate. Medicine (Baltimore). 2015;94(27):e1085. PMID: 26166090 https://doi.org/10.1097/MD.0000000000001085

7. Hurley JC, Guidet B, Offenstad G, Maury E. Endotoxemia and mortality prediction in ICU and other settings: underlying risk and co-detection of gram negative bacteremia are confounders. Crit Care. 2012;16(4): R148. PMID: 22871090 https://doi.org/10.1186/cc11462

8. Lazanovich VA, Markelova EV, Smirnov GA, Smolina TP. Clinical Significance of Toll2, Toll4, CD14, and HLA-DR Expression on the Monocytes in Patients With Sepsis. Medical Immunology (Russia). 2015;17(3):221–228. (In Russ.) https://doi.org/10.15789/1563-0625-2015-3-221-228

9. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. PMID: 26903338 https://doi.org/10.1001/jama.2016.0287

10. Kirov MY, Kuzkov VV, Protsenko DN, Shchegolev AV, Babaev MA, Belotserkovskiy BZ, et al. Septic shock in adults: guidelines of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”. Annals of Critical Care. 2023;(4):7–42. (in Russ.) https://doi.org/10.21320/1818-474X-2023-4-7-42

11. Dellinger RP, Bagshaw SM, Antonelli M, Foster DM, Klein DJ, Marshall JC, et al.; EUPHRATES Trial Investigators. Effect of Targeted Polymyxin B Hemoperfusion on 28-Day Mortality in Patients with Septic Shock and Elevated Endotoxin Level: The EUPHRATES Randomized Clinical Trial. JAMA. 2018;320(14):1455–1463. PMID: 30304428 https://doi.org/10.1001/jama.2018.14618

12. Pais de Barros JP, Gautier T, Sali W, Adrie C, Choubley H, Charron E, et al.; Quantitative lipopolysaccharide analysis using HPLC/MS/MS and its combination with the limulus amebocyte lysate assay. J Lipid Res. 2015;56(7):1363–1369. PMID: 26023073 https://doi.org/10.1194/jlr.D059725.

13. Quadrini KJ, Patti-Diaz L, Maghsoudlou J, Cuomo J, Hedrick MN, McCloskey TW. A flow cytometric assay for HLA-DR expression on monocytes validated as a biomarker for enrollment in sepsis clinical trials. Cytometry B Clin Cytom. 2021;100(1):103–114. PMID: 33432735 https://doi.org/10.1002/cyto.b.21987

14. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009;301(23):2445–2452. PMID: 19531784 https://doi.org/10.1001/jama.2009.856

15. Payen DM, Guilhot J, Launey Y, Lukaszewicz AC, Kaaki M, Veber B, et al.; ABDOMIX Group. Early use of polymyxin B hemoperfusion in patients with septic shock due to peritonitis: a multicenter randomized control trial. Intensive Care Med. 2015;41(6):975–984. PMID: 25862039 https://doi.org/10.1007/s00134-015-3751-z

16. Rey S, Kulabukhov VM, Popov A, Nikitina O, Berdnikov G, Magomedov M, et al. Hemoperfusion using the LPS-selective mesoporous polymeric adsorbent in septic shock: a multicenter randomized clinical trial. Shock. 2023;59(6):846–854. PMID: 37018802 https://doi.org/10.1097/SHK.0000000000002121

17. Nakamura К, Okazaki T, Tampo A, Mochizuki K, Kanda N, Ono T, et al. The polymyxin-B direct hemoperfusion OPTimal Initiation timing with Catecholamine PMX-OPTIC study: A multicenter retrospective observational study. Artif Organs. 2024 Sep 18. PMID: 39291793 https://doi.org/10.1111/aor.14865 Online ahead of print.

18. Lee JH, Han WH, Im H, Kim JH. Effects of Early Initiation of Polymyxin B Hemoperfusion Therapy in Patients with Cancer with Refractory Septic Shock. J Clin Med. 2024;13(4):1009. PMID: 38398322 https://doi. org/10.3390/jcm13041009

19. Fujimori К, Tarasawa К, Fushimi К. Effectiveness of polymyxin B hemoperfusion for sepsis depends on the baseline SOFA score: a nationwide observational study. Ann Intensive Care. 2021;11(1):141. PMID: 34568980 https://doi.org/10.1186/s13613-021-00928-z

20. Osawa I, Goto T, Kudo D, Hayakawa M, Yamakawa K, Kushimoto S, et al. Targeted therapy using polymyxin B hemadsorption in patients with sepsis: a post-hoc analysis of the JSEPTIC-DIC study and the EUPHRATES trial. Crit Care. 2023;27(1):245. PMID: 37344804 https://doi.org/10.1186/s13054-023-04533-3

21. Payen D, Dupuis C, Deckert V, Pais de Barros JP, Rérole AL, Lukaszewicz AC, et al. Endotoxin Mass Concentration in Plasma Is Associated with Mortality in a Multicentric Cohort of PeritonitisInduced Shock. Front Med (Lausanne). 2021:8:749405. PMID: 34778311 https://doi.org/10.3389/fmed.2021.749405 eCollection 2021

22. Cotoia A, Parisano V, Mariotti PS, Lizzi V, Netti GS, Ranieri E, et al. Kinetics of different blood biomarkers during Polymyxin-B extracorporeal hemoperfusion in abdominal sepsis. Blood Purif. 2024;53(7):574–582. PMID: 38653211 https://doi.org/10.1159/000538870

23. Mengos AE, Gastineau DA, Gustafson MP. The CD14+HLA-DRlo/ neg Monocyte: An Immunosuppressive Phenotype That Restrains Responses to Cancer Immunotherapy. Front Immunol. 2019:10:1147. PMID: 31191529 https://doi.org/10.3389/fimmu.2019.01147 eCollection 2019.

24. Papadopoulos P, Pistiki A, Theodorakopoulou M, Christodoulopoulou T, Damoraki G, Goukos D, et al. Immunoparalysis: Clinical and immunological associations in SIRS and severe sepsis patients. Cytokine. 2017;92:83–92. PMID: 28119177 https://doi.org/10.1016/j.cyto.2017.01.012

25. Volk HD, Reinke P, Krausch D, Zuckermann H, Asadullah K, Muller JM, et al. Monocyte deactivation–rationale for a new therapeutic strategy in sepsis. Intensive Care Med. 1996;22 (Suppl. 4):S474–481. PMID: 8923092 https://doi.org/10.1007/BF01743727

26. Lavrik IN, Krammer PH. Life and Death Decisions in the CD95 System: Main Pro- and Anti-Apoptotic Modulators. Acta Naturae. 2009;1(1):80– 83. PMID: 22649588

27. Yoo H, Lee JY, Park J, Suh GY, Jeon K. Association of Plasma Levels of Fas Ligand with Severity and Outcome of Sepsis. Shock. 2021;56(4):544– 550. PMID: 33577245 https://doi.org/10.1097/SHK.0000000000001753

28. Asbun-Bojalil J, Huerta-Yepez S, Vega M. Correlation of the expression of YY1 and Fas cell surface death receptor with apoptosis of peripheral blood mononuclear cells, and the development of multiple organ dysfunction in children with sepsis. Mol Med Rep. 2017;15(5):2433– 2442. PMID: 28447715 https://doi.org/10.3892/mmr.2017.6310