Study of CD64 and HLA-DR as Early Detection Markers of Sepsis in Hepatic ICU Patients

Background and study aim: Sepsis is the most common cause of death in liver cirrhosis patients. Aim: Evaluation of neutrophil and monocyte CD64 and HLA-DR as early biomarkers predicting sepsis in liver cirrhosis. Patients and Methods: This case-control study involved 70 cirrhotic patients (35 with sepsis and 35 without) and 30 healthy individuals. Laboratory studies were performed, including CD64 and HLA-DR using flow cytometry along with sepsis index (SI). Results: Patients were mainly males (80%), aged 62.17 ± 7.56, and 64.69 ± 11.64 years in group 1&2 respectively.


INTRODUCTION
In intensive care units (ICUs), sepsis stands as a leading cause of morbidity and mortality, posing diagnostic challenges due to diverse comorbidities and underlying illnesses [1].Globally, sepsis, responsible for 48.9 million cases and 11.0 million deaths in 2017, remains a critical health concern, necessitating immediate attention, particularly in terms of early detection and innovative therapeutic approaches [2].Traditional diagnostic methods for sepsis, relying on serum analysis and molecular techniques, confront challenges due to vague symptoms and a lack of a definitive gold standard test for confirmation [3].Blood culture tests, commonly used for identifying infectious bacteria, are time-consuming and not always accurate.
Molecular methods, encompassing polymerase chain reaction and microarray, offer varying sensitivity and specificity.Despite the development of over 170 biomarkers for sepsis screening, only a few prove significant in practical applications [4].Cirrhosis was known as a precipitant of sepsis due to Bacterial overgrowth, increased intestinal permeability, and cirrhosis-associated immune dysfunction [CAID] predispose cirrhotic patients to bacterial infections, which in turn leads to four-fold increased mortality compared with non-cirrhotic patients [5].
Nevertheless, the need for early predictors of the occurrence of sepsis and mortality in patients with liver cirrhosis was only conducted by investigating various immune cell markers, including PMN CD64%, PMN CD64 MFI, PMN HLA-DR%, Mono CD64%, Mono CD64 MFI, Mono HLA-DR MFI, and Sepsis Index CD64, a high-affinity Fcγ receptor, exhibits heightened expression on neutrophils during systemic inflammatory response syndrome [SIRS], making it a promising early marker for bacterial infection [6].
Flow cytometry (FCM) emerges as a valuable diagnostic tool for immune-related disorders, offering insights into the systemic response to infection through profiling cytokines and surface markers (e.g., neutrophil CD64 and mHLA-DR).This was the impulse of the current study assessing the role of neutrophil CD64 and HLA-DR as markers of early detection of sepsis in liver cirrhosis patients.

Patients:
This case-control study was conducted on patients diagnosed with liver cirrhosis, either complicated with sepsis or not.Participants were recruited from outpatients, inpatients, and the Intensive Care Unit [ICU] within the Hepatology and Gastroenterology Department at the National Liver Institute, Menoufia University.Patients with cirrhosis were diagnosed based on clinical, laboratory, and radiological criteria [8].

Exclusion criteria
Participants meeting any of the following criteria: Patients younger than

Sampling
The antibody used in this study underwent quality control testing through immunofluorescent staining with flow cytometric analysis.The recommended amount of reagent was 5 μL of antibody per test [for a million cells in 100 μL staining volume or per 100 μL of whole blood].

Ethical Approval
The study protocol received approval from the ethical committee of our institution, and all selected patients provided informed consent before enrolment in the study.

Statistical analysis
The data was first coded and verified before its entry.The computer program Statistical Package for Social Sciences (SPSS) (ver.21)Chicago, USA was used for analyzing the collected data and for drawing figures.
Data expressed as mean ± standard deviation and number, percentage.Student-t-test and ANOVA tests were used to determine the significant difference for the numeric variable.Chi.-square was used to determine the significant values for categorical variables.Person's correlation was used for correlations between groups.P value is considered significant when P value < 0.05 and not significant when P value > 0.05.
The immune markers only Mono CD64% and Mono CD64 MFI were significantly elevated in septic patients than others (P=0.01)(table 3).

DISCUSSION
Exploring the diagnostic markers of early sepsis in cirrhotic patients with CAID had emphasized the significance of cell immune markers in timely detection in the ICU setting [17].The current study had demarcated significant elevations in ordinary sepsis markers like Creactive protein (CRP), PMN counts, lactate, and sepsis index (P=0.001) in ICU patients with sepsis.This is the usual picture of a cirrhotic septic patient in the ICU [18].CRP, being an acute-phase reactant produced by the liver during inflammation, is recognized as a valuable marker, known for its characteristic surge during infection, often rising significantly [18].Additionally, D'Abrantes.et al, emphasized the predictive value of plasma lactate levels in assessing the prognosis of sepsis [19].Hyperlactatemia and lactic acidosis, as observed in our study, may result from increased lactate production due to impaired tissue oxygenation, stemming from reduced oxygen delivery or disorders in oxygen utilization, ultimately leading to heightened anaerobic metabolism [20].
In this study, a significantly elevated total bilirubin (TB) in septic patients compared to the non-septic cirrhotic group, pointing to the role of sepsis in this elevation.Cholestasis-induced sepsis (CIS) differs from hepatic cellular dysfunctionassociated cirrhosis in its gradual onset post-ICU admission, marked by rising bilirubin, alkaline phosphatase, and gamma-glutamyl transferase levels.
Cirrhotic patients with sepsis demonstrated elevated ALBI scores, MELD (UNOS), and MELD-Na values in comparison to non-septic cases.This observation aligns with the understanding that sepsis is a significant milestone in the progression towards mortality, and all these scores serve as reliable indicators of short-term survival [21].Elevated bilirubin due to CIS contributes greatly to these elevations.Also, albumin, which is significantly reduced in cirrhosis-sepsis cases might be an important discriminator [22].Hypoalbuminemia is more common in sepsis patients, particularly those with septic shock, due to the leakage of proteinrich fluid caused by capillary dysfunction.Previous research indicates that low serum albumin levels are associated with higher mortality risk in sepsis [23][24] This study is a pioneer in presenting comprehensive findings on the correlation of immune-related markers with sepsis in a cirrhotic cohort, showcasing the potential of these markers as early indicators of early sepsis management in cirrhotic patients, emphasizing the broader relevance of the findings in critical care settings.

CONCLUSION
Conclusively, compared to traditional markers like CRP and S. Lactate, CD64 has comparable diagnostic value for distinguishing sepsis in cirrhotic patients with the advantageous timely character allowing prompt management for this high-risk critical cohort.

For all patients, the following procedures were conducted: History
18 years, acute pancreatitis, septic shock at the time of enrolment, severe organ failure at the time of Elsabaawy et al., Afro-Egypt J Infect Endem Dis 2024;14(3):xxx https://aeji.journals.ekb.eg/

Table 2 .
Comparison between the two studied groups of cirrhotic patients regarding the source of infection and inflammatory markers.

Table 3 .
Comparison between the three studied groups regarding Neutrophil, Monocytes and sepsis index of the

Table 4 :
Logistic regression analysis for predictors of sepsis group In summary, the combined use of CRP, S. Lactate, Mono CD64%, and Mono CD64 MFI has a higher AUC and shows promising sensitivity, specificity, PPV, and NPV, making it a potentially effective diagnostic tool for sepsis.SO, healthcare professionals may improve their ability to identify sepsis at an early stage, facilitating prompt and targeted interventions for improved patient outcomes.Furthermore, predictive models based on univariate and multivariate analyses highlighted key predictors for early sepsis detection in cirrhotic patients, emphasizing the significance of factors such as creatinine, urea, sodium, total bilirubin, PMN, lymphocytes, Mono CD64%, Mono CD64 MFI, CRP, S. Lactate In addressing the limitations of this study, such as the sample size and potential confounding factors, we delve into recommendations for future research.It is suggested that future investigations should focus on a more in-depth exploration of specific immune markers and their dynamics in larger-size studies on patients with cirrhosis.