Urolithiasis (2015) 43:41–47 DOI 10.1007/s00240-014-0716-6
ORIGINAL PAPER
Procalcitonin as an early diagnostic and monitoring tool in urosepsis following percutaneous nephrolithotomy Ji Zheng · Qianwei Li · Weihua Fu · Jing Ren · Siji Song · Guoxian Deng · Jiwei Yao · Yongquan Wang · Weibing Li · Junan Yan
Received: 21 January 2014 / Accepted: 27 August 2014 / Published online: 7 September 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract To evaluate the value of procalcitonin (PCT) as an early marker for diagnosis and differentiation of without urosepsis, urosepsis, severe urosepsis, and uroseptic shock following PCNL and the ability of PCT to assess the effectiveness of antibiotic therapy in patients with urosepsis. From June 2012 to August 2013, 267 patients undergoing PCNL for renal calculi, and who fulfilled selection criteria, were recruited into our study. The patients’ medical records were reviewed retrospectively. One of selection criteria was the scores of PCT and WBC were collected at operative day, postoperative day one, day two, day three, day five and day seven. The area under the ROC curve for the prediction of urosepsis was 0.960 for PCT and 0.634 for WBC. PCT concentrations were higher in patients with uroseptic shock versus severe urosepsis versus urosepsis versus without urosepsis following PCNL. WBC values showed no significant difference between patients with urosepsis, severe urosepsis and uroseptic shock following PCNL. With time, J. Zheng and Q. Li have been contributed equally to this manuscript J. Zheng · Q. Li · W. Fu · S. Song · G. Deng · J. Yao · Y. Wang · W. Li (*) · J. Yan (*) Urological Surgery Research Institute, Southwest Hospital, Third Military Medical University, Gao Tanyan Rd. 30, Chongqing 400038, China e-mail: [email protected] J. Yan e-mail: [email protected] J. Zheng e-mail: [email protected] J. Ren Service Center for Nursing, Southwest Hospital, Third Military Medical University, Gao Tanyan Rd. 30, Chongqing 400038, China
in patients with successfully treated urosepsis following PCNL, the PCT concentrations significantly declined and kept decreasing from postoperative day two to postoperative day seven and the WBC scores showed no significant change over the first postoperative 2 days and were decreased only after postoperative day three. PCT appears to be a useful early marker to diagnosis and discriminate urosepsis, severe urosepsis and uroseptic shock following PCNL. Daily PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in urosepsis following PCNL. Keywords Procalcitonin · Urosepsis · Percutaneous nephrolithotomy · Diagnostic accuracy
Introduction Percutaneous nephrostolithotomy (PCNL) is an important approach for large renal stone and upper ureteric calculi removal [1]. Urosepsis is a potentially catastrophic complication that can follow PCNL despite sterile preoperative urine and prophylactic antibiotics [2]. Charton et al. [3] addressed the risk of infection in patients without preoperative bacteriuria, finding 35 % postoperative urinary tract infection after PCNL. O’Keefe et al. [4] retrospectively reviewed a series of 700 patients undergoing upper tract manipulation, severe septicemia developed in nine patients and 66 % died. At the same center, Rao et al. [5] observed minor forms of septicemia in 37 % of 27 patients undergoing PCNL. According to Bag et al. [6] the risk of postPCNL urosepsis is 49 % in patients with larger stones and obstructed pelvicalyceal system. Delay in diagnosis and treatment of sepsis increases mortality, prolongs length of hospital stay, and increases
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costs [7], but these adverse consequences can be mitigated by early diagnosis and treatment of sepsis and septic complications [8], which highlight the need for early and reliable diagnostic biomarkers for sepsis. Furthermore, since there is a stepwise increase in mortality rates in the hierarchy from SIRS to septic shock [9], it might be also important that the useful marker could help to differentiate no sepsis, sepsis, severe sepsis and septic shock. Procalcitonin (PCT), a 116-aminoacid polypeptide, is a helpful biomarker for early diagnosis of sepsis and discrimination of sepsis, severe sepsis and septic shock [10]. PCT was also reported to be a valuable tool in monitoring the effectiveness of antibiotic therapy in patients with sepsis [11, 12]. To our knowledge, for patients with urosepsis following PCNL, the diagnostic value of PCT and whether PCT is a useful tool to assess the effectiveness of antibiotic therapy has not been previously reported. The objectives of this study were to evaluate the value of PCT as an early marker for diagnosis and differentiation of without sepsis, urosepsis, severe urosepsis, and uroseptic shock following PCNL and the ability of PCT to assess the effectiveness of antibiotic therapy in patients with urosepsis following PCNL.
Materials and methods From June 2012 to August 2013, 267 patients undergoing PCNL for renal calculi, and who fulfilled selection criteria, were recruited into our study. The patients’ medical records were reviewed retrospectively. Inclusion criteria were: the scores of PCT and WBC were collected at operative day and at postoperative day one, day two, day three, day five and day seven, age of 18 years or above, with normal preoperative PCT value, at least one symptom of UTI (dysuria, frequency, urgency, perineal pain, flank pain or costovertebral tenderness) and a positive nitrite dipstick test or leukocyturia as defined by a positive leukocyte esterase dipstick test or the presence of more than five leukocytes per high-power field in a centrifuged sediment before PCNL. Exclusion criteria were current treatment for urolithiasis or hydronephrosis, pregnancy, hemoor peritoneal dialysis, a history of kidney transplantation or known presence of polycystic kidney disease. After undergoing PCNL, they were divided into control (without urosepsis) group, urosepsis group, severe urosepsis group and uroseptic shock group. Consistent with the study of Bag et al. [6], perinephric collection, pleural effusion, chest infection, and thrombophlebitis were excluded before attributing the postoperative occurrence of SIRS (systemic inflammatory response syndrome) to urosepsis. Severe urosepsis and uroseptic shock following PCNL were defined according to criteria established by the 2001
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Urolithiasis (2015) 43:41–47
Consensus Conference [13]. The definition of severe urosepsis refers to urosepsis complicated by organ dysfunction. Uroseptic shock refers to a state of acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes. Hypotension is defined by a systolic arterial pressure below 90 mmHg, mean arterial pressure lower than 60, or a reduction in systolic blood pressure of more than 40 mmHg from baseline, despite adequate volume resuscitation, in the absence of other causes of hypotension. PCT was measured by an immunoluminometric assay (LUMItest PCT; Brahms Diagnostica, Berlin, Germany) whose detection limit was 0.05 ng/ml. WBC (leukocyte) counts were determined by using an automatic counter. The reference values were between 4,000 and 12,000 cells/ mm3. The scores of PCT and WBC were collected at operative day (6 h after PCNL) and 6:00 am at postoperative day one, day two, day three, day five and day seven. Statistical analysis Except when otherwise stated, continuous variables are presented as mean value and standard deviation for descriptive statistics. Comparison between groups was made by the nonparametric Mann–Whitney test. To determine the predictive ability of PCT and WBC for sepsis, data were analyzed by diagnostic efficiency derived from the receiveroperating characteristic (ROC) curve and area under the ROC curve. Youden’s index (sensitivity + specificity − 1) was used for determination of optimal cutoff values of the diagnostic tests. The sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV) for PCT cutoff levels were calculated. Statistical analysis was performed by using SPSS (SPSS Inc., Chicago, IL, USA, Version 17.0). Probability values
ORIGINAL PAPER
Procalcitonin as an early diagnostic and monitoring tool in urosepsis following percutaneous nephrolithotomy Ji Zheng · Qianwei Li · Weihua Fu · Jing Ren · Siji Song · Guoxian Deng · Jiwei Yao · Yongquan Wang · Weibing Li · Junan Yan
Received: 21 January 2014 / Accepted: 27 August 2014 / Published online: 7 September 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract To evaluate the value of procalcitonin (PCT) as an early marker for diagnosis and differentiation of without urosepsis, urosepsis, severe urosepsis, and uroseptic shock following PCNL and the ability of PCT to assess the effectiveness of antibiotic therapy in patients with urosepsis. From June 2012 to August 2013, 267 patients undergoing PCNL for renal calculi, and who fulfilled selection criteria, were recruited into our study. The patients’ medical records were reviewed retrospectively. One of selection criteria was the scores of PCT and WBC were collected at operative day, postoperative day one, day two, day three, day five and day seven. The area under the ROC curve for the prediction of urosepsis was 0.960 for PCT and 0.634 for WBC. PCT concentrations were higher in patients with uroseptic shock versus severe urosepsis versus urosepsis versus without urosepsis following PCNL. WBC values showed no significant difference between patients with urosepsis, severe urosepsis and uroseptic shock following PCNL. With time, J. Zheng and Q. Li have been contributed equally to this manuscript J. Zheng · Q. Li · W. Fu · S. Song · G. Deng · J. Yao · Y. Wang · W. Li (*) · J. Yan (*) Urological Surgery Research Institute, Southwest Hospital, Third Military Medical University, Gao Tanyan Rd. 30, Chongqing 400038, China e-mail: [email protected] J. Yan e-mail: [email protected] J. Zheng e-mail: [email protected] J. Ren Service Center for Nursing, Southwest Hospital, Third Military Medical University, Gao Tanyan Rd. 30, Chongqing 400038, China
in patients with successfully treated urosepsis following PCNL, the PCT concentrations significantly declined and kept decreasing from postoperative day two to postoperative day seven and the WBC scores showed no significant change over the first postoperative 2 days and were decreased only after postoperative day three. PCT appears to be a useful early marker to diagnosis and discriminate urosepsis, severe urosepsis and uroseptic shock following PCNL. Daily PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in urosepsis following PCNL. Keywords Procalcitonin · Urosepsis · Percutaneous nephrolithotomy · Diagnostic accuracy
Introduction Percutaneous nephrostolithotomy (PCNL) is an important approach for large renal stone and upper ureteric calculi removal [1]. Urosepsis is a potentially catastrophic complication that can follow PCNL despite sterile preoperative urine and prophylactic antibiotics [2]. Charton et al. [3] addressed the risk of infection in patients without preoperative bacteriuria, finding 35 % postoperative urinary tract infection after PCNL. O’Keefe et al. [4] retrospectively reviewed a series of 700 patients undergoing upper tract manipulation, severe septicemia developed in nine patients and 66 % died. At the same center, Rao et al. [5] observed minor forms of septicemia in 37 % of 27 patients undergoing PCNL. According to Bag et al. [6] the risk of postPCNL urosepsis is 49 % in patients with larger stones and obstructed pelvicalyceal system. Delay in diagnosis and treatment of sepsis increases mortality, prolongs length of hospital stay, and increases
13
42
costs [7], but these adverse consequences can be mitigated by early diagnosis and treatment of sepsis and septic complications [8], which highlight the need for early and reliable diagnostic biomarkers for sepsis. Furthermore, since there is a stepwise increase in mortality rates in the hierarchy from SIRS to septic shock [9], it might be also important that the useful marker could help to differentiate no sepsis, sepsis, severe sepsis and septic shock. Procalcitonin (PCT), a 116-aminoacid polypeptide, is a helpful biomarker for early diagnosis of sepsis and discrimination of sepsis, severe sepsis and septic shock [10]. PCT was also reported to be a valuable tool in monitoring the effectiveness of antibiotic therapy in patients with sepsis [11, 12]. To our knowledge, for patients with urosepsis following PCNL, the diagnostic value of PCT and whether PCT is a useful tool to assess the effectiveness of antibiotic therapy has not been previously reported. The objectives of this study were to evaluate the value of PCT as an early marker for diagnosis and differentiation of without sepsis, urosepsis, severe urosepsis, and uroseptic shock following PCNL and the ability of PCT to assess the effectiveness of antibiotic therapy in patients with urosepsis following PCNL.
Materials and methods From June 2012 to August 2013, 267 patients undergoing PCNL for renal calculi, and who fulfilled selection criteria, were recruited into our study. The patients’ medical records were reviewed retrospectively. Inclusion criteria were: the scores of PCT and WBC were collected at operative day and at postoperative day one, day two, day three, day five and day seven, age of 18 years or above, with normal preoperative PCT value, at least one symptom of UTI (dysuria, frequency, urgency, perineal pain, flank pain or costovertebral tenderness) and a positive nitrite dipstick test or leukocyturia as defined by a positive leukocyte esterase dipstick test or the presence of more than five leukocytes per high-power field in a centrifuged sediment before PCNL. Exclusion criteria were current treatment for urolithiasis or hydronephrosis, pregnancy, hemoor peritoneal dialysis, a history of kidney transplantation or known presence of polycystic kidney disease. After undergoing PCNL, they were divided into control (without urosepsis) group, urosepsis group, severe urosepsis group and uroseptic shock group. Consistent with the study of Bag et al. [6], perinephric collection, pleural effusion, chest infection, and thrombophlebitis were excluded before attributing the postoperative occurrence of SIRS (systemic inflammatory response syndrome) to urosepsis. Severe urosepsis and uroseptic shock following PCNL were defined according to criteria established by the 2001
13
Urolithiasis (2015) 43:41–47
Consensus Conference [13]. The definition of severe urosepsis refers to urosepsis complicated by organ dysfunction. Uroseptic shock refers to a state of acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes. Hypotension is defined by a systolic arterial pressure below 90 mmHg, mean arterial pressure lower than 60, or a reduction in systolic blood pressure of more than 40 mmHg from baseline, despite adequate volume resuscitation, in the absence of other causes of hypotension. PCT was measured by an immunoluminometric assay (LUMItest PCT; Brahms Diagnostica, Berlin, Germany) whose detection limit was 0.05 ng/ml. WBC (leukocyte) counts were determined by using an automatic counter. The reference values were between 4,000 and 12,000 cells/ mm3. The scores of PCT and WBC were collected at operative day (6 h after PCNL) and 6:00 am at postoperative day one, day two, day three, day five and day seven. Statistical analysis Except when otherwise stated, continuous variables are presented as mean value and standard deviation for descriptive statistics. Comparison between groups was made by the nonparametric Mann–Whitney test. To determine the predictive ability of PCT and WBC for sepsis, data were analyzed by diagnostic efficiency derived from the receiveroperating characteristic (ROC) curve and area under the ROC curve. Youden’s index (sensitivity + specificity − 1) was used for determination of optimal cutoff values of the diagnostic tests. The sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV) for PCT cutoff levels were calculated. Statistical analysis was performed by using SPSS (SPSS Inc., Chicago, IL, USA, Version 17.0). Probability values
