Introduction

The reports of an early and profound acquired immunodepression syndrome (AIDs) in ICU patients had gained sufficient credence to modify the paradigm of acute inflammation. However, despite several articles published on AIDs and its assessment by monocytic HLA-DR monitoring, several missing informations remained: 1—Which patients’ are more prone to benefit from mHLA-DR measurement, 2—Is the nadir or the duration of the low mHLA-DR expression the main parameter to consider? 3—What are the compared performances of leukocytes’ count analyses (lymphocyte, monocyte).

Material and method

We conducted an observational study in a surgical ICU of a French tertiary hospital. A first mHLA-DR measurement (fixed flow cytometry protocol) was performed within the first 3 days following admission and a 2nd, between day 5 and 10. The other collected parameters were: SAPS II and SOFA scores, sex, age, comorbidities, mortality and ICU-acquired infections (IAI). The associations between mHLA-DR and outcomes were tested by adjusted Fine and Gray subdistribution competing risk models.

Results

1053 patients were included in the study, of whom 592 had a 2nd mHLA-DR measurement. In this cohort, 223 patients (37.7%) complicated by IAI. The initial decrement in mHLA-DR was not associated with the later occurrence of IAI, (p = 0.721), however, the persistence of a low mHLA-DR (< 8000 AB/C), measured between day 5 and day 7, was associated with the later occurrence of IAI (p = 0.01). Similarly, a negative slope between the first and the second value was significantly associated with subsequent IAI (p = 0.009). The best performance of selected markers was obtained with the combination of the second mHLA-DR measurement with SAPSII on admission. Persisting lymphopenia and monocytopenia were not associated with later occurrence of IAI.

Conclusion

Downregulation of mHLA-DR following admission is observed in a vast number of patients whatever the initial motif for admission. IAI mostly occurs among patients with a high severity score on admission suggesting that immune monitoring should be reserved to the most severe patients. The initial downregulation did not preclude the later development of IAI. A decreasing or a persisting low mHLA-DR expression below 8000AB/C within the first 7 days of ICU admission was independently and reliably associated with subsequent IAI among ICU patients with performances superior to leukocyte subsets count alone.

中文翻译：

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监测一大群重症监护患者的循环单核细胞 HLA-DR 表达：与继发感染的关系

介绍

ICU 患者早期和严重的获得性免疫抑制综合征 (AID) 的报告已获得足够的可信度来改变急性炎症的范式。然而，尽管发表了几篇关于艾滋病及其通过单核细胞 HLA-DR 监测进行评估的文章，但仍有一些缺失的信息：1-哪些患者更容易从 mHLA-DR 测量中受益，2-是最低点还是低持续时间mHLA-DR表达主要考虑参数？3—白细胞计数分析（淋巴细胞、单核细胞）的比较性能如何。

材料和方法

我们在法国一家三级医院的外科 ICU 进行了一项观察性研究。在入院后的前 3 天内进行第一次 mHLA-DR 测量（固定流式细胞术方案），在第 5 天和第 10 天之间进行第二次测量。其他收集的参数是：SAPS II 和 SOFA 评分、性别、年龄、合并症、死亡率和 ICU 获得性感染 (IAI)。mHLA-DR 与结果之间的关联通过调整后的 Fine 和 Gray 子分布竞争风险模型进行了测试。

结果

1053 名患者被纳入研究，其中 592 人进行了第二次 mHLA-DR 测量。在这个队列中，223 名患者 (37.7%) 并发 IAI。mHLA-DR 的初始下降与后来 IAI 的发生无关（p  = 0.721），然而，在第 5 天和第 7 天之间测量的低 mHLA-DR（< 8000 AB/C）的持续存在是与后来发生的 IAI 相关（p  = 0.01）。同样，第一个和第二个值之间的负斜率与随后的 IAI 显着相关（p  = 0.009）。入院时将第二次 mHLA-DR 测量与 SAPSII 相结合，获得了选定标记的最佳性能。持续的淋巴细胞减少和单核细胞减少与后来发生的 IAI 无关。

结论

无论入院的初始动机如何，在大量患者中都观察到入院后 mHLA-DR 的下调。IAI 主要发生在入院时严重程度评分较高的患者中，这表明免疫监测应保留给最严重的患者。最初的下调并不排除 IAI 的后期发展。在 ICU 入院的前 7 天内 mHLA-DR 表达降低或持续低于 8000AB/C 与 ICU 患者的后续 IAI 独立且可靠地相关，其表现优于单独的白细胞亚群计数。