|Year : 2017 | Volume
| Issue : 1 | Page : 18-22
Could serum cytokines serve as predictors in outcome of thermal burn injuries
Ranjith J Babu, G. Karthikeyan, Nirmala Ponnambalam
Department of Burns, Plastic & Reconstructive Surgery, Government Kilpauk Medical College Hospital, Chennai, Tamilnadu, India
|Date of Web Publication||13-Dec-2017|
Dr Ranjith J Babu
(Plastic Surgery Postgraduate, Final Year), New No. 16 Ayyasamy Nagar, East Tambaram, Chennai 600059
Source of Support: None, Conflict of Interest: None
Introduction: Thermal burns cause ample havoc to human beings. Multidisciplinary approach plays a pivotal role in reducing morbidity and mortality. Justifiably tailored intervention plays cardinal role to offset further systemic derangements. This study is undertaken to assess whether serum cytokines could serve as predictors in the outcome of thermal burn injuries.
Materials and Methods: Prospective study was conducted in 30 patients during the period of January 2016 to December 2016. The use of proinflammatory cytokines interleukin-1B (IL-1B), interleukin-6 (IL-6) was quantitatively estimated on postburn day 4 and every 5 days thereafter. The proinflammatory cytokine levels were high in patients who had higher percentage total body surface area burns.
Results: Temporal cytokine profiling revealed significant difference in the pattern of patients who survived with those who had a fatal outcome. Reduction in cytokine levels IL-1B, IL-6 in the survival group over the course of treatment and observation of incremental temporal expression in cytokine levels in the nonsurvival group indicate its recalcitrant nature on treatment and thereby dictate catastrophic outcome.
Discussion: The local inflammation in thermal burns releases proinflammatory cytokines systemically which leads to progression in systemic inflammatory response syndrome which can prove detrimental.
Conclusion: Temporal analysis of cytokines could serve as prediction analysis in the outcome of thermal burn injuries because this sequence goes awry with higher percentage of burn area. This could dictate morbidity and mortality which gain significance in the overall outcome of patient.
Keywords: Burn injury, cytokines, inflammation
|How to cite this article:|
Babu RJ, Karthikeyan G, Ponnambalam N. Could serum cytokines serve as predictors in outcome of thermal burn injuries. Indian J Burns 2017;25:18-22
|How to cite this URL:|
Babu RJ, Karthikeyan G, Ponnambalam N. Could serum cytokines serve as predictors in outcome of thermal burn injuries. Indian J Burns [serial online] 2017 [cited 2018 Jul 16];25:18-22. Available from: http://www.ijburns.com/text.asp?2017/25/1/18/217045
| Introduction|| |
Burn wound is a serious injury inflicted on mankind. It destroys the silhouette of the body and cutaneous barrier. Burn wound elicits systemic response to an alarming degree. It hardly spares any of the immune mechanism, and it quite convincingly upregulates many inflammatory mediators. Burn injury induces inflammatory response which is characterized by the activation of inflammatory pathways and release of cytokines. In this complex milieu, the balance of proinflammatory and anti-inflammatory cytokines is essential for controlled inflammation. Both the pleiotrophy of cytokine response wherein a single cytokine can influence multiple cell type and the redundancy of cytokine response wherein multiple cytokines have similar nature of biological effect on a single cell are of primary importance. Herein, this uncontrolled expression of proinflammatory cytokine indeed plays a formidable role and opens up newer avenues in progression of systemic inflammatory response syndrome (SIRS) and in its sequelae results in multiorgan damage and point toward mortality.
Interleukin-1 is considered as an endogenous pyrogen that has a capability to induce acute phase reactions., This also has an ability to regulate interleukin-6 (IL-6) and dictate its further progression. IL-6 has myriad functions that include antibody production, T cell activation and upregulation of acute phase proteins.,,,,
To analyze the temporal cytokine profiling of interleukin-1B (IL-1B), together with IL-6 in post-thermal burn injury state and to determine whether it could serve as a prediction marker in the outcome of thermal burn injuries.
| Materials and methods|| |
Settings and design
Prospective experimental design
A prospective study was conducted involving 30 patients with 30–50% total body surface area (TBSA) burns. The study was conducted after getting the approval of the Institutional Ethics Committee reference number 06/2015. Study conducted during the period of January to December 2016. All the patients were studied with respect to a protocol that consists of personal data, that is, age and sex, date of admission, date of surgery, date of discharge/date of death [Table 1].
Inclusion criteria were hospitalization within 24 h of burn, burn surface 30–50% TBSA burns, mixed burns, survival after the first three days overcoming state of hypovolemic shock, absence of trauma associated with burns, and 25–40 years both male and female.
Exclusion criteria were burn surface <30 and >50% TBSA burns, <25 to >40 years, and comorbid factors (type II DM, systemic hypertension, hepatic dysfunction, renal dysfunction, and epilepsy).
Quantitative estimation of proinflammatory cytokines IL-1B and IL-6 in 30–50% TBSA burns on postburn day (PBD) 4 and every 5 days thereafter.
Estimation of quantitative cytokine levels
Blood was drawn into blood collection tubes which contained ethylenediaminetetraacetic acid. The collected blood was centrifuged at 750 rpm for 20 min. The plasma was removed and 1 ml aliquots stored at −70°C. Cytokines were detected by enzyme-linked immunosorbent assay (ELISA). The IL-1B and IL-6 ELISA kits were purchased from R&D System (Minneapolis, MN) according to the manufacturer’s instructions. All the assays employed the quantitative sandwich enzyme immunoassay technique analyzed by SPECTROMAX ELISA READES, Molecular Devices (USA). Reagents used were polyclonal antibody against IL-1 and IL-6 conjugated to horseradish peroxidase.
A monoclonal antibody specific for IL-1B and IL-6 was precoated onto a microplate. Standards and samples were pipetted into the wells, and interleukin present was bound by the immobilized antibody. After washing away any unbound substances, an enzyme-linked specific antibody for IL-1B and IL-6 was added to the wells. Following washes to remove any unbound antibody-enzyme reagent, a substrate solution was added to the wells. After an incubation period, corresponding antibodies to the interleukin were utilized. The color developed was in proportion to the amount of interleukin bound in the initial step. The optical density was measured at 450 nm. The results of the cytokines IL-1B were expressed as pg/ml and IL-6 was ng/ml.
Statistical analysis used
The mean value, standard deviation, and standard error of mean were computed for all variables. The statistical significance was determined by unpaired Student t test. A P value <0.05 was considered as significant.
| Results|| |
[Table 1] reveals that out of 30 patients, seven had mortality. Out of those seven patients, five patients had deep inhalational burn injury. Out of 23 survivors, four had inhalational burn injury which was inconsequential. Nonsurvivor group had seven patients, survivor group treated conservatively were five, and survivor group surgically intervened were 18 patients.
The mortality cases ranged from 44 to 50% TBSA burns. They could not be surgically intervened because five patients had deep inhalational burns. Also, deep burn comprised a larger portion of the mixed burns, and their hemodynamics were awry and recalcitrant to treatment modality. Eighteen cases were surgically intervened. Other cases were treated conservatively in the survivor group.
Temporal profiling of cytokines and behavioral dynamics
IL-1B was measured on PBD 4 and every 5 days thereafter.
[Figure 1] reveals that mean baseline IL-1B ranged from 4.82 ± 0.26 to 5.63 ± 0.17 pg/ml in all the three groups studied on PBD 4. The average value of the patients in each group is depicted at various time points.
|Figure 1: Interleukin-1B showed an increase in all the three groups from PBD 4 to PBD 9. The incremental increase is found in nonsurvivors group. In both the survivors groups, there is a decline in the quantitative estimation of interleukin-1B. PBD = postburn day, surgery = debridement and split skin grafting|
Click here to view
On day 9, IL-1B in survivor patients treated conservatively was 7.32 ± 0.12 pg/ml, survivors treated surgically was 7.63 ± 0.36 pg/ml, and nonsurvivors was 6.84 ± 0.18 pg/ml. On day 14, the IL-1B survivors treated conservatively was 6.13 ± 0.28 pg/ml, and IL-6 in survivors treated surgically 4.94 ± 0.25 pg/ml and that for nonsurvivors was 10.92 ± 0.12 pg/ml. On PBD 19, survivors treated conservatively was 4.35 ± 0.17 pg/ml, survivors treated surgically was 2.24 ± 0.05 pg/ml, and nonsurvivors was 16.27 ± 0.16 pg/ml. The P values were <0.05 which is statistically significant.
[Figure 2] reveals that mean baseline IL-6 ranged from 13.23 ± 0.11 to 14.14 ± 0.19 ng/ml in all the three groups studied on PBD 4. The average value of the patients in each group is depicted at various time points.
|Figure 2: Interleukin-6 showed an increase in all the three groups from PBD 4 to PBD 9. The incremental increase is found in nonsurvivors group. In both the survivors groups, there is a decline in the quantitative estimation of interleukin-6. PBD = postburn day, surgery = debridement and split skin grafting|
Click here to view
On day 9, IL-6 in survivor patients treated conservatively was 16.18 ± 0.22 ng/ml, survivors treated surgically was 16.68 ± 0.12 ng/ml, and nonsurvivors was 15.73 ± 0.15 ng/ml. On day 14, the survivors treated conservatively was 13.42 ± 0.38 ng/ml, survivors treated surgically 10.16 ± 0.15 ng/ml, and nonsurvivors was 19.96 ± 0.26 ng/ml. On PBD 19, IL-6 in the survivors treated conservatively was 10.96 ± 0.23 ng/ml, survivors treated surgically was 7.74 ± 0.12 ng/ml, and nonsurvivors was 24.52 ± 0.28 ng/ml. The P values were <0.05 which is statistically significant.
Both the proinflammatory cytokines IL-1B and IL-6 showed elevated trends on PBD 9 in all these three groups. In the nonsurvivor group, there was an incremental upregulation in cytokine level expression with onset and progression of sepsis which pointed toward mortality.
Correlation between interleukin-1B, interleukin-6, and % total body surface area burn
There was an upregulation of IL-1B and IL-6 with higher % TBSA burn. The picture revealed an incremental upregulation in its expression with no tendency to decline in mortality cases.
| Discussion|| |
Local inflammation in burns releases pro-inflammatory cytokines systemically. If cytokine levels are increased, there is a high chance of progression in SIRS to higher categories. This SIRS if it goes unchecked could lead to sepsis, and in its unchecked progression leads to multiple organ dysfunction syndrome/multi-organ failure. Hence the temporal analysis of cytokines gains importance because it could dictate the outcome of the burn injury.
Out of seven cases that had mortality, five cases had significant inhalational burn injury. Out of 23 survivors, four patients had inhalational burn injury which was inconsequential. Death in burn injury is multifactorial. One significant entity is the onset of sepsis and progression of sepsis leading to irreversible septic shock and eventually death. All the 30 patients had mixed burns. In all the seven cases that had mortality, there was onset of sepsis 1 week after burn injury and its subsequent progression being recalcitrant to treatment.
In 40% TBSA burns and above, there was deep inhalational burns in five patients, and the deep burn injury was predominant in the mixed burn injury. Those patients were not in a position to be optimized for surgery. Less than 40% TBSA burn patients were evaluated whether they need to undergo surgery or not. Those patients who had an indication for surgery were subjected for the same. Others were conservatively managed. Since the patients had to be stabilized and optimized for undergoing surgery, it required a mean period of around 2 weeks. Hence they could not be subjected to surgery before that timeframe. The response to the treatment was reflected in the IL-1B, IL-6 quantitative assessment.
Both the pro-inflammatory cytokine expressions IL-1B [Figure 1] and IL-6 [Figure 2] were increased from PBD 4 to PBD 9 in both survivor group and nonsurvivor group [Figure 2]. But in the survivor group, there is a considerable decrease in the expression from PBD 9 to PBD 14 [Figure 2]. The surgical intervention (debridement and grafting) also did contribute to the decrease in the pro-inflammatory cytokine expression which was statistically significant (P < 0.05). Since the survivor group responded to the treatment modality whether conservative or surgical, the temporal expression of pro-inflammatory cytokines was well blunted. This outcome analysis dictates a strong relationship of increased and incremental temporal expression throughout with no decline in pro-inflammatory cytokines pointing toward mortality, since the nonsurvivors did not respond to treatment.,,
| Conclusion|| |
In summary, the pro-inflammatory cytokines are upregulated as depicted in the temporal cytokine profiling in thermal burns. Strong correlation of incremental temporal expression with no tendency to decline pointing toward mortality was well established. Hence cytokines could serve as predictors for the outcome of thermal burn injuries.
We would like to thank the Department of Microbiology, Central Leather Research Institute, Adyar, Chennai for their valuable cooperation in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jewo PL, Fadeyibi IO. Progress in burns research: A review of advances in burn pathophysiology. Ann Burns Fire Disasters 2015;28:105-15.
Elias JA, Freundlich B, Kern JA, Rosenbloom J. Cytokine networks in the regulation of inflammation and fibrosis in the lung. Chest 1990;97:1439-45.
Ozaki K, Leonard WJ. Cytokine and cytokine receptor pleiotrophy and redundancy. J Biol Chem 2002;277:29355-8.
Finnerty CC, Herndon DN, Chinkes DL, Jeschke MG. Serum cytokine differences in severely burned children with and without sepsis. Shock 2007;27:4-9.
Jeschke MG, Gauglitz GG, Kulp GA, Finnerty CC, Williams FN, Kraft R et al.
Long-term persistence of the pathophysiologic response to severe burn injury. PLoS One 2011;6:e21245.
Dinarello CA. Interleukin-I. Rev Infect Dis 1984;6:51-95.
Drost AC, Larsen B, Aulick HL. Interleukin-1 (IL-1) activity in the serum of burned rats. FASEB J 1989;3:A319.
Houssiau FA, Coulie PG, Van Snick J. Distinct roles of IL-1 and IL-6 in human T cell activation. J Immunol 1989;143:2520-4.
Marinkovic S, Jahreis GP, Wong GG, Baumann H. IL-6 modulates the synthesis of a specific set of acute phase plasma proteins in vivo
. J Immunol 1989;142:808-12.
Ertel W, Faist E, Nestle C, Hueltner L, Storck M, Schildberg FW. Kinetics of interleukin-2 and interleukin-6 synthesis following major mechanical trauma. J Surg Res 1990;48:622-8.
Nijaten MW, de Groot ER, ten Duis HJ, Klasen HJ, Hack CE, Aarden LA. Serum levels of interleukin-6 and acute phase responses. Lancet 1987;2:921.
Drost AC, Burleson DG, Cioffi WG Jr, Jordan BS, Mason AD Jr, Pruitt BA Jr. Plasma cytokines following thermal injury and their relationship with patient mortality, burn size and time postburn. J Trauma 1993;35:335-9.
Finnerty CC, Jeschke MG, Herndon DN, Gamelli R, Gibran N, Klein M et al.
Temporal cytokine profiles in severely burned patients. Mol Med 2008;14:553-60.
Hur J, Yang HT, Chun W, Kim JH, Shin SH, Kang HJ et al.
Inflammatory cytokines and their prognostic ability in cases of major burn injury. Ann Lab Med 2015;35:105-10.
Gauglitz GG, Finnerty CC, Herndon DN, Mlcak RP, Jeschke MG. Are serum cytokines early predictors for the outcome of burn patients with inhalation injuries who do not survive. Crit Care 2008;12:R81.
[Figure 1], [Figure 2]