Routine & Cell Population Data from Sysmex XN-2000 provide useful information for Sepsis & DIC Chan-Jeoung Park Dept of Lab Medicine, Asan Medical Center April 4th, 2014 XN Contents Principle of XN Sepsis DIC Summary XN Flow Cytometry Side Fluorescent Light DNA/RNA WNR channel Side Scatter Light intracellular information Forward Scatter Light cell size information WDF channel WPC channel PLT-F channel RET channel Principle XN Flow Cytometry Channel WDF SLS-Hemoglobin Parameter Lysercell WDF Fluorocell WDF NEUT, LYMPH, MONO, EO, NEW IG WNR NEW Lysercell WNR Fluorocell WNR WBC, NRBC, BASO WPC NEW Lysercell WPC Fluorocell WPC Blast, HPC RET CELLPACK DFL Fluorocell RET PLT-F NEW CELLPACK DFL Fluorocell PLT PLT-F, IPF CELLPACK DCL or DST RBC, HCT, PLT-I SULFOLYSER & CELLPACK DCL or DST HGB RBC/ Direct Current PLT HGB Hydrodynamic Focusing Reagent CELLPACK DCL or DST RET, PLT-O, RET-He XN WDF Scattergram Blast Atypical Lymph Blast Abn_Lymph SFL IG LYMPH MONO NEUT + Baso EO Debris SSC LYMPH & MONO clusters can be separated more clearly. XN XN provides 36 Routine items & 57 CPD (Cell Population Data) items SEPSIS SEPSIS Sepsis-XN Biomarkers of Sepsis : C-reactive protein (CRP) Lactic acid Procalcitonin (PCT) Immature granulocytes (IG) Aim of Study: Evaluation of Routine & CPD items as Biomarkers for * Diagnosis of sepsis * Discrimination of sepsis severity * Prediction of outcome Methods: 280 normal controls 130 sepsis patients Sepsis-XN Bacteremia, Gram+:57(43.8%), Gram-:48(36.9%), mixed-type:25(19.3%) uncomplicated patients 29 complicated patients 101 36 Routine & 57 CPD (Cell Population Data) Items Results: Detection of Sepsis: Diff. btw NC & Sepsis patients (p<0.05) 80.5% (29/36) routine items 77.2% (44/57) CPD items => AUC values of ROC analysis for detection of sepsis>0.900, 28.8% (21/73) items: Hct, Hb, RBC count, RDW(CV, SD), IG% & No., neutrophil% & No., lymphocyte% & No., platelet count etc 2 granulocytic CPD items of neutrophil area on WDF scattergram NE-SFL: fluorescent light intensity of neutr. AUC 0.909 (> 51.6) NE-WY: fluorescent light distribution width of neutr. AUC 0.905 (> 641.0) NC Uncompl.sepsis 0.3 + 0.1 2.4 + 4.4 IG % 54.54 + 6.69 NE-SFL 47.19 + 2.64 NE-WY 611.81 + 45.49 784.76 + 148.50 Compl.sepsis P btw NC & Sepsis P btw Un & C 3.0 + 4.1 <0.001 0.555 58.44 + 10.02 <0.001 0.017 839.32 + 347.49 <0.001 0.220 Sensitivity Specificity IG % 84.5 % 98.2 % NE-SFL 71.3 % 96.8 % NE-WY 86.2 % 84.2 % Sepsis-XN Discrimination of Sepsis Severity Sepsis-XN Diff. btw uncomplicated sepsis (N=29) & complicated sepsis (N=101) 11.1% (4/36) routine items 15.8% (9/57) CPD items => not satisfactory PLT-F Uncompl. Compl. 181 + 109 102 + 73 P AUC Cut-off Sensitivity Specificity 0.001 0.744 <100 61.4% 79.3% 0.20 +0.10 0.12 + 0.08 0.001 0.743 <0.12 59.6% 82.1% Macro R% 5.01 +2.40 7.68 + 6.34 0.001 0.607 >4.60 55.4% 69.0% >57.6 39.0% 89.7% >1.2 72.9% 64.0% 103/uL PCT % NE-SFL 54.5 + 6.7 58.4 + 10.0 0.017 0.603 NE-WY 785 + 149 839 + 347 0.220 IG % 2.4 + 4.4 3.0 + 4.1 0.555 Lactic 1.54 +1.19 2.75 + 2.95 0.002 0.695 acid mmol/L Mortality at 28 days 2/29 (6.9 %) 21/101 (20.8%) 0.102 Predicting Mortality at 28 days after admission Diff. btw Survivors & Non-survivors 33.3% (12/36) routine items 15.8% (9/57) CPD items => not satisfactory Survivors N=107 Nonsurvivors N=23 RDW-CV (%) 15.3 + 1.9 17.9 + 3.1 0.001 0.766 >15.4 78.3 % 63.6 % RDW-SD (fL) 52.5 + 8.1 62.2 +14.5 0.005 0.732 >51.1 87.0 % 51.1 % PLT-F (103/uL) 128 + 91 0.005 0.677 < 54 52.2 % 84.1 % Lactic 1.89 + 5.10 5.10 + 4.95 0.005 0.712 acid (mmol/L) >3.20 47.8 % 92.9 % 81 + 62 P AUC Cut-off Sensitivity Specificity Sepsis-XN Conclusions: Sepsis-XN Sepsis affects most routine & CPD items obtai ned using Sysmex XN-2000. Neutrophil-related CPD NE-SFL & NE-WY provide useful information for Detecting Sepsis. Routine items, NE-SFL & NE-WY discriminate Sepsis Patients, however, these values cannot discriminate Sepsis Severity or predict Mortality at 28 days. D I C Disseminated Intravascular Coagulation Systemic activation of Coagulation & Inflammation : Activated Monocytes & Neutrophils, Fragmented RBC Microvascular thrombi in Multi-organs Derangement of Oxygen supply to tissues Multiple organ dysfunction syndrome Morphological changes of Activated Monocyte & Neutrophil detected using XN-2000 DIC-XN Aim of Study We investigated 36 routine CBC & 57 CPD items provided by XN-2000 to discover items reflecting morphological changes of blood cells in DIC, and to evaluate for diagnostic & prognostic markers of DIC Methods 280 normal controls 118 patients (ca, infection, hep. failure, hematologic malig. etc) 60: overt DIC (ISTH) 58: diseases ass c DIC, CRP >0.6 mg/dL, normal PT & aPTT Results DIC-XN Discriminate DIC from NC : AUC > 0.90 Discriminate DIC from non-DIC : AUC > 0.75 => RDW-CV (variance of RBC size), IG (immature granulocyte) count, Mo-X (lateral scattered light intensity of monocyte area on WDF, reflecting internal complexibility of monocytes) Median (range) RDW-CV IG count Mo-X Platelet P Cutoff value for diagnosis of DIC DIC Non-DIC NC 16.3 14.4 12.4 <0.001 15.7% (14.8-18.3) (13.5-15.3) (12.0-12.9) 2.0 0.3 0.0 <0.001 0.5/uL (0.9-5.1) (0.1-0.4) (0.0-0.0) 125.2 121.7 120.6 <0.001 120.7 <0.001 75x103/uL (123.5-127.2) (120.9-123.4) (119.7-121.9) 59 (41-109) 123 (79-202) 245 (215-282) 100 DIC-XN Mo-X IG count RDW-CV 80 Sensitivity Specificity RDW-CV 86.7 % 79.0 % IG count IG count 60.0 % Mo-X Platelets 80.0 % RDW-CV 88.0 % Platelet 58.3 % 79.3 % RDW-CV & IG 95.0 % 75.9% Platelet 60 Mo-X 40 20 75.9 % 0 0 20 40 60 100-Specificity 80 100 ROC curves for routine & CPD items for discrimination of DIC group from non-DIC group. Results Predict 28-day mortality in overt DIC DIC-XN *RDW-CV HR 8.404 p=0.047 *IG count HR 1.810 p=0.356 *Mo-X HR 1.471 p=0.541 *Platelet HR 0.958 p=0.968 Kaplan-Meier survival curves for overt DIC according to cutoff values (the best prognostic power to predict 28-day mortality) Conclusions DIC-XN RDW-CV, IG count & Mo-X showed better diagnostic power for diagnosis of DIC than platelet count. RDW-CV, IG count & Mo-X provide valuable information to diagnose & monitor DIC in a time- & cost-effective manner. RDW-CV might be a prognostic marker for overt DIC patients. Summary of XN evaluation Sepsis affects most routine & CPD items. Sepsis-XN Neutrophil-related CPD NE-SFL & NE-WY provide useful information for Detecting Sepsis. DIC-XN RDW-CV, IG count & Mo-X showed better diagnostic power for diagnosis of DIC than platelet count, provide valuable information to diagnose & monitor DIC in a time- & cost-effective manner. RDW-CV might be a prognostic marker for DIC pts. Diagnostic Hematology Section Dept. of Lab Medicine, Asan Medical Center, Seoul, Korea Thank you! Hyun Sook Chi Seongsoo Jang Young Jin Kim Young-Uk Cho Sang Hyuk Park
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