|Year : 2004 | Volume
| Issue : 3 | Page : 147-152
The effect of recent trauma on serum complement activation and serum C3 levels correlated with the injury severity score
DK Sharma , AK Sarda , SA Bhalla , A Goyal , VN Kulshreshta
Department of Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi - 110 002, India
|Date of Submission||04-Jan-2004|
|Date of Acceptance||01-Mar-2004|
Department of Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi - 110 002, India
PURPOSE: The objective of this prospective pilot study was to estimate serum C3 levels and complement activation within 12 hours of injury and to correlate them with abbreviated injury score (AIS) so as to predict the outcome of injury in terms of mortality or sepsis. METHODS: The test group (n=30) of patients with < 12 hours of injury were assessed by the AIS-80 and compared with a control group (n=10). Serum C3 levels were estimated by the single radial immunodiffusion technique and complement activation by both two-dimensional and counter immuno-electrophoresis. Statistical analysis was performed using the correlation regression analysis and the minimum discrimination information statistics (MDIS) analysis. RESULTS: Serum C3 levels were not reduced in patients with injury severity score (ISS) < 12 (n=7). There was a statistically significant difference of serum C3 levels in patients with ISS between 12 and 29 (n=15) and in patients with ISS more than 29 (n=9). Complement activation also correlated well with ISS (p <0.05). Complement activation and serum C3 levels were found to influence subsequent development of septic complications in the post injury period, being significantly lower in patients who developed septic complications. Complement alterations in trauma patients were a direct result of the trauma since they were not seen in patients undergoing surgery. CONCLUSIONS: ISS is a good prognosticator of outcome of trauma and serum C3 levels and complement activation are good predictors for mortality and development of septic complications in recently injured patients. These may prove to be effective parameters in the management of the patients with injury.
|How to cite this article:|
Sharma D K, Sarda A K, Bhalla S A, Goyal A, Kulshreshta V N. The effect of recent trauma on serum complement activation and serum C3 levels correlated with the injury severity score. Indian J Med Microbiol 2004;22:147-52
|How to cite this URL:|
Sharma D K, Sarda A K, Bhalla S A, Goyal A, Kulshreshta V N. The effect of recent trauma on serum complement activation and serum C3 levels correlated with the injury severity score. Indian J Med Microbiol [serial online] 2004 [cited 2019 Oct 15];22:147-52. Available from: http://www.ijmm.org/text.asp?2004/22/3/147/11207
Immune defenses can be depressed following trauma. The immunocompromised state that follows trauma has been demonstrated in operated and traumatized patients, and in experimental animals. Inhibition of phagocytosis and suppression of humoral and cell mediated immunity are well recognized consequences of trauma., Many of these alterations have been shown to correlate with an increased rate of sepsis in the post traumatic and postoperative periods.,
Tissue injury is known to activate complement in both humans and experimental animals.,, Persistent complement depletion following trauma has been shown to correlate with the presence of nonviable tissue and sepsis. However, most aspects of the effects of mechanical trauma on complement function are still under investigation.
Over the years various injury severity scoring (ISS) systems have been devised. The abbreviated injury score (AIS) is a simple numerical method for grading and comparing injuries by severity. However, in an effort to overcome its main drawback of not reflecting the combined effect of multiple injuries, Baker et al introduced the ISS for summarizing multiple injuries in a single patient. Subsequently, in an effort to further improve prognostication of trauma, many modifications of scoring systems have evolved in an effort to include additional relevant information. The validity of various trauma scoring systems as a predictor of mortality and disability has been reported by several workers. ISS has also been reported to correlate with early metabolic response to trauma.,,
In a prospective study we analysed serum C3 levels and complement activation in relation to the recently injured patients as assessed by the ISS.
| ~ Materials and Methods|| |
Forty patients admitted to a single surgical unit of a teaching hospital over one year period were included in the study. The study was a prospective, randomized pilot study. The patients were divided into two groups. Group I included 10 non-injured subjects; three of these patients were studied preoperatively and another seven were studied postoperatively. Group II included 30 patients who were recently injured (i.e., within 12 hours of sustaining injury) with varying degrees of trauma assessed by the ISS based on AIS-80. There were six patients with ISS < 12, 15 with ISS between 12 and 29 and nine having ISS > 29. Patients with preexisting septic focus, elderly patients, and patients with head injury, burns or mainly penetrating injury were excluded from the study.
Patients < 50 years of age with injury sustained not before 12 hours and operated by same surgical team, were included in the study.
Patients with infections at other sites, with chronic diseases like diabetes mellitus, tuberculosis, chronic obstructive airway disease, and with presence of head injury or any pointer thereto, were not included in the study.
The injuries were scaled using the AIS. The time interval between sustaining injury or undergoing surgery and collection of blood sample was referred to as the “window period”.
Serum C3 levels were estimated by the single radial immunodiffusion technique, using the immuno-diffusion plates obtained from Behring-Werke, Germany. Complement activation was detected using crossed electrophoresis. Anti C3 antiserum (1x2ml) with 1D titer 1:32 was used in the study and obtained from Dia Med AG (Switzerland). Precautions taken to prevent in vitro complement activation consisted of using freshly obtained samples, avoiding preservatives and repeated freeze thawing, and excluding haemolysed, lipaemic and obviously contaminated samples.
Activation of complement was detected by two-dimensional electrophoresis and by counter immuno-electrophoresis. The results of C-activation were represented semi-quantitatively as: no activation - 0, equivocal activation - 1, definite activation - 2, strong activation - 3.
Patients were observed in the post operative or the post injury period for the development of septic complications, noting only the presence or absence of these complications without quantifying them.
Statistical analysis was carried out using the correlation regression analysis and the Minimum Discrimination Information Statistic (MDIS) analysis. This was done for three quantitative variables, namely, age, ISS and C3 levels. The significant correlations were chosen and their regression coefficients (R2) were examined. The value of R for a particular pair of variables gave the degree of dependence of one variable on the other, assuming a linear regression. In case this was significant, further regression analysis was carried out assuming a quadratic relationship between the two variables. The R2 values for the two types of correlations (linear and quadratic) were then compared. Based on this comparison, a linear or quadratic relationship was postulated. Equations for a significant linear or quadratic relationship was then computed.
| ~ Results|| |
In the control group, between subgroup A (n=3) in whom the blood was collected preoperatively and subgroup B (n=7) in whom blood was drawn within 12 hours of elective surgery, there was no significant difference in serum C3 levels or complement activation [Table - 1]. Only one patient had a septic complication (stitch abscess) following a modified radical mastectomy. None of the patients in group B showed complement activation by either of the two methods.
All 30 patients in the test group II were males. The patients were categorized into three ISS groups : I-1 (ISS = 12; n = 6); I-2 (12 < ISS = 29; n = 15) and I-3 (ISS> 29; n = 9). Four patients in the test group died; all the non-survivors had ISS > 41 (46.75 ± 3.42; range 41-50) against ISS 21.58 ± 7.6 (range 11-35) for survivors. A strong correlation between ISS and mortality was observed (MDIS value for the null hypothesis = 11.1952 highly significant at p < 0.05). Eleven of the 26 survivors developed septic complications. The mean ISS of the patients with sepsis (27.27 ± 6.2) was higher than that of the patients without any septic complications (17.4 ± 5.55). A statistically significant correlation between ISS and septic complications in the post-injury period was observed (MDIS value for the null hypothesis = 16.91 with p < 0.05).
In group II, 4 of the 30 patients died, three of them within 6 hours of presentation (average survival time = 3.8 + 0.9 hrs). One patient arrived at the emergency within one hour of sustaining injury, underwent surgical intervention (exploratory laparotomy, tube thoracostomy and debridement of the lower extremity wounds), and survived for 5 days, ultimately succumbing to septicemia. All of these patients had activated complement and marked depletion of serum C3 levels [Figure - 1]. Amongst the surviving patients in this group, the serum C3 levels were not reduced in patients with ISS = 12. There was a reduction of serum C3 levels in patients with ISS between 12 and 29 although the values were still within the normal limits. In patients with ISS = 29, there was a marked reduction in serum C3 levels and the difference between the latter two subgroups was significantly different [Table - 2]. Correlation regression analysis showed an inverse dependence of serum C3 levels on ISS [Table - 3]. Further analysis showed that this relationship could be quadratic. Scatter plot of C3 levels versus ISS and the linear regression line are represented in the figure. Complement activation also correlated well with ISS [Table - 4].
Eleven of the 26 surviving patients developed some septic complications in the post injury period, the most common being lung infection (80%), high grade fever (36%), abscess formation (27%), and wound dehiscence (27%). The mean serum C3 level among patients developing septic complications (68.8 + 7.4 mg/dL) was significantly lower than the mean serum C3 level in patients who did not develop septic complications (94.8 + 10.9 mg/dL).
Mean C3 level of nonsurvivors (56.0 ± 1.46 mg/dL) was significantly lower than that of survivors (84.23 ± 15.6 mg/dL). These two groups had comparable window periods (4.0 ± 1.7 hrs and 3.29 ± 1.8 hrs). A significant correlation was observed between complement activation and mortality (p < 0.05) [Table - 5]. All surviving patients with activated complement developed septic complications whereas only one patient developed this complication in the absence of complement activation.
| ~ Discussion|| |
Trauma induced immunosuppression has generated a lot of interest in recent times because of its observed influence on the prognosis of the injured patient. An established parameter in this post traumatic immunosuppression could be of great value to the clinician in predicting the outcome of the injury in the traumatized patients with a reasonable degree of accuracy especially since immunosuppression is reported to correlate well with the occurrence of septic complications in these patients.
The role of the complement system has constantly been under review ever since reports appeared that even nonimmunologic insults activate complement. The relationship in humans of acute injury to complement activation (as measured by a decrease in circulating activity) or the appearance in blood of activation products has been reported. In dogs, significant complement activation within two hours of injection of autologous homogenized muscle tissue has been observed. Extensive amounts of nonviable tissue have been found to be associated with significant depletion of C3, C4 and C5 within 24 hours after injury. Complement activation and a fall in C3 levels have been observed within 45 minutes of injury; the maximum fall in C3 levels and the greatest complement activation occurring several hours after injury. This early complement depletion after trauma has been supported in a later study., Thus, there are significant complement alterations in the early period following trauma and our findings are in concurrence with these reports. Further, the absence of significant complement alterations in the patients in Group I lends credence to the observation that these alterations are a direct result of injury.
A correlation appears to exist between the volume of nonviable tissue formed by injury and complement depletion. A minor trauma produces a less pronounced depletion of C3, C4 and C5 (22% of normal) compared to patients with extensive amounts of nonviable tissue (55% of normal)., Serum C3 levels have been reported to exhibit an inverse relationship with the ISS., The results of the present study substantiate these reports. An inverse quadratic dependence of C3 levels on ISS was found and the degree of complement activation correlated well with the ISS.
It is reported that in an injured patient surgical intervention contributes to the severity of injury leading to complement alteration; any correlation between the initial injury score and the outcome of the injury should thus be valid only if the influence of surgical trauma is insignificant. However, in the present study complement alterations were not observed in the operated patients in Group I. It can, therefore, be assumed that complement estimation at the time of presentation should be a reliable guide to the ultimate outcome of the disease.
The mechanism of complement activation and serum C3 depletion due to mechanical trauma is uncertain. In animals, and under experimental conditions, complement has been shown to be activated via the alternative pathway by endotoxin, injured tissue and homogenized muscle., Thus, non-viable tissue generated by mechanical trauma may cause the complement activation which in turn would cause serum C3 depletion. The larger amount of non-viable tissue generated by more severe injury may account for the greater degree of complement activation, as was observed in our patients.
Chances of bacteraemia increase in the presence of persistently reduced complement levels. Reduced concentration of complement components in burns is associated with increased incidence of infection; failure of serum C3 levels to return to normal within a specified period have been reported to invariably indicate septic complications. In the present study too, a definite correlation was observed between complement activation and serum C3 depletion, and the subsequent development of septic complications.
In conclusion, we believe that complement alterations in traumatized patients are a direct result of injury and are not observed in patients with surgical trauma. Further, serum C3 depletion and complement activation correlate well with the severity of injury and development of septic complications. Therefore, serum complement estimations may prove an effective prognostic parameter for the clinician in managing the injured patients.
| ~ References|| |
|1.||Catania RA, Chaudry IH. Immunological consequences of trauma and shock. Ann Acad Med Singapore 1999;28:120-132. |
|2.||Hecke F, Schmidt U, Kola A, Bautsch W, Klos A, Kohl J. Circulating complement proteins in multiple trauma patients-correlation with injury severity, development of sepsis, and outcome. Crit Care Med 1997;25:2015-2024. |
|3.||Huber-Lang MS, Younkin EM, Sarma JV, McGuire SR, Lu KT, Guo RF, et al. Complement-induced impairment of innate immunity during sepsis. J Immunol 2002;169:3223-3231. |
|4.||Kang HJ, Kim JH, Lee EH, Lee YK, Hur M, Lee KM, Hur M, Lee KM. Change of complement system predicts the outcome of patients with severe thermal injury. J Burn Care Rehabil 2003;24:148-153. |
|5.||Huber-Lang M, Sarma VJ, Lu KT, McGuire SR, Padgaonkar VA, Guo RF, et al. Role of C5a in multiorgan failure during sepsis. J Immunol 2001; 166: 1193-1199. |
|6.||Younger JG, Sasaki N, Waite MD, Murray HN, Saleh EF, Ravage ZA, et al. Detrimental effects of complement activation in hemorrhagic shock. J Appl Physiol 2001;90:441-446. |
|7.||Committee on Injury Scaling: the AIS-1980 Revision. American Association for Automotive Medicine, Arlington Heights, II.60005. |
|8.||Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-196. |
|9.||Rutledge R, Osler T, Emery S. The end of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival. J Trauma 1998;44:41-49. |
|10.||Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 1997;43:922-926. |
|11.||Fosse E, Pillgram-Larsen J, Svennevig JL, Nordby C, Skulberg A, Mollnes TE, Abdelnoor M. Complement activation in injured patients occurs immediately and is dependent on the severity of the trauma. Injury 1998;29:509-514. |
|12.||Sauaia A, Moore FA, Moore EE, Norris JM, Lezotte DC, Hamman RF. Multiple organ failure can be predicted as early as 12 hours after injury. J Trauma 1998;45:291-303. |
|13.||Copes WS, Lawnick M, Champion HR, Sacco WJ. A comparison of Abbreviated Injury Scale 1980 and 1985 versions. J Trauma 1988;28:78-86. [PUBMED] |
|14.||Mancini G, Carbonara AO, Heremans JF. Immunochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 1965;2:235-254. |
|15.||Srivastava N, Srivastava LM, Gupta SP. Studies on serum complement and IgE in bronchial asthma. Clin Allergy 1982;12:569-576. |
|16.||Laurell CB. Antigen-antibody crossed electrophoresis. Anal Biochem 1965;10:358-361. |
|17.||Rojas-Espinosa O, Estrada-Parra S, Serrano-Miranda E, Saul A, Latapi F. Antimycobacterial antibodies in diffuse lepromatous leprosy detected by counterimmunoelectrophoresis. Int J Lepr Other Mycobact Dis 1976;44:448-452. |
|18.||Ku HH, Kullback S. Loglinear models in contingency Table Analysis. Am Statistician 1974;28:115-122. |
|19.||Weiser MR, Williams JP, Moore Jr FD, Kobzik L, Ma M, Hechtman HB, et al. Reperfusion injury of ischemic skeletal muscle is mediated by natural antibody and complement. J Exp Med 1996;183: 2343-2348. |
|20.||Kapur MM, Jain P, Gidh M. The effect of trauma on serum C3 activation and its correlation with Injury Severity Score in man. J Trauma 1986;26:464-466. |
|21.||Kapur MM, Jain P, Gidh M. Estimation of serum complement and its role in management of trauma. World J Surg 1988;12:211-226. |
|22.||Nast-Kolb D, Waydhas C, Gippner-Steppert C, Schneider I, Trupka A, Ruchholtz S, et al. Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries. J Trauma 1997;42:446-455. |
|23.||Roumen RMH, Redl H, Schlag G, Zilow G, Sandtner W, Koller W, et al. Inflammatory mediators in relation to the development of multiple organ failure in patients after severe blunt trauma. Crit Care Med 1995;23:474-480. |