Log in | Register

Genetic polymorphisms in the endotoxin receptor may influence platelet count as part of the acute phase response in critically ill children

Rachel S. Agbeko| John W. Holloway| Meredith L. Allen| Shu Ye| Katy J. Fidler| John Pappachan| Allan Goldman| David Pontefract| John Deanfield| Nigel J. Klein| Mark J. Peters
Pediatric Original
Volume 36, Issue 6 / June , 2010

Pages 1023 - 1032

Abstract

Purpose

To determine if common polymorphisms in the endotoxin recognition complex influence the acute phase response as determined by the development of the systemic inflammatory response syndrome (SIRS) and platelet count on admission.

Methods

This was a prospective observational cohort study. Paediatric intensive care patients (n = 913) were genotyped for common functional polymorphisms in the endotoxin recognition complex, including Toll-like receptor 4 (TLR4). We also selected potentially confounding polymorphisms in other genes of the innate immune system. SIRS was defined by age-specific consensus criteria. Platelet counts were recorded on admission.

Results

The development of SIRS was primarily determined by the nature of the insult, but carriers of TLR4 variant alleles had lower platelet counts than children with wild-type genotype [mean ± standard error of the mean (SEM) 143 ± 7 vs. 175 ± 4; p = 0.0001)—independent of other innate immune system polymorphisms. These findings were validated using a patient cohort of 1,170 adults with coronary artery disease. Carriers of TLR4 polymorphisms with a history of myocardial infarction (n = 573) had lower platelet counts than those with the wild-type genotype (217 ± 7 vs. 237 ± 2.8; p = 0.021).

Conclusions

Our results show that TLR4 variant alleles are associated with lower platelet counts across a range of ages and precipitating insults but that they do not influence the incidence of SIRS. This result may reflect redundancy and ‘robustness’ in the pathways leading to SIRS or the lack of specificity of this endpoint. Platelet count may vary with TLR4 genotype because it may be sufficiently sensitive and more linearly related to inflammation than other markers or, alternatively, there may be a direct TLR4-mediated platelet effect.

Keywords

References

  1. Zarember KA, Godowski PJ (2002) Tissue expression of human Toll-like receptors and differential regulation of Toll-like receptor mRNAs in leukocytes in response to microbes, their products, and cytokines. J Immunol 168:554–561
    • View reference on PubMed
  2. Dauphinee SM, Karsan A (2006) Lipopolysaccharide signaling in endothelial cells. Lab Invest 86:9–22
    • View reference on publisher's website
    • View reference on PubMed
  3. Andonegui G, Kerfoot SM, McNagny K, Ebbert KV, Patel KD, Kubes P (2005) Platelets express functional Toll-like receptor-4. Blood 106:2417–2423
    • View reference on publisher's website
    • View reference on PubMed
  4. Aslam R, Speck ER, Kim M, Crow AR, Bang KW, Nestel FP, Ni H, Lazarus AH, Freedman J, Semple JW (2006) Platelet Toll-like receptor expression modulates lipopolysaccharide-induced thrombocytopenia and tumor necrosis factor-alpha production in vivo. Blood 107:637–641
    • View reference on publisher's website
    • View reference on PubMed
  5. Clark SR, Ma AC, Tavener SA, McDonald B, Goodarzi Z, Kelly MM, Patel KD, Chakrabarti S, McAvoy E, Sinclair GD, Keys EM, Allen-Vercoe E, Devinney R, Doig CJ, Green FH, Kubes P (2007) Platelet TLR4 activates neutrophil extracellular traps to ensnare bacteria in septic blood. Nat Med 13:463–469
    • View reference on publisher's website
    • View reference on PubMed
  6. Takeda K, Kaisho T, Akira S (2003) Toll-like receptors. Annu Rev Immunol 21:335–376
    • View reference on publisher's website
    • View reference on PubMed
  7. Arcaroli J, Silva E, Maloney JP, He Q, Svetkauskaite D, Murphy JR, Abraham E (2006) Variant IRAK-1 haplotype is associated with increased nuclear factor-kappaB activation and worse outcomes in sepsis. Am J Respir Crit Care Med 173:1335–1341
    • View reference on publisher's website
    • View reference on PubMed
  8. Fidler KJ, Wilson P, Davies JC, Turner MW, Peters MJ, Klein NJ (2004) Increased incidence and severity of the systemic inflammatory response syndrome in patients deficient in mannose-binding lectin. Intensive Care Med 30:1438–1445
  9. Stephens RC, Fidler K, Wilson P, Barclay GR, Mythen MG, Dixon GL, Turner MW, Klein NJ, Peters MJ (2006) Endotoxin immunity and the development of the systemic inflammatory response syndrome in critically ill children. Intensive Care Med 32:286–294
  10. Rallabhandi P, Bell J, Boukhvalova MS, Medvedev A, Lorenz E, Arditi M, Hemming VG, Blanco JC, Segal DM, Vogel SN (2006) Analysis of TLR4 polymorphic variants: new insights into TLR4/MD-2/CD14 stoichiometry, structure, and signaling. J Immunol 177:322–332
    • View reference on PubMed
  11. Arbour NC, Lorenz E, Schutte BC, Zabner J, Kline JN, Jones M, Frees K, Watt JL, Schwartz DA (2000) TLR4 mutations are associated with endotoxin hyporesponsiveness in humans. Nat Genet 25:187–191
    • View reference on publisher's website
    • View reference on PubMed
  12. van der Graaf C, Kullberg BJ, Joosten L, Verver-Jansen T, Jacobs L, van der Meer JW, Netea MG (2005) Functional consequences of the Asp299Gly Toll-like receptor-4 polymorphism. Cytokine 30:264–268
    • View reference on publisher's website
    • View reference on PubMed
  13. Imahara SD, O’Keefe GE (2004) Genetic determinants of the inflammatory response. Curr Opin Crit Care 10:318–324
    • View reference on publisher's website
    • View reference on PubMed
  14. Agnese DM, Calvano JE, Hahm SJ, Coyle SM, Corbett SA, Calvano SE, Lowry SF (2002) Human toll-like receptor 4 mutations but not CD14 polymorphisms are associated with an increased risk of Gram-negative infections. J Infect Dis 186:1522–1525
    • View reference on publisher's website
    • View reference on PubMed
  15. Barber RC, Aragaki CC, Rivera-Chavez FA, Purdue GF, Hunt JL, Horton JW (2004) TLR4 and TNF-alpha polymorphisms are associated with an increased risk for severe sepsis following burn injury. J Med Genet 41:808–813
    • View reference on publisher's website
    • View reference on PubMed
  16. Lorenz E, Mira JP, Frees KL, Schwartz DA (2002) Relevance of mutations in the TLR4 receptor in patients with gram-negative septic shock. Arch Intern Med 162:1028–1032
    • View reference on publisher's website
    • View reference on PubMed
  17. Henckaerts L, Nielsen KR, Steffensen R, Van Steen K, Mathieu C, Giulietti A, Wouters PJ, Milants I, Vanhorebeek I, Langouche L, Vermeire S, Rutgeerts P, Thiel S, Wilmer A, Hansen TK, Van den Berghe G (2009) Polymorphisms in innate immunity genes predispose to bacteremia and death in the medical intensive care unit. Crit Care Med 37(192–201):e191–e193
  18. Bochud PY, Chien JW, Marr KA, Leisenring WM, Upton A, Janer M, Rodrigues SD, Li S, Hansen JA, Zhao LP, Aderem A, Boeckh M (2008) Toll-like receptor 4 polymorphisms and aspergillosis in stem-cell transplantation. N Engl J Med 359:1766–1777
    • View reference on publisher's website
    • View reference on PubMed
  19. Vincent JL (1997) Dear SIRS, I’m sorry to say that I don’t like you. Crit Care Med 25:372–374
    • View reference on publisher's website
    • View reference on PubMed
  20. Levi M, Lowenberg EC (2008) Thrombocytopenia in critically ill patients. Semin Thromb Hemost 34:417–424
    • View reference on publisher's website
    • View reference on PubMed
  21. Akca S, Haji-Michael P, de Mendonca A, Suter P, Levi M, Vincent JL (2002) Time course of platelet counts in critically ill patients. Crit Care Med 30:753–756
    • View reference on publisher's website
    • View reference on PubMed
  22. Peters MJ, Ross-Russell RI, White D, Kerr SJ, Eaton FE, Keengwe IN, Tasker RC, Wade AM, Klein NJ (2001) Early severe neutropenia and thrombocytopenia identifies the highest risk cases of severe meningococcal disease. Pediatr Crit Care Med 2:225–231
    • View reference on publisher's website
    • View reference on PubMed
  23. Nguyen TC, Carcillo JA (2006) Bench-to-bedside review: thrombocytopenia-associated multiple organ failure—a newly appreciated syndrome in the critically ill. Crit Care 10:235
    • View reference on publisher's website
    • View reference on PubMed
  24. Ohtaki Y, Shimauchi H, Yokochi T, Takada H, Endo Y (2002) In vivo platelet response to lipopolysaccharide in mice: proposed method for evaluating new antiplatelet drugs. Thromb Res 108:303–309
    • View reference on publisher's website
    • View reference on PubMed
  25. Yang IA, Holloway JW, Ye S (2003) TLR4 Asp299Gly polymorphism is not associated with coronary artery stenosis. Atherosclerosis 170:187–190
    • View reference on publisher's website
    • View reference on PubMed
  26. American College of Chest Physicians/Society of Critical Care Medicine (1992) American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874
  27. Smirnova I, Hamblin MT, McBride C, Beutler B, Di RA (2001) Excess of rare amino acid polymorphisms in the Toll-like receptor 4 in humans. Genetics 158:1657–1664
    • View reference on PubMed
  28. Ferwerda B, McCall MB, Verheijen K, Kullberg BJ, van der Ven AJ, Van der Meer JW, Netea MG (2008) Functional consequences of Toll-like receptor 4 polymorphisms. Mol Med 14:346–352
    • View reference on publisher's website
    • View reference on PubMed
  29. Klinger MH, Jelkmann W (2002) Role of blood platelets in infection and inflammation. J Interferon Cytokine Res 22:913–922
    • View reference on publisher's website
    • View reference on PubMed
  30. Vanderschueren S, De Weerdt A, Malbrain M, Vankersschaever D, Frans E, Wilmer A, Bobbaers H (2000) Thrombocytopenia and prognosis in intensive care. Crit Care Med 28:1871–1876
    • View reference on publisher's website
    • View reference on PubMed
  31. Ragazzi S, Pierro A, Peters M, Fasoli L, Eaton S (2003) Early full blood count and severity of disease in neonates with necrotizing enterocolitis. Pediatr Surg Int 19:376–379
    • View reference on publisher's website
    • View reference on PubMed
  32. Zarbock A, Polanowska-Grabowska RK, Ley K (2007) Platelet-neutrophil-interactions: linking hemostasis and inflammation. Blood Rev 21:99–111
    • View reference on publisher's website
    • View reference on PubMed
  33. Davi G, Patrono C (2007) Platelet activation and atherothrombosis. N Engl J Med 357:2482–2494
    • View reference on publisher's website
    • View reference on PubMed
  34. Gawaz M, Langer H, May AE (2005) Platelets in inflammation and atherogenesis. J Clin Invest 115:3378–3384
    • View reference on publisher's website
    • View reference on PubMed
  35. Zeni F, Freeman B, Natanson C (1997) Anti-inflammatory therapies to treat sepsis and septic shock: a reassessment. Crit Care Med 25:1095–1100
    • View reference on publisher's website
    • View reference on PubMed
  36. Bone RC (1996) Why sepsis trials fail. JAMA 276:565–566
    • View reference on publisher's website
    • View reference on PubMed
  37. Oda K, Kitano H (2006) A comprehensive map of the toll-like receptor signaling network. Mol Syst Biol 2:2006.0015
  38. Shashkin PN, Brown GT, Ghosh A, Marathe GK, McIntyre TM (2008) Lipopolysaccharide is a direct agonist for platelet RNA splicing. J Immunol 181:3495–3502
    • View reference on PubMed
  39. Patrignani P, Di Febbo C, Tacconelli S, Moretta V, Baccante G, Sciulli MG, Ricciotti E, Capone ML, Antonucci I, Guglielmi MD, Stuppia L, Porreca E (2006) Reduced thromboxane biosynthesis in carriers of toll-like receptor 4 polymorphisms in vivo. Blood 107:3572–3574
    • View reference on publisher's website
    • View reference on PubMed
  40. Kiechl S, Lorenz E, Reindl M, Wiedermann CJ, Oberhollenzer F, Bonora E, Willeit J, Schwartz DA (2002) Toll-like receptor 4 polymorphisms and atherogenesis. N Engl J Med 347:185–192
    • View reference on publisher's website
    • View reference on PubMed
  41. Levin M, Quint PA, Goldstein B, Barton P, Bradley JS, Shemie SD, Yeh T, Kim SS, Cafaro DP, Scannon PJ, Giroir BP (2000) Recombinant bactericidal/permeability-increasing protein (rBPI21) as adjunctive treatment for children with severe meningococcal sepsis: a randomised trial. rBPI21 Meningococcal Sepsis Study Group. Lancet 356:961–967
    • View reference on publisher's website
    • View reference on PubMed
  42. Michalek J, Svetlikova P, Fedora M, Klimovic M, Klapacova L, Bartosova D, Elbl L, Hrstkova H, Hubacek JA (2007) Bactericidal permeability increasing protein gene variants in children with sepsis. Intensive Care Med 33:2158–2164
  43. Khor CC, Chapman SJ, Vannberg FO, Dunne A, Murphy C, Ling EY, Frodsham AJ, Walley AJ, Kyrieleis O, Khan A, Aucan C, Segal S, Moore CE, Knox K, Campbell SJ, Lienhardt C, Scott A, Aaby P, Sow OY, Grignani RT, Sillah J, Sirugo G, Peshu N, Williams TN, Maitland K, Davies RJ, Kwiatkowski DP, Day NP, Yala D, Crook DW, Marsh K, Berkley JA, O’Neill LA, Hill AV (2007) A Mal functional variant is associated with protection against invasive pneumococcal disease, bacteremia, malaria and tuberculosis. Nat Genet 39:523–528
    • View reference on publisher's website
    • View reference on PubMed
  44. Ku CL, von Bernuth H, Picard C, Zhang SY, Chang HH, Yang K, Chrabieh M, Issekutz AC, Cunningham CK, Gallin J, Holland SM, Roifman C, Ehl S, Smart J, Tang M, Barrat FJ, Levy O, McDonald D, Day-Good NK, Miller R, Takada H, Hara T, Al-Hajjar S, Al-Ghonaium A, Speert D, Sanlaville D, Li X, Geissmann F, Vivier E, Marodi L, Garty BZ, Chapel H, Rodriguez-Gallego C, Bossuyt X, Abel L, Puel A, Casanova JL (2007) Selective predisposition to bacterial infections in IRAK-4-deficient children: IRAK-4-dependent TLRs are otherwise redundant in protective immunity. J Exp Med 204:2407–2422
    • View reference on publisher's website
    • View reference on PubMed
  45. Baldini M, Lohman IC, Halonen M, Erickson RP, Holt PG, Martinez FD (1999) A Polymorphism* in the 5′ flanking region of the CD14 gene is associated with circulating soluble CD14 levels and with total serum immunoglobulin E. Am J Respir Cell Mol Biol 20:976–983
    • View reference on PubMed
  46. Hubacek JA, Skodova Z, Adamkova V, Lanska V, Vlasakova Z, Poledne R (2004) Association of the −159C –> T polymorphism in the CD14 promoter with variations in serum lipoproteins in healthy subjects. Blood Coagul Fibrinolysis 15:365–366
    • View reference on publisher's website
    • View reference on PubMed
  47. Hubacek JA, Stuber F, Frohlich D, Book M, Wetegrove S, Ritter M, Rothe G, Schmitz G (2001) Gene variants of the bactericidal/permeability increasing protein and lipopolysaccharide binding protein in sepsis patients: gender-specific genetic predisposition to sepsis. Crit Care Med 29:557–561
    • View reference on publisher's website
    • View reference on PubMed
  48. Barber RC, O’Keefe GE (2003) Characterization of a single nucleotide polymorphism in the lipopolysaccharide binding protein and its association with sepsis. Am J Respir Crit Care Med 167:1316–1320
    • View reference on publisher's website
    • View reference on PubMed
  49. Shann F, Pearson G, Slater A, Wilkinson K (1997) Paediatric index of mortality (PIM): a mortality prediction model for children in intensive care. Intensive Care Med 23:201–207

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement