title: Superior accuracy of mid-regional proadrenomedullin for mortality prediction in sepsis with varying levels of illness severity.
abstract: BACKGROUND
  The use of novel sepsis biomarkers has increased in recent years. However, their prognostic value with respect to illness severity has not been explored. In this work, we examined the ability of mid-regional proadrenomedullin (MR-proADM) in predicting mortality in sepsis patients with different degrees of organ failure, compared to that of procalcitonin, C-reactive protein and lactate.
  
  
  METHODS
  This was a two-centre prospective observational cohort, enrolling severe sepsis or septic shock patients admitted to the ICU. Plasma biomarkers were measured during the first 12 h of admission. The association between biomarkers and 28-day mortality was assessed by Cox regression analysis and Kaplan-Meier curves. Patients were divided into three groups as evaluated by the Sequential Organ Failure Assessment (SOFA) score. The accuracy of the biomarkers for mortality was determined by area under the receiver operating characteristic curve (AUROC) analysis.
  
  
  RESULTS
  A total of 326 patients with severe sepsis (21.7%) or septic shock (79.3%) were enrolled with a 28-day mortality rate of 31.0%. Only MR-proADM and lactate were associated with mortality in the multivariate analysis: hazard ratio 8.5 versus 3.4 (p < 0.001). MR-proADM showed the best AUROC for mortality prediction at 28 days in the analysis over the entire cohort (AUROC [95% CI] 0.79 [0.74-0.84]) (p < 0.001). When patients were stratified by the degree of organ failure, MR-proADM was the only biomarker to predict mortality in all severity groups (SOFA ≤ 6, SOFA = 7-12, and SOFA ≥ 13), AUROC [95% CI] of 0.75 [0.61-0.88], 0.74 [0.66-0.83] and 0.73 [0.59-0.86], respectively (p < 0.05). All patients with MR-proADM concentrations ≤0.88 nmol/L survived up to 28 days. In patients with SOFA ≤ 6, the addition of MR-proADM to the SOFA score increased the ability of SOFA to identify non-survivors, AUROC [95% CI] 0.70 [0.58-0.82] and 0.77 [0.66-0.88], respectively (p < 0.05 for both).
  
  
  CONCLUSIONS
  The performance of prognostic biomarkers in sepsis is highly influenced by disease severity. MR-proADM accuracy to predict mortality is not affected by the degree of organ failure. Thus, it is a good candidate in the early identification of sepsis patients with moderate disease severity but at risk of mortality.
authors.affiliation: Servicio de Medicina Intensiva, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.|Group for Biomedical Research in Sepsis (Bio∙Sepsis), Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: David
authors.initials: D
authors.lastname: Andaluz-Ojeda
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, USA.
authors.forename: H Bryant
authors.initials: HB
authors.lastname: Nguyen
authors.affiliation: Service de Réanimation Médicale, Hôpital Bocage Central, C.H.U. DIJON, 14 rue Gaffarel, B.P. 77908-21079, Dijon Cedex, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Meunier-Beillard
authors.affiliation: Servicio de Medicina Intensiva, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.|Group for Biomedical Research in Sepsis (Bio∙Sepsis), Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Ramón
authors.initials: R
authors.lastname: Cicuéndez
authors.affiliation: Service de Réanimation Médicale, Hôpital Bocage Central, C.H.U. DIJON, 14 rue Gaffarel, B.P. 77908-21079, Dijon Cedex, France.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Quenot
authors.affiliation: Servicio de Análisis Clínicos, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Dolores
authors.initials: D
authors.lastname: Calvo
authors.affiliation: Service de Réanimation Médicale, Hôpital Bocage Central, C.H.U. DIJON, 14 rue Gaffarel, B.P. 77908-21079, Dijon Cedex, France.
authors.forename: Auguste
authors.initials: A
authors.lastname: Dargent
authors.affiliation: Servicio de Análisis Clínicos, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Esther
authors.initials: E
authors.lastname: Zarca
authors.affiliation: Servicio de Análisis Clínicos, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Andrés
authors.affiliation: Servicio de Medicina Intensiva, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.|Group for Biomedical Research in Sepsis (Bio∙Sepsis), Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Leonor
authors.initials: L
authors.lastname: Nogales
authors.affiliation: Departmento de Microbiología, Facultad de Medicina, Universidad de Valladolid, Avda/Ramón y Cajal 7, 47005, Valladolid, Spain.
authors.forename: Jose María
authors.initials: JM
authors.lastname: Eiros
authors.affiliation: Group for Biomedical Research in Sepsis (Bio∙Sepsis), Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.|Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario, Avda/Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Tamayo
authors.affiliation: Servicio de Medicina Intensiva, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.|Group for Biomedical Research in Sepsis (Bio∙Sepsis), Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Gandía
authors.affiliation: Group for Biomedical Research in Sepsis (Bio∙Sepsis), Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain. jfbermejo@saludcastillayleon.es.
authors.forename: Jesús F
authors.initials: JF
authors.lastname: Bermejo-Martín
authors.affiliation: Service de Réanimation Médicale, Hôpital Bocage Central, C.H.U. DIJON, 14 rue Gaffarel, B.P. 77908-21079, Dijon Cedex, France.
authors.forename: Pierre Emmanuel
authors.initials: PE
authors.lastname: Charles
keywords: Biomarkers; MR-proADM; Mortality; SOFA; Sepsis