Comparison of the source and prognostic utility of cfDNA in trauma and sepsis

Nicholas L Jackson Chornenki, Robert Coke, Andrew C Kwong, Dhruva J Dwivedi, Michael K Xu, Ellen McDonald, John C Marshall, Alison E Fox-Robichaud, Emmanuel Charbonney, Patricia C Liaw, Nicholas L Jackson Chornenki, Robert Coke, Andrew C Kwong, Dhruva J Dwivedi, Michael K Xu, Ellen McDonald, John C Marshall, Alison E Fox-Robichaud, Emmanuel Charbonney, Patricia C Liaw

Abstract

Background: Circulating cell-free DNA (cfDNA) may contribute to the pathophysiology of post-injury inflammation and coagulation in trauma. However, the source and mechanism of release of cfDNA in trauma is not well understood. One potential source of cfDNA is from Neutrophil Extracellular Traps (NETs), released by activated neutrophils during the process of NETosis. The primary objective of our study was to determine if cfDNA has prognostic utility in trauma. The secondary objective of this study was to determine the source of cfDNA in trauma compared to sepsis.

Methods: We studied trauma patients from two prospective observational cohort studies: the DNA as a Prognostic Marker in ICU Patients (DYNAMICS) study and the Endotoxin in Polytrauma (ENPOLY) study. We also studied septic patients from the DYNAMICS study. Citrated plasma samples were collected longitudinally from the patients (days 1 to 7). The following molecules were measured in the plasma samples: cfDNA, protein C (PC), myeloperoxidase (MPO) (a marker of neutrophil activation), citrullinated Histone H3 (H3Cit, a marker of NETosis), cyclophilin A (a marker of necrosis), and caspase-cleaved K18 (a marker of apoptosis).

Results: A total of 77 trauma patients were included (n = 38 from DYNAMICS and n = 39 from ENPOLY). The median age was 49 years; 27.3% were female, and mortality was 16.9% at 28 days. Levels of cfDNA were elevated compared to healthy values but not significantly different between survivors and non-survivors. There was a positive correlation between MPO and cfDNA in septic patients (r = 0.424, p < 0.001). In contrast, there was no correlation between MPO and cfDNA in trauma patients (r = - 0.192, p = 0.115). Levels of H3Cit, a marker of NETosis, were significantly elevated in septic patients compared to trauma patients (p < 0.01) while apoptosis and necrosis markers did not differ between the two groups.

Conclusion: Our studies suggest that the source and mechanism of release of cfDNA differ between trauma and sepsis patients. In sepsis, cfDNA is likely primarily released by activated neutrophils via the process of NETosis. In contrast, cfDNA in trauma appears to originate mainly from injured or necrotic cells. Although cfDNA is elevated in trauma and sepsis patients compared to healthy controls, cfDNA does not appear to have prognostic utility in trauma patients.

Trial registration: ClinicalTrials.gov Identifier: NCT01355042 . Registered May 17, 2011.

Keywords: Cell-free DNA; NETosis; protein C; traumatic injury.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
cfDNA and PC levels in trauma patients. a Median cfDNA levels in trauma patients, septic patients, and healthy controls. b Median and IQR temporal changes in levels of cfDNA in trauma survivors and non-survivors. c Median PC levels in trauma patients and healthy controls. d Median and IQR temporal changes in levels of PC in trauma survivors and non-survivors. Note: ***p < 0.001. IQR = interquartile range
Fig. 2
Fig. 2
Investigations into the potential sources of cfDNA. a Necrosis as quantified by levels of cyclophilin A. b Apoptosis as quantified by ccK18 fragments. c Day 1 MPO levels in sepsis, trauma, and healthy controls. d Correlation between myeloperoxidase (MPO) and cell-free DNA (cfDNA) in trauma patients. e Correlation between MPO and cfDNA levels in septic patients. f Levels of citrullinated histone H3 in sepsis, trauma, healthy controls. Note: ***p < 0.001, **p < 0.01; data represent median and interquartile range

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