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Midregional proadrenomedullin as a prognostic tool in community-acquired pneumonia
David T Huang1, Derek C Angus2, John A Kellum2
1Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Departments of Critical Care Medicine, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Emergency Medicine, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
Background:
Midregional proadrenomedullin (MR-proADM) is a potential prognostic biomarker in patients with community-acquired pneumonia (CAP). Previous work has been hampered by sample size and illness spectrum limits. We sought to describe the pattern of MR-proADM in a broad CAP cohort, confirm its prognostic role, and compare its performance to procalcitonin, a novel biomarker of infection.
Methods:
We conducted a multicenter prospective cohort study in 28 community and teaching EDs. Patients with a clinical and radiographic diagnosis of CAP were enrolled. We stratified MR-proADM levels a priori into quartiles and quantified severity of illness using the pneumonia severity index (PSI); and confusion (abbreviated mental test score of
Results:
A total of 1,653 patients formed the study cohort. MR-proADM levels consistently rose with PSI class and 30-day mortality (p < 0.001). MR-proADM had a higher area under the curve for 30-day mortality than procalcitonin (0.76 vs 0.65, respectively; p < 0.001), but adding MR-proADM to the PSI in all subjects minimally improved performance. Among low-risk subjects (PSI classes I to III), mortality was low and did not differ by MR-proADM quartile. However, among high-risk subjects (PSI class IV/V; n = 546), subjects in the highest MR-proADM quartile (n = 232; 42%) had higher 30-day mortality than those in MR-proADM quartiles 1 to 3 (23% vs 9%, respectively; p < 0.0001). Similar results were seen with CURB-65. MR-proADM and procalcitonin levels were generally concordant; only 6% of PSI class IV/V subjects in the highest MR-proADM quartile had very low procalcitonin levels (< 0.1 ng/mL).
Conclusions:
In our multicenter CAP cohort, MR-proADM levels correlate with increasing severity of illness and death. High MR-proADM levels offer additional risk stratification in high-risk CAP patients, but otherwise MR-proADM levels do not alter PSI-based risk assessment in most CAP patients.
Insights
Midregional proadrenomedullin (MR-proADM) aids risk stratification in high-risk community-acquired pneumonia (CAP) patients. While not improving overall assessment, elevated MR-proADM levels in severe CAP cases predict higher 30-day mortality.
Area of Science:
- Biomarker research
- Clinical diagnostics
- Pulmonology
Background:
- Midregional proadrenomedullin (MR-proADM) shows promise as a prognostic biomarker in community-acquired pneumonia (CAP).
- Previous studies were limited by small sample sizes and narrow patient populations.
- This study aimed to validate MR-proADM's prognostic value in a broad CAP cohort and compare it with procalcitonin.
Purpose of the Study:
- To investigate the pattern and prognostic significance of MR-proADM in a large, diverse CAP patient cohort.
- To compare the predictive performance of MR-proADM against procalcitonin for 30-day mortality in CAP.
- To assess MR-proADM's utility in refining risk stratification beyond existing scores like PSI and CURB-65.
Main Methods:
- A multicenter prospective cohort study involving 1,653 patients diagnosed with CAP.
- MR-proADM levels were stratified into quartiles and correlated with illness severity scores (PSI, CURB-65).
- The primary endpoint was 30-day mortality, with comparative analysis against procalcitonin.
Main Results:
- MR-proADM levels demonstrated a significant positive correlation with both PSI class and 30-day mortality (p < 0.001).
- MR-proADM exhibited superior predictive performance for 30-day mortality compared to procalcitonin (AUC 0.76 vs. 0.65, p < 0.001).
- In high-risk patients (PSI class IV/V), the highest MR-proADM quartile showed significantly higher mortality (42% vs. 9%, p < 0.0001).
Conclusions:
- MR-proADM levels are associated with increased severity and mortality in CAP patients.
- Elevated MR-proADM provides valuable additional risk stratification for high-risk CAP patients.
- MR-proADM does not significantly alter risk assessment for the majority of CAP patients when using PSI.
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