Diagnostic value of an immune monitoring program for the clinical management of immunosuppressed patients with septic complications

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Abstract
A serious complication in immunosuppressed patients (allograft recipients and patients with autoimmune diseases) is sepsis. Proceeding from cytofluorometric analyses of mononuclear blood cells, septic patients (n = 44) were found to fall into two categories: i) those with “immunoparalysis” (n = 22) which is defined as a drastic reduction of HLA‐DR+ monocytes (< 20%) and a variable decrease of the differentiation antigens on T lymphocytes, and ii) patients without "immunoparalysis" (n = 22). The HLA‐DQ antigen but not HLA‐class I antigen expression was also decreased on monocytes derived from septic patients with "immunoparalysis". In patients with "immunoparalysis" who were continued on immunosuppression, mortality was 90%! Mortality was 0% in those with "immunoparalysis" whose immunosuppression was rapidly tapered. The normalization of HLA‐DR antigen expression on monocytes and the appearance of activated T cells (commonly within 5–10 days after reduction of immunosuppression) indicate the recovery of the immune system and (in order to prevent a rejection) necessitate a return to routine immunosuppression. Using immune monitoring as a guide for immunosuppression, no rejection occurred in consequence of tapered immunosuppression. Septic patients without "immunoparalysis" had no mortality when they were maintained on routine immunosuppression. However, reduction of immunosuppression in this latter group provoked severe rejection crises. Our immune monitoring seems to be useful for the management of immunosuppression in patients with septic complications in order to minimize two risks, i.e. death by sepsis or loss of graft.

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