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Prognostic utility and characterization of cell-free DNA in patients with severe sepsis

Dhruva J Dwivedi17, Lisa J Toltl27, Laura L Swystun27, Janice Pogue34, Kao-Lee Liaw5, Jeffrey I Weitz17, Deborah J Cook136, Alison E Fox-Robichaud17, Patricia C Liaw17* and the Canadian Critical Care Translational Biology Group

Author Affiliations

1 Department of Medicine, McMaster University, 1280 Main St. W., Hamilton, ONT, L8S 4K1, Canada

2 Department of Medical Sciences, McMaster University, 1280 Main St. W., Hamilton, ONT, L8S 4K1, Canada

3 Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St. W., Hamilton, ONT, L8S 4K1, Canada

4 Population Health Research Institute, Hamilton Health Sciences and McMaster University, 237 Barton St. E., Hamilton, ONT, L8L 2X2, Canada

5 Department of Geography and Earth Sciences, 1280 Main St. W., Hamilton, ONT, L8S 4K1, Canada

6 St. Joseph's Healthcare Hamilton, 50 Charlton Ave. E, Hamilton, ONT, L8N 4A6, Canada

7 Thrombosis and Atherosclerosis Research Institute (TaARI), 237 Barton St. E., Hamilton, ONT, L8L 2X2, Canada

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Critical Care 2012, 16:R151  doi:10.1186/cc11466

See related commentary by Rhodes and Cecconi,

Published: 13 August 2012



Although sepsis is the leading cause of death in noncoronary critically ill patients, identification of patients at high risk of death remains a challenge. In this study, we examined the incremental usefulness of adding multiple biomarkers to clinical scoring systems for predicting intensive care unit (ICU) mortality in patients with severe sepsis.


This retrospective observational study used stored plasma samples obtained from 80 severe sepsis patients recruited at three tertiary hospital ICUs in Hamilton, Ontario, Canada. Clinical data and plasma samples were obtained at study inclusion for all 80 patients, and then daily for 1 week, and weekly thereafter for a subset of 50 patients. Plasma levels of cell-free DNA (cfDNA), interleukin 6 (IL-6), thrombin, and protein C were measured and compared with clinical characteristics, including the primary outcome of ICU mortality and morbidity measured with the Multiple Organ Dysfunction (MODS) score and Acute Physiology and Chronic Health Evaluation (APACHE) II scores.


The level of cfDNA in plasma at study inclusion had better prognostic utility than did MODS or APACHE II scores, or the biomarkers measured. The area under the receiver operating characteristic (ROC) curves for cfDNA to predict ICU mortality is 0.97 (95% CI, 0.93 to 1.00) and to predict hospital mortality is 0.84 (95% CI, 0.75 to 0.94). We found that a cfDNA cutoff value of 2.35 ng/μl had a sensitivity of 87.9% and specificity of 93.5% for predicting ICU mortality. Sequential measurements of cfDNA suggested that ICU mortality may be predicted within 24 hours of study inclusion, and that the predictive power of cfDNA may be enhanced by combining it with protein C levels or MODS scores. DNA-sequence analyses and studies with Toll-like receptor 9 (TLR9) reporter cells suggests that the cfDNA from sepsis patients is host derived.


These studies suggest that cfDNA provides high prognostic accuracy in patients with severe sepsis. The serial data suggest that the combination of cfDNA with protein C and MODS scores may yield even stronger predictive power. Incorporation of cfDNA in sepsis risk-stratification systems may be valuable for clinical decision making or for inclusion into sepsis trials.