Clinical and immunological efficacy of immunotherapeutic program after surgical treatment of children with various forms of acute peritonitis

Acute peritonitis (AP) is among the most frequent and severe conditions in pediatric abdominal surgery. Due to development of antibiotic resistance and increasing number of atypical infectious and inflammatory diseases (IIDs), a lot of specialists suggest combined treatments for these patients which should include not only surgical and etiotropic approaches, as well as therapy aimed at correction of functional defects of immunity. Neutrophilic granulocytes (NGs) reepresent a unique population of cells of primary anti-infectious immune response. Functional NG defects in pediatric AP play a leading role in development, prevalence, severity of peritoneal inflammation, and response to the therapy. Special role is given to functionally significant NG subsets responsible for triggering and implementation of phagocytosis and microbicidal properties of NG in purulent lesions and inflammatory process in children. There is an urgent need for development of new approaches to targeted immunomodulatory therapy in order to correct the NG dysfunction. The aim of the present study was to arrange the programs of immunomodulatory therapy after surgical treatment of immunocompromised children with various forms of acute peritonitis followed by subsequent evaluation of its clinical and immunological efficacy. The study included 12 immunocompromised children aged 5-12 years with different clinical course of acute peritonitis. The study group 1 included patients with local nonrestricted AP; study group 2 involved children with diffuse AP. The comparison groups consisted of 6 children who received standard therapy, i.e., clinical comparison groups 1 and 2, matched for sex, age and diagnosis. A control group consisted of 18 conditionally healthy children at similar age. Clinical examination included collection of the patient’s history, complaints, objective examination and clinical course assessment of the underlying disease. Immunological study included determination of receptor, phagocytic and microbicidal activity of NCs; assessment of NC subpopulations by their numbers and phenotype using flow cytometry, i.e., the cells co-expressing CD64, CD16, CD32, CD11b, with testing density of these membrane receptors by the MFI approach. Targeted immunomodulatory therapy programs were applied for treatment of children with unrestricted local and diffuse AP, taking into account clinical features of AP, as well as changes in number and phenotype of NC subpopulations, and impairment of their effector function. The standards of postsurgical treatment in the children with various forms of AP included different courses of treatment with Imunofan (Hexapeptide – arginyl-alpha-aspartyl-lysyl-valyl-tyrosyl-arginine; HP) using different schedules and duration. We have shown high clinical and immunological efficiency of these therapeutic programs. Thus, reversal of adequate NG functioning was observed, including positive rearrangements of negatively transformed functional NG subpopulations. In this respect, a positive clinical effect was noted in children with atypical AP with various clinical courses, i.e., absence of postsurgical complications, rapid regression of intoxication signs, normalization of body temperature, reduced volume of antibiotic therapy and shorter hospitalization terms.

1. Bezrukov S.G., Balabantseva A.N., Grigoreva T.S., Iakovenko V.V. Clinical and thermographical evaluation of the efficiency of treating the wound process in surgical stomatology with use of Wobenzym and Imunofan. Tavricheskiy mediko-biologicheskiy vestnik = Tauride Medical and Biological Bulletin, 2017, Vol. 20, no. 4, рр. 10-15. (In Russ.)

2. Burkov I.V., Tsaregorodtsev A.D., Korenkova S.I. Efficacy of intramuscular galavit in children aged above 6 years who have purulent surgical diseases. Rossiyskiy vestnik perinatologii i pediatrii = Russian Bulletin of Perinatology and Pediatrics, 2008, Vol. 4, рр. 78-83. (In Russ.)

3. Vlasov A.P., Al-Kubaysi Sh., Vlasova T.I., Leshchankina N.Yu., Okunev N.A., Sheyranov N.S., Polozova E.I. The condition of the hemostatic system in acute severe peritonitis during remaxol therapy (in Russian only). Khirurgiya. Zhurnal im. N.I. Pirogova = Surgery. N. Pirogov Journal. 2019, Vol. 2, рр. 65-71. (In Russ.)

4. Gisak S.N., Sklyarova E.A., Vecherkin V.A., Chernykh A.V., Maleev Yu.V., Ptitsyn V.A., Lunev B.V., Baranov D.A., Shestakov A.A., Koryashkin P.V. Modern causative pathogens of peritonitis in cases of the perforation of the stomach, small intestine or colon in children and optimization of the differentiated treatment of patients. Detskaya khirurgiya = Russian Journal of Pediatric Surgery, 2018, Vol. 22, no. 2, рр. 65-72. (In Russ.)

5. Karsonova M.I., Pinegin B.V., Khaitov R.M. Immunocorrecting therapy in surgical infection. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery, 1999, Vol. 4, no. 1, рр. 88-96. (In Russ.)

6. Kiselevsky M., Gromova E., Fomin А. Sepsis: etiology, pathogenesis, extracorporeal detoxification. Мoscow: Osobaya kniga, 2021. 176 р.

7. Kologrivova E.N., Pleshko R.I., Scherbik N.V., Starokha A.V., Chichinskas E. Effects of intranasal Imunofan administration upon phagocytic activity in treatment of exudative otitis media in children. Meditsinskaya immunologiya = Medical Immunology (Russia), 2020, Vol. 2, no. 4, рр. 741-750. (In Russ.) doi: 10.15789/1563-0625-EOI-1720.

8. Nesterova I.V., Kovaleva S.V., Chudiliva G., Malinovskaya V.V. Interferon and immunotherapy in the rehabilitation of immunocompromised children with recurrent respiratory infections. In: Immunotherapy in the practice of an ENT doctor and therapist. Edit. A.S. Simbirtsev, G.V. Lavrenova. St. Petersburg: Dialog, 2018, рр. 167-189.

9. Nesterova I.V., Kolesnikova N.V., Chudilova G.A., Lomtatidze L.V., Kovaleva S.V., Evglevsky A.A., Nguyen T.L. The new look at neutrophilic granulocytes: Rethinking old dogmas. Part 2. Infektsiya i immunitet = Russian Journal of Infection and Immunity, 2018, Vol. 8, no. 1, рр. 7-18. (In Russ.) doi: 10.15789/2220-7619-2018-1-7-18.

10. Nesterova I.V., Chudilova G.A., Kovaleva S.V., Lomtatidze L.V., Kolesnikova N.V., Yevlevsky A.A. Methods for comprehensive assessment of the functional activity of neutrophil granulocytes in health and disease (guidelines). Krasnodar, 2017. 52 p.

11. Okunev N.A., Okuneva A.I., Soldatov O.M., Budanova M.A. Peritonite or debut of diabetes mellitus. Detskaya khirurgiya = Russian Journal of Pediatric Surgery, 2018, Vol. 22, no. 3, рр. 127-129. (In Russ.)

12. Primbekov S.Sh. Experience of treatment of the surgical infection with use of Polyoxidonium. Meditsina i ekologiya = Medicine and Ecology, 2012, no. 2 (63), рр. 10-15. (In Russ.)

13. Savchenko A.A., Borisov A.G., Kudryavcev I.V., Gvozdev I.I., Moshev A.V., Cherdancev D.V., Pervova O.V. The phenotype and metabolism relationship of blood neutrophils in patients with widespread purulent peritonitis in the postoperative period dynamics. Infektsiya i immunitet = Russian Journal of Infection and Immunity, 2017, Vol. 7, no. 3, pp. 259-270. (In Russ.) doi: 10.15789/2220-7619-2017-3-259-270.

14. Savchenko A.A., Zdzitovetsky D.E., Borisov A.G. Immunometabolic disorders in advanced purulent peritonitis. Novosibirsk: Nauka, 2003. 142 р.

15. Chudilova G.A., Nesterova I.V., Pavlenko V.N., Barova N.K., Tarakanov V.A. Variations in the phenotype of subpopulations CD64-CD16+CD32+CD11b+ and CD64+CD16+CD32+CD11b+ neutrophilic granulocytes associated with disorders of phagocytic and microbicidal activity at various forms of peritonitis in children. Allergologiya i immunologiya = Allergology and Immunology, 2021, Vol. 22, no. 1, pp. 28-35. (In Russ.)

16. Akhmedov I.Yu., Rafikov B.R., Azizov Sh.F., Dalerov A.D. Early diagnostics of postoperative purulus complications with disseminated appendicular peritonitis in children // Вопросы науки и образования, 2019. Т. 2, № 45. С. 129-133.

17. Akhmedov I.Yu., Rafikov B.R., Azizov Sh.F., Dalerov A.D. Early diagnostics of postoperative purulus complications with disseminated appendicular peritonitis in children. Voprosy nauki i obrazovaniya = Issues of Science and Education, 2019, Vol. 2 (45), рр. 129-133. (In Russ.)

18. Bobrysheva I.V. Immunomodulator Imunofan affects cell profile of morphofunctional zones of rat thymus and delays its age-related involution. Bulletin of Russian State Medical University, 2016, no. 3, рр. 34-38.

19. Bournazos S., Wang T.T., Ravetch J.V. The role and function of Fcγ receptors on myeloid cells. Microbiol. Spectr., 2016, Vol. 4, no. 6, 10.1128/microbiolspec.MCHD-0045-2016. doi: 10.1128/microbiolspec.MCHD-0045-2016.

20. Coxon A., Cullere X., Knight S., Sethi S., Wakelin M.W., Stavrakis G., Luscinskas F.W., Mayadas T.N. Fc gamma RIII mediates neutrophil recruitment to immune complexes. А mechanism for neutrophil accumulation in immune-mediated inflammation. Immunity, 2001, Vol. 14, no. 6, pp. 693-704.

21. El-Benna J., Dang P.M.-C., Gougerot-Pocidalo M.-A. Priming of the neutrophil NADPH oxidase activation: role of p47phox phosphorylation and NOX2 mobilization to the plasma membrane. Semin. Immunopathol., 2008, Vol. 30, рр. 279-289.

22. Koval L.M., Zverkova A.S., Grailhe R., Utkin Y.N., Tsetlin V.I., Komisarenko S.V., Skok M.V. Nicotinic acetylcholine receptors alpha4beta2 and alpha7 regulate myelo- and erythropoiesis within the bone marrow. Int. J. Biochem. Cell Biol., 2008, Vol. 40, no. 5, рр. 980-990.

23. Liu Z., Zheng X., Wang J., Wang E. Molecular analysis of thymopentin binding to HLA-DR molecules. PLoS One, 2007, Vol. 2, no. 12, e1348. doi: 10.1371/journal.pone.0001348.

24. Malech H.L., de Leo F.R., Quinn M.T. The Role of Neutrophils in the immune system: An оverview. Methods Mol. Biol., 2020, Vol. 2087, рр. 3-10.

25. Mortaz E., Alipoor S.D., Adcock I.M., Mumby S., Koenderman L. Update on neutrophil function in severe inflammation. Front. Immunol., 2018, Vol. 9, 2171. doi: 10.3389/fimmu.2018.02171.

26. Mulcahy M.J., Lester H.A. Granulocytes as models for human protein maker identification following nicotine exposure. J. Neurochem., 2017, Vol. 142, no. 2, pp. 151-161.

27. Nesterova I.V., Chudilova G.A., Pavlenko V.N., Tarakanov V.A. In vitro experimental rewiring of 4 neutrophilic granulocyte subsets from the pro-inflammatory to the anti-inflammatory phenotype in children with surgical purulent infection of soft tissue. Medical Immunology (Russia), 2021, Vol. 23, no. 4, pp. 819-824. doi: 10.15789/1563-0625-IVE-2311.

28. Nimmerjahn F., Ravetch J.V. Fcgamma receptors as regulators of immune responses. Nat. Rev. Immunol., 2008, Vol. 8, no. 1, pp. 34-47.

29. Rollet-Labelle E., Gilbert C., Naccache P.H. Modulation of human neutrophil responses to CD32 cross-linking by serine/threonine phosphatase inhibitors: cross-talk between serine/threonine and tyrosine phosphorylation. J. Immunol., 2000, Vol. 164, no. 2, pp. 1020-1028.

30. Serov D., Tikhonova I., Safronova V., Astashev M. Calcium activity in response to nAChR ligands in murine bone marrow granulocytes with different Gr-1 expression. Cell Biol. Int., 2021, Vol. 45, no. 7, рр. 1533-1545. 30. Silvestre-Roig C., Fridlender Z.G., Glogauer M., Scapini P. Neutrophil diversity in health and disease. Trends Immunol., 2019, Vol. 40, no. 7, рр. 565-583.

31. van Spriel A.B., Leusen J.H., van Egmond M., Dijkman H.B., Assmann K.J., Mayadas T.N., van de Winkel J.G. Mac-1 (CD11b/CD18) is essential for Fc receptor-mediated neutrophil cytotoxicity and immunologic synapse formation. Blood, 2001, Vol. 97, no. 8, pp. 2478-2486.

32. Venkatasubramanian K., Audhya T., Goldstein G. Binding of thymopoietin to the acetylcholine receptor. Proc. Natl Acad. Sci. USA, 1986, Vol. 83, no. 10, рр. 3171-3174.

33. Wang Y., Jönsson F. Expression, role, and regulation of neutrophil Fcγ receptors. Front. Immunol., 2019, Vol. 10, 1958. doi: 10.3389/fimmu.2019.01958.