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1Department of Pharmaceutical Biochemistry, Wroclaw Medical University, Poland;

2Clinic of Infectious Diseases, Liver Diseases and Acquired Immune Deficiency, Wroclaw Medical University, Poland;
3Department of Gastroenterology and Hepatology, Medical University of Silesia, Poland;
4Department of Physiology and Biochemistry, University of Physical Education, Wroclaw, Poland

Life expectancy of patients with liver cirrhosis is closely linked to the degree of liver dysfunction and the occurrence of
bacterial infection. An early diagnosis of infection helps to initiate adequate and timely measures and improves outcome of
cirrhotic patients. Endocan is a newly recognized biomarker of sepsis. However, there have been no studies of the trends
in endocan levels in cirrhotic patients with bacterial infection and their associations with markers of infection and
inflammation. This study sought to assess the diagnostic value of serum levels of endocan, procalcitonin (PCT), C-reactive
protein (CRP), tumor necrosis factor- (TNF-), and interleukin-6 (IL-6) in 126 patients with cirrhosis: 51 with
decompensated infected cirrhosis, 56 with decompensated uninfected and 19 with compensated uninfected cirrhosis at
inclusion. We analyzed the association of endocan with clinical factors in cirrhosis by comparison with indicators of
infection and inflammation. Endocan, PCT, CRP, IL-6 and TNF- were assayed in serum samples by ELISA analyses.
Serum levels of endocan, PCT, CRP and TNF- were significantly higher in cirrhotic patients with clinically overt
infections. Endocan levels were correlated to neither PCT levels nor IL-6 levels in each group of patients with cirrhosis.
CRP and TNF- levels and Child-Pugh score correlated only in the infected group of patients with endocan levels, while
in the uninfected groups of cirrhotic patients no significant correlation could be detected. The diagnostic accuracy of
endocan increased in advanced stage of the disease. Serum endocan levels 2.05 ng/ml had a sensitivity of 76.1% and
specificity of 85% for the diagnosis bacterial infection in decompensated cirrhotic patients. The endocan measured at
admission is a good clinical parameter predicting the occurrence of infection in these patients. Elevated endocan may reflect
the degree of endothelial cell injury induced by a systemic inflammatory response, a pathologic process that could modify
the course of advanced cirrhosis.

K e y w o r d s : bacterial infection, chronic liver disease, cirrhosis, C-reactive protein, endocan, inflammation, interleukin-6,
procalcitonin, tumor necrosis factor-

INTRODUCTION a key player in the regulation of cell adhesion, inflammatory

disorders, and tumor progression (8). It has been established as
Patients suffering from liver cirrhosis often die of life- a serum biomarker in cancer (9-15), bacteremia (16) and sepsis
threatening bacterial infections. The course of advanced (17-19). Additionally, the serum endocan levels are altered by
cirrhosis, regardless of its etiology, is complicated by cirrhosis- antileukemic chemotherapy (20) and leukapheresis procedure
associated immune dysfunction and this constitutes the (stem cell harvesting) in multiple myeloma patients (21) as well
pathophysiological hallmark of an increased susceptibility to as acute graft-versus-host disease after allogeneic stem cell
bacterial infection, distinctive of the disease (1). An early transplantation (22). Endocan gene expression levels may be due
diagnosis of infection helps to initiate adequate and timely to the inflammatory cytokines as well as the lipopolysaccharide
measures and improves outcome of cirrhotic patients (2-5). In (LPS) of the gram-negative bacterial cell wall, and thus
clinical practice, a large number of molecules secreted by the increases (23, 24, 17). On the other hand, the endocan itself has
endothelial cells have been investigated as potential biomarkers been shown to elicit severe inflammatory responses both in vitro
for the early diagnosis of bacterial infection. These have in human umbilical vein endothelial cells (HUVECs) and in vivo
included regulators of endothelial activation, adhesion in mice model (25).
molecules, as well as mediators of inflammation (6). Bacterial LPS is the main stimulus for the production of
Endothelial cell-specific molecule-1 (ESM-1) - so-called endocan and proinflammatory cytokines such as IL-6 and TNF-
endocan - is a soluble 50-kDa proteoglycan that is mainly . The inflammatory response to infection as estimated by the
produced by activated endothelial cells (7). This proteoglycan is levels of TNF- and IL-6 in serum are increased in patients with

liver cirrhosis. A few studies have shown that endocan can be on the basis of conventional criteria. Spontaneous bacterial
acknowledged as a good marker of endothelial dysfunction and peritonitis was defined as an infection of the ascitic fluid in the
multiple organ failure in sepsis (18, 19). In clinical practice, absence of any intra-abdominal source of infection with an
however, the usefulness and characteristics of endocan in ascitic fluid polymorphonuclear cell (PMN) count higher than
bacterial infection in cirrhotic patients, have not been 250 cells/mm3 and/or positive culture. The onset of infection was
investigated. defined as the time of admission.
In light of increasing evidence that endocan and Exclusion criteria were co-existing diseases like chronic
inflammatory response are closely linked, the purpose of the kidney disease, diabetes mellitus, cardiovascular disease,
present study was to investigate the association between cardiac decompensation, and hepatocellular carcinoma.
endocan, as a specific biomarker of bacterial infection in patients Peripheral venous blood from fasted healthy subjects and
with liver cirrhosis, and markers of infection and inflammation. fasted cirrhotic patients was collected in separate tubes, one
Furthermore, we evaluated the performance of endocan assay for containing the anticoagulant EDTA and the other without serum
the early diagnosis of bacterial infection in decompensated anticoagulant. The blood was allowed to clot for 30 min at 25C
cirrhotic patients. and centrifuged at 2000 g for 15 min at room temperature, and
the serum was then separated and aliquoted into tubes for
storage. The tubes were stored frozen at 80C until they were
PATIENTS AND METHODS used to study different parameters. Average storage time for
patients was 30 months and for controls 25 months. The consent
Patients of the Bioethics Committee of the Wroclaw Medical University
was obtained and all patients were informed about the character
This study was performed in 126 patients with liver cirrhosis of analyses made. Studies were conducted in compliance with
with and without decompensation admitted to the Clinic of the ethical standards formulated in the Helsinki Declaration of
Infectious Diseases, Liver Diseases and Acquired Immune 1975 (revised in 1983).
Deficiency for evaluation. Patients were divided into three
groups based on morphological ad bacteriological results: Laboratory determinations
patients with decompensated cirrhosis and infection at
admission (n = 51), patients with decompensated cirrhosis Biochemical parameters were measured before the use of
without infection (n = 56) and compensated patients without antibiotics at admission. Endocan levels were determined by
infection at admission (n = 19). The control group (n = 25) ELISA analyses (JDIEK H1) (Lunginnov SAS, Lille, France).
consisted of healthy blood donors (16 males / 9 females, median The assay range of the ELISA kit was 0.15 ng/ml to 10 ng/ml.
age 53 years) with normal aminotransferases, normal blood Procalcitonin (PCT) was analyzed using an
counts and negative markers for virus hepatitis and HIV. Blood immunoluminometric assay (LUMI test R PCT; BRAHMS
samples were collected in the Department of Physiology and Diagnostica, Berlin, Germany). Detection limit was 0.05 ng/ml.
Biochemistry, University of Physical Education in Wroclaw. Serum C-reactive protein (CRP) level was determined with a
Clinical and biochemical characteristics of the study group are high-sensitivity nephelometric method using the Beckman
reported in detail in Table 1. Image Immunochemistry system (Beckman Instruments,
Inclusion criteria were: histological or clinical diagnosis of Fullerton, CA, USA), which has a minimum level of detection of
cirrhosis, no evidence of metabolic, toxic or autoimmune liver 0.2 mg/L. Serum levels of TNF- and IL-6 were assayed with
disease and at least 1 year of alcohol abstinence. Diagnosis of enzyme-linked immunosorbent assay (ELISA) kits (R&D
cirrhosis was established according histological criteria when Systems Inc., Minneapolis, MN, USA). All analyses were
liver biopsy was performed, or by the combination of clinical, performed in duplicate strictly according to the manufacturers
biochemical and ultrasound imaging data presence of irregular instructions.
margins on ultrasound, portal hypertension with laboratory
evidence of chronic liver disease consistent with such a Statistical analysis
diagnosis. Patients were grouped according to Child-Pugh
classification. Three biochemical variables (serum albumin, Statistical analyses were performed using Statistica 12.5
bilirubin, and prothrombin time (international normalized ratio, software. Continuous variables are expressed as mean standard
INR)) in addition to the presence or absence of ascites and deviation (S.D.) or as median - interquartile range (IQR) and
clinical signs of encephalopathy determine the Child-Pugh score categorical variables as number (percentage). Frequency data
(26). Patients were scored as follows: 5 6 as class (group) A, 7 were compared using the 2 test or the Fischers exact test when
9 as class (group) B and 10 5 as class (group) C. At the time necessary. Because many of the variables analyzed did not have
of the study no Child-Pugh A patients showed clinical features of a normal distribution as determined by the Kolmogorov-
decompensated liver cirrhosis (ascites or hepatic Smirnov test, nonparametric tests were used for comparison of
encephalopathy). data. The Mann-Whitney U test and the Kruskal-Wallis ANOVA
The model for end-stage liver disease (MELD) score was test were used to analyze differences among two or more groups,
also calculated which is the most commonly used alternative respectively. Regression analysis to determine significant
prognostic indicator for cirrhotic patients to the Child-Pugh correlations among different parameters was performed using
score. At enrollment, variceal bleeding was detected by the Spearman correlation coefficient. Statistical significance was
endoscopy in 29% of patients, ascites and hepatic established at P < 0.05.
encephalopathy were present by physical examination in 52 To evaluate the diagnostic performance of endocan receiver
(41%) and 22 (17%) patients, respectively (Table 1). Presence of operator characteristics (ROC) analysis was performed for all
ascites was assessed by ultrasonography. Bacterial infection was significant differences between groups. ROC curves were
confirmed by clinical history, physical examination, differential generated by plotting the sensitivity against 1 - specificity, and
and total white blood cell count, analysis and culture of urine, the area under the curve (AUC) with 95% confidence intervals
thorax X-ray and by the culture and white blood cell count of (95% CI) was calculated. The empirical non-parametric method
ascetic fluid in patients with ascites. Infections of pneumonia, according to DeLong (27) was performed to make pairwise
skin and urinary tract (cystitis, pyelonephritis) were diagnosed comparisons of ROC curves. The optimum cut-off point based

on the ROC analysis was established by selecting the value that patients. Although serum CRP levels were significantly higher in
provides the greatest sum of the sensitivity and specificity, that the decompensated patients with infection than in the uninfected
is, the point closest to the upper left point of the ROC plot. For patients, this biomarker was not a good discriminator because of
the optimum cut-off point provided by each ROC analysis, the the considerable overlap among all groups (Fig. 2). Meanwhile,
sensitivity, specificity, positive predictive value (PPV), and there was no overlap between the levels of TNF- in the infected
negative predictive value (NPV) were calculated using standard patients and that of TNF- in the uninfected groups of cirrhotic
formulas. patients, as can be seen from Fig. 4. However, the non-stability
at room temperature similar to that of other cytokines limits the
prognostic significance of TNF- determination in bacterial
RESULTS infection. The patients with compensated cirrhosis showed high
circulating levels of endocan and cytokines but the median of
A total of 126 patients with liver cirrhosis were this group was not significantly greater than for the control
consecutively analyzed. Table 1 exhibits the characteristics of group (endocan; 1.98 ng/mL (0.3 2.78 ng/mL) versus 0.95
included patients. The median age was 58 years (range 47 to 70 ng/mL (0.0 1.5 ng/mL). Although levels of endocan, CRP, PCT
years) and a male predominance was observed (60%). The and cytokines were higher in decompensated group without
causes of liver cirrhosis were HCV infection (n = 28), HBV infection when compared with compensated group, the
infection (n = 19) and alcohol abuse (n = 79). Alcohol was the difference was not statistically significant (Table 3). At
predominant reason of cirrhosis (63%). The most frequent admission 30 (59%) cirrhotic patients with infection had
infection were spontaneous bacterial peritonitis (59%) and spontaneous bacterial peritonitis (SBP) (Table 1). Endocan
urinary tract infection (22%). concentrations in cirrhotic patients with SBP were not different
to endocan concentrations measured in patients with other types
Characteristics of decompensated cirrhotic patients with of bacterial infections (urinary tract infection, pneumonia, skin
infection at admission infection) (data not shown).
In patients with decompensated cirrhosis regardless whether
The infected patients with liver cirrhosis were compared to infection was present or not, endocan levels were not correlated
the uninfected ones (Table 2). The prevalence of infection with WBC (P = 0.61), PCT (P = 0.28) or with IL-6 (P = 0.21). C-
particularly tended to increase with the severity of liver disease reactive protein (r = 0.36; P < 0.05) and TNF- (r = 0.42, P <
(21%, 35% and 44%, respectively for Child-Pugh class A, B and 0.01) levels and Child-Pugh score (r = 0.48, P < 0.01) correlated
C). Moreover, bacterial infection was associated with only in the infected group of patients with endocan levels, while
significantly higher MELD scores (P < 0.001). Two further in the uninfected groups of cirrhotic patients no significant
factors tended to be related to bacterial infection: presence of correlation could be detected. This was also true for
ascites (59%) and alcoholic cirrhosis (73%) (Table 2). No compensated patients without infections at admission were no
differences between infected and uninfected cirrhotic patients correlation of the investigated biomarkers with endocan could be
were noted regarding the presence of variceal bleeding and detected. These results indicate that the elevation in endocan
encephalopathy. Albumin and total bilirubin levels were similar
among all groups. On the other hand, bacterial infection was
associated with higher median values of white blood cells
(WBC) counts, INR and creatinine (P < 0.001, P < 0.01, P < Table 1. Clinical and biochemical characteristics of the study
0.001, respectively) (Table 2). subjects.

Serum concentrations of endocan, procalcitonin, C-reactive All patients

protein and inflammatory cytokines in cirrhotic patients (n) 126
according to the presence of bacterial infection Male : Female ratio (n) 76:50
Age (years) 58 (47 70)
Serum endocan levels have been reported to vary in healthy
Etiology, n (%)
subjects, and our results (median, 0.95 ng/mL; range, 0.01.5
HCV 28 (22)
ng/mL) were somewhat higher than those reported in previous
HBV 19 (15)
studies (median, 0.3 0.77 ng/mL; range 0.0 1.0 ng/mL) (9,
Alcoholic 79 (63)
11, 25). The cut-off value for endocan was established as 2.05
ng/mL. The patients results are presented in Figs. 1-5 and the Child-Pugh grade,
statistical analyses are summarized in Table 3. Serum endocan A/B/C (n) 26/53/47
(Fig. 1), CRP (Fig 2), PCT (Fig. 3) and levels of TNF- (Fig. 4) Variceal bleeding n (%) 36 (29)
and IL-6 (Fig. 5) were statistically significantly higher in both Ascites, n (%) 52 (41)
decompensated cirrhotic patients with and without infection Encephalopathy, n (%) 22 (17)
when compared with healthy subjects. Infection at admission Infection source, n (%)
was associated with significantly higher median levels of Spontaneous bacterial peritonitis 30 (59)
endocan (P < 0.001), TNF- (P < 0.001), CRP (P < 0.0001) and Urinary tract infection 11 (22)
PCT (P < 0.0001) as compared to the uninfected patients with Pneumonia 7 (14)
both compensated and decompensated cirrhosis (Table 3). IL-6 Skin infection 3 (5)
levels in serum were similar between groups. All decompensated
Albumin (g/L) 28 (16 45)
patients with a bacterial infection had endocan concentrations >
2.05 ng/mL. Additionally, there was no overlap between the Bilirubin (mg/dL) 1.2 (1.0 3.6)
decompensated cirrhosis with bacterial infection and the WBC ( 109/L) 8.5 4.78
compensated cirrhosis and healthy controls (Fig. 1). There was INR (0.8 1.1) 1.4 (0.8 2.9)
only a small overlap between the levels of endocan (Fig. 1) and Creatinine (mg/dL) 1.5 (0.7 5.4)
PCT (Fig. 3) in the infected group of patients and that of
endocan and PCT in the uninfected group of decompensated INR, normalized international ratio; WBC, white blood cells.

Table 2. Clinical and biochemical variables associated with bacterial infection at admission.
Healthy Compensated Decompensated Decompensated
Controls cirrhosis cirrhosis cirrhosis
Absence of bacterial Presence of
-infection bacterial infection
(n) 25 19 56 51
Male:Female ratio (n) 16:9 11:8 33:23 32:19
Age (years) 53 (39 56) 59 (49 67) 58 (47 70) 65 (57 70)
Etiology n (%)
Viral 3 (16) 30 (53) 14 (27)
Alcoholic 16 (84) 26 (47) 37 (73)+
Child-Pugh score 6.9 2.3 8.7 3.2 16.8 7.0++
Child-Pugh grade;
A/B/C (n) 12/7/0 3/28/25 11/18/22
MELD score 5.8 4.6 12.9 7.9 21.1 5.9++
Variceal bleeding n (%) 0 19 (34) 17 (33)
Ascites n (%) 22 (39) 30 (59)+
Encephalopathy n (%) 10 (18) 12 (24)
Albumin (g/L) 45 (36 57) 35 (28 45) 29 (20 40)* 25 (16 32)*
Bilirubin (mg/dL) 0.7 (0.6 0.9) 1.01(1.02 1.03) 1.5 (1.0 2.0)* 2.3 (1.1 3.6)*
WBC ( 109/L) 4.6 (4.2 5.0) 5.1 (1.1 8.6) 8.5 (3.0 12.4)** 10.4 (2.7 16.4)**++
INR (0.8 1.1) 0.9 (0.8 1.09) 1.2 (1.1 1.3) 2.3 (1.6 2.9)+
Creatinine (mg/dL) 0.8 (0.7 1.0) 0.9 (0.7 1.4) 1.32 (0.8 2.4)* 2.6 (0.8 5.4)**++
Continuous variables are expressed as median (interquartile range, IQR) and categorical variables as number (percentage).
Significance between groups: *P < 0.05; **P < 0.01 versus healthy controls; +P < 0.01; ++P < 0.001 versus decompensated cirrhosis
without infection.
INR, normalized international ratio; MELD, model for end stage liver disease; WBC, white blood cells.

Table 3. Comparison between cirrhotic patients classified according to the presence of bacterial infection.

Healthy Compensated Decompensated Decompensated

Controls cirrhosis cirrhosis Cirrhosis
Absence of bacterial Presence of bacterial
infection infection
(n) 25 19 56 51
Endocan 0.95 (0.0 1.5) 1.98 (0.3 2.78) 3.2 (0.55 5.9)* 6.2 (5.3 8.75)**+ #
TNF- 26.0 (22.0 35.0) 34.2 (30.8 41.3) 39.3 (35.6 46.5)* 55.7 (48.7 59.8)**+ #
IL-6 5.8 (2.5 10.7) 14.28 (3.0 20.4) 18,7 (3.0 24.8)** 24.8 (3.0 34.5)***
CRP 1.05 (0.58 2.5) 3.8 (1.75 7.01)* 6.8 (3.1 17.0)** 85.9 (4.9 110.0)***++ ##
PCT 0.05 (0.0 0.09) 0.18 (0.0 1.1)*** 0.4 (0.0 1.1)*** 2.65 (1.00 4.0)***++ ##

Continuous variables are expressed as median (interquartile range; IQR).

Significance between groups: *P < 0.01; **P < 0.001; ***P < 0.0001 versus healthy controls; +P < 0.001; ++P < 0.0001 versus
decompensated cirrhosis without infection; #P < 0.001; ##P < 0.0001 versus compensated cirrhosis without infection.
CRP, C-reactive protein; IL, interleukin; PCT, procalcitonin; TNF-, tumor necrosis factor-.

levels was greater than that of PCT and IL-6, and endocan was endocan, PCT, CRP and TNF- were 0.832, 0.734, 0.584, 0.599,
parameter that was independent of the PCT and IL-6 levels in respectively. The serum endocan level had a specificity of 85%, a
patients with decompensated cirrhosis. sensitivity of 76.1%, positive predictive value of 95.9%, and
negative predictive value of 43.7% at the cut-off level of 2.05
The diagnostic performance of endocan for identification of ng/mL (Table 4). Furthermore, the serum PCT level had a
bacterial infection in decompensated cirrhotic patients specificity of 81.2%, a sensitivity of 69.9%, positive predictive
value of 91.5%, and negative predictive value of 42% at the cut-off
Using biomarkers at admission, receiver operator characteristic level of 0.5 pg/mL. The endocan-assay was the most powerful assay
(ROC) analysis showed that areas under the ROC curve (AUC) of for early diagnosis of infection in decompensated cirrhotic patients.

Fig. 1. Serum concentrations of endocan in cirrhotic patients according to the presence of bacterial infection. Horizontal bars represent
medians of the concentrations in the different figures.

Fig. 2. Serum concentrations of C-reactive protein (CRP) in cirrhotic patients according to the presence of bacterial infection.
Horizontal bars represent medians of the concentrations in the different figures.

Fig. 6 shows ROC curves of endocan for identification of infection in cirrhotic patients increased in advanced liver
patients with infection according to disease severity indicated by disease. The diagnostic accuracy of endocan for identifying
Child-Pugh stage. The accuracy of endocan for diagnosis of patients with infection was the best for Child C stage cirrhosis:

Fig. 3. Serum concentrations of procalcitonin (PCT) in cirrhotic patients according to the presence of bacterial infection. Horizontal
bars represent medians of the concentrations in the different figures.

Fig. 4. Serum concentrations of tumor necrosis factor- (TNF-) in cirrhotic patients according to the presence of bacterial infection.
Horizontal bars represent medians of the concentrations in the different figures.

AUC, (95%CI): 0.917 (0.880 0.939). Endocan showed a Using the DeLong method (27), pairwise comparison of
slightly lower accuracy in patients with Child B: AUC, (95%CI): ROC curves was performed. There were significant differences
0.900 (0.857 0.929), whereas the performance of endocan in between the AUC of endocan in patients with Child A and that
patients with Child A: AUC, (95%CI): 0.794 (0.761 0.817), of endocan in patients with Child C (P = 0.019) for identification
was clearly inferior to the values of endocan for identification of of bacterial infection. There was no difference between the area
infected patients with Child B or C stage cirrhosis. under the ROC curves of endocan for identification of bacterial

Fig. 5. Serum concentrations of interleukin-6 (IL-6) in cirrhotic patients according to the presence of bacterial infection. Horizontal
bars represent medians of the concentrations in the different figures.

Fig. 6. Receiver operating characteristics (ROC) curves of endocan for identification of cirrhotic patients with bacterial infection
according to disease severity indicated by Child-Pugh stage.

infection AUC = 0.794 (95%CI 0.761 0.817) versus 0.900 DISCUSSION

(95%CI 0.857 0.929; P = 0.592), in cirrhotic patients with
Child A and Child B, respectively. There were also no significant Endocan is naturally expressed by endothelial cells, is highly
differences between the AUC of endocan in patients with Child regulated in presence of proinflammatory cytokines and
B and that of endocan in patients with Child C (P = 0.094) (Fig. proangiogenic molecules and may be considered an accurate
6) for identification of infection, but the AUC of endocan in marker of endothelial activation (7). Since endothelial injury is
patients with Child C was higher than that of endocan in patients pivotal in the development of liver failure (28) and in sepsis (18,
with Child B (0.917 versus 0.900). 19), an endothelial marker such as endocan might not only

Table 4. The accuracy of endocan, PCT, CRP and TNF- for the diagnosis of bacterial infection in decompensated cirrhotic patients.

Infected Cut-off Sensitivity Specificity PPV NPV

vs. values (%) (%) (%) (%)
Endocan 2.05 ng/mL 76.1 85.0 95.9 43.7
PCT 0.20 ng/mL 69.9 81.2 91.5 42.0
CRP 14.0 mg/L 53.4 60.0 67.5 31.0
TNF- 37.2 pg/mL 37.9 62.0 70.0 51.3
The optimal cut-off value was calculated from the ROC analysis for endocan, PCT, CRP, and TNF- and subsequently the sensitivity,
specificity, positive predictive
value (PPV) and negative predictive value (NPV) of the markers was calculated.
CRP, C-reactive protein; IL, interleukin; PCT, procalcitonin; TNF-, tumor necrosis factor-.

reflect the severity of liver disease but also represent a promising hepatocellular carcinoma often develops in cirrhotic liver, death
diagnostic marker of bacterial infection in cirrhotic patients. from the underlying disease constitutes a competitive risk of death
The present study provides several lines of evidence to from the tumor. In this context, the combined use of the Child-
suggest that endocan acts as mediator of inflammatory state Pugh score and the serum endocan level enables better prognostic
associated with bacterial infection in liver cirrhosis. First, serum stratification of patients (36). Meanwhile, in our patients with
endocan levels in decompensated cirrhotic patients with cirrhosis, the MELD score was significantly related to the
infections were significantly higher than in uninfected patients. occurrence of bacterial infection, indicating that the hepatic
Second, and more importantly, a significant positive correlation decompensation was associated with an increased risk of
between endocan levels and both Child-Pugh score and infection. Accordingly, the early diagnosis of bacterial infection in
inflammatory markers (TNF-, CRP) was observed in cirrhotic decompensated patients with cirrhosis remain a major challenge,
patients with infection. where time plays a crucial role. Some unique characteristics of
In cirrhosis, systemic inflammation, in form of activated these patients make the diagnosis of bacterial infections
circulating immune cells and increased serum levels of both challenging. For example, the presence of leukocyturia does not
proinflammatory cytokines (e.g. TNF-, IL-6) (29, 30) and cell always correlate with urinary tract infection and the diagnosis of
activation markers, is the result of persistent episodic activation of spontaneous bacteremia can only be established once the results of
circulating immune cells from damage-associated molecular blood cultures are received; since dyspnea, as the predominant
patterns, released from necrotic liver cells and, as infection occurs, presenting symptom in a pulmonary complication of advanced
from pathogen associated molecular patterns, released from the cirrhosis, is frequent in the subclinical forms of hepatopulmonary
leaky gut (1). In our study, we found a correlation between serum syndrome (39), difficulties exists to diagnose pneumonia. Thus, an
endocan level and disease severity and a high level of circulating early diagnosis of bacterial infection would certainly help to
endocan was associated with TNF- and its secondary mediator initiate adequate and timely antibiotics and would possibly
(i.e CRP) in infected cirrhotic patients. In a recent report, endocan improve outcome of decompensated patients with cirrhosis.
appeared to reflect the degree of endothelial cell injury (31). Antibiotics can successfully modify the sequence linking
Furthermore, endocan expression in primary cultured HUVECs is alterations in gut microbiota and intestinal permeability with
regulated by TNF-, a cytokine that is known to stimulate bacterial translocation and pro-inflammatory state, mainly
endothelial cell activation and injury (32), although the precise through their effect on intestinal microbiota. However, infections
mechanism of endocan expression in infection has not been caused by multiresistant bacteria are a growing threat in patients
elucidated. TNF- is a known attractant for leukocytes, enhances with advanced liver cirrhosis. As previous antibiotic
expression of adhesion molecules on endothelial cells, and, administration is strongly related to the development of such
therefore, may play an important role in hepatic inflammatory infections, alternatives to antibiotics are urgently needed in the
responses and cirrhosis progress. In addition, the proinflammatory prevention of bacterial translocation and its consequences. The
activities of endocan on endothelial cells is mediated by in part by evidence is mounting that probiotic treatment through modulation
local release of TNF- (25), which may induces a systemic release of intestinal microbiota have the potential to affect the course of
of CRP by stimulation of IL-6. Even if there was no correlation advanced liver disease (40). It has been observed that VSL#3
between endocan and IL-6, we demonstrated weak association probiotic therapy was well tolerated and led to improvement of
with inflammatory CRP in cirrhotic patients. Although endocan several clinical parameters in patients with decompensated
has not been found to be specific for any systemic inflammatory cirrhosis (41). Interestingly, none of the cirrhotic patients
diseases, it is known to mediate recruitment of circulating developed bacterial infection, which would require
lymphocytes and monocytes to inflammatory sites (7). As a administration of antibiotics. Therefore, the surrogate marker for
consequence, these effects of endocan on inflammation status may bacterial infection which also acts as a guide to the effectiveness
cause the deterioration of hepatic function in patients with of therapy is needed. Thus, in the constant search for biomarkers
advanced cirrhosis and bacterial infection. Collectively, elevated of bacterial infection, endocan has arisen as an attractive
endocan may reflect degree of endothelial cell injury induced by a candidate (16-19).
systemic inflammatory response, a pathologic process that could Although, increased levels of endocan in advanced liver
modify the course of advanced liver failure (33). disease had been previously reported (36, 37, 42), its potential
Several studies suggested a possible role of endocan in value as a diagnostic tool has not been studied. To our
vascular contribution to organ-specific inflammation and in knowledge, ours is the first study in which endocan levels
endothelium-dependent pathological disorders (26, 34, 35). Some revealed significant associations with the severity of liver
other studies also suggest that an elevated serum endocan level disease within the infected group, as demonstrated by significant
can be used to predict future or worsening hepatic correlations with the Child-Pugh score. In addition, the accuracy
decompensation and consequent mortality (36, 37, 38). As of endocan for diagnosis of infection in cirrhotic patients

increased in advanced liver disease. Diagnostic accuracy of 3. Le Moine O, Deviere J, Devaster JM, et al. Interleukin-6: an
endocan for identifying infected patients was the best for Child early marker of bacterial infection in decompensated
C stage cirrhosis (AUC, 0.917), reaching a sensitivity of 81.8%. cirrhosis. J Hepatol 1994; 20: 819-824.
Recently Mosevoll et al. (43) demonstrated that the plasma 4. Navasa M, Follo A, Filella X, et al. Tumor necrosis factor
levels of endocan show a considerable overlap when comparing and interleukin-6 in spontaneousbacterial peritonitis in
healthy subjects, patients with suspected thrombosis and the cirrhosis: relationship with the development of renal
patients without verified thrombosis. Therefore, they suggested impairment and mortality. Hepatology 1998; 27: 1227-1232.
that the plasma endocan alone do not seem to be useful in the 5. Propst T, Propst A, Herold M, et al. Spontaneous bacterial
diagnostic evaluation of these patients, but it may become useful peritonitis is associated with high levels of interleukin-6 and
in combination with other markers. In our study, a relatively its secondary mediators in ascitic fluid. Eur J Clin Invest
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cirrhosis was superior in its diagnostic accuracy compared with endothelial-cell specific molecule-1 binds directly to the
the optimum PCT, CRP and TNF- cut-off levels. These results integrin CD11a/CD18 (LFA-1) and blocks binding to
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earlier than the increase in the PCT or CRP (44, 45). Endocan small cell lung cancer. Clin Cancer Res 2006; 12: 4575-
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as a follow-up (72 hours and beyond) marker of inflammation 10. Maurage CA, Adam E, Mineo JF, et al. Endocan expression
and infection (9). Endocan is still detectable when screened on a and localization in human glioblastomas. J Neuropathol Exp
daily basis, whereas CRP or PCT will have already disappeared Neurol 2009; 68: 633-641.
from the blood. Our results suggest that serum endocan is an 11. Leroy X, Aubert S, Zini L, et al. Vascular endocan (ESM-1)
independent parameter capable of distinguishing infected from is markedly overexpressed in clear cell renal cell carcinoma.
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To understand our findings better, some limitations should carcinoma is associated with angiogenesis and tumour
be considered. First, although the number of patients enrolled invasion. J Int Med Res 2010; 38: 498-510.
might seem small, it adequately represents the sample size 13. Kim JH, Park MY, Kim CN, et al. Expression of endothelial
estimated to provide the specific power. Second, this study was cell-specific molecule-1 regulated by hypoxia inducible
not designed and powered to assess the ability of endocan to factor-1 in human colon carcinoma: impact of ESM-1 on
predict the incidence of bacterial infections in patients without prognosis and its correlation with clinicopathological
overt infections. Lastly, we excluded some diseases that may features. Oncol Rep 2012; 28: 1701-1708.
influence endocan levels; however, some diseases may be 14. Roudnicky F, Poyet C, Wild P, et al. Endocan is upregulated
unrecognized in our study group. on tumor vessels in invasive bladder cancer where it
Life expectancy of patients with liver cirrhosis is closely mediates VEGF-A-induced angiogenesis. Cancer Res 2013;
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bacterial infection. Our study identified serum endocan as a 15. El Behery MM, Seksaka MA, Ibrahiem MA, Saleh HS, El
powerful diagnostic marker to assess the severity of liver disease Alfy Y. Clinicopathological correlation of endocan
and cirrhotic patients with bacterial infection. It may be useful to expression and survival in epithelial ovarian cancer. Arch
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of serum endocam measurements. e0123358. doi: 10.1371/journal.pone.0123358
17. Scherpereel A, Depontieu F, Grigoriu B, et al. Endocan, a
Acknowledgments: The project described was supported by new endothelial marker in human sepsis. Crit Care Med
a grant from the Wroclaw Medical University No. ST- 2006; 34: 532-537.
D020.16.004. 18. Mihajlovic DM, Lendak DF, Brkic SV, et al. Endocan is
useful biomarker of survival and severity in sepsis.
Conflict of interests: None declared. Microvasc Res 2014; 93: 92-97.
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