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Three Part Question

In [adult patients with a diagnosis of acute pancreatitis], [is an elevated Matrix Metalloproteinase/Metallopeptidase-9] accurate in [determining disease severity]?

Clinical Scenario

Following the diagnosis of acute pancreatitis, a 50 year old man awaits treatment in the emergency department. As the right course of action is determined by severity, it is uncertain whether if Matrix Metalloproteinase/Metallopeptidase-9 (MMP-9) can be used to assess the degree of severity in the early stages acute pancreatitis.

Search Strategy

OVID MEDLINE 1946 to June Week 3 2012
EMBASE 1974 to 2012 July 03
([exp Pancreatitis, Acute Necrotizing/ OR exp Pancreatitis/ OR exp Pancreatitis, Chronic/ OR exp Pancreatitis, Alcoholic/ OR pancreatitis.mp.] AND [exp Matrix Metalloproteinase 9/ OR matrix metalloproteinase 9.mp. OR matrix metallopeptidase 9.mp. OR MMP-9.mp. OR metallopeptidase.mp.] LIMIT to Humans AND English Language

Search Outcome

41 papers were found altogether of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
P. Chen et al 2006 China	30 patients: 10 with severe acute pancreatitis (SAP) 10 mild acute pancreatitis (MAP) 10 healthy patients as control (HP)	Prognostic Cohort Study	Serum MMP-9 1 hr after admission	SAP:470.8 ± 51.4, MAP: 329.5 ± 54.0, HP: 246.5 ± 26.8, p<0.01	Different, albeit similar, definition of mild and severe acute pancreatitis. Different interpretation of severity based on APACHE II scores, CRP and TNF-alpha. Strict criterias for sample selection. Data collected was not adequately analysed.
			Serum MMP-9 48 hrs after admission	SAP:350.4 ± 41.5, MAP: 275.6 ± 34.2, HP: 246.5 ± 26.8, p<0.01
			APACHE II Score 1 hr after admission	SAP:13.6 ± 4.3, MAP: 5.6 ± 2.1, HP: 4.3±0.2, p<0.01
			APACHE II Score 48 hrs after admission	SAP: 8.7±5.2, MAP: 4.5±1.3, HP: 4.3±0.2, p<0.01
			Correlation of analysis of MMP-9/APACHE II score	r = 0.957, p<0.01

Comment(s)

Insight into the degree of severity is often required to allow the prompt delivery of appropriate treatment, as a prognosis of severe acute pancreatitis often requires monitoring in the critical care setting. As such, various methods have been put in place for this purpose, including scoring systems, laboratory markers and imaging modalities. Currently, changes in serum CRP at 48 hours is the prognostic marker of choice suggested in the recent UK guidelines. Other quicker methods that could identify severity at 24 hours following admission were also suggested and these included clinical impression of severity, BMI >30, evidence of pleural effusion on chest radiograph. However, with the recent discovery of raised serum MMP-9 as an early indicator of a severe clinical course, this highlighted the disadvantage of delaying severity stratification in using serum CRP. Released in response to extracellular injury, it contributes to pancreatic injury as a proteolytic enzyme of connective tissues. With significant elevations seen within 1 hour of admission and a strong correlation with other prognostic methods, namely APAHCE II score, CRP levels and TNF-α, it was concluded that an elevated serum MMP-9 on admission was a valid assessment for clinical severity in AP. That said, further investigation is required to validate its accuracy.

Clinical Bottom Line

MMP-9 may have predictive value in assessing clinical severity in AP.

References

1. P. Chen et al Serum Matrix Metalloproteinase 9 as a Marker for the Assessment of Severe Acute Pancreatitis Tohoku J. Exp. Med. 2006, 208, 261-266