METHOD FOR GUIDANCE OF FLUID THERAPY BASED ON PROADRENOMEDULLIN

Abstract

The invention relates to a method of therapy guidance, stratification and/or monitoring of fluid therapy based on proadrenomedullin (proADM) levels. The invention therefore relates to a method for therapy guidance, stratification and/or monitoring of a fluid therapy, comprising providing a sample of said patient, determining a level of pro adrenomedullin (proADM) or fragment(s) thereof in said sample, wherein said level of proADM or fragment(s) thereof indicates the prescription of fluid therapy to be administered to the patient. The invention further relates to methods for guiding fluid therapy volume and to methods of treating disease using fluid therapy based on the proADM stratification of patients based on the methods described herein.

Claims

1. Method for therapy guidance, stratification and/or monitoring of a fluid therapy, comprising providing a sample of said patient, determining a level of pro adrenomedullin (proADM) or fragment(s) thereof in said sample, wherein said level of proADM or fragment(s) thereof indicates the prescription of fluid therapy to be administered to the patient.

2. Method according to claim 1, wherein the patient has been diagnosed as having sepsis, severe sepsis or septic shock.

3. Method according to claim 1, wherein the patient has been diagnosed as having one or more organ failure(s), and/or wherein the patient is a posttraumatic or postsurgical patient.

4. Method according to claim 1, wherein the prescription of fluid therapy comprises indicating the volume, frequency and/or rate of fluid to be administered to the patient.

5. Method according to claim 1, wherein the fluid therapy comprises administration of a colloid solution, preferably selected from the group consisting of gelatin, albumin and/or starch solution, or blood or a fluid derived from blood.

6. Method according to claim 1, wherein the fluid therapy comprises administration of a crystalloid solution.

7. Method according to claim 1, comprising additionally determining a level of lactate in a sample isolated from the patient.

8. Method according to claim 1, wherein the patient receives fluid therapy and an intermediate or high severity level of proADM or fragment(s) thereof determined in the sample is indicative of a reduction in the volume and/or rate of fluid to be administered to the patient, wherein an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and wherein a high severity level of proADM or fragment(s) thereof is above 10.9 nmol/l20%.

9. Method according to claim 1, wherein the patient receives fluid therapy and an intermediate or high severity level of proADM or fragment(s) thereof determined in the sample is indicative of an adverse event, wherein an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and wherein a high severity level of proADM or fragment(s) thereof is above 10.9 nmol/l20%.

10. Method according to claim 1, comprising determining a level of proADM or fragment(s) thereof in a first and a second sample from the patient, wherein the second sample is obtained after obtaining the first sample; wherein no change or an increase in the levels of proADM or fragment(s) thereof in the second sample compared to the first sample is indicative of a reduction in the volume, frequency and/or rate of fluid to be administered to the patient, or wherein an increase from a low to an intermediate or high severity level of proADM or fragment(s) thereof, or an increase from an intermediate to a high severity level of proADM or fragment(s) thereof, is indicative of a reduction in the volume and/or rate of fluid to be administered to the patient, wherein a low severity level of proADM or fragment(s) thereof is below 2.75 nmol/l20%, an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and a high severity level of proADM or fragment(s) thereof is above 10.9 nmol/l20%.

11. Method according to claim 10, wherein the first sample is isolated at or before fluid therapy initiation (time point 0) and the second sample is isolated at a time point between 12 and 36 hours, preferably 24 hours, after said therapy initiation, and/or at a time point between 3 and 5 days, preferably 4 days, after said therapy initiation.

12. Method according to claim 1, wherein the patient receives fluid therapy and a low severity level of proADM or fragment(s) thereof determined in the sample is indicative of administering 2.78 ml/kg20% of fluid or less (fluid administered per kg body weight of the patient) to the patient within approximately 24 hours, an intermediate severity level of proADM or fragment(s) thereof determined in the sample is indicative of administering 4.94 ml/kg20% or less of fluid to the patient within approximately 24 hours, or a high severity level of proADM or fragment(s) thereof determined in the sample is indicative of administering 9.95 ml/kg20% or less of fluid to the patient within approximately 24 hours, and wherein a low severity level of proADM or fragment(s) thereof is below 2.75 nmol/l20%, wherein an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and wherein a high severity level of proADM or fragment(s) thereof is above 10.9 nmol/l20%.

13. A method for treating a patient in need of receiving fluid therapy comprising administering to said patient a pharmaceutical composition comprising a therapeutic fluid, preferably a colloid and/or crystalloid solution, wherein the patient is administered said composition after being prescribed said administration by the method according to claim 1.

14. The method according to claim 13, wherein the patient has already received fluid therapy, and when the patient exhibits an intermediate or high severity level of proADM or fragment(s) thereof determined in the sample, the patient receives a reduction in the volume, frequency and/or rate of fluid administered to the patient, wherein an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and wherein a high severity level is above 10.9 nmol/l20%, or wherein a level of proADM or fragment(s) thereof in a first and a second sample from the patient has been determined, wherein the second sample is obtained after obtaining the first sample; wherein when no change or an increase in the levels of proADM or fragment(s) thereof is determined in the second sample compared to the first sample, a reduction in the volume, frequency and/or rate of fluid is administered to the patient.

15. The method according to claim 13, wherein a patient with a low severity level of proADM or fragment(s) thereof determined in the sample is administered 2.7820% or less of fluid (fluid administered per kg body weight of the patient) within approximately 24 hours, a patient with an intermediate severity level of proADM or fragment(s) thereof determined in the sample is administered 4.94 ml/kg20% or less of fluid within approximately 24 hours, a patient with a high severity level of proADM or fragment(s) thereof determined in the sample is administered 9.95 ml/kg20% or less of fluid within approximately 24 hours, and wherein a low severity level of proADM or fragment(s) thereof is below 2.75 nmol/l20%, wherein an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and wherein a high severity level of proADM or fragment(s) thereof is above 10.9 nmol/l20%.

16. The method according to claim 13, wherein when a low and/or intermediate severity level of proADM or fragment(s) thereof determined in the sample are determined, the patient is administered a starch solution, preferably hydroxyethyl starch.

17. The method according to claim 13, wherein when a high severity level of proADM or fragment(s) thereof determined in the sample are determined, the patient is administered an albumin solution, preferably a 20% albumin solution.

18. The method according to claim 13, wherein when an intermediate or high severity level of proADM or fragment(s) thereof determined in the sample are determined, the patient is administered a gelatin solution.

19. The method according to claim 13, wherein the patient receives intravenous administration of the composition.

20. Kit for therapy guidance, stratification and/or monitoring of a fluid therapy, comprising: detection reagents for determining the level of proADM or fragment(s) thereof in a sample from a subject, reference data, such as a reference level, corresponding to high, intermediate and/or low severity levels of proADM, wherein a low severity level of proADM or fragment(s) thereof is below 2.75 nmol/l20%, wherein an intermediate severity level of proADM or fragment(s) thereof is from 2.75 nmol/l20% to 10.9 nmol/l20%, and wherein a high severity level of proADM or fragment(s) thereof is above 10.9 nmol/l20%, wherein said reference data is stored on a computer readable medium and/or employed in the form of computer executable code configured for comparing the determined levels of proADM or fragment(s) thereof, and a pharmaceutical composition comprising a therapeutic fluid, preferably a colloid and optionally crystalloid solution.

Description

FIGURES

[0491] Embodiments of the present invention are illustrated by the figures, as follows:

[0492] FIG. 1: Effects of fluid administration during the first 24 hours according to MR-proADM kinetics. A moderate correlation was achieved based on the mortality rate within these MR-proADM severity groups and the development of RRT (R=0.595).

[0493] FIG. 2: Effects of fluid administration during the first 24 hours according to MR-proADM kinetics. A stronger correlation (R.sup.2=0.931) could be found between each MR-proADM severity group, mortality and fluid administration.

[0494] FIG. 3: Effects of fluid administration during the first 24 hours according to lactate kinetics. Lactate values were assessed in relation to the amount of fluid administered to patients. Lactate levels show a similar relationship to fluid volume compared to proADM. The correlations were comparable to that of MR-proADM (R.sup.2=0.965).

[0495] FIG. 4: Effects of colloid administration during the first 4 days according to MR-proADM kinetics. A high correlation was achieved based on the requirement for RRT within the MR-proADM severity groups and the volume of fluid administered (R=0.894).

[0496] FIG. 5: Effects of colloid administration during the first 4 days according to MR-proADM kinetics. Similar results as in FIG. 4 were also achieved when the patient's weight was taken into account, giving an intravenous fluid administration rate of ml/kg, and an R.sup.2 of 9.49.

[0497] FIG. 6: Effects of colloid administration during the first 4 days according to lactate kinetics. Lactate values were also assessed in relation to the amount of fluid administered to patients. Lactate levels show a similar relationship to fluid volume compared to proADM. The correlations were however significantly weaker (R.sup.2=0.810) than those for MR-proADM.

[0498] The present invention is further described by reference to the following non-limiting examples.

EXAMPLES

Methods of the Examples

[0499] Study Design and Patients:

[0500] This study is a secondary analysis of the Placebo-Controlled Trial of Sodium Selenite and Procalcitonin Guided Antimicrobial Therapy in Severe Sepsis (SISPCT), which was performed across 33 multidisciplinary intensive care units (ICUs) throughout Germany from November 2009 until February 2013 (26). Eligibility criteria included adult patients years presenting with new onset severe sepsis or septic shock (24 hours), according to the SEPSIS-1 definition of the ACCP/SCCM Consensus Conference Committee, and further classified according to the 2016 definitions (sepsis-3 and septic shock-3) (4). Details of the study design, data collection and management were described previously (26). The ethics committee of Jena University Hospital and all other centers approved the study and written informed consent was obtained whenever necessary.

[0501] Biomarker Measurements:

[0502] Patients were enrolled up to 24 hours after diagnosis of severe sepsis or septic shock and PCT, CRP and lactate measured immediately thereafter. PCT was measured on devices with a measuring range of 0.02-5000 ng/ml, and a functional assay sensitivity and lower detection limit of at least 0.06 ng/ml and 0.02 ng/ml, respectively. Additional blood samples from all patients were collected and stored at the central study laboratory in Jena at 80 C. MR-proADM plasma concentrations were measured retrospectively (Kryptor, Thermo Fisher Scientific, Germany) with a limit of detection of 0.05 nmol/L. Clinical severity scores including the Sequential Organ Failure Assessment (SOFA), Acute Physiological and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiological (SAPS) II score were taken upon study enrollment.

[0503] Statistical Analysis:

[0504] Differences in demographic and clinical characteristics with regards to 28 day mortality were assessed using the 2 test for categorical variables, and Student's t-test or Mann-Whitney U test for continuous variables, depending on distribution normality. Normally and non-normally distributed variables were expressed as mean (standard deviation) and median [first quartilethird quartile], respectively. The association between mortality and each biomarker and clinical score at all time points was assessed using area under the receiver operating characteristic curves (AUROC) and Cox regression analysis, with multivariate analysis corrected for age and the presence of comorbidities and septic shock. Patients were further classified into three severity subgroups (low, intermediate and high) based on the calculation of two AUROC cut-offs across the total population for each biomarker and clinical score at each time point, with a predefined sensitivity and specificity of close to 90%. A subgroup clinically stable patients was subsequently identified with an absence of any ICU associated procedures or complications (including focus cleaning procedures, emergency surgery, the emergence of new infections, transfusion of blood products, infusion of colloids, invasive mechanical ventilation, renal/liver replacement or vasopressor therapy and a deterioration in the patient's general clinical signs and symptoms), and a further group identified with corresponding low MR-proADM concentrations which had not shown any increase since the previous measurement. Mortality rates and average lengths of stay were calculated in both groups and compared against the patient group who were discharged at each specific time point.

[0505] Finally, two models stratifying patients with PCT changes of 20% (baseline to day 1, based on average PCT decreases observed over this time period) and 50% (baseline to day four, based on a previously constructed model (26)) were constructed. Patient subgroups were subsequently identified based on MR-proADM severity levels, and respective mortality rates calculated. The risk of mortality within each subgroup was calculated by Cox regression analysis and illustrated by Kaplan-Meier curves. The predicted risk of developing new infections and the requirement for focus cleaning procedures and emergency surgery over days 4 to 7 were subsequently investigated in the baseline to day 4 model. All data were analyzed using the statistics software R (version 3.1.2).

Example 1

Patient Characteristics

[0506] Patient characteristics upon study enrollment are summarized in Table 1.

[0507] A total of 1089 patients with either severe sepsis (13.0%) or septic shock (87.0%) were analyzed, with 445 (41.3%) and 633 (58.7%) patients also satisfying the criteria for sepsis-3 and septic shock-3, respectively. Enrolled patients had an average age of 65.7 (13.7) years and a mean SOFA score of 10.0 (3.3) points. The 28 day all-cause mortality rate (N=1076) was 26.9% (sepsis-3: 20.0%; septic shock-3: 32.1%), with a hospital mortality rate of 33.4% (sepsis-3: 24.4%; septic shock-3: 40.4%). Infections originating from a single focus were found in 836 patients (77.7%), with pneumological (N=324; 30.1%), intra-abdominal (N=252; 23.4%), urogenital (N=57; 5.3%) and bone/soft tissue (N=50; 4.6%) origins most prevalent. Corresponding mortality rates were 26.5%, 24.6%, 22.8% and 28.0%, respectively. Multiple origins of infection were found in 240 (22.3%) patients. The most common causes of mortality included sepsis induced multiple organ failure (N=132; 45.7%), refractory septic shock (N=54; 18.7%), death due to pre-existing illness (N=35; 12.1%) and acute respiratory insufficiency (N=17; 5.9%). Other causes such as cardiogenic and hemorrhagic shock, pulmonary embolism, cerebral oedema, myocardial infarction and cardiac arrhythmia accounted for a combined mortality rate of 8.6%. A limitation of therapy was applied to 3.4% of patients.

Example 2

Association of Baseline Biomarkers and Clinical Scores with Mortality

[0508] Univariate and multivariate Cox regression analysis found that MR-proADM had the strongest association with 28 day mortality across the total patient population, as well as within the sepsis-3 and septic shock-3 subgroups (Table 2). Corresponding AUROC analysis found significant differences in all biomarker and clinical score comparisons with MR-proADM, apart from APACHE II (sepsis-3 patient subgroup).

[0509] Similar results were also found for 7 day, 90 day, ICU and hospital mortality prediction (Table 3), with the addition of MR-proADM to all potential biomarkers and clinical score combinations (N=63) significantly increasing prognostic capability (Table 4).

Example 3

Identification of High-Risk Patients

[0510] The total patient population was further stratified according to existing SOFA severity levels, and biomarker and clinical score performance in predicting 28 day mortality assessed in each subgroup. MR-proADM showed the highest accuracy of all parameters in the low (SOFA7) and moderate (8SOFA13) severity SOFA subgroups (Table 5; Table 6).

[0511] Two corresponding MR-proADM cut-offs were subsequently calculated to identify low (2.7 nmol/L) and high (>10.9 nmol/L) severity subgroups at baseline. Compared to SOFA, a more accurate reclassification could be made at both low (MR-proADM vs. SOFA: N=265 vs. 232; 9.8% vs. 13.8% mortality) and high (MR-proADM vs. SOFA: N=161 vs. 155; 55.9% vs. 41.3%) severity cut-offs (Table 7).

[0512] A subgroup of 94 patients (9.3%) with high MR-proADM concentrations and corresponding low or intermediate SOFA had 28 and 90 day mortality rates of 57.4% and 68.9%, respectively, compared to 19.8% and 30.8% in the remaining patient population with low and intermediate SOFA values. Similar patterns could be found for SAPS II, APACHE II and lactate, respectively (Tables 8-10).

Example 4

Identification of Low Risk Patients Throughout ICU Stay

[0513] The study cohort comprises a subset of clinically stable patients that did not face ICU related procedures or complications, such as focus cleaning procedures, emergency surgery, new infections, transfusion of blood products, infusion of colloids, invasive mechanical ventilation, renal/liver replacement, deterioration in the patient's general clinical signs and symptoms. This group of clinically stable patients was categorized as low risk patients.

[0514] MR-proADM showed the strongest association with 28 day mortality across all subsequent time points (Table 11), and could provide a stable cut-off of 2.25 nmol/L in identifying a low risk patient population, resulting in the classification of greater patient numbers with lower mortality rates compared to other biomarkers and clinical scores (Table 12). Accordingly, 290 low MR-proADM severity patients could be identified on day 4, of which 79 (27.2%) were clinically stable and had no increase in MR-proADM concentrations from the last measurement (Table 13). A continuously low MR-proADM concentration could be found in 51 (64.6%) patients, whilst a decrease from an intermediate to low level severity level could be observed in 28 (35.4%) patients. The average ICU length of stay was 8 [7-10] days, with a 28 and 90 day mortality rate of 0.0% and 1.4%, respectively. In comparison, only 43 patients were actually discharged from the ICU on day 4, with a 28 and 90 day mortality rate of 2.3% and 10.0%. Analysis of the MR-proADM concentrations within this group of patients indicated a range of values, with 20 (52.6%), 16 (42.1%) and 2 (5.3%) patients having low, intermediate and high severity concentrations, respectively. Similar results were found for patients remaining on the ICU on days 7 and 10.

[0515] MR-proADM with a stable cut-off of 2.25 nmol/L could identify a greater number of low risk patients with lower mortality rates compared to other biomarkers and clinical scores. Based on that finding more patients could be discharged from the ICU compared to classifications without using ADM. By discharging more patients, the hospital can more efficiently occupy ICU beds and benefits from avoided costs.

Example 5

Additional Impact of MR-proADM on Procalcitonin Guided Therapy

[0516] Time-dependent Cox regression analysis indicated that the earliest significant additional increase in prognostic information to MR-proADM baseline values could be observed on day 1, with subsequent single or cumulative measurements resulting in significantly stronger associations with 28 day mortality (Table 14). Hence two PCT guided algorithm models were constructed investigating PCT changes from baseline to either day 1 or day 4, with corresponding subgroup analysis based on MR-proADM severity classifications.

[0517] Patients with decreasing PCT concentrations of 20% from baseline to day 1 (Table 15 and Table 16) or 50% from baseline to day 4 (Table 17 and Table 18) were found to have 28 day mortality rates of 18.3% (N=458) and 17.1% (N=557), respectively. This decreased to 5.6% (N=125) and 1.8% (N=111) when patients had continuously low levels of MR-proADM, although increased to 66.7% (N=27) and 52.8% (N=39) in patients with continuously high MR-proADM values (HR [95% CI]: 19.1 [8.0-45.9] and 43.1 [10.1-184.0]).

[0518] Furthermore, patients with decreasing PCT values of 50% (baseline to day 4), but continuously high or intermediate MR-proADM concentrations, had a significantly greater risk of developing subsequent nosocomial infections (HR [95% CI]: high concentrations: 3.9 [1.5-10.5]; intermediate concentrations: 2.4 [1.1-5.1] vs. patients with continuously low concentrations; intermediate concentrations: 2.9 [1.2-6.8]) vs. decreasing intermediate to low concentrations), or requiring emergency surgery (HR [95% CI]: intermediate concentrations: 2.0 [1.1-3.7] vs. decreasing intermediate to low concentrations). Conversely, patients with increasing intermediate to high concentrations were more likely to require cleaning of the infectious origin compared to those with continuously intermediate (HR [95% CI]: 3.2 [1.3-7.6]), or decreasing (HR [95% CI]: intermediate to low: 8.7 [3.1-24.8]); high to intermediate: 4.6 [1.4-14.5]) values. When PCT levels failed to decrease by 50%, a significantly increased risk of requiring emergency surgery was observed if MR-proADM concentrations were either at a continuously high (HR [95% CI]: 5.7 [1.5-21.9]) or intermediate (HR [95% CI]: 4.2 [1.3-13.2]) level, as opposed to being continuously low.

Example 6

Association of Baseline Biomarkers and Clinical Scores with Mortality

[0519] MR-proADM showed the strongest association in patients with pneumological and intra-abdominal infections, as well as in patients with Gram positive infections, irrespective of the infectious origin (Tables 19-20). When patients were grouped according to operative emergency, non-operative emergency and elective surgery history resulting in admission to the ICU, MR-proADM provided the strongest and most balanced association with 28 day mortality across all groups (Table 21).

Example 7

Correlation of Biomarkers and Clinical Scores with SOFA at Baseline and Day 1

[0520] MR-proADM had the greatest correlation of all biomarkers with the SOFA score at baseline, which was significantly increased when baseline values were correlated with day 1 SOFA scores. The greatest correlation could be found between MR-proADM and SOFA on day 10, with differences between individual SOFA sub scores found throughout (Tables 22-24).

Example 8

Identification of High-Risk Patients

[0521] Similar results could be found in a subgroup of 124 patients (12.0%) with high MR-proADM concentrations and either low or intermediate SAPS II values (High MR-proADM subgroup: [54.8% and 65.6% mortality]; remaining SAPS II population [19.7% and 30.0% mortality]), as well as in 109 (10.6%) patients with either low or intermediate APACHE II values (High MR-proADM subgroup: [56.9% and 66.7% mortality]; remaining APACHE II population: [19.5% and 30.3% mortality]).

Example 9

Improved Procalcitonin (PCT) Guided Therapy by Combining PCT and ADM

[0522] Two PCT guided algorithm models were constructed investigating PCT changes from baseline to either day 1 or day 4, with corresponding subgroup analysis based on MR-proADM severity classifications (Tables 25-30).

[0523] The previous examples show an add-on value for ADM in patients having a PCT decrease at <20% or <50%, as well as in patients where PCT decreased by 20% or 50%. However, additional analysis demonstrates that ADM can be an add-on regardless of % of decrease or even increase of PCT. Decreasing PCT values could reflect patients where the antibiotic treatment appears to be working, therefore the clinician thinks they are on a good way to survival (i.e. kill the root cause of the sepsisthe bacteriashould result in the patient getting better).

[0524] For example, some patients have decreasing PCT levels from baseline (day of admission) to day 1 with a 28 d mortality rate of 19%. By additionally measuring ADM, you can conclude from patients with low ADM a much higher chance of survival or much lower probability to die (Table 25; compare 19% mortality rate decreasing PCT only vs. 5% mortality rate PCT +low ADM). By having a reduced risk of dying, patients could be discharged from ICU with more confidence, or fewer diagnostic tests are required (i.e. you know they are on a good path to recovery).

[0525] On the other hand, new measures need to be considered for those with a high ADM value. They are at a much higher risk with regard to mortality (compare 19% mortality rate decreasing PCT only vs 58.8% mortality rate PCT +high ADM). The physician thinks the patient is getting better due to the decrease in PCT value, but in fact the ADM concentration remains the same. It can be therefore concluded that treatment ISNT working, and needs to be adapted as soon as possible).

[0526] In a similar way, ADM can help to stratify those patients with increasing PCT values (Table 25).

[0527] Development of New Infections

[0528] PCT and MR-proADM changes were analyzed in two models, either from baseline to day 1, or from baseline to day 4. Patients were grouped according to overall PCT changes and MR-proADM severity levels.

[0529] The number of new infections over days 1, 2, 3 and 4 (Table 26) and over days 4, 5, 6 and 7 (Table 27) were subsequently calculated in each patient who was present on day 1 or day 4 respectively. In some cases, patients were discharged during the observation period. It is assumed that no new infections were developed after release. Patients with multiple infections over the observation days were counted as a single new infection.

[0530] As a clinical consequence, patients with high MR-proADM concentrations should potentially be treated with a broad-spectrum antibiotic on ICU admission, in conjunction with others, in order to stop the development on new infections. Special care should be taken with these patients due to their high susceptibility to pick up new infections.

[0531] Requirement for Focus Cleaning

[0532] PCT and MR-proADM changes were analyzed in two models, either from baseline to day 1, or from baseline to day 4. Patients were grouped according to overall PCT changes and MR-proADM severity levels.

[0533] The number of focus cleaning events over days 1, 2, 3 and 4 (Table 28) and over days 4, 5, 6 and 7 (Table 29) were subsequently calculated in each patient who was present on day 1 or day 4 respectively. In some cases, patients were discharged during the observation period.

[0534] Requirement of Emergency Surgery

[0535] PCT and MR-proADM changes were analyzed in two models, either from baseline to day 1, or from baseline to day 4. Patients were grouped according to overall PCT changes and MR-proADM severity levels.

[0536] The number of emergency surgery requirements/events over days 1, 2, 3 and 4 (Table 30) were subsequently calculated in each patient who was present on day 1. In some cases, patients were discharged during the observation period.

Example 10

Requirement for Antibiotic Change or Modification

[0537] When combined within a PCT guided antibiotic algorithm, MR-proADM can stratify those patients who will require a future change or modification in antibiotic therapy, from those who will not.

[0538] PCT and MR-proADM changes were analyzed in two models, either from baseline to day 1, or from baseline to day 4. Patients were grouped according to overall PCT changes and MR-proADM severity levels.

[0539] The percentage of antibiotic changes on day 4 required for each patient group was subsequently calculated (Tables 31 and 32).

[0540] In Patients with Decreasing PCT Values 50%

[0541] Patients with increasing MR-proADM concentrations, from a low to intermediate severity level, were more likely to require a modification in antibiotic therapy on day 4 than those who had continuously low levels (Odds Ration [95% CI]: 1.5 [0.6-4.1]).

[0542] In Patients with Decreasing PCT Values <50%

[0543] Patients with either increasing MR-proADM concentrations, from an intermediate to high severity level, or continuously high concentrations, were also more likely to require changes in their antibiotic therapy on day 4 than patients with continuously low MR-proADM concentrations (Odds Ratio [95% CI]: 5.9 [1.9-18.1] and 2.9 [0.8-10.4], respectively).

[0544] Conclusion

[0545] Despite increasing PCT concentrations, either from baseline to day 1, or baseline to day 4, patients with continuously low MR-proADM concentrations had significantly lower modifications made to their prescribed antibiotic treatment than those with continuously intermediate or high concentrations. As a clinical consequence, when faced with increasing PCT concentrations, a physician should check the patient's MR-proADM levels before deciding on changing antibiotics. Those with low MR-proADM concentrations should be considered for either an increased dose or increased strength of the same antibiotic before changes are considered. Those with higher MR-proADM concentrations should be considered for earlier antibiotic changes (i.e. on days 1 to 3, as opposed to day 4).

Example 11

Identification of Patients with Abnormal Platelet Levels and Identification of High Risk Patients with Thrombocytopenia (Tables 33, 34 and 35)

[0546] Proadrenomedullin and Procalcitonin levels were measured and analyzed with regard to thrombocyte count, mortality rate and platelet transfusion at baseline and day 1. Increasing proADM and PCT concentrations correlate with decreasing platelet numbers and platelet numbers (<150.000 per I) that reflect thrombocytopenia. The strongest decrease of platelet count was observed in patients with the highest proADM levels at baseline. Moreover increased proADM and PCT concentrations were in line with patients who required a platelet transfusion therapy. It could also confirmed that a higher mortality rate is associated with patients having thrombocytopenia and increased proADM (>6 nmol/L) and PCT (>7 ng/ml) levels.

[0547] Pro-ADM levels were investigated in patients who had normal thrombocyte levels at baseline to see if increasing proADM could predict thrombocytopenia. 39.4% of patients with continually elevated proADM levels at baseline and on day 1(proADM >10.9 nmol/l) developed thrombocytopenia. 25.6% of patients with increased proADM levels at baseline (proADM >2.75 nmol/L) and on day 1 (proADM >9.5 nmol/L) developed thrombocytopenia. 14.7% of patients with continually low proADM level at baseline and on day 1 (proADM 2.75 nmol/L) developed thrombocytopenia. The increased level of proADM correlated with the severity of the thrombocytopenic event and the associated increased mortality rate (proADM >10.9 nmol/L mortality rate of 51%; proADM 2.75 nmol/L mortality rate 9.1%). Example 11 refers to tables 33-35.

Example 12

Effects of Fluid Volume on Mortality and MR-proADM Concentrations

[0548] Emerging evidence suggests that the type and dose of fluid therapy may affect patient out-comes. The dataset described herein obtained from the secondary analysis of the Placebo-Controlled Trial of Sodium Selenite and Procalcitonin Guided Antimicrobial Therapy in Severe Sepsis (SISPCT), which was performed across 33 multidisciplinary intensive care units (ICUs) throughout Germany from November 2009 until February 2013 (26), was assessed by looking into the effects of fluid volume on mortality and MR-proADM concentrations. At present, there is no way of determining how much fluid should be administered to a patient, nor which fluid to use.

[0549] This analysis described in Example 12 highlights the use of MR-proADM concentrations at baseline, day 1 and day 4 in guiding the volume of fluid to be administered, in order to maintain low or decrease MR-proADM concentrations, as well as to guide the use of specific colloids depending on MR-proADM concentrations.

[0550] The analysis presented herein shows that excess administration of fluid volumes are commonly detrimental, resulting in organ dysfunction and progression to multiple organ failure and ultimately to mortality. Administering the correct volume of fluids on a patient by patient basis is therefore crucial, and may be guided by the proADM values measured for any given patient at any given time during treatment. MR-proADM and lactate perform similarly as biomarkers in guiding the volume of fluids to be administered during the first 24 hours after diagnosis/therapy initiation. MR-proADM is however more accurate in guiding the volume of fluid to be administrated between 24 and 96 hours.

[0551] Methods:

[0552] 1076 patients from the study described in detail above with severe sepsis or septic shock for whom fluid therapy was administered and monitored were retrospectively analyzed. Biomarker values were recorded at baseline (i.e. sepsis diagnosis), 24 hours (day 1) and 96 hours (day 4) later. MR-proADM concentrations at baseline, day 1 and day 4 were used to classify patients into low, moderate or high severity, as is described above in more detail:

TABLE-US-00003 MR-proADM severity Baseline Day 1 Day 4 Low 2.75 2.80 2.80 Moderate >2.75 and 10.9 >2.80 and 9.5 >2.80 and 7.7 High >10.9 >9.5 >7.7

[0553] The total volume of fluid administered was then calculated in order to determine the effect on 28-day mortality and the requirement for RRT. Within the first 24 hours, blood was taken first, then fluid was administered, and a subsequent blood measurement taken. Similarly for determining the effects of fluid administration of biomarker kinetics, blood was taken at baseline, fluid was intermittently added for the next 4 days, and then the biomarker concentration was again measured in the blood.

[0554] Fluid administration is not performed or adjusted in light of proADM concentrations determined during fluid therapy. The assessment is based on each practitioner treating with fluids as they see best fit, without predetermined stratification guidelines. Due to there being no strict guidelines on fluid type or volume for sepsis patients, the fluids administered varied significantly across the patients, also varying within patient groups exhibiting similar symptoms.

[0555] Effects of Fluid Administration During the First 24 Hours According to MR-proADM Kinetics

[0556] Patients with continuously low MR-proADM concentrations received the lowest amount of fluid. Conversely, those patients who initially had intermediate MR-proADM concentrations which increased to high levels, were administered 2-3 times more fluid. Similarly, patients with decreasing MR-proADM concentrations (i.e. intermediate to low or high to intermediate) were administered lower volumes of fluid compared to those patients where concentrations did not change in severity level (i.e. intermediate to intermediate, or high to high).

[0557] The results of this analysis are presented in Table 36. A moderate correlation was achieved based on the mortality rate within these MR-proADM severity groups and the development of RRT (R=0.595). These results are presented in FIG. 1.

[0558] A stronger correlation (R.sup.2=0.931) could be found between each MR-proADM severity group, mortality and fluid administration. These results are presented in FIG. 2.

[0559] Lactate values were also assessed in relation to the amount of fluid administered to patients. Lactate levels show a similar relationship to fluid volume compared to proADM. These results are presented in Table 37. The correlations were comparable to that of MR-proADM (R.sup.2=0.965), as shown in FIG. 3.

[0560] Effects of Colloid Administration During the First 4 Days According to MR-proADM Kinetics:

[0561] A total of 980 patients had MR-proADM values at baseline and at day 4. Patients were subsequently classified according to their MR-proADM severities, as outlined above, and the total volume of colloid fluid and blood products calculated. This was then related to the mortality rate of each group and the requirement of renal replacement therapy (RRT) in patients with an absence of RRT at baseline.

[0562] Results show that based on MR-proADM cut-offs, increasing fluid administration resulted in directly influencing MR-proADM levels, thus increasing or decreasing the likelihood of mortality of RRT requirement. These results are presented in Table 38.

[0563] A high correlation was achieved based on the requirement for RRT within these MR-proADM severity groups and the volume of fluid administered (R=0.894), as shown in FIG. 4.

[0564] Similar results were also achieved when the patient's weight was taken into account, giving an intravenous fluid administration rate of ml/kg, and an R.sup.2 of 9.49, as shown in FIG. 5.

[0565] Lactate values were also assessed in relation to the amount of fluid administered to patients. Lactate levels show a similar relationship to fluid volume compared to proADM. These results are presented in Table 39. The correlations were however significantly weaker (R.sup.2=0.810) than those for MR-proADM, as shown in FIG. 6. The correlation between lactate severity groups, mortality and total fluid volume administered is significantly less accurate than for MR-proADM.

[0566] Effects of Particular Colloid Administration During the First 4 Days According to MR-proADM Kinetics:

[0567] The administration of individual colloids on proADM kinetics was assessed from baseline to day 4 in the above mentioned study population.

[0568] Gelatin:

[0569] A total of 81 (10.6%) patients were administered gelatin during the first 4 days of ICU treatment, with a 28-day mortality rate of 28.4%. Results are presented in Table 40.

[0570] The results show that gelatin seemed to be a poor choice in patients with low ADM concentrations. Patients receiving gelatin as a fluid therapy, even with low proADM levels, had a higher frequency of mortality than one would expect. Mortality was also high in patients with intermediate proADM levels who received higher amount of gelatin. Administering relatively low amounts of gelatin to patients with high proADM levels did however lead to a reduction in ADM levels and associated low mortality.

[0571] 20% Albumin:

[0572] A total of 144 (18.8%) patients were administered 20% albumin solution during the first 4 days of ICU treatment, with a 28-day mortality rate of 29.8%. Results are presented in Table 41.

[0573] The results show that 20% albumin appears to be an appropriate choice for reducing mortality in patients with high ADM concentrations, but it could also push patients towards RRT requirement, as is evident from the high frequency of RRT required in patients who were receiving relatively high amounts of albumin. Both mortality and RRT requirements were very low in patients with intermediate ADM levels who were administered relatively low amounts of albumin.

[0574] HES:

[0575] A total of 103 (13.4%) patients were administered hydroxyethyl starch (HES) solution during the first 4 days of ICU treatment, with a 28-day mortality rate of 15.5%. Results are presented in Table 42.

[0576] A known problem with HES is that administration can cause an increase in RRT requirement. This has been evident from other studies. The data here found that this is not the case when MR-proADM levels were low or at intermediate levels. When MR-proADM concentrations were already high, then all patients who were administered HES required RRT. HES may therefore be administered (preferably in relatively low amounts) to patients with low or intermediate proADM levels at baseline.

Discussion of Examples

[0577] An accurate and rapid assessment of disease severity is crucial in order to initiate the most appropriate treatment at the earliest opportunity. Indeed, delayed or insufficient treatment may lead to a general deterioration in the patient's clinical condition, resulting in further treatment becoming less effective and a greater probability of a poorer overall outcome (8, 27). As a result, numerous biomarkers and clinical severity scores have been proposed to fulfil this unmet clinical need, with the Sequential Organ Failure Assessment (SOFA) score currently highlighted as the most appropriate tool, resulting in its central role in the 2016 sepsis-3 definition (4). This secondary analysis of the SISPCT trial (26), for the first time, compared sequential measurements of conventional biomarkers and clinical scores, such as lactate, procalcitonin (PCT) and SOFA, with those of the microcirculatory dysfunction marker, MR-proADM, in a large patient population with severe sepsis and septic shock.

[0578] Our results indicate that the initial use of MR-proADM within the first 24 hours after sepsis diagnosis resulted in the strongest association with short, mid and long-term mortality compared to all other biomarkers or scores. Previous studies largely confirm our findings (17, 28, 29), however conflicting results (30) may be explained in part by the smaller sample sizes analyzed, as well as other factors highlighted within this study, such as microbial species, origin of infection and previous surgical history preceding sepsis development, all of which may influence biomarker performance, thus adding to the potential variability of results in small study populations. Furthermore, our study also closely confirms the results of a previous investigation (17), highlighting the superior performance of MR-proADM in low and intermediate organ dysfunction severity patients. Indeed, Andaluz-Ojeda et al. (17) place significant importance on the patient group with low levels of organ dysfunction, since this group represents either the earliest presentation in the clinical course of sepsis and/or the less severe form of the disease. Nevertheless, a reasonable performance could be maintained across all severity groups with respect to mortality prediction, which was also the case across both patient groups defined according to the sepsis-3 and septic shock-3 criteria.

[0579] Analysis of the sequential measurements taken after onset of sepsis allowed for the identification of specific patients groups based on disease severity. The identification of both low and high-risk patients was of significant interest in our analysis. In many ICUs, the demand for ICU beds can periodically exceed availability, which may lead to an inadequate triage, a rationing of resources, and a subsequent decrease in the likelihood of correct ICU admission (32-35). Consequently, an accurate assessment of patients with a low risk of hospital mortality that may be eligible for an early ICU discharge to a step down unit may be of significant benefit. At each time point measured within our study, MR-proADM could identify a higher number of low severity patients with the lowest ICU, hospital and 28 day mortality rates. Further analysis of the patient group with a low severity and no further ICU specific therapies indicated that an additional 4 days of ICU stay were observed at each time point after biomarker measurements were taken. When compared to the patient population who were actually discharged at each time point, a biomarker driven approach to accurately identify low severity patients resulted in decreased 28 and 90 day mortality rates. Indeed, patients who were discharged had a variety of low, intermediate and high severity MR-proADM concentrations, which was subsequently reflected in a higher mortality rate. It is, however, unknown whether a number of patients within this group still required further ICU treatment for non-microcirculatory, non-life threatening issues, or that beds in a step down unit were available. Nevertheless, such a biomarker driven approach to ICU discharge in addition to clinician judgement may improve correct stratification of the patient, with accompanied clinical benefits and potential cost savings.

[0580] Conversely, the identification of high-risk patients who may require early and targeted treatment to prevent a subsequent clinical deterioration may be of even greater clinical relevance. Substantial cost savings and reductions in antibiotic use have already been observed following a PCT guided algorithm in the SISPCT study and other trials (26, 36, 37), however relatively high mortality rates can still be observed even when PCT values appear to be decreasing steadily. Our study revealed that the addition of MR-proADM to the model of PCT decreases over subsequent ICU days allowed the identification of low, intermediate and high risk patient groups, with increasing and decreasing MR-proADM severity levels from baseline to day 1 providing a sensitive and early indication as to treatment success. In addition, the prediction of the requirement for future focus cleaning or emergency surgery, as well as the susceptibility for the development of new infections, may be of substantial benefit in initiating additional therapeutic and interventional strategies, thus attempting to prevent any future clinical complications at an early stage.

[0581] The strength of our study includes the thorough examination of several different subgroups with low and high disease severities from a randomized trial database, adjusting for potential confounders and including the largest sample size of patients with sepsis, characterized by both SEPSIS 1 and 3 definitions, and information on MR-proADM kinetics. In conclusion, MR-proADM outperforms other biomarkers and clinical severity scores in the ability to identify mortality risk in patients with sepsis, both on initial diagnosis and over the course of ICU treatment. Accordingly, MR-proADM may be used as a tool to identify high severity patients who may require alternative diagnostic and therapeutic interventions, and low severity patients who may potentially be eligible for an early ICU discharge in conjunction with an absence of ICU specific therapies. The analysis presented herein also enables therapy guidance for fluid therapies based on proADM measurements.

[0582] Tables

TABLE-US-00004 TABLE 1 Patient characteristics at baseline for survival up to 28 days Non- Total Survivors Survivors (N = 1076) (N = 787) (N = 289) P value Age (years) (mean, S.D.) 65.7 (13.7) 64.3 (14.0) 69.5 (12.0) <0.0001 Male gender (n, %) 681 (63.3%) 510 (64.8%) 171 (59.2%) 0.0907 Definitions of sepsis and length of stay Severe sepsis (n, %) 139 (12.9%) 109 (13.9%) 30 (10.4%) 0.1251 Septic shock (n, %) 937 (87.1%) 678 (86.2%) 259 (89.6%) 0.1251 Sepsis-3 (n, %) 444 (41.3%) 356 (45.4%) 88 (30.4%) <0.0001 Septic shock-3 (n, %) 630 (58.7%) 429 (54.6%) 201 (69.6%) <0.0001 ICU length of stay (days) (median, IQR) 12 [6-23] 13 [7-26] 8 [4-15] <0.0001 Hospital length of stay (days) (median, IQR) 28 [17-45] 34 [22-51] 14 [7-23] <0.0001 Pre-existing comorbidities History of diabetes (n, %) 280 (26.0%) 188 (23.9%) 92 (31.8%) 0.0094 Heart failure (n, %) 230 (21.4%) 150 (19.1%) 80 (27.7%) 0.0027 Renal dysfunction (n, %) 217 (20.2%) 135 (17.2%) 82 (28.4%) <0.0001 COPD (n, %) 131 (12.2%) 90 (11.4%) 41 (14.2%) 0.2277 Liver cirrhosis (n, %) 50 (4.7%) 27 (3.4%) 23 (8.0%) 0.0030 History of cancer (n, %) 319 (29.7%) 224 (28.5%) 95 (32.9%) 0.1630 Immunosuppression (n, %) 46 (4.3%) 30 (3.8%) 16 (5.5%) 0.2271 Microbiology Gram positive (n, %) 146 (13.6%) 113 (14.4%) 33 (11.4%) 0.2050 Gram negative (n, %) 132 (12.3%) 95 (12.1%) 37 (12.8%) 0.7467 Fungal (n, %) 51 (4.7%) 37 (4.7%) 14 (4.8%) 0.9223 Gram positive and negative (n, %) 183 (17.0%) 133 (16.9%) 50 (17.3%) 0.8767 Gram positive and fungal (n, %) 92 (8.6%) 68 (8.6%) 24 (8.3%) 0.8610 Gram negative and fungal (n, %) 51 (4.7%) 35 (4.5%) 16 (5.5%) 0.4631 Gram positive and negative and fungal (n, %) 115 (10.7%) 81 (10.3%) 34 (11.8%) 0.4922 Origin of infection Pneumonia (n, %) 453 (43.7%) 327 (42.9%) 126 (46.0%) 0.3798 Upper or lower respiratory (n, %) 44 (4.3%) 29 (3.8%) 15 (5.5%) 0.2523 Thoracic (n, %) 44 (4.3%) 35 (4.6%) 9 (3.3%) 0.3444 Bones/soft tissue (n, %) 78 (7.5%) 56 (7.4%) 22 (8.0%) 0.7161 Gastrointestinal (n, %) 80 (7.7%) 68 (8.9%) 12 (4.4%) 0.0107 Catheter associated (n, %) 30 (2.9%) 18 (2.4%) 12 (4.4%) 0.1015 Surgical wound (n, %) 41 (4.0%) 31 (4.1%) 10 (3.7%) 0.7586 Intraabdominal (n, %) 375 (36.2%) 276 (36.2%) 99 (36.1%) 0.9790 Cardiovascular (n, %) 6 (0.6%) 4 (0.5%) 2 (0.7%) 0.7082 Urogenital (n, %) 99 (9.6%) 70 (9.2%) 29 (10.6%) 0.5039 Central nervous system (n, %) 3 (0.3%) 2 (0.3%) 1 (0.4%) 0.7916 Bacteremia (n, %) 31 (3.0%) 20 (2.6%) 11 (4.0%) 0.2611 Organ dysfunction Neurological (n, %) 348 (32.3%) 240 (30.5%) 108 (37.4%) 0.0340 Respiratory (n, %) 486 (45.2%) 350 (44.5%) 136 (47.1%) 0.4502 Cardiovascular (n, %) 829 (77.0%) 584 (74.2%) 245 (84.8%) 0.0002 Renal dysfunction (n, %) 382 (35.5%) 249 (31.6%) 133 (46.0%) <0.0001 Haematological (n, %) 156 (14.5%) 89 (11.3%) 67 (23.2%) <0.0001 Gastrointestinal (n, %) 387 (36.0%) 271 (34.4%) 116 (40.1%) 0.0855 Metabolic dysfunction (n, %) 718 (66.7%) 504 (64.0%) 214 (74.1%) 0.0017 Other organ dysfunction (n, %) 499 (46.4%) 380 (48.3%) 119 (41.2%) 0.0378 Treatment upon ICU admission Invasive mechanical ventilation (n, %) 789 (73.3%) 567 (72.1%) 222 (76.8%) 0.1133 Non-invasive mechanical ventilation (n, %) 64 (5.9%) 46 (5.8%) 18 (6.2%) 0.8145 Renal replacement therapy (n, %) 326 (30.8%) 158 (20.5%) 168 (58.1%) <0.0001 Vasopressor use (n, %) 980 (91.1%) 712 (90.5%) 268 (92.7%) 0.2391 Biomarker and severity scores MR-proADM (nmol/L) (median, IQR) 5.0 [2.6-8.8] 4.0 [2.3-7.2] 8.2 [5.2-12.6] <0.0001 PCT (ng/mL) (median, IQR) 7.4 [1.6-26.9] 6.6 [1.4-25.1] 9.3 [2.6-31.8] 0.0325 Lactate (mmol/L) (median, IQR) 2.7 [1.6-4.7] 2.4 [1.5-4.0] 3.7 [2.1-7.2] <0.0001 CRP (mg/L) (median, IQR) 188 [120.9-282] 189 [120.5-277.4] 188 [122-287] 0.7727 SOFA (points) (mean, S.D.) 10.02 (3.33) 9.58 (3.18) 11.22 (3.43) <0.0001 SAPS II (points) (mean, S.D.) 63.27 (14.18) 61.08 (13.71) 69.24 (13.74) <0.0001 APACHE II (points) (mean, S.D.) 24.24 (7.60) 23.05 (7.37) 27.49 (7.28) <0.0001 ICU: Intensive Care Unit; COPD: chronic obstructive pulmonary disease; MR-proADM, mid-regional proadrenomedullin; PCT: procalcitonin; CRP: C-reactive protein; SOFA: Sequential Organ Failure Assessment; SAPS II: Simplified Acute Physiological score; APACHE II: Acute Physiological and Chronic Health Evaluation. Data are presented as absolute number and percentages in brackets, indicating the proportion of surviving and non-surviving patients at 28 days.

TABLE-US-00005 TABLE 2 Prediction of 28 day mortality following sepsis diagnosis Univariate Multivariate C- HR IQR C- HR IQR N Events AUROC LR .sub.X2 index [95%] p LR .sub.X2 index [95%] All patients MR- 1030 275 0.73 142.7 0.71 3.2 [2.6-3.9] <0.0001 161.69 0.72 2.9 [2.4-3.6] proADM PCT 1031 275 0.56 12.2 0.56 1.4 [1.2-1.7] 0.0005 70.28 0.64 1.4 [1.1-1.7] CRP 936 251 0.49 0.12 0.51 1.0 [0.9-1.2] 0.7304 50.54 0.62 1.1 [0.9-1.2] Lactate 1066 289 0.65 78.3 0.64 2.2 [1.8-2.5] <0.0001 122.72 0.69 2.1 [1.7-2.5] SOFA 1051 282 0.64 47.3 0.62 1.6 [1.4-1.8] <0.0001 96.05 0.67 1.6 [1.4-1.8] SAPS II 1076 289 0.67 70.5 0.65 1.8 [1.6-2.0] <0.0001 100.3 0.67 1.6 [1.4-1.9] APACHE 1076 289 0.67 69.9 0.65 1.9 [1.6-2.2] <0.0001 99.21 0.67 1.7 [1.4-2.0] II Sepsis-3 MR- 425 83 0.73 40.9 0.71 2.8 [2.0-3.8] <0.0001 61.4 0.74 2.6 [1.8-3.7] proADM PCT 425 83 0.56 4.6 0.56 1.4 [1.0-1.9] 0.0312 40.6 0.70 1.5 [1.1-2.1] CRP 382 81 0.55 2.1 0.54 0.9 [0.7-1.1] 0.1505 36.7 0.69 0.9 [0.7-1.1] Lactate 439 88 0.57 7.7 0.56 1.3 [1.1-1.6] 0.0057 45.0 0.69 1.3 [1.1-1.7] SOFA 428 86 0.58 3.2 0.56 1.2 [1.0-1.5] 0.0745 40.8 0.69 1.2 [1.0-1.5] SAPS II 439 88 0.62 14.5 0.61 1.7 [1.3-2.3] 0.0001 45.0 0.69 1.5 [1.1-2.0] APACHE 439 88 0.70 30.8 0.68 2.1 [1.6-2.6] <0.0001 52.6 0.71 1.7 [1.3-2.3] II Septic MR- 597 192 0.72 77.4 0.69 2.4 [2.0-3.0] <0.0001 93.5 0.71 2.3 [1.8-2.9] shock-3 proADM PCT 597 192 0.50 0.4 0.51 1.1 [0.9-1.3] 0.5264 35.7 0.62 1.1 [0.9-1.4] CRP 545 170 0.53 2.1 0.53 1.1 [1.0-1.3] 0.1498 31.7 0.63 1.1 [1.0-1.4] Lactate 627 201 0.64 52.2 0.64 2.0 [1.7-2.4] <0.0001 79.4 0.68 2.0 [1.7-2.4] SOFA 616 196 0.65 31.1 0.62 1.6 [1.4-1.9] <0.0001 56.5 0.66 1.6 [1.3-1.9] SAPS II 627 201 0.67 42.2 0.65 1.7 [1.4-1.9] <0.0001 59.8 0.66 1.6 [1.3-1.8] APACHE 627 201 0.63 28.3 0.61 1.6 [1.3-1.9] <0.0001 50.7 0.65 1.5 [1.3-1.8] II N: Number; AUROC: Area under the Receiver Operating Curve; LR .sub.X2: HR: Hazard Ratio; IQR: Interquartile range. All multivariate analyses were associated by p < 0.0001 to 28 day mortality.

TABLE-US-00006 TABLE 3 Survival analysis for 7 day, 90 day, ICU and hospital mortality Univariate Multivariate Patients Mortality LR C- HR IQR p- LR C- HR IQR (N) (N) AUROC X.sup.2 index [95% CI] value X.sup.2 index [95% CI] 7 day MR- 1037 131 0.72 71.6 0.71 3.3 [2.4-4.3] <0.0001 82.1 0.73 3.4 [2.5-4.6] proADM PCT 1038 131 0.58 9.7 0.58 1.5 [1.2-2.0] 0.0019 28.4 0.64 1.6 [1.2-2.1] CRP 943 111 0.55 1.2 0.55 1.1 [0.9-1.4] 0.2843 16.6 0.62 1.2 [0.9-1.4] Lactate 1074 135 0.72 86.0 0.71 3.1 [2.4-3.9] <0.0001 99.1 0.73 3.1 [2.4-4.0] SOFA 1059 130 0.63 25.5 0.63 1.7 [1.4-2.0] <0.0001 41.0 0.67 1.7 [1.4-2.1] SAPS II 1085 135 0.66 38.5 0.66 1.8 [1.5-2.2] <0.0001 50.1 0.67 1.8 [1.5-2.2] APACHE 1085 135 0.63 24.4 0.63 1.7 [1.4-2.1] <0.0001 37.8 0.65 1.7 [1.4-2.1] II 90 day MR- 1000 379 0.71 146.2 0.68 2.7 [2.3-3.2] <0.0001 194.1 0.71 2.4 [2.0-2.8] proADM PCT 1000 379 0.55 11.8 0.55 1.3 [1.1-1.5] 0.0006 113.5 0.65 1.3 [1.1-1.5] CRP 909 348 0.51 0.2 0.51 1.0 [0.9-1.2] 0.6641 92.3 0.64 1.1 [0.9-1.2] Lactate 1037 399 0.64 83.2 0.63 2.0 [1.7-2.3] <0.0001 168.8 0.68 1.9 [1.6-2.2] SOFA 1021 388 0.62 48.1 0.61 1.5 [1.4-1.7] <0.0001 143.7 0.67 1.5 [1.3-1.7] SAPS II 1045 399 0.66 81.1 0.64 1.7 [1.5-1.9] <0.0001 144.4 0.67 1.5 [1.3-1.7] APACHE 1045 399 0.67 86.4 0.64 1.8 [1.6-2.1] <0.0001 146.8 0.67 1.6 [1.4-1.8] II ICU MR- 1023 264 0.73 136.4 0.73 4.0 [3.1-5.2] <0.0001 158.3 0.75 3.7 [2.8-4.9] proADM PCT 1024 264 0.58 18.0 0.58 1.6 [1.3-2.0] <0.0001 73.0 0.67 1.6 [1.3-2.1] CRP 928 237 0.54 2.5 0.54 1.1 [1.0-1.3] 0.1108 51.4 0.65 1.2 [1.0-1.4] Lactate 1059 277 0.66 75.2 0.66 2.4 [2.0-3.0] <0.0001 115.5 0.71 2.4 [1.9-2.9] SOFA 1044 270 0.64 48.6 0.64 1.8 [1.5-2.2] <0.0001 95.2 0.69 1.8 [1.5-2.2] SAPS II 1070 277 0.65 58.7 0.65 1.9 [1.6-2.3] <0.0001 91.2 0.68 1.8 [1.5-2.2] APACHE 1070 277 0.66 62.5 0.66 2.1 [1.7-2.6] <0.0001 91.6 0.69 1.9 [1.5-2.3] II Hospital MR- 980 323 0.73 152.0 0.74 4.0 [3.1-5.2] <0.0001 186.8 0.76 3.6 [2.7-4.6] proADM PCT 981 323 0.57 15.0 0.57 1.5 [1.2-1.9] 0.0001 96.2 0.68 1.5 [1.2-1.9] CRP 891 299 0.52 0.9 0.52 1.1 [0.9-1.3] 0.3480 76.0 0.67 1.1 [1.0-1.3] Lactate 1016 342 0.66 77.8 0.66 2.4 [2.0-2.9] <0.0001 146.2 0.72 2.3 [1.9-2.9] SOFA 1001 333 0.63 41.3 0.63 1.7 [1.4-2.0] <0.0001 118.9 0.70 1.7 [1.4-2.0] SAPS II 1027 342 0.65 59.1 0.65 1.9 [1.6-2.2] <0.0001 115.9 0.69 1.7 [1.4-2.0] APACHE 1027 342 0.67 76.7 0.67 2.2 [1.9-2.7] <0.0001 127.1 0.71 1.9 [1.6-2.4] II All multivariate p values < 0.0001 apart from PCT and CRP for 7 day mortality (0.0015 and 0.0843, respectively).

TABLE-US-00007 TABLE 4 Survival analysis for MR-proADM when added to individual biomarkers or clinical scores Bivariate Added value Multivariate Added value Patients Mortality LR C- HR IQR LR p- LR C- HR IQR LR p- (N) (N) X.sup.2 index [95% CI] X.sup.2 value X.sup.2 index [95% CI] X.sup.2 value 7 day PCT 1037 131 76.5 0.72 4.0 [2.9-5.6] 66.8 <0.0001 86.2 0.73 4.2 [2.9-6.1] 57.8 <0.0001 CRP 904 108 56.9 0.71 3.2 [2.3-4.3] 55.0 <0.0001 67.7 0.73 3.3 [2.3-4.7] 49.4 <0.0001 Lactate 1029 131 112.5 0.75 2.3 [1.7-3.1] 28.1 <0.0001 125.1 0.76 2.4 [1.7-3.3] 26.4 <0.0001 SOFA 1014 126 77.8 0.72 3.3 [2.3-4.6] 53.5 <0.0001 86.9 0.74 3.3 [2.3-4.7] 46.6 <0.0001 SAPS 1037 131 83.1 0.73 2.8 [2.0-3.7] 48.1 <0.0001 93.5 0.74 2.9 [2.1-4.0] 46.7 <0.0001 II APACHE 1037 131 73.3 0.71 3.0 [2.2-4.1] 50.9 <0.0001 84.5 0.73 3.1 [2.2-4.2] 48.6 <0.0001 II 28 day PCT 1030 275 163.0 0.73 4.3 [3.4-5.5] 150.7 <0.0001 174.9 0.73 3.9 [3.0-5.1] 105.0 <0.0001 CRP 898 239 114.4 0.70 3.0 [2.5-3.8] 114.2 <0.0001 132.4 0.72 2.8 [2.2-3.6] 80.5 <0.0001 Lactate 1022 275 163.8 0.72 2.7 [2.2-3.3] 85.9 <0.0001 184.5 0.73 2.5 [2.0-3.1] 61.4 <0.0001 SOFA 1007 268 150.6 0.72 3.1 [2.5-3.9] 104.1 <0.0001 169.9 0.73 2.8 [2.2-3.6] 74.4 <0.0001 SAPS 1030 275 163.4 0.72 2.7 [2.2-3.3] 97.1 <0.0001 176.5 0.73 2.6 [2.1-3.3] 79.1 <0.0001 II APACHE 1030 275 153.6 0.72 2.7 [2.2-3.4] 88.8 <0.0001 169.1 0.73 2.6 [2.1-3.3] 74.1 <0.0001 II 90 day PCT 1000 379 170.8 0.70 3.6 [3.0-4.4] 159.0 <0.0001 208.2 0.71 3.1 [2.5-3.9] 94.8 <0.0001 CRP 872 331 116.0 0.68 2.6 [2.2-3.1] 116.0 <0.0001 160.3 0.70 2.3 [1.9-2.8] 68.8 <0.0001 Lactate 993 379 169.4 0.69 2.3 [1.9-2.7] 86.6 <0.0001 217.5 0.71 2.0 [1.7-2.4] 50.2 <0.0001 SOFA 977 368 151.0 0.69 2.6 [2.1-3.1] 103.1 <0.0001 200.6 0.71 2.2 [1.8-2.7] 59.9 <0.0001 SAPS 1000 379 173.7 0.70 2.3 [1.9-2.7] 94.7 <0.0001 208.4 0.71 2.2 [1.8-2.6] 67.6 <0.0001 II APACHE 1000 379 165.0 0.70 2.3 [1.9-2.7] 83.3 <0.0001 202.9 0.71 2.1 [1.8-2.6] 62.5 <0.0001 II ICU PCT 1023 264 149.5 0.75 5.7 [4.1-7.9] 131.4 <0.0001 165.3 0.76 4.9 [3.5-7.0] 92.6 <0.0001 CRP 889 226 104.6 0.72 3.7 [2.8-4.8] 102.5 <0.0001 127.4 0.74 3.4 [2.5-4.6] 75.6 <0.0001 Lactate 1015 264 153.5 0.74 3.2 [2.4-4.2] 78.9 <0.0001 175.6 0.76 2.9 [2.2-3.9] 57.5 <0.0001 SOFA 1000 257 140.7 0.74 3.6 [2.7-4.8] 91.8 <0.0001 163.8 0.76 3.2 [2.4-4.4] 65.8 <0.0001 SAPS 1023 264 152.5 0.75 3.4 [2.6-4.4] 94.4 <0.0001 169.2 0.76 3.3 [2.5-4.3] 77.7 <0.0001 II APACHE 1023 264 148.2 0.74 3.3 [2.5-4.4] 87.9 <0.0001 165.7 0.76 3.3 [2.5-4.3] 75.6 <0.0001 II Hospital PCT 980 323 174.7 0.76 6.4 [4.6-8.8] 159.5 <0.0001 198.9 0.77 5.2 [3.6-7.3] 103.2 <0.0001 CRP 852 283 117.9 0.72 3.7 [2.9-4.8] 117.3 <0.0001 150.1 0.75 3.3 [2.5-4.3] 77.7 <0.0001 Lactate 972 323 167.4 0.75 3.3 [2.5-4.3] 89.2 <0.0001 202.5 0.76 2.8 [2.1-3.8] 57.6 <0.0001 SOFA 957 314 155.5 0.74 3.9 [3.0-5.2] 113.7 <0.0001 191.3 0.76 3.4 [2.5-4.5] 74.6 <0.0001 SAPS 980 323 165.8 0.75 3.5 [2.7-4.5] 107.7 <0.0001 194.2 0.76 3.2 [2.4-4.2] 81.3 <0.0001 II APACHE 980 323 169.7 0.75 3.3 [2.6-4.3] 95.4 <0.0001 197.2 0.76 3.1 [2.4-4.1] 75.1 <0.0001 II HR IQR [95% CI] indicates the hazard ratio for MR-proADM in each bivariate or multivariate model. 2 degrees of freedom in each bivariate model, compared to 11 in each multivariate model.

TABLE-US-00008 TABLE 5 AUROC analysis for 28 day mortality prediction based on SOFA severity levels Univariate Multivariate LR C- HR IQR LR C- HR IQR N Events AUROC X.sup.2 index [95%] p X.sup.2 index [95%] p SOFA 7 MR- 232 32 0.74 25.1 0.72 3.6 [2.2-6.0] <0.0001 37.6 0.77 3.1 [1.7-5.6] <0.0001 proADM PCT 232 32 0.55 0.9 0.55 1.3 [0.8-2.2] 0.3519 22.4 0.72 1.2 [0.7-2.1] 0.0134 CRP 210 32 0.45 1.1 0.55 1.3 [0.8-2.0] 0.2881 17.5 0.69 1.3 [0.8-2.1] 0.0647 Lactate 236 35 0.62 5.5 0.61 1.8 [1.1-3.0] 0.0186 24.3 0.71 1.7 [1.0-2.8] 0.0069 SAPS II 240 35 0.65 9.3 0.50 2.0 [1.3-3.0] 0.0023 22.5 0.71 1.4 [0.8-2.5] 0.013 APACHE 240 35 0.69 14.3 0.64 2.4 [1.5-3.9] 0.0002 24.6 0.71 1.7 [1.0-3.0] 0.00161 II SOFA 8-13 MR- 620 172 0.72 74.3 0.70 2.7 [2.1-3.3] <0.0001 89.3 0.72 2.3 [1.8-3.01] <0.0001 proADM PCT 620 172 0.54 3.9 0.54 1.3 [1.0-1.6] 0.0482 46.3 0.65 1.3 [1.0-1.6] <0.0001 CRP 572 161 0.51 0.1 0.52 1.0 [0.9-1.2] 0.7932 39.3 0.64 1.0 [0.9-1.2] <0.0001 Lactate 650 181 0.61 26.9 0.61 1.7 [1.4-2.0] <0.0001 61.6 0.67 1.6 [1.3-2.0] <0.0001 SAPS II 653 181 0.64 27.7 0.57 1.6 [1.3-1.9] 0.0014 53.9 0.64 1.4 [1.2-1.7] <0.0001 APACHE 653 181 0.63 22.1 0.62 1.5 [1.3-1.8] <0.0001 49.3 0.65 1.3 [1.1-1.6] <0.0001 II SOFA 14 MR- 155 64 0.67 14.9 0.65 2.0 [1.4-3.0] 0.0001 25.6 0.69 2.2 [1.4-3.3] 0.0043 proADM PCT 155 64 0.49 0.2 0.52 1.1 [0.8-1.5] 0.6944 11.5 0.62 1.2 [0.8-1.7] 0.3169 CRP 136 53 0.57 2.0 0.55 0.9 [0.7-1.1] 0.1569 14.9 0.64 2.6 [1.7-3.8] 0.0004 Lactate 158 66 0.69 22.6 0.68 2.5 [1.7-3.6] <0.0001 32.3 0.71 0.9 [0.7-1.1] 0.1370 SAPS II 158 66 0.54 2.8 0.56 1.3 [0.9-1.8] 0.0930 15.3 0.63 1.2 [0.8-1.7] 0.2958 APACHE 158 66 0.54 1.8 0.54 1.3 [0.9-1.7] 0.1754 11.8 0.62 1.2 [0.9-1.7] 0.2487 II N: Number; AUROC: Area under the Receiver Operating Curve; LR X.sup.2: HR: Hazard Ratio; IQR: Interguartile range.

TABLE-US-00009 TABLE 6 Survival analysis for MR-proADM within different organ dysfunction severity groups when combined with individual biomarkers or clinical scores Univariate Multivariate Patients Mortality LR C- HR IQR p- LR C- HR IQR p- (N) (N) X.sup.2 index [95% CI] value X.sup.2 index [95% CI] value SOFA 7 PCT 232 32 30.0 0.75 5.3 [2.8-10.1] <0.0001 41.8 0.78 5.0 [2.3-10.8] <0.0001 CRP 204 29 20.1 0.71 3.1 [1.8-5.3] <0.0001 30.5 0.75 2.7 [1.4-5.0] 0.0013 Lactate 229 32 25.1 0.72 3.5 [2.0-5.9] <0.0001 37.2 0.77 3.1 [1.7-5.7] 0.0001 SOFA 232 32 27.3 0.73 3.9 [2.3-6.7] <0.0001 40.4 0.78 3.5 [1.9-6.5] <0.0001 SAPS 232 32 28.9 0.74 3.2 [1.9-5.4] <0.0001 38.4 0.78 3.1 [1.7-5.5] 0.0001 II APACHE 232 32 34.2 0.77 2.9 [1.7-4.9] <0.0001 41.4 0.79 3.0 [1.7-5.5] <0.0001 II SOFA 8-13 PCT 620 172 90.4 0.72 3.8 [2.8-5.0] <0.0001 98.0 0.72 3.2 [2.3-4.4] <0.0001 CRP 544 153 63.1 0.69 2.6 [2.0-3.3] <0.0001 78.6 0.71 2.4 [1.7-2.9] <0.0001 Lactate 617 172 81.4 0.70 2.4 [1.9-3.1] <0.0001 97.0 0.72 2.1 [1.6-2.7] <0.0001 SOFA 620 172 76.2 0.70 2.6 [2.0-3.2] <0.0001 90.7 0.72 2.3 [1.8-2.9] <0.0001 SAPS 620 172 87.2 0.71 2.4 [1.9-3.1] <0.0001 97.2 0.72 2.3 [1.8-2.9] <0.0001 II APACHE 620 172 79.0 0.70 2.5 [1.9-3.1] <0.0001 90.9 0.72 2.3 [1.8-2.9] <0.0001 II SOFA 14 PCT 155 64 16.3 0.66 2.2 [1.5-3.2] 0.0001 27.1 0.69 2.4 [1.5-3.9] 0.0001 CRP 134 52 13.4 0.65 1.9 [1.3-2.9] 0.0007 26.9 0.70 2.1 [1.3-3.3] 0.0007 Lactate 155 64 28.9 0.69 1.7 [1.1-2.5] 0.0063 38.1 0.71 1.8 [1.1-2.8] 0.0068 SOFA 155 64 15.3 0.65 2.0 [1.3-2.9] 0.0004 26.7 0.69 2.1 [1.3-3.2] 0.0004 SAPS 155 64 17.0 0.65 2.1 [1.4-3.1] 0.0001 26.2 0.69 2.2 [1.4-3.3] 0.0001 II APACHE 155 64 15.1 0.64 2.0 [1.3-2.9] 0.0002 25.7 0.69 2.1 [1.4-3.3] 0.0002 II

TABLE-US-00010 TABLE 7 Corresponding 28 day SOFA and MR-proADM disease severity groups SOFA severity groups Low severity Intermediate severity High severity (7 points) (8 points 13) (14 points) N = 232, 13.8% mortality N = 620, 27.7% mortality N = 155, 41.3% mortality MR-proADM Low severity N = 111 (41.9%) N = 139 (52.8%) N = 15 (5.7%) severity groups (2.7 nmol/L) 7.2% mortality 10.8% mortality 20.0% mortality N = 265, 9.8% mortality Intermediate severity N = 114 (19.6%) N = 394 (68.0%) N = 73 (12.6%) (<2.7 nmol/L 10.9) 15.8% mortality 27.7% mortality 34.2% mortality N = 581, 26.2% mortality High severity N = 7 (4.3%) N = 87 (53.4%) N = 67 (41.6%) (>10.9 nmol/L) 85.7% mortality 55.2% mortality 53.7% mortality N = 161 55.9% mortality MR-proADM: mid-regional proadrenomedullin; SOFA: Sequential Organ Failure Assessment

TABLE-US-00011 TABLE 8 Corresponding 28 day SAPS II and MR-proADM disease severity groups SAPS II severity groups Low severity Intermediate severity High severity (53 points) (54 points 79) (80 points) N = 235, 11.5% mortality N = 656, 29.3% mortality N = 139, 40.3% mortality MR-proADM Low severity N = 108 (39.9%) N = 143 (52.8%) N = 20 (7.4%) severity groups (2.7 nmol/L) 7.4% mortality 11.2% mortality 20.0% mortality N = 271, 10.3% mortality Intermediate severity N = 118 (19.9%) N = 398 (67.0%) N = 78 (13.1%) (<2.7 nmol/L 10.9) 13.6% mortality 27.9% mortality 38.5% mortality N = 594, 26.4% mortality High severity N = 9 (5.5%) N = 115 (69.7%) N = 41 (24.8%) (>10.9 nmol/L) 33.3% mortality 56.5% mortality 53.7% mortality N = 165, 54.5% mortality MR-proADM: mid-regional proadrenomedullin; SAPS II: Simplified Acute Physiological II

TABLE-US-00012 TABLE 9 Corresponding 28 day APACHE II and MR-proADM disease severity groups APACHE II severity groups Low severity Intermediate severity High severity (19 points) (20 points 32) (33 points) N = 287, 11.5% mortality N = 591, 30.3% mortality N = 152, 41.4% mortality MR-proADM Low severity N = 122 (45.0%) N = 137 (50.6%) N = 12 (4.4%) severity groups (2.7 nmol/L) 7.4% mortality 10.9% mortality 33.3% mortality N = 271, 10.3% mortality Intermediate severity N = 154 (25.9%) N = 356 (59.9%) N = 84 (14.1%) (<2.7 nmol/L 10.9) 12.3% mortality 30.1% mortality 36.9% mortality N = 594, 26.4% mortality High severity N = 11 (6.7%) N = 98 (59.4%) N = 56 (33.9%) (>10.9 nmol/L) 45.5% mortality 58.2% mortality 50.0% mortality N = 165, 54.5% mortality MR-proADM: mid-regional proadrenomedullin; APACHE II: Acute Physiological and Chronic Health Evaluation II

TABLE-US-00013 TABLE 10 Corresponding 28 day lactate and MR-proADM disease severity groups Lactate severity groups Low severity Intermediate severity High severity (1.4 mmol/L) (<1.4 mmol/L 6.4) (>6.4 mmol/L) N = 196, 15.8% mortality N = 668, 24.1% mortality N = 158, 52.5% mortality MR-proADM Low severity N = 99 (37.1%) N = 154 (57.7%) N = 14 (5.2%) severity groups (2.7 nmol/L) 8.1% mortality 9.1% mortality 42.9% mortality N = 267, 10.5% mortality Intermediate severity N = 90 (15.2%) N = 421 (71.2%) N = 80 (13.5%) (<2.7 nmol/L 10.9) 21.1% mortality 25.2% mortality 40.0% mortality N = 591, 26.6% mortality High severity N = 7 (4.3%) N = 93 (56.7%) N = 64 (39.0%) (>10.9 nmol/L) 57.1% mortality 44.1% mortality 70.3% mortality N = 164, 54.9% mortality MR-proADM: mid-regional proadrenomedullin

TABLE-US-00014 TABLE 11 Biomarker and SOFA association with 28 day mortality at days 1, 4, 7 and 10 Patients Mortality LR C- HR IQR p- LR C- HR IQR p- (N) (N) AUROC X.sup.2 index [95% CI] value X.sup.2 index [95% CI] value Day 1 MR- 993 242 0.76 152.5 0.73 3.3 [2.8-4.0] <0.0001 173.2 0.74 3.2 [2.6-4.0] <0.0001 proADM PCT 993 242 0.59 23.1 0.59 1.6 [1.3-2.0] <0.0001 74.6 0.65 1.6 [1.3-2.0] <0.0001 CRP 919 226 0.54 6.2 0.54 0.9 [0.8-1.0] 0.0128 61.2 0.65 0.9 [0.8-1.0] <0.0001 Lactate 1041 265 0.73 206.4 0.72 2.4 [2.2-2.7] <0.0001 253.9 0.75 2.5 [2.2-2.8] <0.0001 SOFA 1011 260 0.74 143.8 0.72 2.5 [2.2-2.9] <0.0001 192.8 0.75 2.6 [2.2-3.0] <0.0001 Day 4 MR- 777 158 0.76 100.5 0.73 3.2 [2.5-4.0] <0.0001 123.7 0.75 3.0 [2.3-3.8] <0.0001 proADM PCT 777 158 0.62 22.6 0.61 1.7 [1.4-2.1] <0.0001 69.3 0.68 1.8 [1.4-2.2] <0.0001 CRP 708 146 0.48 0.7 0.52 1.1 [0.9-1.3] 0.3925 45.8 0.65 1.1 [0.9-1.4] <0.0001 Lactate 803 166 0.69 60.6 0.68 1.8 [1.6-2.0] <0.0001 100.9 0.71 1.7 [1.5-2.0] <0.0001 SOFA 767 162 0.75 111.5 0.72 3.0 [2.4-3.6] <0.0001 155.9 0.76 3.1 [2.5-3.8] <0.0001 Day 7 MR- 630 127 0.78 93.7 0.76 3.4 [2.6-4.3] <0.0001 117.8 0.76 3.3 [2.5-4.3] <0.0001 proADM PCT 631 128 0.72 62.3 0.70 2.6 [2.1-3.3] <0.0001 101.6 0.74 2.7 [2.1-3.4] <0.0001 CRP 583 121 0.56 3.5 0.55 1.3 [1.0-1.6] 0.0606 47.1 0.67 1.3 [1.0-1.7] <0.0001 Lactate 658 138 0.68 69.4 0.68 2.0 [1.7-2.3] <0.0001 112.2 0.73 2.0 [1.7-2.4] <0.0001 SOFA 617 128 0.75 107.7 0.73 2.7 [2.3-3.3] <0.0001 140.2 0.77 2.8 [2.3-3.4] <0.0001 Day 10 MR- 503 82 0.78 72.6 0.76 4.3 [3.0-6.1] <0.0001 90.9 0.78 3.8 [2.6-5.5] <0.0001 proADM PCT 503 82 0.75 52.0 0.74 2.8 [2.2-3.7] <0.0001 90.4 0.78 3.1 [2.3-4.2] <0.0001 CRP 457 80 0.61 10.0 0.60 1.6 [1.2-2.2] <0.0001 51.2 0.71 1.8 [1.3-2.6] <0.0001 Lactate 516 88 0.61 19.8 0.61 1.6 [1.3-2.0] <0.0001 54.7 0.70 1.6 [1.3-2.0] <0.0001 SOFA 490 84 0.76 85.8 0.75 3.3 [2.6-4.3] <0.0001 107.8 0.78 3.1 [2.4-4.1] <0.0001

TABLE-US-00015 TABLE 12 Low and high risk severity groups and corresponding mortality rates throughout ICU treatment Low severity patient population High severity patient population Patients Mortality Optimal Patients Mortality Optimal (N) (N, %) cut-off Sensitivity Specificity (N) (N, %) cut-off Sensitivity Specificity Day 1 MR- 304 24 (7.9%) 2.80 0.90 0.37 162 87 (53.7%) 9.5 0.36 0.90 proADM PCT 203 25 (12.3%) 1.02 0.90 0.24 115 40 (34.8%) 47.6 0.17 0.90 CRP 101 32 (31.7%) 99 0.90 0.14 88 18 (4.8%) 373 0.08 0.90 Lactate 310 33 (10.6%) 1.22 0.88 0.36 185 109 (58.9%) 3.5 0.43 0.89 SOFA 435 49 (11.3%) 8.0 0.88 0.40 165 87 (52.7%) 14 0.33 0.90 Day 4 MR- 290 16 (5.5%) 2.25 0.90 0.44 120 58 (48.3%) 7.7 0.37 0.90 proADM PCT 147 16 (10.9%) 0.33 0.90 0.21 87 25 (28.7%) 14.08 0.16 0.90 CRP 65 9 (13.8%) 32.7 0.90 0.06 51 15 (29.4%) 276.5 0.06 0.90 Lactate 124 15 (12.1%) 0.89 0.91 0.17 136 65 (47.8%) 2.15 0.39 0.89 SOFA 213 15 (7.0%) 5.5 0.91 0.33 137 67 (48.9%) 12.75 0.41 0.88 Day 7 MR- 252 14 (5.6%) 2.25 0.89 0.47 104 54 (51.9%) 6.95 0.43 0.90 proADM PCT 184 14 (7.6%) 0.31 0.89 0.34 85 35 (41.2%) 4.67 0.27 0.90 CRP 62 12 (19.4%) 27.4 0.90 0.11 69 23 (37.7%) 207 0.19 0.90 Lactate 104 15 (14.4%) 0.84 0.89 0.17 102 51 (50.0%) 2.10 0.37 0.90 SOFA 207 16 (7.7%) 5.5 0.88 0.39 91 48 (52.7%) 12.5 0.38 0.91 Day 10 MR- 213 8 (3.8%) 2.25 0.90 0.49 78 35 (44.9%) 7.45 0.43 0.90 proADM PCT 177 9 (5.1%) 0.30 0.89 0.40 74 32 (43.2%) 2.845 0.39 0.90 CRP 69 8 (11.6%) 32.1 0.90 0.16 52 14 (26.9%) 204 0.18 0.90 Lactate 47 7 (14.9%) 0.68 0.92 0.09 65 24 (36.9%) 2.15 0.27 0.90 SOFA 116 9 (7.8%) 4.5 0.89 0.26 85 42 (49.4%) 11.5 0.50 0.89

TABLE-US-00016 TABLE 13 Mortality and duration of ICU therapy based on MR-proADM concentrations and ICU specific therapies 28 day 90 day Length of stay mortality mortality Patient severity group N SOFA (days) (N, %) (N, %) Day 4 Total patient 777 8.4 (4.3) 16 [10-27] 158 (20.3%) 256 (33.9%) population Clinically stable 145 4.5 (2.4) 8 [6-11] 10 (6.9%) 22 (15.8%) Clinically stable and 79 3.6 (1.5) 8 [7-10] 0 (0.0%) 1 (1.4%) low MR-proADM Actual day 4 43 3.6 (2.1) 1 (2.3%) 4 (10.0%) discharges* Day 7 Total patient 630 8.0 (4.2) 19 [13-31] 127 (20.2%) 214 (34.9%) population Clinically stable 124 3.9 (1.7) 11.5 [9-16] 9 (7.3%) 17 (13.9%) Clinically stable and 78 3.4 (1.6) 11 [9-14] 1 (1.3%) 4 (5.3%) low MR-proADM Actual day 7 36 3.6 (2.6) 2 (5.6%) 5 (13.9%) discharges* Day 10 Total patient 503 7.6 (4.0) 23.5 [17-34.25] 82 (16.3%) 159 (32.6%) population Clinically stable 85 3.5 (1.8) 15 [13-22] 9 (10.6%) 14 (17.3%) Clinically stable and 57 3.2 (1.3) 14 [12.25-19] 1 (1.8%) 2 (3.8%) low MR-proADM Actual day 10 29 4.0 (2.6) 5 (17.2%) 7 (24.1%) discharges* *excludes same or next day mortalities

TABLE-US-00017 TABLE 14 Time dependent Cox regressions for single and cumulative additions of MR-proADM Univariate model Multivariate model LR Added Added p- LR Added Added p- X.sup.2 DF LR X.sup.2 DF value X.sup.2 DF LR X.sup.2 DF value Addition of single days to baseline values MR-proADM baseline 144.2 1 Reference 163.0 10 Reference +Day 1 169.8 2 25.6 1 <0.001 190.6 11 27.6 1 <0.001 +Day 4 161.9 2 17.7 1 <0.001 180.4 11 17.4 1 <0.001 +Day 7 175.7 2 31.5 1 <0.001 195.1 11 32.1 1 <0.001 +Day 10 179.8 2 35.6 1 <0.001 197.9 11 34.9 1 <0.001 Addition of consecutive days to baseline values MR-proADM baseline 144.2 1 Reference 163.0 10 Reference +Day 169.8 2 25.6 1 <0.001 190.6 11 27.6 1 <0.001 +Day 1 + Day 4 174.9 3 5.1 1 0.0243 195.4 12 4.8 1 0.0280 +Day 1 + Day 4 + Day 7 188.7 4 13.9 1 <0.001 210.4 13 15.0 1 <0.001 +Day 1 + Day 4 + Day 7 + 195.2 5 6.5 1 0.0111 216.6 14 6.2 1 0.0134 Day 10 MR-proADM: mid-regional proadrenomedullin; DF: Degrees of Freedom

TABLE-US-00018 TABLE 15 28 and 90 day mortality rates following PCT and MR-proADM kinetics Biomarker Kinetics 28 day mortality 90 day mortality Baseline Day 1 N % HR IQR [95% CI] N % HR IQR [95% CI] PCT decrease 20% 458 18.3% 447 28.2% MR-proADM Low Low 125 5.6% 3.6 [1.6-8.1]* 121 13.2% 2.7 [1.6-4.8]* severity level Intermediate Intermediate 204 19.1% 5.3 [3.0-9.3]** 201 32.3% 3.8 [2.3-6.3]** High High 27 66.7% 19.1 [8.0-45.9]*** 27 70.4% 10.4 [5.3-20.2]*** Increasing Low Intermediate 2 50.0% 2 50.0% Intermediate High 10 40.0% 2.5 [0.9-7.0] 10 50.0% 1.9 [0.8-4.8] Decreasing High Intermediate 30 36.7% 0.4 [0.2-0.9] 29 44.8% 0.5 [0.2-0.9] High Low Intermediate Low 60 8.3% 0.4 [0.2-1.0] 57 12.3% 0.3 [0.2-0.7] PCT decrease <20% 522 29.7% 508 42.5% MR-proADM Low Low 106 10.4% 3.1 [1.7-5.9]* 105 16.2% 3.2 [1.9-5.3]* severity level Intermediate Intermediate 229 29.7% 2.0 [1.3-2.9]** 221 43.4% 1.9 [1.3-2.6]** High High 77 49.4% 6.2 [3.2-12.2]*** 75 64.0% 5.9 [3.4-10.3]*** Increasing Low Intermediate 29 17.2% 1.8 [0.6-5.2] 27 44.4% 3.2 [1.5-6.7] Intermediate High 45 53.3% 2.3 [1.4-3.6] 45 68.9% 2.1 [1.4-3.2] Decreasing High Intermediate 11 54.5% 11 72.7% High Low 1 0.0% 1 100.0% Intermediate Low 24 12.5% 0.4 [0.1-1.2] 23 13.0% 0.2 [0.1-0.8] Hazard ratios for patients with: *continuously intermediate vs. low values; **continuously high vs. intermediate values ***continuously high vs. low values; Increasing low to intermediate vs. continuously low values; Increasing intermediate to high vs. continuously intermediate values; decreasing high to intermediate vs. continuously high values; Decreasing intermediate to low vs. increasing intermediate to high values. Kaplan Meier plots illustrate either individual patient subgroups, or grouped increasing or decreasing subgroups.

TABLE-US-00019 TABLE 16 Mortality rates following changes in PCT concentrations and MR-proADM severity levels 7 day mortality ICU mortality Hospital mortality Baseline Day 1 N % HR IQR [95% CI] N % HR IQR [95% CI] N % HR IQR [95% CI] PCT decrease 20% 461 6.1% 456 16.7% 439 24.1% MR-proADM Low Low 126 2.4% 1.9 [0.5-6.9]* 126 4.8% 3.9 [1.6-9.6]* 123 7.3% 4.9 [2.3-10.3]* severity level Intermediate Intermediate 205 4.4% 8.2 [3.4-21.2]** 202 16.3% 8.7 [3.7-20.7]** 194 27.8% 6.2 [2.5-14.9]** High High 27 29.6% 15.2 [4.0-57.3]*** 27 63.0% 34.0 [11.0-105.5]*** 27 70.4% 30.1 [10.3-87.6]*** Increasing Low Intermediate 3 0.0% 2 0.0% 2 0.0% Intermediate High 10 20.0% 4.7 [1.0-21.6] 10 30.0% 2.2 [0.5-8.9] 10 50.0% 2.6 [0.7-9.3] Decreasing High Intermediate 30 16.7% 0.5 [0.2-1.6] 29 37.9% 0.4 [0.1-1.1] 28 46.4% 0.4 [0.1-1.1] Intermediate Low 60 1.7% 0.4 [0.0-3.0] 59 10.2% 0.6 [0.1-1.5] 55 10.9% 0.3 [0.1-0.8] PCT decrease <20% 526 13.7% 517 30.2% 493 36.9% MR-proADM Low Low 107 5.6% 2.0 [0.8-4.9]* 107 10.3% 3.4 [1.7-6.8]* 102 13.7% 3.6 [1.9-6.8]* severity level Intermediate Intermediate 230 10.9% 2.6 [1.5-4.7]** 225 28.0% 3.0 [1.8-5.2]** 216 36.6% 2.4 [1.4-4.2]** High High 77 26.0% 5.3 [2.1-13.2]*** 74 54.1% 10.3 [4.7-22.3]*** 72 58.3% 8.8 [4.2-18.3]*** Increasing Low Intermediate 30 13.3% 2.5 [0.7-8.9] 29 31.0% 3.9 [1.4-10.7] 27 37.0% 3.7 [1.4-9.7] Intermediate High 46 28.3% 3.0 [1.5-5.8] 45 57.8% 3.3 [1.7-6.4] 43 65.1% 3.2 [1.6-6.4] Decreasing High Intermediate 11 36.6% 0.5 [0.2-1.6] 11 54.5% 1.0 [0.3-3.7] 10 80.0% High Low 1 0.0% 1 0.0% 1 0.0% Intermediate Low 24 0.0% ? 24 4.2% 0.1 [0.0-0.8] 22 4.5% 0.1 [0.0-0.6] Hazard ratios for patients with: *continuously intermediate vs. low values; **continuously high vs. intermediate values ***continuously high vs. low values; increasing low to intermediate vs. continuously low values; increasing intermediate to high vs. continuously intermediate values; decreasing high to intermediate vs. continuously high values; decreasing intermediate to low vs. continuously intermediate values

TABLE-US-00020 TABLE 17 28 and 90 day mortality rates following changes in PCT concentrations and MR- proADM severity levels Biomarker Kinetics 28 day mortality 90 day mortality Baseline Day 4 N % HR IQR [95% CI] N % HR IQR [95% CI] PCT decrease 50% 557 17.1% 542 29.3% MR-proADM Low Low 111 1.8% 11.2 [2.7-46.4]* 107 7.5% 5.3 [2.5-10.9]* severity level Intermediate Intermediate 209 18.7% 3.8 [2.3-6.5]** 206 33.5% 3.3 [2.1-5.1]** High High 39 53.8% 43.1 [10.1-184.0]*** 39 71.8% 17.4 [7.9-38.2]*** Increasing Low Intermediate 24 25.0% 15.6 [3.1-77.2] 24 41.7% 7.1 [2.8-17.9] Intermediate High 23 43.5% 2.6 [1.3-5.3] 23 65.2% 2.6 [1.5-4.5] Decreasing High Intermediate 42 21.4% 0.3 [0.1-0.7] 41 36.6% 0.3 [0.2-0.6] High Low 3 0.0% 2 50.0% Intermediate Low 105 7.6% 0.4 [0.2-0.8] 100 13.0% 0.3 [0.2-0.6] PCT decrease <50% 210 29.5% 203 45.5% MR-proADM Low Low 56 7.1% 6.3 [2.2-18.1]* 55 12.7% 6.2 [2.8-3.9]* severity level Intermediate Intermediate 70 38.6% 1.5 [0.8-3.0]** 68 57.4% 1.3 [0.7-2.3]** High High 23 52.2% 9.5 [3.1-29.5]*** 22 63.6% 7.9 [3.2-19.5]*** Increasing Low Intermediate 17 17.6% 2.8 [0.6-12.5] 15 53.3% 5.5 [2.0-15.2] Low High 4 0.0% 4 25.0% Intermediate High 30 46.7% 1.4 [0.7-2.6] 30 66.7% 1.3 [0.8-2.2] Decreasing High Intermediate High Low Intermediate Low 10 20.0% 9 33.4% Hazard ratios for patients with: *continuously intermediate vs. low values; **continuously high vs. intermediate values ***continuously high vs. low values; Increasing low to intermediate vs. continuously low values; Increasing intermediate to high vs. continuously intermediate values; decreasing high to intermediate vs. continuously high values; Decreasing intermediate to low vs. continuously intermediate values

TABLE-US-00021 TABLE 18 ICU and hospital mortality rates following changes in PCT concentrations and MR- proADM severity levels ICU mortality Hospital mortality Baseline Day 4 N % HR IQR [95% CI] N % HR IQR [95% CI] PCT decrease 50% 555 16.8% 532 24.1% MR-proADM Low Low 114 2.6% 6.9 [2.1-23.1]* 109 2.8% 13.3 [4.1-43.8]* severity level Intermediate Intermediate 208 15.9% 8.1 [3.8-17.2]** 197 27.4% 5.1 [2.4-10.7]** High High 38 60.5% 56.2 [15.0-210.2]*** 38 65.8% 67.9 [18.0-256.6]*** Low Intermediate 24 29.2% 15.1 [3.6-64.1] 24 33.3% 17.7 [4.2-73.6] Intermediate High 23 43.5% 4.1 [1.7-10.0] 23 56.5% 3.4 [1.4-8.3] High Intermediate 41 22.0% 0.2 [0.1-0.5] 39 33.3% 1.3 [0.6-2.7] High Low 3 0.0% 2 50.0% Intermediate Low 103 8.7% 0.5 [0.2-1.0] 99 11.1% 0.3 [0.2-0.7] PCT decrease <50% 204 28.9% 194 30.4% MR-proADM Low Low 56 1.8% 28.1 [3.7-216.3]* 54 7.4% 10.1 [3.3-31.2]* severity level Intermediate Intermediate 68 33.8% 1.8 [0.7-4.8]** 65 44.6% 1.9 [0.7-5.2]** High High 21 47.6% 50.0 [5.8-431.5]*** 20 60.0% 18.8 [4.8-72.7]*** Low Intermediate 16 43.7% 42.8 [4.7-390.2] 14 57.1% 16.7 [3.8-72.4] Low High 4 0.0% 4 25.0% Intermediate High 29 58.6% 2.8 [1.1-6.8] 28 64.3% 2.2 [0.9-5.6] High Intermediate High Low Intermediate Low 10 10.0% 9 33.3% Hazard ratios for patients with: *continuously intermediate vs. low values; **continuously high vs. intermediate values ***continuously high vs. low values; Increasing low to intermediate vs. continuously low values; Increasing intermediate to high vs. continuously intermediate values; decreasing high to intermediate vs. continuously high values; Decreasing intermediate to low vs. continuously intermediate values

TABLE-US-00022 TABLE 19 Influence of infectious origin on 28 day mortality prediction Univariate Multivariate Patients Mortality LR C- HR IQR p- LR C- HR IQR p- (N) (N) AUROC X.sup.2 index [95% CI] value X.sup.2 index [95% CI] value Pneumological MR- 313 83 0.72 37.9 0.69 2.7 [2.0-3.7] <0.0001 45.1 0.71 2.5 [1.7-3.6] <0.0001 proADM PCT 313 83 0.59 6.4 0.58 1.6 [1.1-2.2] 0.0112 26.0 0.66 1.5 [1.1-2.2] 0.0038 CRP 267 65 0.46 0.8 0.53 0.9 [0.7-1.1] 0.3754 14.7 0.63 0.9 [0.7-1.1] 0.1422 Lactate 322 86 0.61 12.6 0.61 1.6 [1.2-2.1] 0.0004 30.1 0.67 1.5 [1.1-2.0] 0.0008 SOFA 315 83 0.63 12.4 0.62 1.7 [1.3-2.3] 0.0004 29.6 0.68 1.6 [1.1-2.2] 0.0010 SAPS II 324 86 0.63 13.2 0.62 1.6 [1.3-2.1] 0.0003 28.8 0.67 1.5 [1.1-1.9] 0.0014 APACHE II 324 86 0.63 19.5 0.64 1.9 [1.4-2.5] <0.0001 33.4 0.68 1.7 [1.3-2.3] 0.0002 Intrabdominal MR- 238 58 0.78 47.4 0.75 4.5 [2.9-7.1] <0.0001 55.7 0.76 4.8 [2.9-8.0] <0.0001 proADM PCT 238 58 0.52 0.4 0.52 1.1 [0.8-1.7] 0.5249 15.0 0.64 1.2 [0.8-1.9] 0.1312 CRP 233 59 0.48 0.1 0.53 1.0 [0.8-1.3] 0.7807 12.0 0.62 1.1 [0.8-1.4] 0.2864 Lactate 249 62 0.67 18.0 0.66 2.2 [1.5-3.0] <0.0001 28.2 0.70 2.1 [1.5-3.0] 0.0017 SOFA 248 62 0.66 8.9 0.63 1.5 [1.2-2.0] 0.0029 18.3 0.64 1.5 [1.1-2.0] 0.0494 SAPS II 252 62 0.68 17.9 0.66 1.9 [1.4-2.6] <0.0001 24.3 0.67 1.9 [1.3-2.6] 0.0069 APACHE II 252 62 0.68 14.6 0.65 1.8 [1.3-2.3] 0.0001 20.6 0.66 1.6 [1.2-2.2] 0.0241 MR-proADM AUROC values are significantly greater than all other parameters apart from APACHE II in pneumological origins of infection.

TABLE-US-00023 TABLE 20 Influence of microbial species on 28 day mortality prediction Univariate Multivariate Patients Mortality LR C- HR IQR p- LR C- HR IQR (N) (N) AUROC X.sup.2 index [95% CI] value X.sup.2 index [95% CI] p-value Gram MR- 141 33 0.82 37.2 0.81 5.0 [2.9-8.6] <0.0001 50.0 0.84 5.0 [2.7-9.2] <0.0001 positive proADM PCT 142 33 0.64 7.9 0.64 2.4 [1.3-4.4] 0.0050 30.3 0.76 3.0 [1.5-5.7] 0.0008 CRP 131 31 0.54 0.2 0.51 0.9 [0.7-1.3] 0.6561 19.8 0.71 1.0 [0.7-1.4] 0.0309 Lactate 143 33 0.75 28.9 0.74 4.6 [2.6-8.1] <0.0001 44.9 0.83 5.0 [2.6-9.7] <0.0001 SOFA 143 32 0.66 8.8 0.65 1.9 [1.3-2.8] 0.0031 31.8 0.76 2.7 [1.6-4.6] 0.0004 SAP II 146 33 0.72 16.8 0.71 2.9 [1.7-4.7] <0.0001 28.4 0.76 2.7 [1.5-4.9] 0.0016 APACHE 146 33 0.73 17.3 0.71 2.4 [1.6-3.5] <0.0001 33.1 0.77 2.8 [1.7-4.7] 0.0003 II Gram MR- 124 35 0.69 12.1 0.68 2.3 [1.4-3.8] 0.0005 26.0 0.75 2.2 [1.2-3.8] 0.0037 negative proADM PCT 124 35 0.54 0.6 0.54 1.2 [0.7-2.1] 0.4580 17.8 0.67 1.2 [0.7-2.3] 0.0580 CRP 110 30 0.57 0.4 0.56 1.2 [0.7-1.8] 0.5255 17.1 0.68 1.4 [0.9-2.2] 0.0727 Lactate 131 37 0.65 10.0 0.64 1.9 [1.3-2.8] 0.0016 23.4 0.71 1.7 [1.1-2.7] 0.0093 SOFA 129 37 0.65 9.0 0.64 1.8 [1.2-2.7] 0.0027 25.5 0.72 1.9 [1.2-2.9] 0.0045 SAPS II 132 37 0.67 9.9 0.65 1.9 [1.3-2.8] 0.0017 25.1 0.71 1.9 [1.2-3.0] 0.0051 APACHE 132 37 0.69 7.9 0.66 1.7 [1.2-2.4] 0.0049 22.3 0.70 1.7 [1.1-2.6] 0.0139 II Fungal MR- 50 14 0.74 7.9 0.69 2.5 [1.3-4.9] 0.0051 14.4 0.78 3.4 [1.1-10.7] 0.1548 proADM PCT 50 14 0.46 0.3 0.52 1.3 [0.5-3.0] 0.6104 8.5 0.72 1.1 [0.4-3.0] 0.5792 CRP 43 12 0.65 0.6 0.65 0.8 [0.5-1.3] 0.4404 14.7 0.81 0.5 [0.2-1.2] 0.1427 Lactate 51 14 0.60 2.7 0.59 2.0 [0.9-4.7] 0.1032 13.2 0.74 3.3 [1.0-11.0] 0.2128 SOFA 49 12 0.54 0.8 0.54 1.4 [0.7-2.8] 0.3668 7.1 0.73 1.1 [0.5-2.8] 0.7164 SAPS II 51 14 0.60 2.2 0.60 1.5 [0.9-2.6] 0.1412 10.0 0.75 1.4 [0.7-2.8] 0.4427 APACHE 51 14 0.62 1.6 0.62 1.6 [0.8-3.3] 0.2053 10.1 0.76 1.7 [0.7-4.4] 0.4321 II

TABLE-US-00024 TABLE 21 Influence of mode of ICU entry on 28 day mortality prediction Univariate Multivariate Patients Mortality LR C- HR IQR p- LR HR IQR (N) (N) AUROC X.sup.2 index [95% CI] value X.sup.2 C-index [95% CI] p-value Operative MR- 466 113 0.77 87.4 0.75 4.1 [3.0-5.6] <0.0001 106.4 0.77 3.8 [2.8-5.3] <0.0001 proADM PCT 466 113 0.60 11.8 0.59 1.6 [1.2-2.2] 0.0006 53.1 0.70 1.7 [1.3-2.4] <0.0001 CRP 421 106 0.48 1.2 0.52 1.1 [0.9-1.4] 0.2696 39.7 0.68 1.2 [0.9-1.4] <0.0001 Lactate 483 120 0.68 46.4 0.67 2.4 [1.9-3.1] <0.0001 73.7 0.71 2.3 [1.8-3.0] <0.0001 SOFA 482 118 0.68 34.9 0.65 2.0 [1.6-2.4] <0.0001 65.7 0.71 2.0 [1.6-2.5] <0.0001 SAPS II 489 120 0.71 50.5 0.68 2.2 [1.8-2.7] <0.0001 65.9 0.70 2.0 [1.6-2.5] <0.0001 APACHE 489 120 0.71 47.8 0.68 2.3 [1.8-2.8] <0.0001 64.8 0.71 2.0 [1.6-2.5] <0.0001 II Non- MR- 448 132 0.70 48.6 0.68 2.6 [2.0-3.4] <0.0001 56.5 0.69 2.4 [1.8-3.3] <0.0001 operative proADM PCT 449 132 0.52 0.8 0.52 1.1 [0.9-1.5] 0.3644 24.4 0.62 1.1 [0.8-1.4] 0.0066 CRP 424 121 0.50 0.2 0.49 1.0 [0.8-1.2] 0.6280 23.6 0.62 1.0 [0.8-1.2] 0.0088 Lactate 462 137 0.62 24.5 0.62 1.9 [1.5-2.4] <0.0001 43.7 0.67 1.8 [1.4-2.3] <0.0001 SOFA 450 132 0.62 15.9 0.61 1.7 [1.3-2.1] 0.0001 39.5 0.66 1.7 [1.3-2.2] <0.0001 SAPS II 466 137 0.65 25.4 0.64 1.6 [1.3-1.9] <0.0001 43.4 0.66 1.5 [1.3-1.8] <0.0001 APACHE 466 137 0.64 23.9 0.63 1.7 [1.4-2.1] <0.0001 40.2 0.66 1.6 [1.3-2.0] <0.0001 II Elective MR- 116 30 0.71 12.1 0.69 2.8 [1.6-5.2] 0.0005 17.3 0.72 2.3 [1.2-4.5] 0.0440 proADM PCT 116 30 0.59 3.3 0.59 1.6 [1.0-2.6] 0.0675 15.1 0.70 1.7 [1.0-2.8] 0.0873 CRP 91 24 0.51 0.0 0.50 1.0 [0.7-1.4] 0.8650 11.5 0.70 0.8 [0.5-1.3] 0.3219 Lactate 121 32 0.63 9.5 0.63 2.2 [1.4-3.6] 0.0020 21.0 0.72 2.2 [1.3-3.6] 0.0211 SOFA 119 32 0.58 0.9 0.56 1.2 [0.9-1.6] 0.3476 13.7 0.69 1.0 [0.7-1.3] 0.1860 SAPS II 121 32 0.60 1.4 0.59 1.3 [0.9-1.9] 0.2333 13.1 0.68 0.9 [0.6-1.5] 0.2177 APACHE 121 32 0.57 1.1 0.57 1.3 [0.8-1.9] 0.2945 13.1 0.69 0.9 [0.6-1.5] 0.2164 II

TABLE-US-00025 TABLE 22 Baseline biomarker and clinical score correlation with SOFA at baseline and day 1 Baseline SOFA Day 1 SOFA Patients Correlation Patients Correlation (N) [95% CI] p-value (N) [95% CI] p-value MR-proADM 1007 0.46 [0.41-0.51] <0.0001 MR-proADM* 969 0.47 [0.41-0.51] <0.0001 969 0.57 [0.52-0.61] <0.0001 PCT 1007 0.23 [0.17-0.29] <0.0001 969 0.22 [0.16-0.28] <0.0001 CRP 918 0.06 [0.00-0.13] 0.0059 885 0.04 [0.00-0.12] 0.2709 Lactate 1044 0.33 [0.27-0.38] <0.0001 1005 0.40 [0.35-0.45] <0.0001 SAPS II 1051 0.60 [0.56-0.64] <0.0001 1011 0.50 [0.45-0.54] <0.0001 APACHE II 1051 0.62 [0.58-0.65] <0.0001 1011 0.53 [0.48-0.57] <0.0001 *using the same patients on baseline as on day 1

TABLE-US-00026 TABLE 23 Baseline MR-proADM correlations with SOFA subscores on baseline and day 1 Baseline SOFA Day 1 SOFA SOFA Patients Correlation Patients Correlation subscore (N) [95% CI] p-value (N) [95% CI] p-value Circulation 1022 0.18 [0.12-0.23] <0.0001 995 0.23 [0.17-0.29] <0.0001 Pulmonary 1025 0.12 [0.06-0.18] <0.0001 994 0.15 [0.09-0.21] <0.0001 Coagulation 1028 0.30 [0.25-0.36] <0.0001 1002 0.40 [0.35-0.45] <0.0001 Renal 1030 0.50 [0.45-0.54] <0.0001 1001 0.62 [0.58-0.66] <0.0001 Liver 1014 0.20 [0.14-0.26] <0.0001 993 0.36 [0.30-0.40] <0.0001 CNS 1030 0.03 [0.03-0.09] 0.3856 1003 0.08 [0.02-0.14] 0.0089

TABLE-US-00027 TABLE 24 Biomarker correlations with SOFA scores throughout ICU treatment MR-proADM PCT CRP Lactate Day 1 Patients (N) 960 960 894 1008 Correlation [95% CI] 0.51 [0.46-0.55] 0.24 [0.18-0.30] 0.04 [0.10-0.03] 0.48 [0.43-0.53] p-value <0.0001 <0.0001 <0.0001 <0.0001 Day 4 Patients (N) 729 729 667 754 Correlation [95% CI] 0.58 [0.53-0.63] 0.13 [0.06-0.20] 0.14 [0.06-0.21] 0.36 [0.29-0.42] p-value <0.0001 0.0003 0.0004 <0.0001 Day 7 Patients (N) 580 581 547 612 Correlation [95% CI] 0.58 [0.53-0.64] 0.05 [0.03-0.13] 0.15 [0.07-0.23] 0.43 [0.37-0.50] p-value <0.0001 0.2368 0.0004 <0.0001 Day 10 Patients (N) 473 473 429 483 Correlation [95% CI] 0.65 [0.59-0.70] 0.28 [0.20-0.37] 0.13 [0.03-0.22] 0.34 [0.26-0.42] p-value <0.0001 <0.0001 0.0076 <0.0001

TABLE-US-00028 TABLE 25 Mortalities based on MR-proADM severities and increasing or decreasing PCT concentrations-Baseline to day 1 28 day 90 day 7 day ICU Hospital mortality mortality mortality mortality mortality Baseline Day 1 N % N % N % N % N % Decreasing PCT 657 19.0% 636 28.9% 657 6.4% 650 11.6% 623 25.2 MR-proADM Low Low 161 5.0% 157 14.0% 163 2.5% 162 5.6% 157 8.3% severity level Intermediate Intermediate 314 19.1% 308 31.8% 316 4.7% 310 17.1% 299 27.8% High High 51 58.8% 50 64.0% 51 23.5% 51 54.9% 49 63.3% Increasing Low Intermediate 10 20.0% 10 30.0% 11 0.0% 11 18.2% 10 20.0% Intermediate High 17 35.3% 17 41.2% 17 17.6% 17 29.4% 17 41.2% Decreasing High Intermediate 35 40.0% 34 47.1% 35 20.0% 34 41.2% 32 50.0% High Low Intermediate Low 63 7.9% 60 10.0% 63 1.6% 63 7.9% 58 8.6% Increasing PCT 329 35.0% 319 46.6% 331 17.5% 324 35.8% 31 42.3% MR-proADM Low Low 66 13.6% 65 15.4% 66 7.6% 66 10.6% 64 14.1% severity level Intermediate Intermediate 131 36.6% 126 51.6% 131 14.5% 128 35.2% 122 42.6% High High 53 49.1% 52 67.3% 53 20.2% 50 58.0% 50 60.0% Increasing Low Intermediate 25 20.0% 23 47.8% 26 15.4% 25 32.0% 23 39.1% Low High Intermediate High 38 57.9% 38 76.3% 39 30.8% 39 61.5% 36 72.2% Decreasing High Intermediate 6 50.0% 6 66.7% 6 33.3% 6 50.0% 6 83.3% High Low 1 0.0% 1 100.0% 1 0.0% 1 0.0% 1 0.0% Intermediate Low 9 22.2% 8 25.0% 9 0.0% 9 0.0% 8 0.0%

TABLE-US-00029 TABLE 26 PCT kinetics from baseline to day 1 - development of new infections over days 1, 2, 3, 4. New infections over Days 1, 2, 3, 4 Baseline Day 1 N % Decreasing PCT 652 9.7% MR-proADM Low Low 161 6.8% severity level Intermediate Intermediate 315 11.7% High High 51 11.8% Increasing Low Intermediate 10 0.0% Intermediate High 17 5.9% Decreasing High Intermediate 34 8.8% High Low Intermediate Low 63 7.9% Increasing PCT 329 18.5% MR-proADM Low Low 66 9.1% severity level Intermediate Intermediate 131 18.3% High High 53 22.6% Increasing Low Intermediate 25 24.0% Low High Intermediate High 38 18.4% Decreasing High Intermediate 6 50.0% High Low 1 0.0% Intermediate Low 9 33.3%

TABLE-US-00030 TABLE 27 PCT kinetics from baseline to day 4 - development of new infections over days 4, 5, 6, 7. New infections over Days 4, 5, 6, 7 Baseline Day 4 N % Decreasing PCT 681 14.5% MR-proADM Low Low 144 8.3% severity level Intermediate Intermediate 256 17.6% High High 57 28.1% Increasing Low Intermediate 31 22.6% Intermediate High 36 13.9% Decreasing High Intermediate 42 11.9% High Low 3 0.0% Intermediate Low 111 8.1%

TABLE-US-00031 TABLE 28 PCT kinetics from baseline to day 1 - requirement for focus cleaning over days 1, 2, 3, 4. Focus cleaning events over days 1, 2, 3, 4 Baseline Day 1 N % Increasing PCT 329 21.0% MR-proADM Low Low 57 10.5% severity level Intermediate Intermediate 113 20.4% High High 58 19.0% Increasing Low Intermediate 31 32.3% Low High 3 33.3% Intermediate High 59 28.8% Decreasing High Intermediate 1 0.0% High Low 1 100.0% Intermediate Low 6 0.0%

TABLE-US-00032 TABLE 29 PCT kinetics from baseline to day 4 - requirement for focus cleaning over days 4, 5, 6, 7. Focus cleaning events over days 4, 5, 6, 7 Baseline Day 4 N % Decreasing PCT 681 22.0% MR-proADM Low Low 144 16.7% severity level Intermediate Intermediate 256 24.2% High High 57 31.6% Increasing Low Intermediate 31 32.3% Intermediate High 36 50.0% Decreasing High Intermediate 42 16.7% High Low 3 0.0% Intermediate Low 111 9.9%

TABLE-US-00033 TABLE 30 PCT kinetics from baseline to day 1 - requirement of emergency surgery over days 1, 2, 3, 4. Emergency surgery requirement over days 1, 2, 3, 4 Baseline Day 1 N % Increasing PCT 329 23.7% MR-proADM Low Low 66 18.2% severity level Intermediate Intermediate 131 26.0% High High 53 28.3% Increasing Low Intermediate 25 16.0% Low High Intermediate High 38 31.6% Decreasing High Intermediate 6 0.0% High Low 1 100.0% Intermediate Low 9 0.0%

TABLE-US-00034 TABLE 31 Increasing PCT from baseline to day 1 - antibiotic changes on day 4 Increasing PCT 259 21.6% MR-proADM Low Low 55 5.5% severity level Intermediate Intermediate 106 27.4% High High 39 25.6% Increasing Low Intermediate 20 25.0% Intermediate High 26 26.9% Decreasing High Intermediate 5 20.0% High Low 1 100.0% Intermediate Low 7 0.0%

TABLE-US-00035 TABLE 32 Increasing PCT from baseline to day 4 - antibiotic changes on day 4 Increasing PCT 85 23.5% MR-proADM Low Low 23 8.7% severity level Intermediate Intermediate 22 36.4% High High 5 20.0% Increasing Low Intermediate 10 20.0% Intermediate High 17 41.2% Low High 4 0.0% Decreasing High Intermediate High Low Intermediate Low 4 0.0%

TABLE-US-00036 TABLE 33 Biomarker levels based on platelet count Median Platelet Median PCT Median Platelet Median Median Platelet level Mortality count (baseline; Median proADM level Platelet count (day proADM PCT level (10.sup.3/l) Patients (N) (N, %) 10.sup.3/l)) level (baseline) (baseline) transfusion 1; 10.sup.3/l)) level (day 1) (day 1) <20 3 1 (33.3%) 12 15.6 171.7 1 (33.3%) 15 9.8 58.1 20 to <150 233 90 (38.6%) 109 6.6 9.0 24 (10.3%) 78 5.5 7.4 150 to 399 658 165 (25.1%) 249 4.5 7.0 11 (1.7%) 191 4.3 5.8 >399 177 32 (18.1%) 494 4.9 5.7 1 (0.6%) 342 3.7 4.3

TABLE-US-00037 TABLE 34 Platelet count based on proADM levels Median Platelet Median Platelet % Platelet Median Day 1 MR-proADM Patients Mortality count (baseline; Platelet count (day 1; decrease from proADM level Thrombocytopenia (nmol/L) (N) (N, %) 10.sup.3/l)) transfusion 10.sup.3/l)) baseline (day 1) development 2.75 271 28 (10.3%) 251.5 3 (1.1%) 206 18% 1.7 73 (26.9%) >2.75 and 10.9 594 157 (26.4%) 246 14 (2.4%) 177 28% 5.0 249 (41.9%) >10.9 165 90 (54.5%) 178.5 19 (11.5%) 103.5 42% 11.8 102 (61.8%)

TABLE-US-00038 TABLE 35 Development of Thrombocytopenia and proADM kinetics at baseline and day 1. Median Platelet Median Platelet % Platelet Median Day 1 MR-proADM Patients Mortality count (baseline; Platelet count (day 1; decrease proADM level Thrombocytopenia (nmol/L) (N) (N, %) 10.sup.3/l) transfusion 10.sup.3/l) from baseline (day 1) development 2.75 232 21 (9.1%) 274 1 (0.4%) 227 17.2% 1.75 34 (14.7%) >2.75 and 10.9 464 112 (24.1%) 281 5 (1.1%) 215 23.5% 4.9 119 (25.6%) >10.9 104 53 (51.0%) 259 5 (4.8%) 162 37.5% 11.6 41 (39.4%)

TABLE-US-00039 TABLE 36 Fluid volume ADM ADM Mortality New RRT adjusted by baseline day 1 N N (%) reguirement weight Low Low 231 3 (7.8%) 1.3% 2.78 ml/kg Inter- Inter- 433 107 (24.7%) 11.8% 4.94 ml/kg mediate mediate Inter- Low 84 8 (9.5%) 1.3% 4.20 ml/kg mediate Inter- High 55 28 (50.9%) 47.5% 7.93 ml/kg mediate High High 104 56 (53.8%) 64.8% 9.95 ml/kg High Inter- 41 17 (41.5%) 22.2% 7.15 ml/kg mediate

TABLE-US-00040 TABLE 37 Fluid volume Lactate Lactate adjusted by baseline day 1 N Mortality weight Low Low 128 10.2% 2.78 ml/kg Intermediate Intermediate 417 22.1% 3.80 ml/kg Intermediate Low 170 10.6% 4.14 ml/kg Intermediate High 99 49.5% 10.97 ml/kg High High 83 68.7% 15.39 ml/kg High Intermediate 58 27.6% 6.14 ml/kg

TABLE-US-00041 TABLE 38 Average fluid volume Fluid volume ADM New RRT administered adjusted by baseline ADM day 4 N Mortality requirement (ml) weight Low Low 167 3.6% 0.0% 524.98 6.97 ml/kg Low Intermediate 41 22.0% 11.1% 1262.68 17.82 ml/kg Intermediate Intermediate 279 23.7% 12.2% 1092.65 14.47 ml/kg Intermediate Low 115 8.7% 2.8% 817.75 11.45 ml/kg Intermediate High 53 45.3% 66.7% 2653.83 32.31 ml/kg High High 62 53.2% 86.7% 2439.53 32.30 ml/kg High Intermediate 42 21.4% 29.2% 1160.52 14.10 ml/kg

TABLE-US-00042 TABLE 39 Fluid volume ADM ADM adjusted by baseline day 4 N Mortality weight Low Low 45 13.3% 10.60 ml/kg Low Intermediate 108 9.3% 11.51 ml/kg Intermediate Intermediate 376 17.3% 13.45 ml/kg Intermediate Low 74 9.5% 12.42 ml/kg Intermediate High 92 43.5% 22.28 ml/kg High High 35 51.4% 42.27 ml/kg High Intermediate 59 18.6% 19.42 ml/kg

TABLE-US-00043 TABLE 40 Average fluid volume ADM ADM New RRT administered baseline day 4 N Mortality reguirement (ml) Low Low 13 (16.0%) 15.4% 0.0% 1256.46 Low Inter- 2 (2.5%) 0.0% 50.0% 2500 mediate Inter- Inter- 27 (33.3%) 29.6% 0.0% 2711.33 mediate mediate Inter- Low 5 (6.2%) 0.0% 0.0% 1452 mediate Inter- High 16 (19.8%) 31.3% 66.7% 3310.67 mediate High High 13 (16.0%) 65.2% 46.2% 4483.92 High Inter- 3 (3.7%) 0.0% 0.0% 1163.33 mediate

TABLE-US-00044 TABLE 41 Average fluid volume ADM ADM New RRT administered baseline day 4 N Mortality reguirement (ml) Low Low 13 (6.8%) 0.0% 0.0% 689.46 Low Inter- 8 (4.2%) 25.0% 28.6% 743.75 mediate Inter- Inter- 55 (28.8%) 21.8% 14.6% 1153.95 mediate mediate Inter- Low 23 (10.5%) 8.7% 0.0% 696.96 mediate Inter- High 12 (6.35) 58.3% 33.3% 2583.25 mediate High High 19 (9.9%) 42.2% 100.0% 3173.86 High Inter- 12 (6.6%) 33.3% 37.5% 1000.83 mediate

TABLE-US-00045 TABLE 42 Average fluid volume ADM ADM New RRT administered baseline day 4 N Mortality reguirement (ml) Low Low 21 4.8% 0.0% 1713 Low Inter- 8 25.0% 0.0% 3703.75 mediate Inter- Inter- 33 15.2% 13.3% 3020.27 mediate mediate Inter- Low 20 10.0% 0.0% 2224.45 mediate Inter- High 8 37.5% 100.0% 4612.5 mediate High High 4 50.0% 100.0% 6440 High Inter- 7 14.3% 100.0% 2834.29 mediate

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