BioMed Research International
Volume 2020 (2020), Article ID 7936434, 9 pages
https://doi.org/10.1155/2020/7936434

Research Article

Association between the Lymphotoxin-α A252g Gene Polymorphism and the Risk of Sepsis and Mortality: A Meta-Analysis

Shujin Guo, Qiunan Zuo, Xiaohui Li, Ye He, and Yutian Zhou

The Geriatric Respiratory Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu 611731, China

Correspondence should be addressed to Yutian Zhou; 475368570@qq.com

Received 14 April 2020; Revised 20 July 2020; Accepted 29 July 2020; Published 20 August 2020

Academic Editor: Gerald J. Wyckoff

Copyright © 2020 Shujin Guo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. The association between the lymphotoxin-α (LTA) A252G polymorphism and sepsis risk has been extensively studied, but the results have been controversial. This study is aimed at investigating the overall association between the LTA A252G polymorphism and the risk of sepsis/septic shock and sepsis-related mortality. Methods. We searched the PubMed and EMBASE databases to identify studies that investigated the association between the LTA A252G polymorphism and risks of sepsis, septic shock, and mortality. The relevant data were extracted, and statistical analyses were performed using the Revman 5.0 and STATA 12 software. Results. A total of 32 publications were included in the meta-analysis. The results demonstrated that the LTA A252G polymorphism showed no significant association with sepsis risk (GG+GA vs. AA: , –1.07, ) or with sepsis shock risk (GG+GA vs. AA: , –1.22, ). However, in the subgroup analyzed by ethnicity, the LTA A252G polymorphism significantly decreased sepsis risk in the Asian population for the recessive model [GG vs. GA+AA: , –0.99, ] but not in the Caucasian population. Moreover, comparisons between sepsis patients who survived and those who did not suggested that the LTA A252G polymorphism decreases the risk of mortality [GG+GA vs. AA: , –0.80, ]. Conclusion. Our results suggested that the A252G polymorphism in the LTA gene decreased the risk of sepsis in Asians and may reduce mortality in septic individuals.

1. Introduction

Sepsis is a severe condition in terms of mortality, morbidity, and the associated economic and social burden, worldwide. Despite advanced treatments, the sepsis mortality rate, which is around 20-30%, remains hard to ignore [1]. Although the pathogenesis of sepsis is complicated, several factors are known to contribute to sepsis susceptibility and these include aging, multidrug-resistant organisms, immune suppression, and invasive procedures [1]. Furthermore, an increasing number of studies suggest that host predisposition, mainly influenced by the individual’s genetic variability, is closely linked with the incidence and outcome of sepsis [2]. As sepsis is potentially a damaging inflammatory response to infection, pro- and anti-inflammatory cytokines were recognized as candidate sepsis susceptibility genes. Several susceptibility genes have been identified in genome-wide association studies (GWAS) or genetic association case-control studies [3–6], and among these genes, the lymphotoxin-α gene (LTA, also termed as tumor necrosis factor-β) has been extensively studied.

Genotype frequency showed that the LTA+252 A allele frequency was the most predominant allele in most of the world populations; and the LTA+252 G allele was associated with the outcome of different diseases [7]. The higher level of TNFA and LTA production is associated with the mutant allele (G) [8]. LTA exerts anti-inflammatory effects and promotes normal lymphoid tissue development [9]. It has been found that LTA A252G polymorphism (NcoI, rs909253, the first intron) was associated with inflammatory response, including sepsis. The LTA A252G polymorphism has been reported as a sepsis susceptibility variant; however, the results have been inconclusive. In 2011, a meta-analysis was performed to assess the overall association between sepsis risk and the LTA A252G polymorphism [9]. In our study we aimed to perform an updated meta-analysis that also included subgroup analysis, as subgroup differences may affect the reliability of the conclusions. Furthermore, in the past five years, more studies have been conducted in different populations to evaluate the impact of the LTA A252G polymorphism on sepsis risk, and these studies should also be included. To obtain a more reliable and precise conclusion about the association between the LTA A252G polymorphism and sepsis/septic shock risk and sepsis-related mortality, we performed this updated meta-analysis with accurate data and current eligible studies.

2. Materials and Methods

2.1. Study Identification and Selection

We carried out a literature search in the PubMed and EMBASE databases to identify studies that investigated the association between the LTA A252G polymorphism and sepsis/septic shock risk and mortality, updated on July 14, 2020. The search terms used were as follows: “sepsis or severe sepsis or septic shock” in combination with “polymorphism or variant or mutation” and “lymphotoxin-α or LTA or tumor necrosis factor-β or TNF-β.” The inclusion criteria were as follows: (1) they were case-control genetic studies, (2) they evaluated the association between the LTA A252G polymorphism and sepsis/septic shock risk or mortality, and (3) the genotype distributions for cases and controls were sufficient to estimate the odd’s ratio (OR) with a 95% confidence interval (95% CI). The exclusion criteria were as follows: (1) abstracts, letters, and review articles; (2) genotype frequency not shown, and (3) repeated or overlapping data.

2.2. Data Extraction

Two independent authors checked all the included studies and reached a consensus on every item. The following data were extracted from the included studies: author, year of publication, country of origin, ethnicity, sepsis source, sepsis definition, gene assay method, total number and distribution of genotypes, and genotyping methods.

2.3. Statistical Analysis

Hardy-Weinberg equilibrium (HWE) was tested using Pearson’s test. A value of <0.05 indicated deviation from HWE. The strength of the association between the LTA A252G polymorphism and sepsis risk was assessed by the odds ratio (OR) with its corresponding 95% confidence interval (95% CI). We applied a random effects (DerSimonian and Laird method) or fixed effects model (Mantel-Haenszel method) to pool the OR values according to the results of the heterogeneity examination. Heterogeneity was assessed by a -based statistic and , and a value of <0.10 was statistically significant. For , the pooled OR was calculated using a random effects model. Otherwise, a fixed effects model was used. The statistic was used to estimate the degree of heterogeneity, and a was considered an indication of a large degree of heterogeneity. The significance of the pooled OR was evaluated by a -test, and a was statistically significant. The dominant genetic model (GG+GA vs. AA), recessive model (GG vs. GA+AA), codominant model (GG vs. AA), heterozygote model (GA vs. AA), and allele model (G vs. A) were used to pool ORs and assess the association of each genotype with the risk of sepsis. Subgroup analyses were performed for accordance with HWE, ethnic group, septic shock, and mortality of sepsis population.

Publication bias was assessed by Begg’s funnel plots and Egger’s test. Sensitivity analyses indicating the reliability of a meta-analysis were conducted to identify the potential influence of individual data sets to the pooled OR. All statistical analyses were performed using the Revman 5.0 software (Review Manager, version 5.0, the Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, 2008) and the STATA 12.0 software (Statistical Software, Release 12.0, College Station, TX: StataCorp LP, American, 2009).

3. Results

3.1. Characteristics of Included Studies

A total of 225 studies were identified after an initial search of the PubMed and EMBASE databases. After reading the full-text, one article [10] that was included in a previous meta-analysis [9] was excluded due to unavailable data for the genotype distribution in the sepsis group. A total of and 32 articles were included in this meta-analysis [11–42] (Supplementary Figure 1). HWE was performed in the control groups, and deviation from HWE was observed in eight studies. Seven studies were performed in Asians [22, 23, 28, 29, 36, 39, 41] and 19 in Caucasians [11–16, 18–20, 24–27, 30–33, 38, 42]. Three studies were performed in children [24, 30, 40], whereas 27 studies were performed in adults [11, 13–23, 25–29, 31–33, 35–39, 41, 42]. The relationship between the LTA A252G polymorphism and sepsis risk was reported in 25 studies [14, 17, 19–42], while nine studies were related to septic shock risk [20–23, 29, 31, 32, 38, 40], and 21 studies investigated the association with the mortality of sepsis [11–18, 21, 24, 26, 29, 31, 32, 34, 38–41]. The characteristics, genotype, and allele distributions of each case-control study are summarized in Table 1 and Supplement Table 1.

Table 1: Characteristics of case-control studies.

Author [Ref]
Country
Ethnicity
Age
Sepsis source
Sepsis type
SNP method
HWE
Primer
BM
Sepsis definition

Stuber et al. [11]
Germany
Caucasian
>18
ICU
SS
PCR
Yes
Yes
No
Yes

Stuber et al. [12]
Germany
Caucasian
NA
ICU
SS
PCR
Yes
Yes
No
Yes

Fang et al. [13]
Germany
Caucasian
>18
ICU
SS
PCR
No
Yes
No
Yes

Majetschak et al. [14]
Germany
Caucasian
≥18
Trauma
SS
PCR
Yes
Yes
No
Yes

Schroder et al. [15]
Germany
Caucasian
>18
ICU
S
PCR
Yes
Yes
No
Yes

Schroeder et al. [16]
Germany
Caucasian
>18
SICU
SS
PCR
Yes
Yes
No
Yes

Waterer et al. [17]
American
Mixed
≥18
CAP
SS
PCR
Yes
Yes
Yes
Yes

Rauchschwalbe et al. [18]
Germany
Caucasian
>18
Surgery
S, SS
MS-PCR
Yes
Yes
No
Yes

Majetschak et al. [19]
Netherland
Caucasian
≥18
Trauma
SS
PCR-RFLP
Yes
Yes
No
Yes

Schaaf et al. [20]
Germany
Caucasian
≥18
CAP
S, SS, SSH
PCR
Yes
Yes
No
Yes

Calvano et al. [21]
American
Mixed
≥18
SICU
SH, S
PCR
Yes
Yes
Yes
Yes

Zhang 1 et al. [22]
China
Asian
≥18
ASP
SH
PCR
No
Yes
No
Yes

Zhang 2 et al. [23]
China
Asian
≥18
ASBP
SH
PCR
No
Yes
No
Yes

Balding et al. [24]
Ireland
Caucasian
Child
Sepsis
S
PCR
No
Yes
No
No

Riese et al. [25]
Germany
Caucasian
>18
Surgery
S
PCR
No
Yes
No
Yes

Kahlke et al. [26]
Germany
Caucasian
≥18
Surgery
S
PCR-RFLP
Yes
Yes
No
Yes

Gordon et al. [27]
UK
Caucasian
≥18
ICU
SS, SSH
PCR-RFLP
Yes
Yes
Yes
Yes

Nakada et al. [28]
Japan
Asian
≥18
ICU
S
PCR-RFLP
Yes
Yes
No
Yes

Watanabe et al. [37]
Japan
Asian
>18
ICU
S, SSH
PCR
NA
Yes
No
Yes

Schueller et al. [30]
Germany
Caucasian
Infant
Sepsis
S
PCR
Yes
Yes
Yes
Yes

Garnacho et al. [31]
Spain
Caucasian
>18
ICU
S, SS, SSH
PCR
Yes
Yes
No
Yes

García-Segarra et al. [32]
Spain
Caucasian
>18
ICU
S, SS, SSH
PCR
Yes
No
No
Yes

Menges et al. [33]
Germany
Caucasian
≥18
Trauma
S
PCR
Yes
Yes
Yes
Yes

Read et al. [34]
UK
Mixed
Mix
Sepsis
S
PCR
Yes
Yes
No
No

Carregaro et al. [35]
Brasil
Mixed
≥18
ICU
S, SS, SSH
Taqman
Yes
Yes
No
Yes

Gu et al. [36]
China
Asian
≥18
Trauma
S
PCR
Yes
No
No
Yes

Watanabe et al. [37]
American
Mixed
≥18
ICU
S, SS
PCR
No
No
Yes
Yes

Sole-Violan et al. [38]
Spain
Caucasian
≥18
CAP
S, SS, SSH
PCR
Yes
Yes
No
Yes

Song et al. [39]
China
Asian
≥18
Sepsis
S, SS
PCR
No
Yes
No
Yes

Azevedo et al. [40]
Brazil
Mixed
<18
ICU
S, SS, SSH
PCR-RFLP
Yes
No
No
Yes

Baghel et al. [41]
Indian
Asian
>18
Surgery
S
PCR
Yes
Yes
No
Yes

Montoya-Ruiz et al. [42]
American
Caucasian
>18
Emergency
S
PCR
Yes
Yes
No
Yes

S: sepsis; SS: severe sepsis; SSH: septic shock; NA: not available; HEW: Hardy-Weinberg equilibrium; PCR: Polymerase chain reaction; PCR-RFLP: Polymerase Chain Reaction-Restriction Fragment Length Polymorphism; BM: blind method.

3.2. Quantitative Synthesis

For an overall analysis of sepsis risk, we analyzed the heterogeneity of GG+GA vs. AA for all 24 studies and the value was 59.5 with 23 degrees of freedom (). In addition, the -square value, another index of heterogeneity, was 61%. A fixed effects model was used to pool the data. The overall OR was 0.92 (–1.07), and the overall effect value was 1.10 () for the GG+GA vs. AA model (Figure 1). The results showed that GG homozygote and GA heterozygote carriers did not increase the sepsis risk when compared with AA homozygote individuals. The results for the recessive model (GG vs. GA+AA), codominant model (GG vs. AA), and allele model (G vs. A), which did not indicate any associations with the risk of sepsis, are listed in Table 2.

Figure 1: Forest plot of the association between lymphotoxin-α A252G (GG+GA vs. AA) polymorphism and sepsis risk.

Table 2: Summary of results from different comparative genetic models.

Comparison
Stratification
No
OR (95% CI)

(%) ()
Model

GG + GA vs. AA
Overall
24
0.92 [0.79, 1.07]
0.27
61 (<0.01)
Random

HWE
20
0.94 [0.79, 1.13]
0.51
60 (<0.01)
Random

Caucasian
14
0.95 [0.76, 1.19]
0.65
62 (<0.01)
Random

Asian
4
0.84 [1.57, 1.25]
0.39
63 (0.04)
Random

Shock
9
1.01 [0.84, 1.22]
0.91
50 (0.05)
Fixed

Mortality
19
0.57 [0.41, 0.80]
<0.01
63 (<0.01)
Random

GG vs. GA + AA
Overall
25
0.92 [0.84, 1.02]
0.12
26 (0.12)
Fixed

HWE
18
1.01 [0.88, 1.15]
0.93
14 (0.29)
Fixed

Caucasian
12
1.08 [0.90, 1.30]
0.39
19 (0.26)
Fixed

Asian
7
0.82 [0.68, 0.99]
0.04
0 (0.72)
Fixed

Shock
8
0.92 [0.70, 1.22]
0.58
38 (0.13)
Fixed

Mortality
19
0.73 [0.57, 0.93]
0.01
28 (0.13)
Fixed

GG vs. AA
Overall
22
0.94 [0.79, 1.12]
0.48
39 (0.03)
Random

HWE
18
0.99 [0.85, 1.15]
0.92
29 (0.12)
Fixed

Caucasian
12
1.04 [0.86, 1.26]
0.70
29 (0.17)
Fixed

Asian
4
0.84 [0.65, 1.07]
0.15
0 (0.91)
Fixed

Shock
5
1.02 [0.71, 1.46]
0.92
39 (0.16)
Fixed

Mortality
17
0.52 [0.31, 0.85]
0.009
56 (<0.01)
Random

G vs. A
Overall
22
0.94 [0.85, 1.03]
0.19
56 (<0.01)
Random

HWE
18
0.95 [0.85, 1.07]
0.41
50 (<0.01)
Random

Caucasian
12
0.96 [0.83, 1.12]
0.63
53 (0.01)
Random

Asian
4
0.91 [0.80, 1.03]
0.13
27 (0.25)
Fixed

Shock
5
0.97 [0.82, 1.13]
0.67
49 (0.10)
Fixed

Mortality
17
0.70 [0.54, 0.90]
0.005
67 (<0.01)
Random

GA vs. AA
Overall
22
0.89 [0.77, 1.03]
0.13
53 (0.002)
Random

HWE
18
0.89 [0.74, 1.06]
0.19
54 (0.003)
Random

Caucasian
12
0.86 [0.69, 1.07]
0.18
53 (0.02)
Random

Asian
4
0.86 [0.54, 1.36]
0.51
69 (0.02)
Random

Shock
5
0.54 [0.18, 1,61]
0.27
94 (<0.01)
Random

Mortality
17
0.61 [0.44, 0.86]
0.004
57 (0.002)
Random

For studies in accordance with HWE, no significant association was found between the LTA A252G polymorphism and sepsis risk (, –1.13, for GG+GA vs. AA). In the subgroup analysis by ethnicity (Caucasian and Asian), no association was identified between the LTA A252G polymorphism and sepsis risk in Caucasians (, –1.19, for GG+GA vs. AA) and Asians (, –1.25, for GG+GA vs. AA). However, the recessive model for the Asian populations showed decreased risk of sepsis (, –0.99, for GG vs. GA+AA) (Figure 2).

Figure 2: Forest plot of the association between lymphotoxin-α A252G (GG vs. GA+AA) polymorphism and sepsis risk in Asians.

Nine studies had reported a potential effect of the LTA A252G polymorphism on septic shock risk [18–21, 27, 29, 30, 36, 38], while no significant association between this polymorphism and septic shock susceptibility was identified (, –1.22, for GG+GA vs. AA). Furthermore, a total of 21 studies had determined the association between the LTA A252G polymorphism and the mortality of sepsis [9–16, 19, 22, 24, 27, 29, 30, 32, 36–39], and the results of all the four models showed that the LTA A252G polymorphism significantly decreased the mortality risk of sepsis patients (Figure 3). A summary of all the results of statistical analysis is shown in Table 2.

Figure 3: Forest plot of the association between lymphotoxin-α A252G (GG+GA vs. AA) polymorphism and sepsis mortality.

3.3. Sensitivity Analysis and Publication Bias

A sensitivity analysis was performed to evaluate the stability of the individual data to the pooled OR (GG+GA vs. AA). After sequentially excluding each one of the 25 studies that assessed the overall relationship between the LTA A252G polymorphism and sepsis risk, statistically similar results were obtained, suggesting the results of this meta-analysis were stable (Figure 4). Furthermore, similar findings were identified in other statistical models (data not shown). Moreover, publication bias was assessed by Begg’s funnel plots and Egger’s test. The shape of the funnel plots appeared symmetrical in the GG+GA vs. the AA comparison model, suggesting the absence of publication bias (Figure 5). Egger’s test was performed to provide statistical evidence of funnel plot asymmetry. The value was 0.42, indicating an absence of publication bias. In addition, no publication bias was identified in other statistical models (data not shown).

Figure 4: Sensitivity analysis of included studies investigated the association between lymphotoxin-α A252G (GG+GA vs. AA) polymorphism and sepsis risk.

Figure 5: Begg’s funnel plot for publication bias in selection of studies on lymphotoxin-α A252G (GG+GA vs. AA) polymorphism.

4. Discussion

Sepsis is a severe complication of infectious diseases which may develop to severe sepsis, septic shock or even death. Even with advanced life support and antibiotics, the mortality of sepsis is still remarkable [43]. Host genetic and immune factors play an important role in the prognosis of sepsis patients. Genetic variants can predict an individual’s susceptibility to sepsis and may be helpful in determining the risk for serious complications and death in sepsis patients [43]. As inflammatory cells and cytokines are essential for the pathogenesis of sepsis, many researchers have studied polymorphisms of inflammatory cytokines. The A252G polymorphism of the LTA gene is one of the most studied gene polymorphisms, but the results have been conflicting. To reach a more accurate and objective conclusion, we performed this updated meta-analysis to assess the overall association between the LTA A252G polymorphism and sepsis risk based on current available publications. Compared with the previous meta-analysis, there are some advantages in the article. First, the article is an updated meta-analysis and included subgroup analysis. Second, the previous meta-analysis analyzed the correlation between A allele and sepsis risk. However, according to the allele frequency studies, the A allele is the predominant allele. So, we mainly analyzed the G allele in our meta-analysis. Third, we analyzed publication bias and sensitivity in our meta-analysis which was deficient in the previous article.

The meta-analysis involved 32 articles; considering the genetic background, subgroup analyses were performed for accordance with HWE, ethnic group, septic shock, and mortality of the sepsis population. The results of both overall studies and studies in accordance with HWE showed no association between the LTA A252G polymorphism and risk of sepsis. However, ethnicity is an important factor for the pathogenesis of sepsis, and single nucleotide polymorphisms can be used to distinguish among different ethnic populations. In terms of allele frequencies, a significant difference of G allele was found between Moroccan, African, and Asian populations; however, no difference was found in Mediterranean, European, and Japanese populations [44, 45]. In this meta-analysis, 19 of the included studies were conducted in Caucasian and seven in Asian populations. While no association was found in the Caucasian populations, in the Asian populations, the G allele was found to decrease sepsis risk, indicating the importance of ethnic differences. Only two studies included African-Americans; therefore, due to the small sample size, additional studies are needed to assess this association in the future.

Since sepsis, in severe cases, can progress to septic shock and death, we also analyzed the association between the LTA A252G polymorphism and the risk of septic shock and mortality. In this meta-analysis, nine studies had reported the effect of the LTA A252G polymorphism on septic shock susceptibility, and 21 studies had analyzed the LTA A252G gene variants in septic patients who survived and those who did not. The results suggested no significant effect of the LTA A252G polymorphism on septic shock susceptibility. The genetic distribution of GG, GA, and AA could not be extracted independently in four of the nine articles, and therefore, the negative associations for septic shock could be attributed to the small sample size. Further studies are needed for future evaluation. In the mortality analysis, all the results indicated that the LTA A252G polymorphism decreased the risk of sepsis-related mortality, suggesting that the presence of the G allele (GG and G) could decrease the mortality rate in septic patients.

GWAS is the most appropriate method to identify susceptible genes for sepsis [43], and many sepsis-susceptibility genes have been so far identified by GWAS [3, 4]. However, no GWAS has reported a significant association between the LTA A252G polymorphism and sepsis risk, indicating that this polymorphism might not have been included in those GWAS arrays. Thus, future studies are needed to further assess and validate our results.

Heterogeneity and publication bias play a determining role in the reliability of the results in a meta-analysis. Significant heterogeneity was detected in some comparisons; however, this may be due to study design differences among the included studies. When significant heterogeneity was found, a random effects model was applied for analysis. In addition, the genetic distribution of GG, GA, and AA could not be extracted independently in some cases, probably partly contributing to the existence of heterogeneity.

Publication bias and sensitivity analysis constitute an essential index for the quality and reliability of the study. Publication bias was analyzed using Begg’s funnel plots and Egger’s test in our study. The results indicated the reliability of our meta-analysis.

Hitherto, this is the most specific and comprehensive meta-analysis to investigate the association of the LTA A252G polymorphism with sepsis risk. However, this study had some limitations. First, since our literature search was conducted only in the selected databases, we might have missed relevant studies deposited in other databases. Second, since we only included published studies written in English, studies in other languages were excluded. Third, most of the included studies were conducted in Caucasian and Asian populations; therefore, the results may only be applicable to these populations. Hence, future studies are warranted to explore these associations further, particularly in African-American, African, and Latin populations. Nevertheless, this meta-analysis has made an important contribution to this field. A comprehensive evaluation of the association between the LTA A252G polymorphism and sepsis risk is more powerful than a single study. Furthermore, the reliability of this meta-analysis was confirmed by heterogeneity, publication bias, and sensitivity analyses.

To our knowledge, this is the most comprehensive meta-analysis to assess the relationship between the A252G polymorphism in the LTA gene and sepsis risk. Our results suggested that the LTA A252G polymorphism was significantly associated with a decreased risk of sepsis in Asian populations and with a decreased risk for mortality among septic individuals.

Data Availability

The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.

Additional Points

Highlights. Hitherto, this is the most specific and comprehensive meta-analysis to investigate the association of the LTA A252G polymorphism with sepsis risk, septic shock, and mortality.

Disclosure

The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of Interest

The authors declare that they have no conflict of interest.

Authors’ Contributions

Shujin Guo, Qiunan Zuo, and Xiaohui Li searched the studies and extracted and analyzed the data. Ye He contributed to the statistical analyses. Shujin Guo edited the manuscript. Yutian Zhou reviewed and edited the manuscript. Shujin Guo, Qiunan Zuo, and Xiaohui Li contributed equally to this work and are joint first authors.

Acknowledgments

This work was funded by Grant 81700044 from the National Natural Science Foundation of China and Grant 16PJ416 from the Health and Family Planning Commission of Sichuan Province to Dr. Shujin Guo.

Supplementary Materials

Supplementary Table 1: characteristics of case-control studies and distributions of LTA genotype and allele among sepsis patients and controls [11–42]. Supplementary Figure 1: flow chart of study inclusion. (Supplementary Materials)

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