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Abstract
OBJECTIVE To review the current knowledge of common comorbidities in the intensive care unit, including diabetes mellitus, chronic obstructive pulmonary disease, cancer, end-stage renal disease, end-stage liver disease, HIV infection, and obesity, with specific attention to epidemiology, contribution to diseases and outcomes, and the impact on treatments in these patients. DATA SOURCE Review of the relevant medical literature for specific common comorbidities in the critically ill. RESULTS Critically ill patients are admitted to the intensive care unit for various reasons, and often the admission diagnosis is accompanied by a chronic comorbidity. Chronic comorbid conditions commonly seen in critically ill patients may influence the decision to provide intensive care unit care, decisions regarding types and intensity of intensive care unit treatment options, and outcomes. The presence of comorbid conditions may predispose patients to specific complications or forms of organ dysfunction. The impact of specific comorbidities varies among critically ill medical, surgical, and other populations, and outcomes associated with certain comorbidities have changed over time. Specifically, outcomes for patients with cancer and HIV have improved, likely related to advances in therapy. Overall, the negative impact of chronic comorbidity on survival in critical illness may be primarily influenced by the degree of organ dysfunction or the cumulative severity of multiple comorbidities. CONCLUSION Chronic comorbid conditions are common in critically ill patients. Both the acute illness and the chronic conditions influence prognosis and optimal care delivery for these patients, particularly for adverse outcomes and complications influenced by comorbidities. Further work is needed to fully determine the individual and combined impact of chronic comorbidities on intensive care unit outcomes.
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102
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Chang CW, Kok VC, Tseng TC, Horng JT, Liu CE. Diabetic patients with severe sepsis admitted to intensive care unit do not fare worse than non-diabetic patients: a nationwide population-based cohort study. PLoS One 2012; 7:e50729. [PMID: 23236389 PMCID: PMC3517561 DOI: 10.1371/journal.pone.0050729] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/24/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We sought to examine whether type 2 diabetes increases the risk of acute organ dysfunction and of hospital mortality following severe sepsis that requires admission to an intensive care unit (ICU). METHODS Nationwide population-based retrospective cohort study of 16,497 subjects with severe sepsis who had been admitted for the first time to an ICU during the period of 1998-2008. A diabetic cohort (n = 4573) and a non-diabetic cohort (n = 11924) were then created. Relative risk (RR) of organ dysfunctions, length of hospital stay (LOS), 90-days hospital mortality, ICU resource utilization and hazard ratio (HR) of mortality adjusted for age, gender, Charlson-Deyo comorbidity index score, surgical condition and number of acute organ dysfunction, were compared across patients with severe sepsis with or without diabetes. RESULTS Diabetic patients with sepsis had a higher risk of developing acute kidney injury (RR, 1.54; 95% confidence interval (CI), 1.44-1.63) and were more likely to be undergoing hemodialysis (15.55% vs. 7.24%) in the ICU. However, the diabetic cohort had a lower risk of developing acute respiratory dysfunction (RR = 0.96, 0.94-0.97), hematological dysfunction (RR = 0.70, 0.56-0.89), and hepatic dysfunction (RR = 0.77, 0.63-0.93). In terms of adjusted HR for 90-days hospital mortality, the diabetic patients with severe sepsis did not fare significantly worse when afflicted with cardiovascular, respiratory, hepatic, renal and/or neurologic organ dysfunction and by numbers of organ dysfunction. There was no statistically significant difference in LOS between the two cohorts (median 17 vs. 16 days, interquartile range (IQR) 8-30 days, p = 0.11). Multiple logistic regression analysis to predict the occurrence of mortality shows that being diabetic was not a predictive factor with an odds ratio of 0.972, 95% CI 0.890-1.061, p = 0.5203. INTERPRETATION This large nationwide population-based cohort study suggests that diabetic patients do not fare worse than non-diabetic patients when suffering from severe sepsis that requires ICU admission.
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Affiliation(s)
- Cheng-Wei Chang
- Department of Information Management, Hsing Wu University, New Taipei City, Taiwan
- Division of Medical Oncology, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan
| | - Victor C. Kok
- Public Health and Clinical Informatics Research Group, Department of Biomedical Informatics, Asia University Taiwan, Taichung, Taiwan
- Division of Medical Oncology, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan
- * E-mail:
| | - Ta-Chien Tseng
- Bioinformatics Center, National Cheng Kung University, Tainan, Taiwan
| | - Jorng-Tzong Horng
- Public Health and Clinical Informatics Research Group, Department of Biomedical Informatics, Asia University Taiwan, Taichung, Taiwan
- Department of Computer Science and Information Engineering, National Central University, Chungli, Taiwan
| | - Chun-Eng Liu
- Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
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103
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Schuetz P, Jones AE, Howell MD, Trzeciak S, Ngo L, Younger JG, Aird W, Shapiro NI. Diabetes is not associated with increased mortality in emergency department patients with sepsis. Ann Emerg Med 2011; 58:438-44. [PMID: 21683473 PMCID: PMC3425373 DOI: 10.1016/j.annemergmed.2011.03.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Revised: 01/29/2011] [Accepted: 03/28/2011] [Indexed: 01/15/2023]
Abstract
STUDY OBJECTIVE Despite its high prevalence, the influence of diabetes on outcomes of emergency department (ED) patients with sepsis remains undefined. Our aim is to investigate the association of diabetes and initial glucose level with mortality in patients with suspected infection from the ED. METHODS Three independent, observational, prospective cohorts from 2 large US tertiary care centers were studied. We included patients admitted to the hospital from the ED with suspected infection. We investigated the association of diabetes and inhospital mortality within each cohort separately and then overall with logistic regression and generalized estimating equations adjusted for age, sex, disease severity, and sepsis syndrome. We also tested for an interaction between diabetes and hyperglycemia/hypoglycemia. RESULTS A total of 7,754 patients were included. The mortality rate was 4.3% (95% confidence interval [CI] 3.9% to 4.8%) and similar in diabetic and nondiabetic patients (4.1% versus 4.4%; absolute risk difference 0.4%; 95% CI -0.7% to 1.4%). There was no significant association between diabetes and mortality in adjusted analysis (odds ratio [OR] overall 0.85; 95% CI 0.71 to 1.01). Diabetes significantly modified the effect of hyperglycemia and hypoglycemia with mortality; initial glucose levels greater than 200 mg/dL were associated with higher mortality in nondiabetic patients (OR 2.1; 95% CI 1.4 to 3.0) but not in diabetic patients (OR 1.0; 95% CI 0.2 to 4.7), whereas glucose levels less than 100 mg/dL were associated with higher mortality mainly in the diabetic population (OR 2.3; 95% CI 1.6 to 3.3) and to a lesser extent in nondiabetic patients (OR 1.1; 95% CI 1.03 to 1.14). CONCLUSION We found no evidence for a harmful association of diabetes and mortality in patients across different sepsis severities. High initial glucose levels were associated with adverse outcomes in the nondiabetic population only. Further investigation is warranted to determine the mechanism for these effects.
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Affiliation(s)
- Philipp Schuetz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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104
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Abstract
Increasing incidence of morbidity and mortality of diabetic subjects due to infection necessitates the understanding of its patho-biology and further remedial measures for its prevention and treatment. The increased incidence of infection is because of systemic illness that has compromising effects on multiple organs including the nervous, vascular, musculoskeletal, and immunologic systems of the diabetic patients. Many factors contribute to this condition including hyperglycemia, insulin deficiency, ischemia and impaired immunity. Sepsis, as a separate entity, lead to destruction of cytokine network that can be fatal. Compromised defense mechanisms due to sepsis and cytokine dysregulation in diabetic patients make the situation worse. Early identification of local infection by applying advanced molecular tools, appropriate selection of antibiotics, intensive wound management, control of glycemic status and supportive treatment can reduce the rate of morbidity and mortality due to sepsis in patients with diabetes.
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Affiliation(s)
- Shalbha Tiwari
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, UP, India
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105
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Koh GCKW, Peacock SJ, van der Poll T, Wiersinga WJ. The impact of diabetes on the pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis 2011; 31:379-88. [PMID: 21805196 PMCID: PMC3303037 DOI: 10.1007/s10096-011-1337-4] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/21/2011] [Indexed: 02/06/2023]
Abstract
Diabetes is associated with an increased susceptibility to infection and sepsis. Conflicting data exist on whether the mortality of patients with sepsis is influenced by the presence of diabetes, fuelling the ongoing debate on the benefit of tight glucose regulation in patients with sepsis. The main reason for which diabetes predisposes to infection appears to be abnormalities of the host response, particularly in neutrophil chemotaxis, adhesion and intracellular killing, defects that have been attributed to the effect of hyperglycaemia. There is also evidence for defects in humoral immunity, and this may play a larger role than previously recognised. We review the literature on the immune response in diabetes and its potential contribution to the pathogenesis of sepsis. In addition, the effect of diabetes treatment on the immune response is discussed, with specific reference to insulin, metformin, sulphonylureas and thiazolidinediones.
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Affiliation(s)
- G C K W Koh
- The Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK.
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106
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Lee KA, Gong MN. Pre-B-cell colony-enhancing factor and its clinical correlates with acute lung injury and sepsis. Chest 2011; 140:382-390. [PMID: 21565968 DOI: 10.1378/chest.10-3100] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Pre-B-cell colony-enhancing factor (PBEF) is a potential biomarker for acute lung injury (ALI) in sepsis. We aimed to determine the clinical correlates for elevated plasma PBEF upon ICU admission for severe sepsis and the usefulness of PBEF to predict ALI development and sepsis mortality. METHODS This is a prospective cohort of patients admitted to the medical ICU with severe sepsis. Patients without available blood samples or who were not enrolled within 24 h of admission were excluded. Plasma collected within 24 h of ICU admission was measured for PBEF concentrations by enzyme-linked immunosorbent assay. Patients were followed for ALI development as defined by the American-European Consensus Conference and for all-cause hospital mortality. RESULTS Between September 30, 2008, and March 10, 2009, 113 patients were enrolled, and 50 (44%) developed ALI. Elevated PBEF levels significantly correlated with higher APACHE (Acute Physiology and Chronic Health Evaluation) III scores (R(2) = 0.08, P = .003) and failure to reach early sepsis goals within 6 h of severe sepsis (P = .003). PBEF did not differ by ALI status (P = .58). The mortality rate was 46%. Nonsurvivors had higher PBEF levels than survivors (2.53 ng/mL; interquartile range [IQR], 1.07-8.16 vs 1.44 ng/mL; IQR, 0.84-2.81; P = .02). After adjusting for severity of illness, PBEF levels were no longer significantly associated with mortality (OR, 1.44 per 10-fold increase; 95% CI, 0.69-3.03, P = .34). CONCLUSIONS In this study, elevated PBEF did not correlate with lung injury in sepsis. However, it was associated with sepsis mortality mainly due to its association with greater severity of illness on ICU admission.
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Affiliation(s)
- Kathleen A Lee
- Department of Medicine, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Michelle N Gong
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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107
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Schlussel AT, Holt DB, Crawley EA, Lustik MB, Wade CE, Uyehara CF. Effect of diabetes mellitus on outcomes of hyperglycemia in a mixed medical surgical intensive care unit. J Diabetes Sci Technol 2011; 5:731-40. [PMID: 21722589 PMCID: PMC3192640 DOI: 10.1177/193229681100500328] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intensive insulin therapy and degree of glycemic control in critically ill patients remains controversial, particularly in patients with diabetes mellitus. We hypothesized that diabetic patients who achieved tight glucose control with continuous insulin therapy would have less morbidity and lower mortality than diabetic patients with uncontrolled blood glucose. METHOD A retrospective chart review was performed on 395 intensive care unit (ICU) patients that included 235 diabetic patients. All patients received an intravenous insulin protocol targeted to a blood glucose (BG) level of 80-140 mg/dl. Outcomes were compared between (a) nondiabetic and diabetic patients, (b) diabetic patients with controlled BG levels (80-140 mg/dl) versus uncontrolled levels (>140 mg/dl), and (c) diabetic survivors and nonsurvivors. RESULTS Diabetic patients had a shorter ICU stay compared to nondiabetic patients (10 ± 0.7 vs 13 ± 1.1, p = .01). The mean BG of the diabetic patients was 25% higher on average in the uncontrolled group than in the controlled (166 ± 26 vs 130 ± 9.4 mg/dl, p < .01). There was no difference in ICU and hospital length of stay (LOS) between diabetic patients who were well controlled compared to those who were uncontrolled. Diabetic nonsurvivors had a significantly higher incidence of hypoglycemia (BG <60 mg/dl) compared to diabetic survivors. CONCLUSION The results showed that a diagnosis of diabetes was not an independent predictor of mortality, and that diabetic patients who were uncontrolled did not have worse outcomes. Diabetic nonsurvivors were associated with a greater amount of hypoglycemic episodes, suggesting these patients may benefit from a more lenient blood glucose protocol.
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Affiliation(s)
- Andrew T Schlussel
- Department of Surgery, Tripler Army Medical Center, Tripler AMC, Hawaii, USA
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108
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Schuetz P, Yano K, Sorasaki M, Ngo L, St Hilaire M, Lucas JM, Aird W, Shapiro NI. Influence of diabetes on endothelial cell response during sepsis. Diabetologia 2011; 54:996-1003. [PMID: 21286681 DOI: 10.1007/s00125-011-2059-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 01/07/2011] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS Several endothelial pathways of cell adhesion, coagulation and vascular endothelial growth factor (VEGF) signalling are activated during sepsis. The objective of this analysis was to investigate the influence of diabetes on biomarkers of endothelial cell activation in sepsis. METHODS This was a prospective observational cohort study of a convenience sample of adult patients (age ≥ 18 years) for whom infection was clinically suspected and who presented to an urban tertiary care emergency department between February 2005 and November 2008. We investigated the association of diabetes and sepsis with various endothelial activation biomarkers of cell adhesion (E-selectin, vascular cell adhesion molecule 1 [VCAM-1] and intercellular adhesion molecule 1 [ICAM-1]), coagulation (plasminogen activator inhibitor 1 [PAI-1]) and VEGF signalling (soluble fms-like tyrosine kinase-1 [sFLT-1]). RESULTS A total of 207 patients (34% with sepsis, 32% with severe sepsis and 34% with septic shock) were studied, including 63 (30%) with diabetes. Compared with patients without diabetes, patients with diabetes had significantly increased E-selectin and sFLT-1 levels overall; this was most pronounced during septic shock in the stratified analysis. Multivariate models including age, sex, sepsis severity and other variables as potential covariates confirmed the association of diabetes with elevated circulating plasma levels of E-selectin (standardised β 0.24, p < 0.001) and sFLT-1 (standardised β 0.19, p < 0.01), but there was no significant association with VCAM-1, ICAM-1 or PAI-1. CONCLUSIONS/INTERPRETATION During septic shock, patients with diabetes had higher levels of circulating biomarkers of endothelial cell adhesion (E-selectin) and VEGF signalling (sFLT-1). Future studies should address whether enhanced activation of the endothelium places patients with diabetes at increased risk for the development of sepsis and worsening morbidity and mortality.
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Affiliation(s)
- P Schuetz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, CC2-W, Boston, MA 02215, USA.
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109
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Yang Y, Salam ZHA, Ong BC, Yang KS. Respiratory dysfunction in patients with sepsis: protective effect of diabetes mellitus. Am J Crit Care 2011; 20:e41-7. [PMID: 21362712 DOI: 10.4037/ajcc2011391] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sepsis is a common complication in patients with diabetes mellitus. In a Western population, risk of respiratory dysfunction was lower in diabetic patients with sepsis. OBJECTIVE To compare organ dysfunction, particularly respiratory dysfunction, between sepsis patients with and without diabetes mellitus in an Asian population. METHOD Hospital discharge data were collected for the period 2004 through 2008. Patients with sepsis, diabetes mellitus, and organ dysfunction were identified by using the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification codes. RESULTS Of the 383 238 patients hospitalized during the 5 years, 2943 of the 9221 who had sepsis also had diabetes (31.9%).The most common organ dysfunctions in patients with sepsis were renal (31.5%), cardiovascular (19.2%), and respiratory (10.9%). Among patients with sepsis, respiratory dysfunction was less likely in patients with diabetes (9.4%) than in those without (11.6%; P = .002), but renal dysfunction was more likely in patients with diabetes (46.5%) than in those without (24.4%; P < .001). However, only 27.6% of patients with diabetes had a respiratory source of sepsis compared with 33.4% in patients without diabetes (P < .001). Among patients with sepsis, diabetes mellitus was a significant and independent predictor of respiratory dysfunction (odds ratio, 0.80; 95% confidence interval, 0.66-0.98) after adjustments for age, sex, ethnicity, admission to intensive care, number of comorbid conditions, and other infection sources. CONCLUSION Among an Asian population, respiratory dysfunction in patients with sepsis is less likely to develop in those with diabetes than in those without diabetes.
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Affiliation(s)
- Yong Yang
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
| | - Zakir-Hussain Abdul Salam
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
| | - Biauw Chi Ong
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
| | - Kok Soong Yang
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
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110
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Affiliation(s)
- Philipp Schuetz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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111
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Koh GCKW, Maude RR, Schreiber MF, Limmathurotsakul D, Wiersinga WJ, Wuthiekanun V, Lee SJ, Mahavanakul W, Chaowagul W, Chierakul W, White NJ, van der Poll T, Day NPJ, Dougan G, Peacock SJ. Glyburide is anti-inflammatory and associated with reduced mortality in melioidosis. Clin Infect Dis 2011; 52:717-25. [PMID: 21293047 PMCID: PMC3049341 DOI: 10.1093/cid/ciq192] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Patients with diabetes have better survival from septic melioidosis than patients who without diabetes. This difference was seen only in patients taking glyburide prior to presentation and was associated with an anti-inflammatory effect of glyburide. Background. Patients with diabetes mellitus are more prone to bacterial sepsis, but there are conflicting data on whether outcomes are worse in diabetics after presentation with sepsis. Glyburide is an oral hypoglycemic agent used to treat diabetes mellitus. This KATP-channel blocker and broad-spectrum ATP-binding cassette (ABC) transporter inhibitor has broad-ranging effects on the immune system, including inhibition of inflammasome assembly and would be predicted to influence the host response to infection. Methods. We studied a cohort of 1160 patients with gram-negative sepsis caused by a single pathogen (Burkholderia pseudomallei), 410 (35%) of whom were known to have diabetes. We subsequently studied prospectively diabetics with B. pseudomallei infection (n = 20) to compare the gene expression profile of peripheral whole blood leukocytes in patients who were taking glyburide against those not taking any sulfonylurea. Results. Survival was greater in diabetics than in nondiabetics (38% vs 45%, respectively, P = .04), but the survival benefit was confined to the patient group taking glyburide (adjusted odds ratio .47, 95% confidence interval .28–.74, P = .005). We identified differential expression of 63 immune-related genes (P = .001) in patients taking glyburide, the sum effect of which we predict to be antiinflammatory in the glyburide group. Conclusions. We present observational evidence for a glyburide-associated benefit during human melioidosis and correlate this with an anti-inflammatory effect of glyburide on the immune system.
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Affiliation(s)
- Gavin C K W Koh
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
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112
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Untreated type 1 diabetes increases sepsis-induced mortality without inducing a prelethal cytokine response. Shock 2010; 34:369-76. [PMID: 20610941 DOI: 10.1097/shk.0b013e3181dc40a8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diabetes mellitus is the leading comorbidity in patients with sepsis, but its impact upon survival and immunoinflammatory signaling in sepsis is undetermined. We investigated the effect of untreated diabetes mellitus upon survival and immunoinflammatory responses in the acute phase (days 1-5) of murine polymicrobial sepsis using the AKITA model of type 1 diabetes. Diabetic female C57BL/6-Ins2 (AKITA) and C57BL/6 wild-type (WT) mice underwent cecal ligation and puncture (CLP), blood (20 μL) was sampled for 5 days, and survival was monitored for 28 days. By day 5, all 8 AKITA mice died compared with 10 of 28 deaths in WT mice. Blood glucose declined post-CLP in all groups (most dramatically in AKITAs by 75%). To compare the evolution of inflammatory profiles, mice were retrospectively divided based on outcome into AKITA, WT-Died, and WT-Survived (within days 1-5). Hypoglycemia developed in all groups, which resolved in WT-Survived (97 mg/dL at 96 h) but intensified in WT-Died and AKITAs (∼30 mg/dL). Dramatic increases in both proinflammatory and anti-inflammatory cytokines were observed in WT-Died (i.e., interleukin 6, 38.2 ± 17.8 ng/mL at 24 h), which contrasted with a lack of prelethal cytokine response in AKITA mice (interleukin 6, 4.3 ± 3.4 ng/mL at 24 h). A prelethal composite cytokine score was calculated on values obtained 24 h before death. This score was 3-fold lower for proinflammatory cytokines and 6-fold lower for anti-inflammatory mediators in the AKITA mice compared with the WT-Died mice but identical to the composite score in WT-Survived. These data demonstrate that untreated type I diabetes mellitus severely exacerbates sepsis mortality without inducing a prelethal release of systemic proinflammatory or anti-inflammatory cytokines.
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113
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Yende S, van der Poll T, Lee M, Huang DT, Newman AB, Kong L, Kellum JA, Harris TB, Bauer D, Satterfield S, Angus DC. The influence of pre-existing diabetes mellitus on the host immune response and outcome of pneumonia: analysis of two multicentre cohort studies. Thorax 2010; 65:870-7. [PMID: 20861291 DOI: 10.1136/thx.2010.136317] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although diabetes mellitus is implicated in susceptibility to infection, the association of diabetes with the subsequent course and outcome is unclear. METHODS A retrospective analysis of two multicentre cohorts was carried out. The effect of pre-existing diabetes on the host immune response, acute organ function and mortality in patients hospitalised with community-acquired pneumonia (CAP) in the GenIMS study (n=1895) and on mortality following either CAP or non-infectious hospitalisations in the population-based cohort study, Health ABC (n=1639) was determined. Measurements included the mortality rate within the first year, risk of organ dysfunction, and immune responses, including circulating inflammatory (tumour necrosis factor, interleukin 6, interleukin 10), coagulation (Factor IX, thrombin-antithrombin complexes, antithrombin), fibrinolysis (plasminogen-activator inhibitor-1 and D-dimer) and cell surface markers (CD120a, CD120b, human leucocyte antigen (HLA)-DR, Toll-like receptor-2 and Toll-like receptor-4). RESULTS In GenIMS, diabetes increased the mortality rate within the first year after CAP (unadjusted HR 1.41, 95% CI 1.12 to 1.76, p=0.002), even after adjusting for pre-existing cardiovascular and renal disease (adjusted HR 1.3, 95% CI 1.03 to 1.65, p=0.02). In Health ABC, diabetes increased the mortality rate within the first year following CAP hospitalisation, but not after hospitalisation for non-infectious illnesses (significant interaction for diabetes and reason for hospitalisation (p=0.04); HR for diabetes on mortality over the first year after CAP 1.87, 95% CI 0.76 to 4.6, p=0.16, and after non-infectious hospitalisation 1.16, 95% CI 0.8 to 1.6, p=0.37). In GenIMS, immediate immune response was similar, as evidenced by similar circulating immune marker levels, in the emergency department and during the first week. Those with diabetes had a higher risk of acute kidney injury during hospitalisation (39.3% vs 31.7%, p=0.005) and they were more likely to die due to cardiovascular and kidney disease (34.4% vs 26.8% and 10.4% vs 4.5%, p=0.03). CONCLUSIONS Pre-existing diabetes was associated with a higher risk of death following CAP. The mechanism is not due to an altered immune response, at least as measured by a broad panel of circulating and cell surface markers, but may be due to worsening of pre-existing cardiovascular and kidney disease.
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Affiliation(s)
- Sachin Yende
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, University of Pittsburgh, Pittsburgh, PA, USA.
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Monitoring nonenzymatic glycation of human immunoglobulin G by methylglyoxal and glyoxal: A spectroscopic study. Anal Biochem 2010; 408:59-63. [PMID: 20816660 DOI: 10.1016/j.ab.2010.08.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 08/23/2010] [Accepted: 08/27/2010] [Indexed: 12/25/2022]
Abstract
The accumulation of dicarbonyl compounds, methylglyoxal (MG) and glyoxal (G), has been observed in diabetic conditions. They are formed from nonoxidative mechanisms in anaerobic glycolysis and lipid peroxidation, and they act as advanced glycation endproduct (AGE) precursors. The objective of this study was to monitor and characterize the AGE formation of human immunoglobulin G (hIgG) by MG and G using ultraviolet (UV) and fluorescence spectroscopy, circular dichroism (CD), and matrix-assisted laser desorption/ionization-mass spectrometry (MALDI-MS). hIgG was incubated over time with MG and G at different concentrations. Formation of AGE was monitored by UV and fluorescence spectroscopy. The effect of AGE formation on secondary structure of hIgG was studied by CD. Comparison of AGE profile for MG and G was performed by MALDI-MS. Both MG and G formed AGE, with MG being nearly twice as reactive as G. The combination of these techniques is a convenient method for evaluating and characterizing the AGE proteins.
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115
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Andreasen AS, Pedersen-Skovsgaard T, Berg RMG, Svendsen KD, Feldt-Rasmussen B, Pedersen BK, Møller K. Type 2 diabetes mellitus is associated with impaired cytokine response and adhesion molecule expression in human endotoxemia. Intensive Care Med 2010; 36:1548-55. [PMID: 20229041 DOI: 10.1007/s00134-010-1845-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 12/01/2009] [Indexed: 12/19/2022]
Abstract
PURPOSE Type 2 diabetes is associated with an increased risk of acquiring infectious diseases and developing sepsis. This may partly be due to immune dysfunction. We investigated the in vivo innate immune response of type 2 diabetic persons to an intravenous injection of E. coli lipopolysaccharide (LPS). METHODS After ethics approval, informed consent and a thorough physical examination, 19 type 2 diabetic patients and 23 healthy controls were included. LPS was given as an intravenous bolus injection of 0.3 ng/kg. Physiological variables, white blood cell count, and plasma concentrations of tumour necrosis factor (TNF), interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1ra), and the adhesion molecules E-selectin, vascular adhesion molecule (VCAM)-1, and intracellular adhesion molecule (ICAM)-1 were measured hourly for 8 h. RESULTS LPS injection induced a systemic inflammatory response with increases in neutrophils, temperature, heart rate and plasma concentrations of cytokines and adhesion molecules in healthy and type 2 diabetic volunteers. Type 2 diabetes was associated with less pronounced LPS-induced increases in TNF, IL-1ra, VCAM-1 and ICAM-1. There was a trend towards an attenuated upregulation of E-selectin in diabetics, even though the plasma concentration tended to be generally higher compared to healthy controls. CONCLUSIONS Patients with type 2 diabetes exhibit an attenuated increase in plasma levels of TNF and IL-1ra, as well as an attenuated upregulation of VCAM-1 and ICAM-1 to LPS in vivo. This finding may provide a mechanistic explanation for the adverse outcome seen during infectious diseases in diabetic patients.
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Affiliation(s)
- Anne Sofie Andreasen
- Centre of Inflammation and Metabolism, Department of Infectious Diseases, University Hospital Rigshospitalet, Rigshospitalet-M 7641, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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Abstract
OBJECTIVE Chronic diabetes mellitus (DM) is a known cause of multisystem injury. The effect of DM in acute critical illness may also be detrimental, but is not specifically known. We hypothesized that the preexisting diagnosis of DM is an independent risk factor for mortality in critically ill patients. DESIGN Parallel retrospective and prospective cohort study. SETTING Two large patient datasets were used: the retrospective University HealthSystem Consortium database (UHC) and the prospective Mayo Clinic Acute Physiology And Chronic Health Evaluation III critical care database (Mayo). PATIENTS Inclusion criteria were admission to an intensive care unit and age > or =18 yrs. Patients with diabetic ketoacidosis or hyperosmolar nonketotic coma were excluded. A total of 1,509,890 patients (including 143,078 deaths) in the UHC cohort and 36,414 patients (including 3562 deaths) in the Mayo cohort were included in the study analysis. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality compared between patients with a history of DM and all other patients. Other outcomes included in-hospital mortality in prespecified subgroups. In the UHC dataset, patients with DM had a lower unadjusted odds ratio (0.90, 95% confidence interval 0.89-0.91, p < .001) and a lower adjusted effect on mortality (odds ratio 0.75, 0.74-0.76, p < .001) compared with that seen in patients without DM. In the Mayo dataset, patients with DM had a comparable unadjusted odds ratio (1.07, 0.97-1.17, p = NS) and a lower adjusted effect on mortality (odds ratio 0.88, 0.79-0.98, p = .022) compared with that seen in patients without DM. A lower mortality in diabetic patients held across multiple demographic subgroups, including patients who underwent coronary-artery bypass grafting (UHC data: unadjusted odds ratio 0.66, 0.62-0.71, p < .001). CONCLUSIONS Critically ill adults with DM do not have an increased mortality compared with that seen in patients without DM, and may have a decreased mortality. Further investigation needs to be done to determine the mechanism for this effect.
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Yende S, van der Poll T. Diabetes and sepsis outcomes--it is not all bad news. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:117. [PMID: 19291261 PMCID: PMC2688126 DOI: 10.1186/cc7707] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with diabetes mellitus have an increased risk of developing infections and sepsis. In this issue of Critical Care Esper and colleagues report on a large survey, involving 12.5 million sepsis cases, that examined the impact of pre-existing diabetes on organ dysfunction during sepsis. Their main conclusion was that diabetes patients, relative to non-diabetics, were less likely to develop respiratory failure and more likely to develop renal failure during the course of sepsis.
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Affiliation(s)
- Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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