1
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Guo Q, Lian H, Wang G, Zhang H, Wang X. Prospective Evaluation of the Peripheral Perfusion Index in Assessing the Organ Dysfunction and Prognosis of Adult Patients With Sepsis in the ICU. J Intensive Care Med 2024:8850666241252758. [PMID: 38748544 DOI: 10.1177/08850666241252758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Background: The peripheral perfusion index (PI) reflects microcirculatory blood flow perfusion and indicates the severity and prognosis of sepsis. Method: The cohort comprised 208 patients admitted to the intensive care unit (ICU) with infection, among which 117 had sepsis. Demographics, medication history, ICU variables, and laboratory indexes were collected. Primary endpoints were in-hospital mortality and 28-day mortality. Secondary endpoints included organ function variables (coagulation function, liver function, renal function, and myocardial injury), lactate concentration, mechanical ventilation time, and length of ICU stay. Univariate and multivariate analyses were conducted to assess the associations between the PI and clinical outcomes. Sensitivity analyses were performed to explore the associations between the PI and organ functions in the sepsis and nonsepsis groups. Result: The PI was negatively associated with in-hospital mortality (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.55), but was not associated with 28-day mortality. The PI was negatively associated with the coagulation markers prothrombin time (PT) (β -0.36, 95% CI -0.59 to 0.13) and activated partial thromboplastin time (APTT) (β -1.08, 95% CI -1.86 to 0.31), and the myocardial injury marker cardiac troponin I (cTnI) (β -2085.48, 95% CI -3892.35 to 278.61) in univariate analysis, and with the PT (β -0.36, 95% CI -0.60 to 0.13) in multivariate analysis. The PI was negatively associated with the lactate concentration (β -0.57, 95% CI -0.95 to 0.19), mechanical ventilation time (β -23.11, 95% CI -36.54 to 9.69), and length of ICU stay (β -1.28, 95% CI -2.01 to 0.55). Sensitivity analyses showed that the PI was significantly associated with coagulation markers (PT and APTT) and a myocardial injury marker (cTnI) in patients with sepsis, suggesting that the associations between the PI and organ function were stronger in the sepsis group than the nonsepsis group. Conclusion: The PI provides new insights for assessing the disease severity, short-term prognosis, and organ function damage in ICU patients with sepsis, laying a theoretical foundation for future research.
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Affiliation(s)
- Qirui Guo
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangjian Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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2
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How to manage coagulopathies in critically ill patients. Intensive Care Med 2023; 49:273-290. [PMID: 36808215 DOI: 10.1007/s00134-023-06980-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/06/2023] [Indexed: 02/19/2023]
Abstract
Coagulopathy is a severe and frequent complication in critically ill patients, for which the pathogenesis and presentation may be variable depending on the underlying disease. Based on the dominant clinical phenotype, the current review differentiates between hemorrhagic coagulopathies, characterized by a hypocoagulable and hyperfibrinolysis state, and thrombotic coagulopathies with a systemic prothrombotic and antifibrinolytic phenotype. We discuss the differences in pathogenesis and treatment of the common coagulopathies.
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3
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Forceville X, Van Antwerpen P, Annane D, Vincent JL. Selenocompounds and Sepsis-Redox Bypass Hypothesis: Part B-Selenocompounds in the Management of Early Sepsis. Antioxid Redox Signal 2022; 37:998-1029. [PMID: 35287478 DOI: 10.1089/ars.2020.8062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Significance: Endothelial barrier damage, which is in part caused by excess production of reactive oxygen, halogen and nitrogen species (ROHNS), especially peroxynitrite (ONOO-), is a major event in early sepsis and, with leukocyte hyperactivation, part of the generalized dysregulated immune response to infection, which may even become a complex maladaptive state. Selenoenzymes have major antioxidant functions. Their synthesis is related to the need to limit deleterious oxidant redox cycling by small selenocompounds, which may be of therapeutic cytotoxic interest. Plasma selenoprotein-P is crucial for selenium transport from the liver to the tissues and for antioxidant endothelial protection, especially against ONOO-. Above micromolar concentrations, sodium selenite (Na2SeO3) becomes cytotoxic, with a lower cytotoxicity threshold in activated cells, which has led to cancer research. Recent Advances: Plasma selenium (<2% of total body selenium) is mainly contained in selenoprotein-P, and concentrations decrease rapidly in the early phase of sepsis, because of increased selenoprotein-P binding and downregulation of hepatic synthesis and excretion. At low concentrations, Na2SeO3 acts as a selenium donor, favoring selenoprotein-P synthesis in physiology, but probably not in the acute phase of sepsis. Critical Issues: The cytotoxic effects of Na2SeO3 against hyperactivated leukocytes, especially the most immature forms that liberate ROHNS, may be beneficial, but they may also be harmful for activated endothelial cells. Endothelial protection against ROHNS by selenoprotein-P may reduce Na2SeO3 toxicity, which is increased in sepsis. Future Direction: The combination of selenoprotein-P for endothelial protection and the cytotoxic effects of Na2SeO3 against hyperactivated leukocytes may be a promising intervention for early sepsis. Antioxid. Redox Signal. 37, 998-1029.
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Affiliation(s)
- Xavier Forceville
- Medico-surgical Intensive Care Unit, Great Hospital of East Francilien - Meaux site, Meaux, France.,Clinical Investigation Centre (CIC Inserm1414) CHU de Rennes - Université de Rennes 1, Rennes, France
| | - Pierre Van Antwerpen
- Pharmacognosy, Bioanalysis and Drug Discovery and Analytical Platform of the Faculty of Pharmacy, Univesité libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Djillali Annane
- Service de Réanimation Médicale, Hôpital Raymond Poincaré (APHP), Garches, France.,U1173 Lab. of Inflammation & Infection, (Fédération Hospitalo-Universitaire) FHU SEPSIS, Université Paris Saclay-campus (Université de Versailles Saint-Quentin-en-Yvelines) UVSQ, Versailles, France
| | - Jean Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
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4
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Ebihara T, Matsumoto H, Matsubara T, Togami Y, Nakao S, Matsuura H, Onishi S, Kojima T, Sugihara F, Okuzaki D, Hirata H, Yamamura H, Ogura H. Resistin Associated With Cytokines and Endothelial Cell Adhesion Molecules Is Related to Worse Outcome in COVID-19. Front Immunol 2022; 13:830061. [PMID: 35784283 PMCID: PMC9243394 DOI: 10.3389/fimmu.2022.830061] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/17/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction Resistin is reported to form a cytokine network and cause endothelial damage. The pathogenesis of coronavirus disease 2019 (COVID-19) remains unknown, but the association between cytokine storm and endothelial damage is crucial. This study aimed to evaluate resistin in COVID-19 pathogenesis compared with sepsis. Materials and Methods First, we evaluated the association of plasma resistin levels and disease severity and clinical outcome in two large cohorts: a publicly available cohort including 306 COVID-19 patients in the United States (MGH cohort) and our original cohort including only intubated 113 patients in Japan (Osaka cohort 1). Second, to understand pathogenesis, we evaluate resistin, cytokines and endothelial cell adhesion molecules in COVID-19 compared with sepsis. Blood samples were collected from 62 ICU-treated COVID-19 patients and 38 sepsis patients on day 1 (day of ICU admission), days 2-3, days 6-8, and from 18 healthy controls (Osaka cohort 2). The plasma resistin, inflammatory cytokines (IL-6, IL-8, MCP-1 and IL-10) and endothelial cell adhesion molecules (ICAM-1 and VCAM-1) were compared between patients and control. Correlations among resistin, inflammatory cytokines and endothelial cell adhesion molecules were evaluated in COVID-19 and sepsis. Results In the MGH cohort, the day 1 resistin levels were associated with disease severity score. The non-survivors showed significantly greater resistin levels than survivors on days 1, 4 and 8. In the Osaka cohort 1, 28-day non-survivors showed significantly higher resistin levels than 28-day survivors on days 6-8. Patients with late recovery (defined as the day of weaning off mechanical ventilation >12 or death) had significantly higher resistin levels than those with early recovery on day 1 and days 6-8. In the Osaka cohort 2, plasma resistin levels were elevated in COVID-19 and sepsis patients compared to controls at all measurement points and were associated with inflammatory cytokines and endothelial cell adhesion molecules. Conclusion Resistin was elevated in COVID-19 patients and was associated with cytokines and endothelial cell adhesion molecules. Higher resistin levels were related to worse outcome.
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Affiliation(s)
- Takeshi Ebihara
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- *Correspondence: Hisatake Matsumoto,
| | - Tsunehiro Matsubara
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuki Togami
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroshi Matsuura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Osaka Prefectural Nakakawachi Emergency and Critical Care Center, Higashiosaka, Japan
| | - Shinya Onishi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takashi Kojima
- Laboratory for Clinical Investigation, Osaka University Hospital, Suita, Japan
| | - Fuminori Sugihara
- Core Instrumentation Facility, Immunology Frontier Research Center and Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Daisuke Okuzaki
- Genome Information Research Center, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hitoshi Yamamura
- Osaka Prefectural Nakakawachi Emergency and Critical Care Center, Higashiosaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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5
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Hattori Y, Hattori K, Machida T, Matsuda N. Vascular endotheliitis associated with infections: Its pathogenetic role and therapeutic implication. Biochem Pharmacol 2022; 197:114909. [PMID: 35021044 PMCID: PMC8743392 DOI: 10.1016/j.bcp.2022.114909] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 12/20/2022]
Abstract
Vascular endothelial cells are major participants in and regulators of immune responses and inflammation. Vascular endotheliitis is regarded as a host immune-inflammatory response of the endothelium forming the inner surface of blood vessels in association with a direct consequence of infectious pathogen invasion. Vascular endotheliitis and consequent endothelial dysfunction can be a principle determinant of microvascular failure, which would favor impaired perfusion, tissue hypoxia, and subsequent organ failure. Emerging evidence suggests the role of vascular endotheliitis in the pathogenesis of coronavirus disease 2019 (COVID-19) and its related complications. Thus, once initiated, vascular endotheliitis and resultant cytokine storm cause systemic hyperinflammation and a thrombotic phenomenon in COVID-19, leading to acute respiratory distress syndrome and widespread organ damage. Vascular endotheliitis also appears to be a contributory factor to vasculopathy and coagulopathy in sepsis that is defined as life-threatening organ dysfunction due to a dysregulated response of the host to infection. Therefore, protecting endothelial cells and reversing vascular endotheliitis may be a leading therapeutic goal for these diseases associated with vascular endotheliitis. In this review, we outline the etiological and pathogenic importance of vascular endotheliitis in infection-related inflammatory diseases, including COVID-19, and possible mechanisms leading to vascular endotheliitis. We also discuss pharmacological agents which may be now considered as potential endotheliitis-based treatment modalities for those diseases.
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Affiliation(s)
- Yuichi Hattori
- Advanced Research Promotion Center, Health Sciences University of Hokkaido, Tobetsu, Japan; Department of Molecular and Medical Pharmacology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan.
| | - Kohshi Hattori
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Takuji Machida
- Department of Pharmacological Sciences, School of Pharmaceutical Sciences, Health Sciences University of Hokkaido, Tobetsu, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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6
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The impact of DAMP-mediated inflammation in severe COVID-19 and related disorders. Biochem Pharmacol 2022; 195:114847. [PMID: 34801526 PMCID: PMC8600760 DOI: 10.1016/j.bcp.2021.114847] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 01/08/2023]
Abstract
The host response to SARS-CoV-2, the virus that causes COVID-19, is highly heterogeneous, ranging from mild/asymptomatic to severe. The moderate to severe forms of COVID-19 often require hospitalization, are associated with a high rate of mortality, and appear to be caused by an inappropriately exaggerated inflammatory response to the virus. Emerging data confirm the involvement of both innate and adaptive immune pathways both in protection from SARS-CoV-2, and in driving the pathology of severe COVID-19. In particular, innate immune cells including neutrophils appear to be key players in the inflammation that causes the vicious cycle of damage and inflammation that underlies the symptomatology of severe COVID-19. Several recent studies support a link between damage and inflammation, with damage-associated molecular patterns (DAMPs) playing a key role in the pathology of severe COVID-19. In this review, we put into perspective the role of DAMPs and of components of the DAMP-signaling cascade, including Siglecs and their cognate ligands CD24 and CD52, in COVID-19. Further, we review clinical data on proposed therapeutics targeting DAMP pathways to treat SARS-CoV-2 infection and the regulation of these signaling cascades in COVID-19. We also discuss the potential impact of DAMP-mediated inflammation in other indications related to COVID-19, such as ARDS, endothelial dysfunction, hypercoagulation, and sepsis.
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7
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Cui N, Mi S, Jiang C, Sun W, Mao W, Zhang L, Feng X. Deep vein thrombosis in acute respiratory distress syndrome caused by bacterial pneumonia. BMC Pulm Med 2021; 21:264. [PMID: 34391407 PMCID: PMC8364306 DOI: 10.1186/s12890-021-01632-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 08/03/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by acute hypoxaemia, and few studies have reported the incidence of deep vein thrombosis (DVT) in direct ARDS caused by bacterial pneumonia. We performed a study to evaluate the prevalence, risk factors, prognosis and potential thromboprophylaxis strategies of DVT in these patients. Methods Ninety patients were included. Demographic, and clinical data, laboratory data and outcome variables were obtained, and comparisons were made between the DVT and non-DVT groups. Results Of the 90 patients, 40 (44.4%) developed lower extremity DVT. Compared with non-DVT patients, DVT patients had higher systemic inflammatory response syndrome (SIRS) scores, lower serum creatinine levels, higher D-dimer levels, and higher rates of sedative therapy and invasive mechanical ventilation (IMV). Multivariate analysis showed an association between the SIRS score (OR 3.803, P = 0.027), level of serum creatinine (OR 0.988, P = 0.001), IMV (OR 5.822, P = 0.002) and DVT. The combination of SIRS score, serum creatinine level and IMV has a sensitivity of 80.0% and a specificity of 74.0% for screening for DVT. The survival rate within 28 days after ARDS in the DVT group was significantly lower than that in the non-DVT group (P = 0.003). There was no difference in the prevalence of DVT between the 41 patients who received thromboprophylaxis and the 49 patients who did not receive thromboprophylaxis (41.5% vs 46.9%; P = 0.603). Conclusions The prevalence of DVT is high in hospitalized patients with direct ARDS caused by bacterial pneumonia and may be associated with adverse outcomes. The current thromboprophylaxis strategies may need to be further optimized.
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Affiliation(s)
- Na Cui
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Song Mi
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Chunguo Jiang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Wanlu Sun
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Wenping Mao
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China
| | - Liming Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China. .,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China.
| | - Xiaokai Feng
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People's Republic of China. .,Beijing Institute of Respiratory Medicine, Beijing, 100020, People's Republic of China.
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8
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Forceville X, Van Antwerpen P, Preiser JC. Selenocompounds and Sepsis: Redox Bypass Hypothesis for Early Diagnosis and Treatment: Part A-Early Acute Phase of Sepsis: An Extraordinary Redox Situation (Leukocyte/Endothelium Interaction Leading to Endothelial Damage). Antioxid Redox Signal 2021; 35:113-138. [PMID: 33567962 DOI: 10.1089/ars.2020.8063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Significance: Sepsis is a health disaster. In sepsis, an initial, beneficial local immune response against infection evolves rapidly into a generalized, dysregulated response or a state of chaos, leading to multiple organ failure. Use of life-sustaining supportive therapies creates an unnatural condition, enabling the complex cascades of the sepsis response to develop in patients who would otherwise die. Multiple attempts to control sepsis at an early stage have been unsuccessful. Recent Advances: Major events in early sepsis include activation and binding of leukocytes and endothelial cells in the microcirculation, damage of the endothelial surface layer (ESL), and a decrease in the plasma concentration of the antioxidant enzyme, selenoprotein-P. These events induce an increase in intracellular redox potential and lymphocyte apoptosis, whereas apoptosis is delayed in monocytes and neutrophils. They also induce endothelial mitochondrial and cell damage. Critical Issues: Neutrophil production increases dramatically, and aggressive immature forms are released. Leukocyte cross talk with other leukocytes and with damaged endothelial cells amplifies the inflammatory response. The release of large quantities of reactive oxygen, halogen, and nitrogen species as a result of the leukocyte respiratory burst, endothelial mitochondrial damage, and ischemia/reperfusion processes, along with the marked decrease in selenoprotein-P concentrations, leads to peroxynitrite damage of the ESL, reducing flow and damaging the endothelial barrier. Future Directions: Endothelial barrier damage by activated leukocytes is a time-sensitive event in sepsis, occurring within hours and representing the first step toward organ failure and death. Reducing or stopping this event is necessary before irreversible damage occurs.
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Affiliation(s)
- Xavier Forceville
- Medico-Surgical Intensive Care Unit, Great Hospital of East Francilien-Meaux Site, Hôpital Saint Faron, Meaux, France.,Clinical Investigation Center (CIC Inserm 1414), CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Pierre Van Antwerpen
- Pharmacognosy, Bioanalysis and Drug Discovery and Analytical Platform of the Faculty of Pharmacy, Université libre de Bruxelles (ULB), Bruxelles, Belgium
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9
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Lambden S, Cowburn AS, Macias D, Garrud TAC, Krause BJ, Giussani DA, Summers C, Johnson RS. Endothelial cell regulation of systemic haemodynamics and metabolism acts through the HIF transcription factors. Intensive Care Med Exp 2021; 9:28. [PMID: 34114090 PMCID: PMC8192653 DOI: 10.1186/s40635-021-00390-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The vascular endothelium has important endocrine and paracrine roles, particularly in the regulation of vascular tone and immune function, and it has been implicated in the pathophysiology of a range of cardiovascular and inflammatory conditions. This study uses a series of transgenic murine models to explore for the first time the role of the hypoxia-inducible factors, HIF-1α and HIF-2α in the pulmonary and systemic circulations as potential regulators of systemic vascular function in normoxic or hypoxic conditions and in response to inflammatory stress. We developed a series of transgenic mouse models, the HIF-1α Tie2Cre, deficient in HIF1-α in the systemic and pulmonary vascular endothelium and the L1Cre, a pulmonary endothelium specific knockout of HIF-1α or HIF-2α. In vivo, arterial blood pressure and metabolic activity were monitored continuously in normal atmospheric conditions and following an acute stimulus with hypoxia (10%) or lipopolysaccharide (LPS). Ex vivo, femoral artery reactivity was assessed using wire myography. RESULTS Under normoxia, the HIF-1α Tie2Cre mouse had increased systolic and diastolic arterial pressure compared to litter mate controls over the day-night cycle under normal environmental conditions. VO2 and VCO2 were also increased. Femoral arteries displayed impaired endothelial relaxation in response to acetylcholine mediated by a reduction in the nitric oxide dependent portion of the response. HIF-1α L1Cre mice displayed a similar pattern of increased systemic blood pressure, metabolic rate and impaired vascular relaxation without features of pulmonary hypertension, polycythaemia or renal dysfunction under normal conditions. In response to acute hypoxia, deficiency of HIF-1α was associated with faster resolution of hypoxia-induced haemodynamic and metabolic compromise. In addition, systemic haemodynamics were less compromised by LPS treatment. CONCLUSIONS These data show that deficiency of HIF-1α in the systemic or pulmonary endothelium is associated with increased systemic blood pressure and metabolic rate, a pattern that persists in both normoxic conditions and in response to acute stress with potential implications for our understanding of the pathophysiology of vascular dysfunction in acute and chronic disease.
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Affiliation(s)
- Simon Lambden
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Andrew S Cowburn
- National Heart and Lung Institute, Imperial College London, London, UK
| | - David Macias
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Tessa A C Garrud
- Department of Physiology, Development and Neuroscience, University of Cambridge, Downing Street, Cambridge, CB2 3EG, UK
| | - Bernardo J Krause
- Department of Neonatology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dino A Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Downing Street, Cambridge, CB2 3EG, UK
| | | | - Randall S Johnson
- Department of Physiology, Development and Neuroscience, University of Cambridge, Downing Street, Cambridge, CB2 3EG, UK. .,Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden.
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10
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Morrison JM, Betensky M, Kiskaddon AL, Goldenberg NA. Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist. Semin Thromb Hemost 2021; 48:434-445. [PMID: 33962474 DOI: 10.1055/s-0041-1729170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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11
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Hedetoft M, Garred P, Madsen MB, Hyldegaard O. Hyperbaric oxygen treatment is associated with a decrease in cytokine levels in patients with necrotizing soft-tissue infection. Physiol Rep 2021; 9:e14757. [PMID: 33719215 PMCID: PMC7957267 DOI: 10.14814/phy2.14757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/24/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The pathophysiological understanding of the inflammatory response in necrotizing soft-tissue infection (NSTI) and its impact on clinical progression and outcomes are not resolved. Hyperbaric oxygen (HBO2 ) treatment serves as an adjunctive treatment; however, its immunomodulatory effects in the treatment of NSTI remains unknown. Accordingly, we evaluated fluctuations in inflammatory markers during courses of HBO2 treatment and assessed the overall inflammatory response during the first 3 days after admission. METHODS In 242 patients with NSTI, we measured plasma TNF-α, IL-1β, IL-6, IL-10, and granulocyte colony-stimulating factor (G-CSF) upon admission and daily for three days, and before/after HBO2 in the 209 patients recieving HBO2 . We assessed the severity of disease by Simplified Acute Physiology Score (SAPS) II, SOFA score, and blood lactate. RESULTS In paired analyses, HBO2 treatment was associated with a decrease in IL-6 in patients with Group A-Streptococcus NSTI (first HBO2 treatment, median difference -29.5 pg/ml; second HBO2 treatment, median difference -7.6 pg/ml), and overall a decrease in G-CSF (first HBO2 treatment, median difference -22.5 pg/ml; 2- HBO2 treatment, median difference -20.4 pg/ml). Patients presenting with shock had significantly higher baseline cytokines values compared to non-shock patients (TNF-α: 51.9 vs. 23.6, IL-1β: 1.39 vs 0.61, IL-6: 542.9 vs. 57.5, IL-10: 21.7 vs. 3.3 and G-CSF: 246.3 vs. 11.8 pg/ml; all p < 0.001). Longitudinal analyses demonstrated higher concentrations in septic shock patients and those receiving renal-replacement therapy. All cytokines were significantly correlated to SAPS II, SOFA score, and blood lactate. In adjusted analysis, high baseline G-CSF was associated with 30-day mortality (OR 2.83, 95% CI: 1.01-8.00, p = 0.047). CONCLUSION In patients with NSTI, HBO2 treatment may induce immunomodulatory effects by decreasing plasma G-CSF and IL-6. High levels of inflammatory markers were associated with disease severity, whereas high baseline G-CSF was associated with increased 30-day mortality.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Hyperbaric Unit, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology Section 7631, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Hyperbaric Unit, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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12
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Bellomo R, Forni LG, Busse LW, McCurdy MT, Ham KR, Boldt DW, Hästbacka J, Khanna AK, Albertson TE, Tumlin J, Storey K, Handisides D, Tidmarsh GF, Chawla LS, Ostermann M. Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock. A Clinical Trial. Am J Respir Crit Care Med 2020; 202:1253-1261. [PMID: 32609011 PMCID: PMC7605187 DOI: 10.1164/rccm.201911-2172oc] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Rationale: Exogenous angiotensin II increases mean arterial pressure in patients with catecholamine-resistant vasodilatory shock (CRVS). We hypothesized that renin concentrations may identify patients most likely to benefit from such therapy. Objectives: To test the kinetic changes in renin concentrations and their prognostic value in patients with CRVS. Methods: We analyzed serum samples from patients enrolled in the ATHOS-3 (Angiotensin II for the Treatment of High-Output Shock) trial for renin, angiotensin I, and angiotensin II concentrations before the start of administration of angiotensin II or placebo and after 3 hours. Measurements and Main Results: Baseline serum renin concentration (normal range, 2.13–58.78 pg/ml) was above the upper limits of normal in 194 of 255 (76%) study patients with a median renin concentration of 172.7 pg/ml (interquartile range [IQR], 60.7 to 440.6 pg/ml), approximately threefold higher than the upper limit of normal. Renin concentrations correlated positively with angiotensin I/II ratios (r = 0.39; P < 0.001). At 3 hours after initiation of angiotensin II therapy, there was a 54.3% reduction (IQR, 37.9% to 66.5% reduction) in renin concentration compared with a 14.1% reduction (IQR, 37.6% reduction to 5.1% increase) with placebo (P < 0.0001). In patients with renin concentrations above the study population median, angiotensin II significantly reduced 28-day mortality to 28 of 55 (50.9%) patients compared with 51 of 73 patients (69.9%) treated with placebo (unstratified hazard ratio, 0.56; 95% confidence interval, 0.35 to 0.88; P = 0.012) (P = 0.048 for the interaction). Conclusions: The serum renin concentration is markedly elevated in CRVS and may identify patients for whom treatment with angiotensin II has a beneficial effect on clinical outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 02338843).
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Affiliation(s)
- Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine & Radiology, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lui G Forni
- Intensive Care Unit, Royal Surrey Hospital Foundation Trust, Guildford, United Kingdom.,Department of Clinical & Experimental Medicine, School of Biosciences & Medicine, University of Surrey, Guildford, United Kingdom
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, and
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Kealy R Ham
- Department of Critical Care, Regions Hospital, University of Minnesota, St. Paul, Minnesota
| | - David W Boldt
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Johanna Hästbacka
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California-Davis, Northern California Health System, Mather, California
| | - James Tumlin
- Renal Division, Department of Medicine, Emory University Medical Center, Emory University, Atlanta, Georgia
| | | | | | - George F Tidmarsh
- La Jolla Pharmaceutical Company, San Diego, California.,Stanford University, Palo Alto, California
| | - Lakhmir S Chawla
- La Jolla Pharmaceutical Company, San Diego, California.,Department of Medicine, Veterans Affairs Medical Center, San Diego, California; and
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St. Thomas' Hospital, King's College London, London, United Kingdom
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13
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Kamijo H, Mochizuki K, Nakamura Y, Mori K, Ichikawa M, Nitta K, Imamura H. Nafamostat Mesylate Improved Survival Outcomes of Sepsis Patients Who Underwent Blood Purification: A Nationwide Registry Study in Japan. J Clin Med 2020; 9:jcm9082629. [PMID: 32823637 PMCID: PMC7464767 DOI: 10.3390/jcm9082629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
Nafamostat mesylate (NM) is a synthetic serine protease inhibitor that can be used as an anticoagulant during blood purification in critically ill patients, as well as a treatment for disseminated intravascular coagulation. Although NM has been reported to reduce the risk of bleeding during blood purification, its effect on survival outcomes of patients who received blood purification treatments is unclear. We hypothesized that administration of NM during blood purification can reduce mortality in patients with sepsis. A post hoc analysis was conducted on a nationwide retrospective registry that included data from 3195 sepsis patients registered at 42 intensive care units throughout Japan. We evaluated the effect of NM on hospital mortality and bleeding complications using propensity score matching in 1216 sepsis patients who underwent blood purification in the intensive care unit (ICU). Two-hundred-and-sixty-eight pairs of propensity score-matched patients who received NM and conventional therapy were compared. Hospital and ICU mortality rates in the NM group were significantly lower than those in the conventional therapy group. However, rates of bleeding complications did not differ significantly between the two groups. These data suggest that administration of NM improved the survival outcomes of sepsis patients who underwent blood purification in the ICU.
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Affiliation(s)
- Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
- Correspondence: ; Tel.: +81-263-37-3018
| | - Yuta Nakamura
- Department of Emergency Medicine, Saiseikai Kumamoto Hospital, 5-3-1 Chikami Minami-ku, Kumamoto 861-4193, Japan;
| | - Kotaro Mori
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Michitaro Ichikawa
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan; (H.K.); (K.M.); (M.I.); (K.N.); (H.I.)
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14
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Mochizuki K, Mori K, Kamijo H, Ichikawa M, Nitta K, Imamura H. Beneficial effect modification on survival outcome of sepsis between ART-123 and polymyxin B‑immobilised haemoperfusion: a nationwide Japanese registry study. Ann Intensive Care 2020; 10:57. [PMID: 32405776 PMCID: PMC7221014 DOI: 10.1186/s13613-020-00674-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022] Open
Abstract
Background Although recently published randomised controlled trials did not confirm significant positive effect of ART-123 or polymyxin B‑immobilised haemoperfusion (PMX-HP) on survival outcome, previous studies using a dataset of 3195 patients with sepsis registered at 42 intensive care units throughout Japan revealed significantly reduced mortality following these treatments. A study has suggested the efficacy of combination therapy with ART-123 and PMX-HP; however, it did not evaluate the effect modification between them. We hypothesised that coadministration of ART-123 and PMX-HP has a significant positive effect modification on survival outcome. The purpose of this study was to evaluate the effect modification between ART-123 and PMX-HP treatment on the survival outcome of sepsis using post hoc analysis of the dataset of the Japan Septic Disseminated Intravascular Coagulation registry. Results Of the 3195 patients recorded in the registry, 2350 were analysed. The product term between ART-123 and PMX-HP was analysed by the Cox regression model to evaluate significance. The primary outcome of this study was hospital mortality. Although the administration of ART-123 was independently positively associated with survival outcome (adjusted hazard ratio [HR]: 0.834, 95% confidence interval [CI] 0.695–0.999; P = 0.049) in the model prior to the introduction of the product term, a significant effect modification on survival outcome was observed between the administration of ART-123 and PMX-HP treatment (adjusted HR: 0.667, 95% CI 0.462–0.961; P = 0.030). Conclusions The main effect of the administration of ART-123 may be beneficial for survival outcome in patients with sepsis. In addition, a significant beneficial effect modification on survival outcome was observed between the administration of ART-123 and PMX-HP treatment.
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Affiliation(s)
- Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Kotaro Mori
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Michitaro Ichikawa
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
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15
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Schopka S, Philipp A, Müller T, Lubnow M, Lunz D, Unterbuchner C, Rupprecht L, Keyser A, Schmid C. The impact of interleukin serum levels on the prognosis of patients undergoing venoarterial extracorporeal membrane oxygenation. Artif Organs 2020; 44:837-845. [PMID: 32043591 DOI: 10.1111/aor.13666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/31/2019] [Accepted: 02/07/2020] [Indexed: 12/14/2022]
Abstract
Extracorporeal life support is increasingly used in the treatment of patients presenting with cardiogenic shock or in need of cardiopulmonary resuscitation. Identifying therapeutic targets and factors associated with the prognosis are highly desirable. The present study analyzed the impact of interleukin 6 and 8 on the outcome of patients undergoing venoarterial extracorporeal membrane oxygenation (VA ECMO). Interleukin 6 and 8 serum levels of 329 patients were analyzed prior to, on days 1 and 5 of VA ECMO therapy. Interleukin 6 and 8 serum levels of surviving and nonsurviving patients were compared. At time points with significant differences, receiver operating characteristics and cutoff levels were analyzed to determine the prognostic value of interleukin serum levels. Survival analysis was performed to compare patients above and below cutoff levels. Interleukin 6 serum levels were significantly elevated in nonsurviving patients prior to VA ECMO initiation. Interleukin 6 and 8 serum levels in nonsurviving patients were significantly elevated on day 1 of VA ECMO. Receiver operating characteristics analysis revealed significant prognostic impact of interleukin 6 and 8 on day 1 of VA ECMO (AUC 0.70 and 0.72). Survival analysis comparing patients above and below the cutoff showed a 1-year survival of 32.6% for IL6 and 20.8% for IL8 above, as well as 66.9% for IL6 and 61.9% for IL8 below the cutoff (P < .05). Interleukin 6 and 8 serum levels demonstrated prognostic value early in VA ECMO therapy. The technical applicability of interleukin reduction raises interest in interleukins 6 and 8 as therapeutic targets.
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Affiliation(s)
- Simon Schopka
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Christoph Unterbuchner
- Department of Anaesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Leopold Rupprecht
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Keyser
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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16
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Glycocalyx in Endotoxemia and Sepsis. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:791-798. [PMID: 32035882 DOI: 10.1016/j.ajpath.2019.06.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/30/2019] [Accepted: 06/06/2019] [Indexed: 12/20/2022]
Abstract
Along with the recognition of a crucial role played by endothelial dysfunction secondarily igniting cardiovascular, pulmonary, and renal complications, investigational focus has extended toward endothelial glycocalyx. This delicate coating of cells, including the vascular endothelium, regulates permeability, leukocyte traffic, nitric oxide production, and coagulation, and harbors diverse growth and survival factors. In this brief overview, we discuss the metabolic signatures of sepsis as they relate to the loss of glycocalyx integrity and highlight the contribution of several proteases, heparanase, and hyaluronidase to the shedding of glycocalyx. Clinical manifestations of glycocalyx degradation in unraveling acute respiratory distress syndrome and the cardiovascular, microcirculatory, and renal complications of sepsis are concisely presented. Finally, we list therapeutic strategies for preventing the degradation of, and for restoration of, the glycocalyx.
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17
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Evidence That the Anti-Inflammatory Effect of Rubiadin-1-methyl Ether Has an Immunomodulatory Context. Mediators Inflamm 2019; 2019:6474168. [PMID: 31780865 PMCID: PMC6874871 DOI: 10.1155/2019/6474168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background In spite of the latest therapeutic developments, no effective treatments for handling critical conditions such as acute lung injuries have yet been found. Such conditions, which may result from lung infections, sepsis, multiple trauma, or shock, represent a significant challenge in intensive care medicine. Seeking ways to better deal with this challenge, the scientific community has recently devoted much attention to small molecules derived from natural products with anti-inflammatory and immunomodulatory effects. Aims In this context, we investigated the anti-inflammatory effect of Rubiadin-1-methyl ether isolated from Pentas schimperi, using an in vitro model of RAW 264.7 macrophages induced by LPS and an in vivo model of acute lung injury (ALI) induced by LPS. Methods The macrophages were pretreated with the compound and induced by LPS (1 μg/mL). After 24 h, using the supernatant, we evaluated the cytotoxicity, NOx, and IL-6, IL-1β, and TNF-α levels, as well as the effect of the compound on macrophage apoptosis. Next, the compound was administered in mice with acute lung injury (ALI) induced by LPS (5 mg/kg), and the pro- and anti-inflammatory parameters were analyzed after 12 h using the bronchoalveolar lavage fluid (BALF). Results Rubiadin-1-methyl ether was able to inhibit the pro-inflammatory parameters studied in the in vitro assays (NOx, IL-6, and IL-1β) and, at the same time, increased the macrophage apoptosis rate. In the in vivo experiments, this compound was capable of decreasing leukocyte infiltration; fluid leakage; NOx; IL-6, IL-12p70, IFN-γ, TNF-α, and MCP-1 levels; and MPO activity. In addition, Rubiadin-1-methyl ether increased the IL-10 levels in the bronchoalveolar lavage fluid (BALF). Conclusions These findings support the evidence that Rubiadin-1-methyl ether has important anti-inflammatory activity, with evidence of an immunomodulatory effect.
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18
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Pathophysiology of Acute Illness and Injury. OPERATIVE TECHNIQUES AND RECENT ADVANCES IN ACUTE CARE AND EMERGENCY SURGERY 2019. [PMCID: PMC7122041 DOI: 10.1007/978-3-319-95114-0_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The pathophysiology of acute illness and injury recognizes three main effectors: infection, trauma, and ischemia-reperfusion injury. Each of them can act by itself or in combination with the other two in developing a systemic inflammatory reaction syndrome (SIRS) that is a generalized reaction to the morbid event. The time course of SIRS is variable and influenced by the number and severity of subsequent insults (e.g., reparative surgery, acquired hospital infections). It occurs simultaneously with a complex of counter-regulatory mechanisms (compensatory anti-inflammatory response syndrome, CARS) that limit the aggressive effects of SIRS. In adjunct, a progressive dysfunction of the acquired (lymphocytes) immune system develops with increased risk for immunoparalysis and associated infectious complications. Both humoral and cellular effectors participate to the development of SIRS and CARS. The most important humoral mediators are pro-inflammatory (IL-1β, IL-6, IL-8, IL-12) and anti-inflammatory (IL-4, IL-10) cytokines and chemokines, complement, leukotrienes, and PAF. Effector cells include neutrophils, monocytes, macrophages, lymphocytes, and endothelial cells. The endothelium is a key factor for production of remote organ damage as it exerts potent chemo-attracting effects on inflammatory cells, allows for leukocyte trafficking into tissues and organs, and promotes further inflammation by cytokines release. Moreover, the loss of vasoregulatory properties and the increased permeability contribute to the development of hypotension and tissue edema. Finally, the disseminated activation of the coagulation cascade causes the widespread deposition of microthrombi with resulting maldistribution of capillary blood flow and ultimately hypoxic cellular damage. This mechanism together with increased vascular permeability and vasodilation is responsible for the development of the multiple organ dysfunction syndrome (MODS).
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19
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Mochizuki K, Mori K, Nakamura Y, Uchimido R, Kamijo H, Takeshige K, Nitta K, Imamura H. Early Changes in the Sequential Organ Failure Assessment Score Among Patients With Sepsis-Induced Disseminated Intravascular Coagulation. Clin Appl Thromb Hemost 2018; 24:332S-339S. [PMID: 30486666 PMCID: PMC6714847 DOI: 10.1177/1076029618814346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
It is unclear whether initial infection control or anticoagulant therapy exerts a greater
effect on early changes in the Sequential Organ Failure Assessment (SOFA) score among
patients with sepsis-induced disseminated intravascular coagulation (DIC). This
retrospective propensity score cohort study aimed to evaluate whether adequacy of
infection control or anticoagulation therapy had a greater effect on early changes in the
SOFA scores among 52 patients with sepsis-induced DIC. Inadequate initial infection
control was associated with a lower 28-day survival rate among patients with
sepsis-induced DIC (odds ratio [OR]: 0.116, 95% confidence interval [CI]: 0.022-0.601;
P = .010); however, the adequacy was not associated with an early
improvement in the SOFA score. However, despite adjusting for inadequate initial infection
control, administration of recombinant human soluble thrombomodulin was associated with an
early improvement in the SOFA score (OR: 5.058, 95% CI: 1.047-24.450; P =
.044). Therefore, early changes in the SOFA score within 48 hours after the DIC diagnosis
were more strongly affected by the administration of recombinant human soluble
thrombomodulin than the adequacy of initial infection control.
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Affiliation(s)
- Katsunori Mochizuki
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kotaro Mori
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Nakamura
- Department of Emergency Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Ryo Uchimido
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kanako Takeshige
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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20
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Chawla LS, Chen S, Bellomo R, Tidmarsh GF. Angiotensin converting enzyme defects in shock: implications for future therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:274. [PMID: 30368243 PMCID: PMC6204272 DOI: 10.1186/s13054-018-2202-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/24/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Lakhmir S Chawla
- Veterans Affairs Medical Center, San Diego, CA, USA. .,La Jolla Pharmaceutical Company, 4550 Towne Centre Court, San Diego, CA, 92121, USA.
| | - Steve Chen
- La Jolla Pharmaceutical Company, 4550 Towne Centre Court, San Diego, CA, 92121, USA
| | - Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - George F Tidmarsh
- La Jolla Pharmaceutical Company, 4550 Towne Centre Court, San Diego, CA, 92121, USA.,Stanford School of Medicine, Stanford, CA, USA
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21
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Iba T, Ogura H. Role of extracellular vesicles in the development of sepsis-induced coagulopathy. J Intensive Care 2018; 6:68. [PMID: 30377532 PMCID: PMC6194680 DOI: 10.1186/s40560-018-0340-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background The advances of research on extracellular vesicles (EVs) are of particular interest to the clinicians as well as the researchers who are studying coagulation disorder in sepsis. Here, we intend to update the latest knowledge and currently unsolved problems that should be addressed. Main body Secreted membrane-enclosed vesicles including apoptotic bodies, exosomes, ectosomes, microvesicles, and microparticles are generically called EVs. Though the basic structure of these vesicles is the same, i.e., originating from the plasma membrane, their characteristics differ significantly depending on their surface structures and interior components. Numerous studies have shown elevated levels of circulating EVs that exhibit proinflammatory and procoagulant properties during sepsis. These EVs are known to play important roles in the development of coagulation disorder and organ dysfunction in sepsis. Coagulation disorder in sepsis is characterized by activated coagulation, disrupted anticoagulant systems, and imbalanced fibrinolytic systems. These processes collaborate with one another and contribute to the development of disseminated intravascular coagulation (DIC), with devastating consequences. As part of this pathogenesis, the membrane-exposed tissue factor, phosphatidylserine and bioactive substances contained within the vesicles, such as histones, nucleosomes, and high-mobility group box 1, contribute to the development of DIC. EVs not only upregulate the procoagulant systems by themselves, but they also disseminate prothrombotic activities by transferring their procoagulant properties to distant target cells. Though the basic concept behind the role of procoagulant properties, EVs in the development of sepsis-induced coagulopathy has started to be unveiled, knowledge of the actual status is far from satisfactory, mainly because of the lack of standardized assay procedures. Recent advances and current problems that remain to be resolved are introduced in this review. Conclusion The recent studies succeeded to elucidate the important roles of EVs in the progress of coagulation disorder in sepsis. However, further harmonization in terminology, methodology, and evaluation methods is required for future studies.
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Affiliation(s)
- Toshiaki Iba
- 1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Hiroshi Ogura
- 2Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Matsumoto H, Ogura H, Shimizu K, Ikeda M, Hirose T, Matsuura H, Kang S, Takahashi K, Tanaka T, Shimazu T. The clinical importance of a cytokine network in the acute phase of sepsis. Sci Rep 2018; 8:13995. [PMID: 30228372 PMCID: PMC6143513 DOI: 10.1038/s41598-018-32275-8] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/04/2018] [Indexed: 12/29/2022] Open
Abstract
Sepsis remains a major cause of death. Cytokines interact closely with each other and play a crucial role in the progression of sepsis. We focussed on the associations of a cytokine network with prognosis and disease severities in sepsis. This retrospective study included 31 patients with sepsis and 13 healthy controls. Blood samples were collected from patients on days 1, 2, 4, 6, 8, 11 and 15 and from healthy controls. Levels of PAI-1, IFN-α, IFN-γ, IL-1β, IL-6, IL-8, IL-12/IL-23p40, IL-17A, TNF-α, MCP-1, IL-4 and IL-10 were measured. SOFA, JAAM DIC and ISTH DIC scores were evaluated at the same times blood samples were taken. Network analysis revealed a network formed by PAI-1, IL-6, IL-8, MCP-1 and IL-10 on days 1, 2 and 4 throughout the acute phase of sepsis. There were positive correlations of each cytokine and the combined score (IL-6 + IL-8 + IL-10 + MCP-1) with the SOFA, JAAM DIC and ISTH DIC scores throughout the acute phase. A Cox proportional hazards model focussed on the acute phase showed that the above combined score was significantly related with patient prognosis, suggesting that the cytokine network of IL-6, IL-8, MCP-1 and IL-10 could play a pivotal role in the acute phase of sepsis.
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Affiliation(s)
- Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Mitsunori Ikeda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroshi Matsuura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Sujin Kang
- Department of Clinical Application of Biologics, Osaka University Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kanae Takahashi
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toshio Tanaka
- Department of Clinical Application of Biologics, Osaka University Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Abstract
PURPOSE Endothelial pathology is considered to play a key role in septic shock. Since endothelial-derived microvesicles (MV) are elevated in various diseases associated with endothelial pathology, they are considered surrogate markers of the endothelial state. By analyzing the signature of circulating MV with high-sensitivity flow cytometry (hsFC), we wanted to test the hypothesis whether endothelial-derived MV are increased in septic shock. METHODS MV in blood from healthy volunteers and patients with septic shock treated in a medical intensive care unit were quantified by hsFC, which has an improved detection limit of approximately 0.3 μm. RESULTS Patients with septic shock (n = 30) showed 3-fold higher levels of CD31+/CD41- MV (58.5 (26.4-101.2) [median (25th-75th percentile)] vs. 19.5 (12.8-25.4) MV/μL; P <0.001) compared with healthy volunteers (n = 18). Absolute counts of CD144+, CD62E+, and CD106+ MV, specific for endothelial-derived MV, were low in all groups. The number of CD31+/CD41- MV correlated significantly with leukocyte count (rs = 0.64; P <0.001). Platelet-derived CD41+ MV were significantly elevated in the group dying within 48 h after inclusion (639.1 (321.3-969.7) vs. 221.5 (119.5-456.9) MV/μL; P = 0.037). Patients dying within 48 h had also significantly higher levels of CD31+/CD41-/AnnexinV- MV (51.9 (24.9-259.8) vs. 18.9 (9.7-31) MV/μL; P = 0.028). CONCLUSIONS Despite an improved detection limit for MV by using hsFC, counts of endothelial-specific MV are unexpectedly low in patients with septic shock. Increased amounts of CD41+ and CD31+/CD41-/AnnexinV- MV indicate release by activated platelets and possibly leukocytes correlating with unfavorable outcome.
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Branchford BR, Carpenter SL. The Role of Inflammation in Venous Thromboembolism. Front Pediatr 2018; 6:142. [PMID: 29876337 PMCID: PMC5974100 DOI: 10.3389/fped.2018.00142] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/27/2018] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT), and pulmonary embolism (PE), is becoming increasingly recognized as a cause of morbidity and mortality in pediatrics, particularly among hospitalized children. Furthermore, evidence is accumulating that suggests the inflammatory response may be a cause, as well as consequence, of VTE, but current anticoagulation treatment regimens are not designed to inhibit inflammation. In fact, many established clinical VTE risk factors such as surgery, obesity, cystic fibrosis, sepsis, systemic infection, cancer, inflammatory bowel disease, and lupus likely modulate thrombosis through inflammatory mediators. Unlike other traumatic mechanisms of thrombosis involving vascular transection and subsequent exposure of subendothelial collagen and other procoagulant extracellular matrix materials, inflammation of the vessel wall may initiate thrombosis on an intact vein. Activation of endothelial cells, platelets, and leukocytes with subsequent formation of microparticles can trigger the coagulation system through the induction of tissue factor (TF). Identification of biomarkers to evaluate VTE risk could be of great use to the clinician caring for a patient with inflammatory disease to guide decisions regarding the risk:benefit ratio of various types of potential thromboprophylaxis strategies, or suggest a role for anti-inflammatory therapy. Unfortunately, no such validated inflammatory scoring system yet exists, though research in this area is ongoing. Elevation of C-reactive protein, IL-6, IL-8, and TNF-alpha during a response to systemic inflammation have been associated with increased VTE risk. Consequent platelet activation enhances the prothrombotic state, leading to VTE development, particularly in patients with other risk factors, most notably central venous catheters.
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Affiliation(s)
- Brian R Branchford
- University of Colorado Hemophilia and Thrombosis Center, Pediatric Hematology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Shannon L Carpenter
- Kansas City Regional Hemophilia Treatment Center, Pediatric Hematology, UMKC School of Medicine and Children's Mercy Hospital, Kansas, CO, United States
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Huxley VH, Kemp SS. Sex-Specific Characteristics of the Microcirculation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:307-328. [PMID: 30051393 DOI: 10.1007/978-3-319-77932-4_20] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The requirements of metabolizing tissue are both continuous and variable; accordingly, the microvasculature serving that tissue must be similarly dynamic. Just as it is recognized that males and females of the same species have differing metabolic requirements, is it not likely that the microvasculature serving these tissues will differ by sex? This section focusing on the constituents of the microcirculation identifies what is known presently about the role sex plays in matching metabolic demand with microvascular function and areas requiring additional study. Many of the identified sex differences are subtle and easily ignored. In the aggregate, though, they can profoundly alter phenotype, especially under stressful conditions including pregnancy, exercise, and disease states ranging from diabetes to heart failure. Although the features presently identified to "have sex" range from differences in growth, morphology, protein expression, and intracellular signaling, males and females alike achieve homeostasis, likely by different means. Studies of microvascular sexual dimorphism are also identifying age as an independent but interacting factor requiring additional attention. Overall, attempting to ignore either sex and/or age is inappropriate and will prevent the design and implementation of appropriate interventions to present, ameliorate, or correct microvascular dysfunction.
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Affiliation(s)
- Virginia H Huxley
- Center for Gender Physiology, Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri, Columbia, MO, USA.
| | - Scott S Kemp
- Center for Gender Physiology, Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri, Columbia, MO, USA
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Helms J, Clere-Jehl R, Bianchini E, Le Borgne P, Burban M, Zobairi F, Diehl JL, Grunebaum L, Toti F, Meziani F, Borgel D. Thrombomodulin favors leukocyte microvesicle fibrinolytic activity, reduces NETosis and prevents septic shock-induced coagulopathy in rats. Ann Intensive Care 2017; 7:118. [PMID: 29222696 PMCID: PMC5722785 DOI: 10.1186/s13613-017-0340-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 11/27/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Septic shock-induced disseminated intravascular coagulation is responsible for increased occurrence of multiple organ dysfunction and mortality. Immunothrombosis-induced coagulopathy may contribute to hypercoagulability. We aimed at determining whether recombinant human thrombomodulin (rhTM) could control exaggerated immunothrombosis by studying procoagulant responses, fibrinolysis activity borne by microvesicles (MVs) and NETosis in septic shock. METHODS In a septic shock model after a cecal ligation and puncture-induced peritonitis (H0), rats were treated with rhTM or a placebo at H18, resuscitated and monitored during 4 h. At H22, blood was sampled to perform coagulation tests, to characterize MVs and to detect neutrophils extracellular traps (NETs). Lungs were stained with hematoxylin-eosin for inflammatory injury assessment. RESULTS Coagulopathy was attenuated in rhTM-treated septic rats compared to placebo-treated rats, as attested by a significant decrease in procoagulant annexin A5+-MVs and plasma procoagulant activity of phospholipids and by a significant increase in antithrombin levels (84 ± 8 vs. 64 ± 6%, p < 0.05), platelet count (582 ± 157 vs. 319 ± 91 × 109/L, p < 0.05) and fibrinolysis activity borne by MVs (2.9 ± 0.26 vs. 0.48 ± 0.29 U/mL urokinase, p < 0.05). Lung histological injury score showed significantly less leukocyte infiltration. Decreased procoagulant activity and lung injury were concomitant with decreased leukocyte activation as attested by plasma leukocyte-derived MVs and NETosis reduction after rhTM treatment (neutrophil elastase/DNA: 93 ± 33 vs. 227 ± 48 and citrullinated histones H3/DNA: 96 ± 16 vs. 242 ± 180, mOD for 109 neutrophils/L, p < 0.05). CONCLUSION Thrombomodulin limits procoagulant responses and NETosis and at least partly restores hemostasis control during immunothrombosis. Neutrophils might thus stand as a promising therapeutic target in septic shock-induced coagulopathy.
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Affiliation(s)
- Julie Helms
- UMR INSERM 1176-Universite Paris Sud, Hôpital Bicêtre, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
- Réanimation Médicale, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, 20 Rue Leblanc, 75015 Paris, France
| | - Raphaël Clere-Jehl
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Elsa Bianchini
- UMR INSERM 1176-Universite Paris Sud, Hôpital Bicêtre, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Pierrick Le Borgne
- Service d’Accueil des Urgences, Hôpital de Hautepierre, CHU de Strasbourg, 1 Avenue de Molière, 67200 Strasbourg, France
| | - Mélanie Burban
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Fatiha Zobairi
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Jean-Luc Diehl
- Réanimation Médicale, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, 20 Rue Leblanc, 75015 Paris, France
| | - Lelia Grunebaum
- Laboratoire d’hématologie et hémostase, Hôpital de Hautepierre, CHU de Strasbourg, 1 Avenue de Molière, 67200 Strasbourg, France
| | - Florence Toti
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Delphine Borgel
- UMR INSERM 1176-Universite Paris Sud, Hôpital Bicêtre, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
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Delabranche X, Helms J, Meziani F. Immunohaemostasis: a new view on haemostasis during sepsis. Ann Intensive Care 2017; 7:117. [PMID: 29197958 PMCID: PMC5712298 DOI: 10.1186/s13613-017-0339-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022] Open
Abstract
Host infection by a micro-organism triggers systemic inflammation, innate immunity and complement pathways, but also haemostasis activation. The role of thrombin and fibrin generation in host defence is now recognised, and thrombin has become a partner for survival, while it was seen only as one of the "principal suspects" of multiple organ failure and death during septic shock. This review is first focused on pathophysiology. The role of contact activation system, polyphosphates and neutrophil extracellular traps has emerged, offering new potential therapeutic targets. Interestingly, newly recognised host defence peptides (HDPs), derived from thrombin and other "coagulation" factors, are potent inhibitors of bacterial growth. Inhibition of thrombin generation could promote bacterial growth, while HDPs could become novel therapeutic agents against pathogens when resistance to conventional therapies grows. In a second part, we focused on sepsis-induced coagulopathy diagnostic challenge and stratification from "adaptive" haemostasis to "noxious" disseminated intravascular coagulation (DIC) either thrombotic or haemorrhagic. Besides usual coagulation tests, we discussed cellular haemostasis assessment including neutrophil, platelet and endothelial cell activation. Then, we examined therapeutic opportunities to prevent or to reduce "excess" thrombin generation, while preserving "adaptive" haemostasis. The fail of international randomised trials involving anticoagulants during septic shock may modify the hypothesis considering the end of haemostasis as a target to improve survival. On the one hand, patients at low risk of mortality may not be treated to preserve "immunothrombosis" as a defence when, on the other hand, patients at high risk with patent excess thrombin and fibrin generation could benefit from available (antithrombin, soluble thrombomodulin) or ongoing (FXI and FXII inhibitors) therapies. We propose to better assess coagulation response during infection by an improved knowledge of pathophysiology and systematic testing including determination of DIC scores. This is one of the clues to allocate the right treatment for the right patient at the right moment.
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Affiliation(s)
- Xavier Delabranche
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
| | - Julie Helms
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM, EFS Grand Est, BPPS UMR-S 949, Université de Strasbourg, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg, Faculté de Médecine & Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
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Hattori Y, Hattori K, Suzuki T, Matsuda N. Recent advances in the pathophysiology and molecular basis of sepsis-associated organ dysfunction: Novel therapeutic implications and challenges. Pharmacol Ther 2017; 177:56-66. [DOI: 10.1016/j.pharmthera.2017.02.040] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Early Detection of Disseminated Intravascular Coagulation During Septic Shock: A Multicenter Prospective Study. Crit Care Med 2017; 44:e930-9. [PMID: 27322364 DOI: 10.1097/ccm.0000000000001836] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Inadequate stratification of septic shock patients may result in inappropriate treatment allocation in randomized clinical trials, especially regarding anticoagulant. We previously reported that endothelial-derived microparticles are relevant biomarkers of sepsis-induced disseminated intravascular coagulation. In this validation cohort, we assess microparticles as surrogates of cell activation to improve early disseminated intravascular coagulation diagnosis and patient stratification. DESIGN Prospective observational study in septic shock patients. SETTINGS Four medical ICUs in university hospitals. PATIENTS AND METHODS Two hundred sixty-five patients with septic shock from four ICUs were consecutively enrolled. Disseminated intravascular coagulation was diagnosed according to Japanese Association for Acute Medicine 2006 score. Endothelial- and leukocyte-derived circulating procoagulant microparticles were isolated and quantified by prothrombinase assay at admission, day 3, and day 7. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Two hundred fifty-nine patients were analyzed. Sixty-one had disseminated intravascular coagulation at admission, and 32 developed disseminated intravascular coagulation during the first 24 hours after admission. Multiple logistic regression model confirmed that endothelial cell-derived microparticles were associated with disseminated intravascular coagulation: CD105-microparticles (odds ratio, 2.13) and CD31-microparticles (odds ratio, 0.65) (p < 0.05). Furthermore, CD11a-microparticles to leukocyte ratio evidenced leukocyte activation (odds ratio, 1.59; p < 0.05). Prediction of disseminated intravascular coagulation was also analyzed after exclusion of patients with disseminated intravascular coagulation at admission. A new multiple logistic regression analysis demonstrated the association of CD105-microparticles (> 0.60 nM eq. PhtdSer; odds ratio, 1.67; p < 0.01), platelets count (≤ 127 g/L; odds ratio, 0.99; p < 0.01), and prothrombin time (≤ 58%; odds ratio, 0.98; p < 0.05) with disseminated intravascular coagulation. A combining score at admission is predictive of the absence of disseminated intravascular coagulation (area under the curve, 72.9%; specificity, 71.2%; sensitivity, 71.0%, with a negative predictive value of 93.1% and a positive predictive value of 31.0%). CONCLUSIONS Procoagulant microparticles from endothelial cells and leukocytes reflect a vascular injury during sepsis-induced disseminated intravascular coagulation that precedes obvious activation of coagulation. A combination of prothrombin time, endothelium-derived CD105-microparticles, and platelet count at admission could predict the absence of disseminated intravascular coagulation and allow a better stratification in future randomized clinical trials.
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Olland A, Reeb J, Leclerq A, Renaud-Picard B, Falcoz PE, Kessler R, Schini-Kerth V, Kessler L, Toti F, Massard G. Microparticles: A new insight into lung primary graft dysfunction? Hum Immunol 2016; 77:1101-1107. [PMID: 27381358 DOI: 10.1016/j.humimm.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 04/17/2016] [Accepted: 07/01/2016] [Indexed: 10/21/2022]
Abstract
Lung transplantation is the only life-saving treatment for end stage respiratory disease. The immediate outcome is still hampered by primary graft dysfunction. The latter is a form of acute lung injury occurring within the 30min following the unclamping of the pulmonary artery that prompts ischemia reperfusion injury. Severe forms may need prolonged mechanical ventilation and extra-corporeal membrane oxygenation. Overall, primary graft dysfunction accounts for at least one third of the deaths during the first post-operative month. Despite increasing experience and knowledge on the underlying cellular events, there is still a lack of an early marker of ischemia reperfusion graft injuries. Microparticles are plasma membrane vesicles that are released from damaged or stressed cells in biological fluids and remodeling tissues, among which the lung parenchyma during acute or chronic injury. We recently evidenced alveolar microparticles as surrogate markers of strong ischemia injury in ex-vivo reperfusion experimental models. We propose herein new insights on how microparticles may be helpful to evaluate the extent of lung ischemia reperfusion injuries and predict the occurrence of primary graft dysfunction.
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Affiliation(s)
- Anne Olland
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France.
| | - Jérémie Reeb
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
| | - Alexandre Leclerq
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
| | - Benjamin Renaud-Picard
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
| | - Pierre-Emmanuel Falcoz
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
| | - Romain Kessler
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
| | - Valérie Schini-Kerth
- UMR CNRS 7213, Biophotonique and Pharmacology Laboratory, Pharmacology School, University of Strasbourg, Strasbourg, France
| | - Laurence Kessler
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
| | - Florence Toti
- UMR CNRS 7213, Biophotonique and Pharmacology Laboratory, Pharmacology School, University of Strasbourg, Strasbourg, France
| | - Gilbert Massard
- Labex Transplantex, Translational Medecine Federation, University of Strasbourg, Strasbourg, France; Lung Transplantation Group, University Hospital Strasbourg, Strasbourg France; EA 7293 SVTT 'Stress Vasculaire et Tissulaire en Transplantation', Translational Medecine Federation, University of Strasbourg, Strasbourg, France
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Guo J, Sang Y, Yin T, Wang B, Yang W, Li X, Li H, Kang Y. miR-1273g-3p participates in acute glucose fluctuation-induced autophagy, dysfunction, and proliferation attenuation in human umbilical vein endothelial cells. Am J Physiol Endocrinol Metab 2016; 310:E734-43. [PMID: 26908504 DOI: 10.1152/ajpendo.00444.2015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/15/2016] [Indexed: 02/05/2023]
Abstract
Acute glucose fluctuations (AGF) often cause high mortality among critically ill patients, but the mechanisms induced by AGF are not clear. Recent studies suggest that endothelial dysfunction is a key factor that leads to high mortality among critically ill patients. Our goal is to evaluate the phenomenon and mechanisms of endothelial dysfunction induced by AGF. In this study, the functions of human umbilical vein endothelial cells (HUVECs) were compared after treatment with sustained high glucose (SHG), AGF in two groups (AGF1 fluctuations between 5 and 16 mM and AGF2 fluctuations between 5 and 25 mM), and normal glucose levels as a control group (CTR). The medium of the groups was changed every 4 h. The influence of AGF on wound healing was also tested on C57BL/6 mice. The results show that cell proliferation, angiogenesis, and migration functions were injured in the SHG and both AGF groups. AGF2 group shows the worse condition in vitro. In vivo, the wound healing was delayed after the AGF treatment. Furthermore, the markers of apoptosis and autophagy were analyzed. We observed that the autophagy changed in all treatment groups, but apoptosis showed no change. To get to know the mechanism of dysfunction and autophagy, we performed the microRNA chip assay and real-time PCR and found miR-1273g-3p remarkably changed in AGF2 group. After the mimic and inhibitor of miR-1273g-3p were transfected during the AGF2 treatment, we found that the dysfunction and autophagy were partially enhanced by miR-1273g-3p mimic and reversed by miR-1273g-3p inhibitor in AGF2 group. Thus, we conclude that AGF can induce more dysfunction and autophagy, and miR-1273g-3p is also an important factor that leads to the injury.
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Affiliation(s)
- Jun Guo
- Department of Critical Care Medicine, West China Hospital
| | - Yaxiong Sang
- College of Life Science; State Key Laboratory of Biotherapy and Cancer Center, West China Hospital
| | - Tao Yin
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital
| | | | - Xue Li
- West China School of Preclinical and Forensic Medicine; and
| | - Huan Li
- Anesthesia Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital;
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Enhanced expression of cell-specific surface antigens on endothelial microparticles in sepsis-induced disseminated intravascular coagulation. Shock 2016; 43:443-9. [PMID: 25608138 PMCID: PMC4418778 DOI: 10.1097/shk.0000000000000331] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sepsis-induced disseminated intravascular coagulation (DIC) is a major cause of death in patients admitted to intensive care units. Endothelial injury with microparticle production is reported in the pathogenesis of sepsis. Endothelial microparticles (EMPs) present several cell-specific surface antigens with different bioactivities, for example, tissue factor (TF), thrombomodulin (TM), and endothelial protein C receptor (EPCR). We investigated associations between these three different surface antigen-positive EMPs and sepsis-induced DIC. This cross-sectional study composed of 24 patients with sepsis and 23 healthy controls was conducted from November 2012 to September 2013. Blood samples were collected from patients within 24 h of diagnosis of severe sepsis and from healthy controls. Numbers of TF-positive EMPs (TF EMPs), TM-positive EMPs (TM EMPs), and EPCR-positive EMPs (EPCR EMPs) were measured by flow cytometry immediately thereafter. Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were assessed in the severe sepsis patients at enrollment. We assessed DIC with the International Society of Thrombosis and Haemostasis (ISTH) overt DIC diagnostic criteria algorithm. Numbers of antigen-positive EMPs were increased significantly in both severe sepsis patients and controls and with the increase in ISTH DIC score. Numbers of TF EMPs and EPCR EMPs correlated significantly with Sequential Organ Failure Assessment score, and numbers of EPCR EMPs correlated significantly with Acute Physiology and Chronic Health Evaluation II score. Numbers of the three antigen-positive EMPs were increased significantly in severe sepsis patients versus those in healthy controls and with the increase of ISTH DIC score, suggesting that the specific bioactivity of each antigen-positive EMP may play a role in the progression of sepsis-induced DIC.
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Abstract
PURPOSE OF REVIEW Sepsis, defined by the presence of infection and host inflammation, is a lethal clinical syndrome with an increasing mortality rate worldwide. In severe disease, the coagulation system becomes diffusely activated, with consumption of multiple clotting factors resulting in disseminated intravascular coagulation (DIC). When present, DIC portends a higher mortality rate. Understanding the mechanisms that tie inflammation and diffuse thrombosis will allow therapeutic interventions to be developed. The coagulopathy of acute sepsis is a dynamic process that is time and disease burden specific. Whole-blood testing of coagulation may provide more clinically useful information than the classical tests. Natural anticoagulants that regulate thrombosis are downregulated in sepsis. Patients may benefit from the modulation of the coagulation system when systemic inflammation and hypercoagulopathy exist. Proper timing of anticoagulant therapy may ultimately lead to decreased incidence of multisystem organ dysfunction. RECENT FINDINGS The pathogenesis of coagulopathy in sepsis is driven by an upregulation of procoagulant mechanisms and simultaneous downregulation of natural anticoagulants. Inflammation caused by the invading organism is a natural host defense that cannot be eliminated during treatment. Successful strategies to prevent multisystem organ dysfunction center on stratifying patients at high risk for DIC and restoring the balance of inflammation and coagulation. SUMMARY The prevention of DIC in septic patients is a key therapeutic target in preventing death from multisystem organ failure. Stratifying patients for therapy using thromboelastometry, specific markers for DIC, and composite scoring systems is an area of growing research.
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The clinical significance of circulating soluble RAGE in patients with severe sepsis. J Trauma Acute Care Surg 2015; 78:1086-93; discussion 1093-4. [PMID: 26002402 DOI: 10.1097/ta.0000000000000651] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The receptor for advanced glycation end products (RAGE) is a pattern-recognition receptor involved in the pathogenesis of inflammatory diseases. However, the significance of the soluble isoform of RAGE (sRAGE) has not been clarified in critical illness. We investigated circulating sRAGE in blood samples from septic patients. METHODS In this cross-sectional study, criteria for inclusion were patients with severe sepsis and age older than 18 years. Samples were collected within 24 hours after the diagnosis of sepsis and also from healthy volunteers. The levels of sRAGE and RAGE signaling pathway-associated biologic parameters were measured with an enzyme-linked immunosorbent assay kit. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were calculated at the time of patient enrollment. We used the International Society of Thrombosis and Haemostasis (ISTH) overt disseminated intravascular coagulation (DIC) diagnostic criteria algorithm to assess coagulopathy. RESULTS Included were 24 septic patients and 12 healthy volunteers. Serum sRAGE level was significantly increased in the patients compared with healthy controls. Significant correlations were found between sRAGE levels and APACHE II, SOFA, and ISTH DIC scores. The increase in sRAGE levels also correlated with the upregulation of interleukin-6, soluble vascular adhesion molecule 1, and plasminogen activator inhibitor 1 levels and a reduction in platelet count. The fraction of sRAGE other than the endogenous secreted form of RAGE (esRAGE) was augmented in the patients. CONCLUSION We demonstrated for the first time that the serum level of sRAGE increased with the progression of DIC and the severity of sepsis, suggesting that circulating sRAGE reflects RAGE signaling pathway activity, which induces the excessive inflammatory response involved in endothelial injury and coagulopathy and that its measurement may be useful as a biomarker for sepis. LEVEL OF EVIDENCE Prognostic study, level IV.
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Cohen J, Vincent JL, Adhikari NKJ, Machado FR, Angus DC, Calandra T, Jaton K, Giulieri S, Delaloye J, Opal S, Tracey K, van der Poll T, Pelfrene E. Sepsis: a roadmap for future research. THE LANCET. INFECTIOUS DISEASES 2015; 15:581-614. [DOI: 10.1016/s1473-3099(15)70112-x] [Citation(s) in RCA: 658] [Impact Index Per Article: 73.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Bone Marrow Mesenchymal Stem Cells Alleviate Extracellular Kynurenine Levels, as Detected by High-Performance Liquid Chromatography. Inflammation 2015; 38:1450-7. [PMID: 25854176 DOI: 10.1007/s10753-015-0119-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Endothelial cell dysfunction plays an important role in the occurrence and development of sepsis, which is a consequence of the interaction between coagulation and inflammation. Kynurenine (KYN) is an endothelium-derived relaxing factor that makes a large contribution to sepsis pathophysiology. In this study, we investigated the influence of bone marrow mesenchymal stem cells (BMSCs) on KYN production by cultured endothelial cells. KYN and tryptophan (TRP) concentrations in cell supernatants were simultaneously measured with a high-performance liquid chromatography (HPLC) system equipped with a fluorescence detector (FLD) and an ultraviolet detector (UVD). Our results revealed that lipopolysaccharide-stimulated endothelial cells produced more KYN, which was accompanied by a parallel decrease in TRP. When co-cultured with BMSCs, KYN and TRP production were significantly decreased compared to lipopolysaccharide (LPS)-induction alone. Our results suggest that BMSCs can attenuate endothelial cell damage by decreasing KYN as detected with HPLC. This method is the first to be capable of capturing functional changes in the cells and is simple, fast, and suitable for cellular level research purposes.
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37
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Levi M, Sivapalaratnam S. Hemostatic abnormalities in critically ill patients. Intern Emerg Med 2015; 10:287-96. [PMID: 25537442 DOI: 10.1007/s11739-014-1176-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/09/2014] [Indexed: 12/17/2022]
Abstract
Hemostatic abnormalities frequently occur in critically ill patients and may vary from prolonged global clotting tests or isolated thrombocytopenia, to composite defects, such as consumption coagulopathies. There are many reasons for a disturbed coagulation in intensive care patients, and each of these underlying syndromes may require specific therapeutic intervention. Hence, an adequate differential diagnosis and initiation of proper (supportive) therapeutic strategies are critical to decrease morbidity and mortality in critically ill patients with hemostatic abnormalities.
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Affiliation(s)
- Marcel Levi
- Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,
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Sapru A, Calfee CS, Liu KD, Kangelaris K, Hansen H, Pawlikowska L, Ware LB, Alkhouli MF, Abbott J, Abbot J, Matthay MA. Plasma soluble thrombomodulin levels are associated with mortality in the acute respiratory distress syndrome. Intensive Care Med 2015; 41:470-8. [PMID: 25643902 PMCID: PMC4500527 DOI: 10.1007/s00134-015-3648-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/08/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Thombomodulin (TM) is an activator of protein C and a biomarker for endothelial injury. We hypothesized that (1) elevated plasma levels would be associated with clinical outcomes and (2) polymorphisms in the TM gene would be associated with plasma levels. PATIENTS We studied 449 patients enrolled in the Fluid and Catheter Treatment Trial (FACTT) for whom both plasma and DNA were available. We used logistic regression and receiver operator curves (ROC) to test for associations between soluble TM (sTM) and mortality at 60 days. MEASUREMENTS AND RESULTS Plasma sTM levels were higher in non-survivors than survivors at baseline [median 147 (IQR, 95-218) vs. 89 (56-129) ng/mL, p < 0.0001] and on day 3 after study enrollment [205 (146-302) vs. 127 (85-189), p < 0.0001]. The odds of death increased by 2.4 (95 % CI 1.5-3.8, p < 0.001), and by 2.8 (1.7-4.7, P < 0.001) for every log increase in baseline and day 3 sTM levels, respectively, after adjustment for age, race, gender, severity of illness, fluid management strategy, baseline creatinine, and non-pulmonary sepsis as the primary cause of ARDS. By ROC analysis, plasma sTM levels discriminated between non-survivors and survivors [AUC = 72 % (66-78 %) vs. AUC = 54 % for severity based on Berlin criteria). Addition of sTM improved discrimination based on APACHE III from 77 to 80 % (P < 0.03). sTM levels at baseline were not statistically different among subjects stratified by genotypes of tag SNPs in the TM gene. CONCLUSIONS Higher plasma sTM levels are associated with increased mortality in ARDS. The lack of association between the sTM levels and genetic variants suggests that the increased levels of sTM may reflect severity of endothelial damage rather than genetic heterogeneity. These findings underscore the importance of endothelial injury in ARDS pathogenesis and suggest that, in combination with clinical markers, sTM could contribute to risk stratification.
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Affiliation(s)
- Anil Sapru
- Department of Pediatrics, University of California, San Francisco, CA, USA,
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39
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Abstract
The endothelium provides an essential and selective membrane barrier that regulates the movement of water, solutes, gases, macromolecules and the cellular elements of the blood from the tissue compartment in health and disease. Its structure and continuous function is essential for life for all vertebrate organisms. Recent evidence indicates that the endothelial surface does not have a passive role in systemic inflammatory states such as septic shock. In fact, endothelial cells are in dynamic equilibrium with a myriad of inflammatory mediators and elements of the innate immune and coagulation systems to orchestrate the host response in sepsis. The barrier function of the endothelial surface is almost uniformly impaired in septic shock, and it is likely that this contributes to adverse outcomes. In this review, we will highlight recent advances in the understanding of the signalling events that regulate endothelial function and molecular events that induce endothelial dysfunction in sepsis. Endothelial barrier repair strategies as a treatment for sepsis include modulation of C5a, high-mobility group box 1 and VEGF receptor 2; stimulation of angiopoietin-1, sphingosine 1 phosphate receptor 1 and Slit; and a number of other innovative approaches.
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Affiliation(s)
- S M Opal
- Infectious Disease Division, Alpert Medical School of Brown University, Pawtucket, RI, USA
| | - T van der Poll
- Academic Medical Center, Division of Infectious Diseases & The Center of Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, the Netherlands
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40
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Zampieri FG, Ranzani OT, Sabatoski V, de Souza HP, Barbeiro H, da Neto LMC, Park M, Pinheiro da Silva F. An increase in mean platelet volume after admission is associated with higher mortality in critically ill patients. Ann Intensive Care 2014; 4:20. [PMID: 25520853 PMCID: PMC4265891 DOI: 10.1186/s13613-014-0020-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 05/23/2014] [Indexed: 12/29/2022] Open
Abstract
Background Platelet activation and consumption are common in critically ill patients and are associated with poorer prognosis. Mean platelet volume is a simple surrogate for platelet activation, with higher MPV being associated with worse clinical condition on a large array of clinical diagnoses. We therefore aimed to investigate associations between changes in platelet count and mean platelet volume (MPV) with prognosis and inflammatory cytokine values in critically ill patients. Methods This study prospectively included 84 critically ill patients. Patients were stratified into four groups according to proportional changes in MPV (ΔMPV24h) and platelet count (ΔPlat24h) in the first 24 hours after admission. Mortality between groups was compared using the χ2 test. Logistic regression was performed using hospital mortality as outcome and Simplified Acute Physiology Score (SAPS 3), ΔPlat24h and ΔMPV24h as covariates. Concentrations of the following inflammatory mediators were measured using Miliplex® technology: IL1β, IL6, IL8, IL10, epidermal growth factor, vascular endothelial growth factor, TNFα and IFNα. Cytokine concentrations were compared between groups using the Kruskal-Wallis test with Bonferroni correction. Results Patients in whom MPV increased and platelet count decreased had higher mortality rates (46%). According to logistic regression, ΔMPV24h was independently associated with increased mortality (OR 1.28 per 1% increase; 95% CI 1.08 to 1.48). No strong associations between inflammatory mediators and changes in MPV and platelet count were found. Conclusion An increase in MPV after admission to an ICU is independently associated with higher hospital mortality.
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Affiliation(s)
- Fernando G Zampieri
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil ; Laboratory of Medical Investigation 51 (LIM 51), Faculty of Medicine, University of São Paulo, São Paulo, Brazil ; Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Otavio T Ranzani
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Viviane Sabatoski
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Heraldo Possolo de Souza
- Laboratory of Medical Investigation 51 (LIM 51), Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Hermes Barbeiro
- Laboratory of Medical Investigation 51 (LIM 51), Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luiz Monteiro Cruz da Neto
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Marcelo Park
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - Fabiano Pinheiro da Silva
- Laboratory of Medical Investigation 51 (LIM 51), Faculty of Medicine, University of São Paulo, São Paulo, Brazil
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Karnad DR, Bhadade R, Verma PK, Moulick ND, Daga MK, Chafekar ND, Iyer S. Intravenous administration of ulinastatin (human urinary trypsin inhibitor) in severe sepsis: a multicenter randomized controlled study. Intensive Care Med 2014; 40:830-8. [PMID: 24737258 PMCID: PMC4028549 DOI: 10.1007/s00134-014-3278-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 03/24/2014] [Indexed: 01/17/2023]
Abstract
Purpose Ulinastatin, a serine protease inhibitor, inhibits several pro-inflammatory proteases and decreases inflammatory cytokine levels and mortality in experimental sepsis. We studied the effect of ulinastatin on 28-day all-cause mortality in a double-blind trial in patients with severe sepsis in seven Indian hospitals. Methods Patients with sepsis were randomized within 48 h of onset of one or more organ failures to receive intravenous administration of ulinastatin (200,000 IU) or placebo 12 hourly for 5 days. Results Of 122 randomized subjects, 114 completed the study (55 receiving ulinastatin, 59 receiving placebo). At baseline, the mean APACHE II score was 13.4 (SD = 4.4), 48 (42 %) patients were receiving mechanical ventilation, 58 (51 %) were on vasopressors, and 35 % had multiple organ failure. In the modified intention-to-treat analysis (patients receiving six or more doses of study drugs), 28-day all-cause mortality was 7.3 % with ulinastatin (4 deaths) versus 20.3 % (12 deaths) with placebo (p = 0.045). On multivariate analysis too, treatment with ulinastatin (odds ratio 0.26, 95 % CI 0.07–0.95; p = 0.042) independently decreased 28-day all-cause mortality. However, the mortality difference did not reach statistical significance in the intention-to-treat analysis [10.2 % (6/59 deaths) with ulinastatin versus 20.6 % (13/63 deaths) in the placebo group; p = 0.11]. The ulinastatin group had lower incidence of new-onset organ failure (10 vs. 26 patients, p = 0.003), more ventilator-free days (mean ± SD 19.4 ± 10.6 days vs. 10.2 ± 12.5 days, p = 0.019), and shorter hospital stay (11.8 ± 7.1 days vs. 24.2 ± 7.2 days, p < 0.001). Conclusions In this pilot study, intravenous administration of ulinastatin reduced mortality in patients with severe sepsis in the modified intention-to-treat analysis, but not in the intention-to-treat analysis. Electronic supplementary material The online version of this article (doi:10.1007/s00134-014-3278-8) contains supplementary material, which is available to authorized users.
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Timsit JF, Citerio G, Bakker J, Bassetti M, Benoit D, Cecconi M, Curtis JR, Hernandez G, Herridge M, Jaber S, Joannidis M, Papazian L, Peters M, Singer P, Smith M, Soares M, Torres A, Vieillard-Baron A, Azoulay E. Year in review in Intensive Care Medicine 2013: III. Sepsis, infections, respiratory diseases, pediatrics. Intensive Care Med 2014; 40:471-83. [PMID: 24519574 PMCID: PMC7095429 DOI: 10.1007/s00134-014-3235-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Jean-Francois Timsit
- Medical and Infectious Diseases ICU, Bichat Hospital, Paris Diderot University, Paris, France,
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