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Slim MA, van Mourik N, Bakkerus L, Fuller K, Acharya L, Giannidis T, Dionne JC, Oczkowski SJW, Netea MG, Pickkers P, Giamarellos-Bourboulis EJ, Müller MCA, van der Poll T, Wiersinga WJ, Vlaar APJ, van Vught LA. Towards personalized medicine: a scoping review of immunotherapy in sepsis. Crit Care 2024; 28:183. [PMID: 38807151 PMCID: PMC11134696 DOI: 10.1186/s13054-024-04964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
Despite significant progress in our understanding of the pathophysiology of sepsis and extensive clinical research, there are few proven therapies addressing the underlying immune dysregulation of this life-threatening condition. The aim of this scoping review is to describe the literature evaluating immunotherapy in adult patients with sepsis, emphasizing on methods providing a "personalized immunotherapy" approach, which was defined as the classification of patients into a distinct subgroup or subphenotype, in which a patient's immune profile is used to guide treatment. Subgroups are subsets of sepsis patients, based on any cut-off in a variable. Subphenotypes are subgroups that can be reliably discriminated from other subgroup based on data-driven assessments. Included studies were randomized controlled trials and cohort studies investigating immunomodulatory therapies in adults with sepsis. Studies were identified by searching PubMed, Embase, Cochrane CENTRAL and ClinicalTrials.gov, from the first paper available until January 29th, 2024. The search resulted in 15,853 studies. Title and abstract screening resulted in 1409 studies (9%), assessed for eligibility; 771 studies were included, of which 282 (37%) were observational and 489 (63%) interventional. Treatment groups included were treatments targeting the innate immune response, the complement system, coagulation and endothelial dysfunction, non-pharmalogical treatment, pleiotropic drugs, immunonutrition, concomitant treatments, Traditional Chinese Medicine, immunostimulatory cytokines and growth factors, intravenous immunoglobulins, mesenchymal stem cells and immune-checkpoint inhibitors. A personalized approach was incorporated in 70 studies (9%). Enrichment was applied using cut-offs in temperature, laboratory, biomarker or genetic variables. Trials often showed conflicting results, possibly due to the lack of patient stratification or the potential influence of severity and timing on immunomodulatory therapy results. When a personalized approach was applied, trends of clinical benefit for several interventions emerged, which hold promise for future clinical trials using personalized immunotherapy.
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Affiliation(s)
- Marleen A Slim
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands.
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Niels van Mourik
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieke Bakkerus
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Lydia Acharya
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Simon J W Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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2
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Girardis M, Coloretti I, Antonelli M, Berlot G, Busani S, Cortegiani A, De Pascale G, De Rosa FG, De Rosa S, Donadello K, Donati A, Forfori F, Giannella M, Grasselli G, Montrucchio G, Oliva A, Pasero D, Piazza O, Romagnoli S, Tascini C, Viaggi B, Tumbarello M, Viale P. Adjunctive immunotherapeutic agents in patients with sepsis and septic shock: a multidisciplinary consensus of 23. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:28. [PMID: 38689337 PMCID: PMC11059820 DOI: 10.1186/s44158-024-00165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND In the last decades, several adjunctive treatments have been proposed to reduce mortality in septic shock patients. Unfortunately, mortality due to sepsis and septic shock remains elevated and NO trials evaluating adjunctive therapies were able to demonstrate any clear benefit. In light of the lack of evidence and conflicting results from previous studies, in this multidisciplinary consensus, the authors considered the rational, recent investigations and potential clinical benefits of targeted adjunctive therapies. METHODS A panel of multidisciplinary experts defined clinical phenotypes, treatments and outcomes of greater interest in the field of adjunctive therapies for sepsis and septic shock. After an extensive systematic literature review, the appropriateness of each treatment for each clinical phenotype was determined using the modified RAND/UCLA appropriateness method. RESULTS The consensus identified two distinct clinical phenotypes: patients with overwhelming shock and patients with immune paralysis. Six different adjunctive treatments were considered the most frequently used and promising: (i) corticosteroids, (ii) blood purification, (iii) immunoglobulins, (iv) granulocyte/monocyte colony-stimulating factor and (v) specific immune therapy (i.e. interferon-gamma, IL7 and AntiPD1). Agreement was achieved in 70% of the 25 clinical questions. CONCLUSIONS Although clinical evidence is lacking, adjunctive therapies are often employed in the treatment of sepsis. To address this gap in knowledge, a panel of national experts has provided a structured consensus on the appropriate use of these treatments in clinical practice.
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Affiliation(s)
- Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Antonelli
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Berlot
- Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Gennaro De Pascale
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Silvia De Rosa
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, and Anesthesia and Intensive Care Unit B, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, Departement of Anesthesia, Resuscitation and Emergency Torino, University of Turin, Turin, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniela Pasero
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Ornella Piazza
- University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Stefano Romagnoli
- Department of Health Science, Department of Anesthesia and Intensive Care, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, Udine, Italy
| | - Bruno Viaggi
- Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Mario Tumbarello
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Braunsteiner J, Siedler S, Jarczak D, Kluge S, Nierhaus A. Septic shock due to Capnocytophaga canimorsus treated with IgM-enriched immunoglobulin as adjuvant therapy in an immunocompetent woman. JOURNAL OF INTENSIVE MEDICINE 2024; 4:265-268. [PMID: 38681795 PMCID: PMC11043631 DOI: 10.1016/j.jointm.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 05/01/2024]
Affiliation(s)
- Josephine Braunsteiner
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stephanie Siedler
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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4
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Méndez R, González-Jiménez P, Mengot N, Menéndez R. Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:225-236. [PMID: 38224700 DOI: 10.1055/s-0043-1778139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.
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Affiliation(s)
- Raúl Méndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Paula González-Jiménez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Noé Mengot
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Rosario Menéndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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5
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Pei F, Gu B, Miao SM, Guan XD, Wu JF. Clinical practice of sepsis-induced immunosuppression: Current immunotherapy and future options. Chin J Traumatol 2024; 27:63-70. [PMID: 38040590 DOI: 10.1016/j.cjtee.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/07/2023] [Accepted: 08/17/2023] [Indexed: 12/03/2023] Open
Abstract
Sepsis is a potentially fatal condition characterized by the failure of one or more organs due to a disordered host response to infection. The development of sepsis is closely linked to immune dysfunction. As a result, immunotherapy has gained traction as a promising approach to sepsis treatment, as it holds the potential to reverse immunosuppression and restore immune balance, thereby improving the prognosis of septic patients. However, due to the highly heterogeneous nature of sepsis, it is crucial to carefully select the appropriate patient population for immunotherapy. This review summarizes the current and evolved treatments for sepsis-induced immunosuppression to enhance clinicians' understanding and practical application of immunotherapy in the management of sepsis.
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Affiliation(s)
- Fei Pei
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Bin Gu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Shu-Min Miao
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Xiang-Dong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Jian-Feng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China.
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6
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Portefaix A, Dhelens C, Recher M, Cour-Andlauer F, Naudin J, Mortamet G, Joram N, Tissières P, Ginhoux T, Kassai B, Boutitie F, Maucort-Boulch D, Javouhey E. High-dose intravenous immunoglobulin versus albumin 4% in paediatric toxic shock syndrome: a randomised controlled feasibility study. Arch Dis Child 2024:archdischild-2022-325274. [PMID: 38360044 DOI: 10.1136/archdischild-2022-325274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/26/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Toxic shock syndrome (TSS) is a rare disease responsible for significant morbidity and mortality. Intravenous immunoglobulin (IG) therapy in paediatric TSS could improve shock and organ failure, but more consistent efficacy and safety data are needed. Our objective was to determine whether a randomised clinical trial (RCT) assessing intravenous IG in TSS in children is feasible. METHODS We performed a multicentre, feasibility, double-blind RCT assessing efficacy of high-dose intravenous IG versus albumin 4% (control group) within the first 12 hours of shock onset. Included patients were aged above 1 month and below 18 years with suspected TSS and septic shock. Feasibility was assessed by measuring inclusion rate, protocol compliance and missing data regarding death and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score. Other secondary clinical outcomes were evaluated during hospital stay, at 60 day and 1 year. RESULTS 28 patients, admitted in 6 paediatric intensive care units during 36 consecutive months and followed for 1 year, received the allocated treatment: 13 in intravenous IG group, 15 in control group. The median age was 10.6 years and the sex ratio was 1. Inclusion rate was above 50%, protocol deviations were below 30% and missing data regarding death and PELOD-2 Score below 10%. No difference concerning secondary clinical outcomes between groups was observed, and more adverse events were reported in the control group. CONCLUSION It seems to be feasible to conduct an RCT assessing intravenous IG efficacy and safety in paediatric TSS but must be realised internationally, with choice of a clinically relevant endpoint and a specific design in order to be realistic. TRIAL REGISTRATION NUMBER NCT02219165.
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Affiliation(s)
- Aurélie Portefaix
- Clinical Investigation Center, Hospices Civils de Lyon, Lyon Bron, France
- EMET LBBE, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Carole Dhelens
- Pharmacie FRIPHARM, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Morgan Recher
- Services de Réanimation Pédiatrique, CHU Lille, F59000-Lille, France
- METRICS, Universite Lille Nord de France, Villeneuve-d'Ascq, Hauts-de-France, France
| | - Fleur Cour-Andlauer
- Réanimation Pédiatrique, Centre Hospitalier Universitaire de Lyon, Bron, France
| | - Jérôme Naudin
- Service de Réanimation Pédiatrique, Hôpital Universitaire Robert-Debré, Paris, Île-de-France, France
| | | | - Nicolas Joram
- Réanimation Pédiatrique, CHU Nantes, Nantes, Pays de la Loire, France
| | - Pierre Tissières
- Paediatric Intensive Care Unit, Hospital Bicetre, Le Kremlin-Bicetre, Île-de-France, France
- Institute for Integrative Cell Biology, Gif-sur-Yvette, Île-de-France, France
| | - Tiphanie Ginhoux
- Clinical Investigation Center, Hospices Civils de Lyon, Lyon Bron, France
| | - Behrouz Kassai
- Clinical Investigation Center, Hospices Civils de Lyon, Lyon Bron, France
- Université Lyon 1, CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Florent Boutitie
- Biostatistics, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | | | - Etienne Javouhey
- Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- EA 7426 Joint Research Unit HCL-bioMérieux, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
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7
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Biswas S, Mandal G, Anadon CM, Chaurio RA, Lopez-Bailon LU, Nagy MZ, Mine JA, Hänggi K, Sprenger KB, Innamarato P, Harro CM, Powers JJ, Johnson J, Fang B, Eysha M, Nan X, Li R, Perez BA, Curiel TJ, Yu X, Rodriguez PC, Conejo-Garcia JR. Targeting intracellular oncoproteins with dimeric IgA promotes expulsion from the cytoplasm and immune-mediated control of epithelial cancers. Immunity 2023; 56:2570-2583.e6. [PMID: 37909039 PMCID: PMC10703011 DOI: 10.1016/j.immuni.2023.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 06/05/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023]
Abstract
Dimeric IgA (dIgA) can move through cells via the IgA/IgM polymeric immunoglobulin receptor (PIGR), which is expressed mainly on mucosal epithelia. Here, we studied the ability of dIgA to target commonly mutated cytoplasmic oncodrivers. Mutation-specific dIgA, but not IgG, neutralized KRASG12D within ovarian carcinoma cells and expelled this oncodriver from tumor cells. dIgA binding changed endosomal trafficking of KRASG12D from accumulation in recycling endosomes to aggregation in the early/late endosomes through which dIgA transcytoses. dIgA targeting of KRASG12D abrogated tumor cell proliferation in cell culture assays. In vivo, KRASG12D-specific dIgA1 limited the growth of KRASG12D-mutated ovarian and lung carcinomas in a manner dependent on CD8+ T cells. dIgA specific for IDH1R132H reduced colon cancer growth, demonstrating effective targeting of a cytoplasmic oncodriver not associated with surface receptors. dIgA targeting of KRASG12D restricted tumor growth more effectively than small-molecule KRASG12D inhibitors, supporting the potential of this approach for the treatment of human cancers.
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Affiliation(s)
- Subir Biswas
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; Tumor Immunology and Immunotherapy, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai 410210, India
| | - Gunjan Mandal
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; Division of Cancer Biology, DBT-Institute of Life Sciences, Bhubaneswar 751023, India
| | - Carmen M Anadon
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; Department of Integrated Immunobiology, Duke School of Medicine, Durham, NC 27710, USA; Duke Cancer Institute, Duke School of Medicine, Durham, NC 27710, USA
| | - Ricardo A Chaurio
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; Department of Integrated Immunobiology, Duke School of Medicine, Durham, NC 27710, USA; Duke Cancer Institute, Duke School of Medicine, Durham, NC 27710, USA
| | - Luis U Lopez-Bailon
- Department of Integrated Immunobiology, Duke School of Medicine, Durham, NC 27710, USA; Duke Cancer Institute, Duke School of Medicine, Durham, NC 27710, USA
| | - Mate Z Nagy
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Jessica A Mine
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; Department of Integrated Immunobiology, Duke School of Medicine, Durham, NC 27710, USA; Duke Cancer Institute, Duke School of Medicine, Durham, NC 27710, USA
| | - Kay Hänggi
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Kimberly B Sprenger
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Patrick Innamarato
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Carly M Harro
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - John J Powers
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Joseph Johnson
- Analytic Microscopy Core, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Bin Fang
- Proteomics and Metabolomics Core, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Mostafa Eysha
- Department of Medicine, Duke School of Medicine, Durham, NC 27710, USA
| | - Xiaolin Nan
- Department of Biomedical Engineering, Knight Cancer Institute, and OHSU Center for Spatial Systems Biomedicine (OCSSB), Oregon Health and Science University, Portland, OR 97239, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Bradford A Perez
- Department of Radiation Therapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Tyler J Curiel
- Departments of Medicine and Microbiology and Immunology, Dartmouth Geisel School of Medicine, Hanover, NH 03755, USA
| | - Xiaoqing Yu
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Paulo C Rodriguez
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Jose R Conejo-Garcia
- Department of Immunology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; Department of Integrated Immunobiology, Duke School of Medicine, Durham, NC 27710, USA; Duke Cancer Institute, Duke School of Medicine, Durham, NC 27710, USA.
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Schmidt C, Weißmüller S, Heinz CC. Multifaceted Tissue-Protective Functions of Polyvalent Immunoglobulin Preparations in Severe Infections-Interactions with Neutrophils, Complement, and Coagulation Pathways. Biomedicines 2023; 11:3022. [PMID: 38002022 PMCID: PMC10669904 DOI: 10.3390/biomedicines11113022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Severe infections induce immune defense mechanisms and initial tissue damage, which produce an inflammatory neutrophil response. Upon dysregulation of these responses, inflammation, further tissue damage, and systemic spread of the pathogen may occur. Subsequent vascular inflammation and activation of coagulation processes may cause microvascular obstruction at sites distal to the primary site of infection. Low immunoglobulin (Ig) M and IgG levels have been detected in patients with severe infections like sCAP and sepsis, associated with increased severity and mortality. Based on Ig's modes of action, supplementation with polyvalent intravenous Ig preparations (standard IVIg or IgM/IgA-enriched Ig preparations) has long been discussed as a treatment option for severe infections. A prerequisite seems to be the timely administration of Ig preparations before excessive tissue damage has occurred and coagulopathy has developed. This review focuses on nonclinical and clinical studies that evaluated tissue-protective activities resulting from interactions of Igs with neutrophils, complement, and the coagulation system. The data indicate that coagulopathy, organ failure, and even death of patients can possibly be prevented by the timely combined interactions of (natural) IgM, IgA, and IgG with neutrophils and complement.
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Affiliation(s)
- Carolin Schmidt
- Department of Corporate Clinical Research and Development, Biotest AG, 63303 Dreieich, Germany
| | | | - Corina C Heinz
- Department of Corporate Clinical Research and Development, Biotest AG, 63303 Dreieich, Germany
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Singer M, Torres A, Heinz CC, Weißmüller S, Staus A, Kistner S, Jakubczyk K, Häder T, Langohr P, Wartenberg-Demand A, Schüttrumpf J, Vincent JL, Welte T. The immunomodulating activity of trimodulin (polyvalent IgM, IgA, IgG solution): a post hoc analysis of the phase II CIGMA trial. Crit Care 2023; 27:436. [PMID: 37946226 PMCID: PMC10634136 DOI: 10.1186/s13054-023-04719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The phase II CIGMA trial performed in 160 patients with severe community-acquired pneumonia (sCAP) found treatment with trimodulin (human polyvalent immunoglobulin [Ig]: ~ 23% IgM, ~ 21% IgA, ~ 56% IgG) was associated with a lower mortality in those patients with elevated baseline serum levels of C-reactive protein (CRP) and/or subnormal IgM. METHODS In this post hoc analysis, the pharmacodynamic effects of trimodulin treatment (182.6 mg/kg/day for 5 days) were investigated on Ig replenishment, cellular markers of inflammation (absolute neutrophil [ANC] and lymphocyte [ALC] count, neutrophil-to-lymphocyte ratio [NLR]), and soluble markers of inflammation (procalcitonin [PCT] and CRP). The impact of these pharmacodynamic effects on mortality was also evaluated. RESULTS Compared with healthy subjects, baseline serum levels of IgM, IgG, and ALC were significantly lower, and ANC, NLR, PCT and CRP significantly higher in sCAP patients (p < 0.0001). Low Ig concentrations increased with trimodulin. Normalization of ANC (analysis of variance [ANOVA] p = 0.016) and PCT (ANOVA p = 0.027) was more rapid with trimodulin compared with placebo. These and other effects were more evident in patients with low baseline IgM levels. Normalization of PCT and CRP levels was both steadier and faster with trimodulin treatment. In patients with low baseline ALC, trimodulin was associated with a lower 28-day all-cause mortality rate (14.5% vs 32.1% in placebo, p = 0.043) and more ventilator-free days ([VFD]; median VFD: 3.5 vs 11 in placebo, p = 0.043). These numerical differences were greater if baseline IgM was also low (low ALC, low IgM: 8.1% mortality vs 34.1% placebo, p = 0.006; 3 VFD vs 15 VFD, p = 0.009, respectively). Results were consistent in patients with high baseline CRP (low ALC, high CRP: 10.9% mortality vs 34.1% placebo, p = 0.011). CONCLUSIONS This post hoc pharmacodynamic analysis of a blinded phase II trial suggests that trimodulin compensates for, and more rapidly modifies, the dysregulated inflammatory response seen in sCAP patients. Trimodulin was associated with significantly lower mortality and more VFD in subgroups with high CRP and low ALC. This effect was particularly marked in patients who also had low baseline IgM values. These findings require confirmation in prospective trials.
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Affiliation(s)
- Mervyn Singer
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Antoni Torres
- Hospital Clínic, Servei de Pneumologia I Allèrgia Respiratòria, Catedràtic de Medicina, Universitat de Barcelona, Barcelona, Spain.
- IDIBAPS, ICREA, CIBER de Enfermedades Respiratorias, Barcelona, Spain.
| | - Corina C Heinz
- Biotest AG, Landsteinerstraße 5, 63303, Dreieich, Germany
| | | | | | | | | | - Thomas Häder
- Biotest AG, Landsteinerstraße 5, 63303, Dreieich, Germany
| | | | | | | | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
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10
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Li W, Cornelius V, Finfer S, Venkatesh B, Billot L. Adaptive designs in critical care trials: a simulation study. BMC Med Res Methodol 2023; 23:236. [PMID: 37853343 PMCID: PMC10585789 DOI: 10.1186/s12874-023-02049-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Adaptive clinical trials are growing in popularity as they are more flexible, efficient and ethical than traditional fixed designs. However, notwithstanding their increased use in assessing treatments for COVID-19, their use in critical care trials remains limited. A better understanding of the relative benefits of various adaptive designs may increase their use and interpretation. METHODS Using two large critical care trials (ADRENAL. CLINICALTRIALS gov number, NCT01448109. Updated 12-12-2017; NICE-SUGAR. CLINICALTRIALS gov number, NCT00220987. Updated 01-29-2009), we assessed the performance of three frequentist and two bayesian adaptive approaches. We retrospectively re-analysed the trials with one, two, four, and nine equally spaced interims. Using the original hypotheses, we conducted 10,000 simulations to derive error rates, probabilities of making an early correct and incorrect decision, expected sample size and treatment effect estimates under the null scenario (no treatment effect) and alternative scenario (a positive treatment effect). We used a logistic regression model with 90-day mortality as the outcome and the treatment arm as the covariate. The null hypothesis was tested using a two-sided significance level (α) at 0.05. RESULTS Across all approaches, increasing the number of interims led to a decreased expected sample size. Under the null scenario, group sequential approaches provided good control of the type-I error rate; however, the type I error rate inflation was an issue for the Bayesian approaches. The Bayesian Predictive Probability and O'Brien-Fleming approaches showed the highest probability of correctly stopping the trials (around 95%). Under the alternative scenario, the Bayesian approaches showed the highest overall probability of correctly stopping the ADRENAL trial for efficacy (around 91%), whereas the Haybittle-Peto approach achieved the greatest power for the NICE-SUGAR trial. Treatment effect estimates became increasingly underestimated as the number of interims increased. CONCLUSIONS This study confirms the right adaptive design can reach the same conclusion as a fixed design with a much-reduced sample size. The efficiency gain associated with an increased number of interims is highly relevant to late-phase critical care trials with large sample sizes and short follow-up times. Systematically exploring adaptive methods at the trial design stage will aid the choice of the most appropriate method.
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Affiliation(s)
- W Li
- MRC Biostatistics Unit, East Forvie Building, University of Cambridge, Cambridge, CB2 0QY, UK.
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK.
| | - V Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Woodlane, London, W12 7RH, UK
| | - S Finfer
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
- Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - B Venkatesh
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - L Billot
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
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11
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Renard Triché L, Futier E, De Carvalho M, Piñol-Domenech N, Bodet-Contentin L, Jabaudon M, Pereira B. Sample size estimation in clinical trials using ventilator-free days as the primary outcome: a systematic review. Crit Care 2023; 27:303. [PMID: 37528425 PMCID: PMC10394791 DOI: 10.1186/s13054-023-04562-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/04/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Ventilator-free days (VFDs) are a composite endpoint increasingly used as the primary outcome in critical care trials. However, because of the skewed distribution and competitive risk between components, sample size estimation remains challenging. This systematic review was conducted to systematically assess whether the sample size was congruent, as calculated to evaluate VFDs in trials, with VFDs' distribution and the impact of alternative methods on sample size estimation. METHODS A systematic literature search was conducted within the PubMed and Embase databases for randomized clinical trials in adults with VFDs as the primary outcome until December 2021. We focused on peer-reviewed journals with 2021 impact factors greater than five. After reviewing definitions of VFDs, we extracted the sample size and methods used for its estimation. The data were collected by two independent investigators and recorded in a standardized, pilot-tested forms tool. Sample sizes were calculated using alternative statistical approaches, and risks of bias were assessed with the Cochrane risk-of-bias tool. RESULTS Of the 26 clinical trials included, 19 (73%) raised "some concerns" when assessing risks of bias. Twenty-four (92%) trials were two-arm superiority trials, and 23 (89%) were conducted at multiple sites. Almost all the trials (96%) were unable to consider the unique distribution of VFDs and death as a competitive risk. Moreover, significant heterogeneity was found in the definitions of VFDs, especially regarding varying start time and type of respiratory support. Methods for sample size estimation were also heterogeneous, and simple models, such as the Mann-Whitney-Wilcoxon rank-sum test, were used in 14 (54%) trials. Finally, the sample sizes calculated varied by a factor of 1.6 to 17.4. CONCLUSIONS A standardized definition and methodology for VFDs, including the use of a core outcome set, seems to be required. Indeed, this could facilitate the interpretation of findings in clinical trials, as well as their construction, especially the sample size estimation which is a trade-off between cost, ethics, and statistical power. Systematic review registration PROSPERO ID: CRD42021282304. Registered 15 December 2021 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282304 ).
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Affiliation(s)
- Laurent Renard Triché
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France. lrenard--
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | | | | | - Laëtitia Bodet-Contentin
- Medical Intensive Care Unit, CHRU de Tours, Tours, France
- INSERM, SPHERE, UMR1246, Université de Tours et Nantes, Tours et Nantes, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Department of Clinical Research, and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
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12
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Berlot G, Zanchi S, Moro E, Tomasini A, Bixio M. The Role of the Intravenous IgA and IgM-Enriched Immunoglobulin Preparation in the Treatment of Sepsis and Septic Shock. J Clin Med 2023; 12:4645. [PMID: 37510760 PMCID: PMC10380743 DOI: 10.3390/jcm12144645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Polyclonal Intravenous Immunoglobulins (IvIg) are often administered to critically ill patients more as an act of faith than on the basis of relevant clinical studies. This particularly applies to the treatment of sepsis and septic shock because the current guidelines recommend against their use despite many investigations that have demonstrated their beneficial effects in different subsets of patients. The biology, mechanisms of action, and clinical experience related to the administration of IvIg are reviewed, which aim to give a more in-depth understanding of their properties in order to clarify their possible indications in sepsis and septic shock patients.
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Affiliation(s)
- Giorgio Berlot
- Azienda Sanitaria Universitaria Giuliano Isontina, Department of Anesthesia and Intensive Care, 34148 Trieste, Italy
- UCO Anestesia Rianimazione e Terapia Antalgica, Azienda Sanitaria Universitaria Giuliano Isontina, Strada di Fiume 447, 34149 Trieste, Italy
| | - Silvia Zanchi
- Azienda Sanitaria Universitaria Giuliano Isontina, Department of Anesthesia and Intensive Care, 34148 Trieste, Italy
| | - Edoardo Moro
- Azienda Sanitaria Universitaria Giuliano Isontina, Department of Anesthesia and Intensive Care, 34148 Trieste, Italy
| | - Ariella Tomasini
- Azienda Sanitaria Universitaria Giuliano Isontina, Department of Anesthesia and Intensive Care, 34148 Trieste, Italy
| | - Mattia Bixio
- Ospedale Policlinico San Martino, Department of Anesthesia and Intensive Care, 16132 Genova, Italy
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13
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Bohländer F. A new hope? Possibilities of therapeutic IgA antibodies in the treatment of inflammatory lung diseases. Front Immunol 2023; 14:1127339. [PMID: 37051237 PMCID: PMC10083398 DOI: 10.3389/fimmu.2023.1127339] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Inflammatory lung diseases represent a persistent burden for patients and the global healthcare system. The combination of high morbidity, (partially) high mortality and limited innovations in the last decades, have resulted in a great demand for new therapeutics. Are therapeutic IgA antibodies possibly a new hope in the treatment of inflammatory lung diseases? Current research increasingly unravels the elementary functions of IgA as protector against infections and as modulator of overwhelming inflammation. With a focus on IgA, this review describes the pathological alterations in mucosal immunity and how they contribute to chronic inflammation in the most common inflammatory lung diseases. The current knowledge of IgA functions in the circulation, and particularly in the respiratory mucosa, are summarized. The interplay between neutrophils and IgA seems to be key in control of inflammation. In addition, the hurdles and benefits of therapeutic IgA antibodies, as well as the currently known clinically used IgA preparations are described. The data highlighted here, together with upcoming research strategies aiming at circumventing the current pitfalls in IgA research may pave the way for this promising antibody class in the application of inflammatory lung diseases.
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14
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Kharga K, Kumar L, Patel SKS. Recent Advances in Monoclonal Antibody-Based Approaches in the Management of Bacterial Sepsis. Biomedicines 2023; 11:biomedicines11030765. [PMID: 36979744 PMCID: PMC10045367 DOI: 10.3390/biomedicines11030765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Sepsis is a life-threatening condition characterized by an uncontrolled inflammatory response to an infectious agent and its antigens. Immune cell activation against the antigens causes severe distress that mediates a strong inflammatory response in vital organs. Sepsis is responsible for a high rate of morbidity and mortality in immunosuppressed patients. Monoclonal antibody (mAb)-based therapeutic strategies are now being explored as a viable therapy option for severe sepsis and septic shock. Monoclonal antibodies may provide benefits through two major strategies: (a) monoclonal antibodies targeting the pathogen and its components, and (b) mAbs targeting inflammatory signaling may directly suppress the production of inflammatory mediators. The major focus of mAb therapies has been bacterial endotoxin (lipopolysaccharide), although other surface antigens are also being investigated for mAb therapy. Several promising candidates for mAbs are undergoing clinical trials at present. Despite several failures and the investigation of novel targets, mAb therapy provides a glimmer of hope for the treatment of severe bacterial sepsis and septic shock. In this review, mAb candidates, their efficacy against controlling infection, with special emphasis on potential roadblocks, and prospects are discussed.
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Affiliation(s)
- Kusum Kharga
- School of Biotechnology, Faculty of Applied Sciences and Biotechnology, Shoolini University, Solan 173229, Himachal Pradesh, India
| | - Lokender Kumar
- School of Biotechnology, Faculty of Applied Sciences and Biotechnology, Shoolini University, Solan 173229, Himachal Pradesh, India
- Cancer Biology Laboratory, Raj Khosla Centre for Cancer Research, Shoolini University, Solan 173229, Himachal Pradesh, India
- Correspondence: (L.K.); (S.K.S.P.)
| | - Sanjay Kumar Singh Patel
- Department of Chemical Engineering, Konkuk University, Seoul 05029, Republic of Korea
- Correspondence: (L.K.); (S.K.S.P.)
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15
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Pei F, Yao RQ, Ren C, Bahrami S, Billiar TR, Chaudry IH, Chen DC, Chen XL, Cui N, Fang XM, Kang Y, Li WQ, Li WX, Liang HP, Lin HY, Liu KX, Lu B, Lu ZQ, Maegele M, Peng TQ, Shang Y, Su L, Sun BW, Wang CS, Wang J, Wang JH, Wang P, Xie JF, Xie LX, Zhang LN, Zingarelli B, Guan XD, Wu JF, Yao YM. Expert consensus on the monitoring and treatment of sepsis-induced immunosuppression. Mil Med Res 2022; 9:74. [PMID: 36567402 PMCID: PMC9790819 DOI: 10.1186/s40779-022-00430-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/14/2022] [Indexed: 12/27/2022] Open
Abstract
Emerged evidence has indicated that immunosuppression is involved in the occurrence and development of sepsis. To provide clinical practice recommendations on the immune function in sepsis, an expert consensus focusing on the monitoring and treatment of sepsis-induced immunosuppression was developed. Literature related to the immune monitoring and treatment of sepsis were retrieved from PubMed, Web of Science, and Chinese National Knowledge Infrastructure to design items and expert opinions were collected through an online questionnaire. Then, the Delphi method was used to form consensus opinions, and RAND appropriateness method was developed to provide consistency evaluation and recommendation levels for consensus opinions. This consensus achieved satisfactory results through two rounds of questionnaire survey, with 2 statements rated as perfect consistency, 13 as very good consistency, and 9 as good consistency. After summarizing the results, a total of 14 strong recommended opinions, 8 weak recommended opinions and 2 non-recommended opinions were produced. Finally, a face-to-face discussion of the consensus opinions was performed through an online meeting, and all judges unanimously agreed on the content of this consensus. In summary, this expert consensus provides a preliminary guidance for the monitoring and treatment of immunosuppression in patients with sepsis.
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Affiliation(s)
- Fei Pei
- Department of Critical Care Medicine, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Er Road, Yuexiu District, Guangzhou, 510080, Guangdong, China
| | - Ren-Qi Yao
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.,Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China
| | - Chao Ren
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Soheyl Bahrami
- Ludwig-Boltzmann Institute for Experimental and Clinical Traumatology, 1200, Vienna, Austria
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Irshad H Chaudry
- Center for Surgical Research and Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, 35294, USA
| | - De-Chang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, 200025, China
| | - Xu-Lin Chen
- Department of Burns, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xiang-Ming Fang
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 31003, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wei-Qin Li
- Department of Critical Care Medicine, General Hospital of Eastern Theater Command of Chinese PLA, Nanjing, 210002, China
| | - Wen-Xiong Li
- Department of Surgical Intensive Critical Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Hua-Ping Liang
- State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Hong-Yuan Lin
- Department of Critical Care Medicine, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, 100048, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Ben Lu
- Department of Critical Care Medicine and Hematology, the Third Xiangya Hospital, Central South University, Changsha, 410000, China
| | - Zhong-Qiu Lu
- Emergency Department, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Marc Maegele
- Department of Traumatology and Orthopedic Surgery, University Witten-Herdecke, 51109, Cologne, Germany
| | - Tian-Qing Peng
- Critical Illness Research, Lawson Health Research Institute, London Health Sciences Centre, London, ON, N6A 4G4, Canada
| | - You Shang
- Department of Critical Care Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Lei Su
- Department of Intensive Care Unit, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou, 510030, China
| | - Bing-Wei Sun
- Department of Burns and Plastic Surgery, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, 215002, China
| | - Chang-Song Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Jian Wang
- Children's Hospital of Soochow University, Pediatric Research Institute of Soochow University, Suzhou, 215123, China
| | - Jiang-Huai Wang
- Department of Academic Surgery, University College Cork, Cork University Hospital, Cork, T12 E8YV, Ireland
| | - Ping Wang
- Center for Immunology and Inflammation, the Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
| | - Jian-Feng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Li-Xin Xie
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, 100853, China
| | - Li-Na Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 41073, USA
| | - Xiang-Dong Guan
- Department of Critical Care Medicine, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Er Road, Yuexiu District, Guangzhou, 510080, Guangdong, China.
| | - Jian-Feng Wu
- Department of Critical Care Medicine, the First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Er Road, Yuexiu District, Guangzhou, 510080, Guangdong, China. .,Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China.
| | - Yong-Ming Yao
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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16
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Tocut M, Kolitz T, Shovman O, Haviv Y, Boaz M, Laviel S, Debi S, Nama M, Akria A, Shoenfeld Y, Soroksky A, Zandman-Goddard G. Outcomes of ICU patients treated with intravenous immunoglobulin for sepsis or autoimmune diseases. Clin Exp Rheumatol 2022; 21:103205. [PMID: 36195246 DOI: 10.1016/j.autrev.2022.103205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the outcomes of hospitalized patients in two intensive care units (ICU) treated with intravenous immunoglobulin (IVIg) added to standard-of-care therapy. The indications for IVIg therapy were sepsis or autoimmune disease. METHODS We conducted a retrospective study involving adult patients with sepsis and autoimmune diseases, who received IVIg in the ICU at Wolfson and Sheba Medical Centers. A predefined chart was compiled on Excel to include a complete demographic collection, patient comorbidities, chronic medication use, disease severity scores (Charlson Comorbidity Index; SOFA and APACHE II index scores), indication and dosage of IVIg administration, duration of hospitalization and mortality rates. RESULTS Patients (n - 111) were divided into 2 groups: patients with sepsis only (n-67) and patients with autoimmune disease only (n-44). Septic patients had a shorter ICU stay, received IVIg early, and had reduced mortality if treated with high dose IVIg. Patients with autoimmune diseases did not have a favorable outcome despite IVIg treatment. In this group, IVIg was administered later than in the sepsis group. CONCLUSIONS IVIg therapy improved the outcomes for ICU patients with sepsis.
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Affiliation(s)
- Milena Tocut
- Department of Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases
| | - Tamara Kolitz
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center
| | - Ora Shovman
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases; Department of Medicine B
| | - Yael Haviv
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Intensive Care Unit, Sheba Medical Center, Israel
| | - Mona Boaz
- Nutrition Sciences Department, Ariel University, Israel
| | - Shira Laviel
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Stav Debi
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Mona Nama
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Amir Akria
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases; Ariel University, Ariel, Israel; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Arie Soroksky
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Intensive Care Unit, Wolfson Medical Center, Israel
| | - Gisele Zandman-Goddard
- Department of Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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17
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Beudeker CR, Vijlbrief DC, van Montfrans J, Rooijakkers SH, van der Flier M. Neonatal sepsis and transient immunodeficiency: Potential for novel immunoglobulin therapies? Front Immunol 2022; 13:1016877. [PMID: 36330515 PMCID: PMC9623314 DOI: 10.3389/fimmu.2022.1016877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/04/2022] [Indexed: 10/30/2023] Open
Abstract
Neonates, especially preterm neonates, have the highest risk of sepsis of all age groups. Transient immaturity of the neonatal immune system is an important risk factor. Neonates suffer from hypogammaglobulinemia as nor IgA nor IgM is transferred over the placenta and IgG is only transferred over the placenta late in gestation. In addition, neutrophil numbers and complement function are also decreased. This mini-review focuses on strategies to improve neonatal host-defense. Both clinical and preclinical studies have attempted to boost neonatal immunity to lower the incidence of sepsis and improve outcome. Recent advances in the development of (monoclonal) antibodies show promising results in preclinical studies but have yet to be tested in clinical trials. Strategies to increase complement activity seem efficient in vitro but potential disadvantages such as hyperinflammation have held back further clinical development. Increase of neutrophil numbers has been tested extensively in clinical trials but failed to show improvement in mortality. Future research should focus on clinical applicability of promising new prevention strategies for neonatal sepsis.
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Affiliation(s)
- Coco R. Beudeker
- Department of Pediatric Infectious Diseases and Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Daniel C. Vijlbrief
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joris M. van Montfrans
- Department of Pediatric Infectious Diseases and Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Suzan H.M. Rooijakkers
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michiel van der Flier
- Department of Pediatric Infectious Diseases and Immunology, University Medical Center Utrecht, Utrecht, Netherlands
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18
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Pletz MW, Jensen AV, Bahrs C, Davenport C, Rupp J, Witzenrath M, Barten-Neiner G, Kolditz M, Dettmer S, Chalmers JD, Stolz D, Suttorp N, Aliberti S, Kuebler WM, Rohde G. Unmet needs in pneumonia research: a comprehensive approach by the CAPNETZ study group. Respir Res 2022; 23:239. [PMID: 36088316 PMCID: PMC9463667 DOI: 10.1186/s12931-022-02117-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Despite improvements in medical science and public health, mortality of community-acquired pneumonia (CAP) has barely changed throughout the last 15 years. The current SARS-CoV-2 pandemic has once again highlighted the central importance of acute respiratory infections to human health. The “network of excellence on Community Acquired Pneumonia” (CAPNETZ) hosts the most comprehensive CAP database worldwide including more than 12,000 patients. CAPNETZ connects physicians, microbiologists, virologists, epidemiologists, and computer scientists throughout Europe. Our aim was to summarize the current situation in CAP research and identify the most pressing unmet needs in CAP research.
Methods
To identify areas of future CAP research, CAPNETZ followed a multiple-step procedure. First, research members of CAPNETZ were individually asked to identify unmet needs. Second, the top 100 experts in the field of CAP research were asked for their insights about the unmet needs in CAP (Delphi approach). Third, internal and external experts discussed unmet needs in CAP at a scientific retreat.
Results
Eleven topics for future CAP research were identified: detection of causative pathogens, next generation sequencing for antimicrobial treatment guidance, imaging diagnostics, biomarkers, risk stratification, antiviral and antibiotic treatment, adjunctive therapy, vaccines and prevention, systemic and local immune response, comorbidities, and long-term cardio-vascular complications.
Conclusion
Pneumonia is a complex disease where the interplay between pathogens, immune system and comorbidities not only impose an immediate risk of mortality but also affect the patients’ risk of developing comorbidities as well as mortality for up to a decade after pneumonia has resolved. Our review of unmet needs in CAP research has shown that there are still major shortcomings in our knowledge of CAP.
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19
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Li Q, Zhang X, Chen B, Ji Y, Chen W, Cai S, Xu M, Yu M, Bao Q, Li C, Zhang H. Early predictors of lung necrosis severity in children with community-acquired necrotizing pneumonia. Pediatr Pulmonol 2022; 57:2172-2179. [PMID: 35686616 DOI: 10.1002/ppul.26020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/17/2022] [Accepted: 05/29/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To analyze baseline clinical and laboratory characteristics and explore the possible predictors of lung necrosis severity in children with community-acquired necrotizing pneumonia (NP). METHODOLOGY This retrospective observational study was performed in a tertiary referral center. A total of 104 patients aged <15 years with community-acquired pneumonia and radiologically confirmed NP by computed tomography (CT) were included. Patients were classified into the mild, moderate, or massive necrosis groups. RESULTS Among them, 29, 41, and 34 patients had mild, moderate, and massive necrosis, respectively. Moreover, 34.6% of the patients were admitted to pediatric intensive care unit. Massive necrosis was more likely to occur during winter (p < 0.05) and was associated with more severe clinical outcomes, such as longer duration of fever, longer hospitalization, increased mortality, and a higher risk of subsequent surgical intervention (p < 0.05). Multivariate analysis demonstrated that the following were independent risk factors for massive necrosis in this study: C-reactive protein (CRP) (p = 0.036), serum albumin (p = 0.009), and immunoglobulin M (IgM) (p = 0.022). Receiver operating characteristic analysis showed that when the cut-off value for CRP, serum albumin, and IgM were set at 122 mg/L, 30.8 g/L, and 95.7 mg/dl, respectively, they showed good diagnostic performance for differentiating patients with massive necrosis from all patients with NP. CONCLUSION NP is a potentially severe complication of pediatric community-acquired pneumonia. Different severities of lung necrosis can lead to different clinical outcomes. CRP, serum albumin, and IgM levels are independent predictors of the degree of lung necrosis.
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Affiliation(s)
- Qiaoling Li
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China.,Institute of Biomedical Informatics, School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China
| | - Xueya Zhang
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China.,Institute of Biomedical Informatics, School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China
| | - Bo Chen
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yongan Ji
- Department of Clinical Laboratory, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Wei Chen
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Shujing Cai
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Ming Xu
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Mingwei Yu
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Qiyu Bao
- Institute of Biomedical Informatics, School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Medical Genetics of Zhejiang Province, Key Laboratory of Laboratory Medicine, Ministry of Education of China, School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China.,Department of Laboratory Sciences, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Changchong Li
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Hailin Zhang
- Department of Pediatric Respiratory Disease, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China.,Institute of Biomedical Informatics, School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China
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20
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McCulloch L, Harris AJ, Malbon A, Daniels MJD, Younas M, Grainger JR, Allan SM, Smith CJ, McColl BW. Treatment with IgM-enriched intravenous immunoglobulins (IgM-IVIg) enhances clearance of stroke-associated bacterial lung infection. Immunol Suppl 2022; 167:558-575. [PMID: 35881080 DOI: 10.1111/imm.13553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/03/2022] [Indexed: 11/29/2022]
Abstract
Post-stroke infection is a common complication of stroke that is associated with poor outcome. We previously reported that stroke induces an ablation of multiple sub-populations of B cells and reduces levels of IgM antibody, which coincides with the development of spontaneous bacterial pneumonia. The loss of IgM after stroke could be an important determinant of infection susceptibility and highlights this pathway as a target for intervention. We treated mice with a replacement dose of IgM-enriched intravenous immunoglobulin (IgM-IVIg) prior to and 24 h after middle cerebral artery occlusion (MCAO) and allowed them to recover for 2 d or 5 d post-surgery. Treatment with IgM-IVIg enhanced bacterial clearance from the lung after MCAO and improved lung pathology but did not impact brain infarct volume. IgM-IVIg treatment induced immunomodulatory effects systemically, including rescue of splenic plasma B cell numbers and endogenous mouse IgM and IgA circulating immunoglobulin concentrations that were reduced by MCAO. Treatment attenuated MCAO-induced elevation of selected pro-inflammatory cytokines in the lung. IgM-IVIg treatment did not increase the number of lung mononuclear phagocytes or directly modulate macrophage phagocytic capacity but enhanced phagocytosis of Staphylococcus aureus bioparticles in vitro. Low dose IgM-IVIg contributes to increased clearance of spontaneous lung bacteria after MCAO likely via increasing availability of antibody in the lung to enhance opsonophagocytic activity. Immunomodulatory effects of IgM-IVIg treatment may also contribute to reduced levels of damage in the lung after MCAO. IgM-IVIg shows promise as an antibacterial and immunomodulatory agent to use in the treatment of post-stroke infection.
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Affiliation(s)
- Laura McCulloch
- Centre for Inflammation Research, University of Edinburgh, Edinburgh
| | - Alison J Harris
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Alexandra Malbon
- Easter Bush Pathology, The Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Easter Bush Campus, Roslin, Midlothian
| | | | - Mehwish Younas
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester.,Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester
| | - John R Grainger
- Lydia Becker Institute of Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester.,Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester.,Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester
| | - Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester.,Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester
| | - Barry W McColl
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
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21
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Strohl WR, Ku Z, An Z, Carroll SF, Keyt BA, Strohl LM. Passive Immunotherapy Against SARS-CoV-2: From Plasma-Based Therapy to Single Potent Antibodies in the Race to Stay Ahead of the Variants. BioDrugs 2022; 36:231-323. [PMID: 35476216 PMCID: PMC9043892 DOI: 10.1007/s40259-022-00529-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/15/2022]
Abstract
The COVID-19 pandemic is now approaching 2 years old, with more than 440 million people infected and nearly six million dead worldwide, making it the most significant pandemic since the 1918 influenza pandemic. The severity and significance of SARS-CoV-2 was recognized immediately upon discovery, leading to innumerable companies and institutes designing and generating vaccines and therapeutic antibodies literally as soon as recombinant SARS-CoV-2 spike protein sequence was available. Within months of the pandemic start, several antibodies had been generated, tested, and moved into clinical trials, including Eli Lilly's bamlanivimab and etesevimab, Regeneron's mixture of imdevimab and casirivimab, Vir's sotrovimab, Celltrion's regdanvimab, and Lilly's bebtelovimab. These antibodies all have now received at least Emergency Use Authorizations (EUAs) and some have received full approval in select countries. To date, more than three dozen antibodies or antibody combinations have been forwarded into clinical trials. These antibodies to SARS-CoV-2 all target the receptor-binding domain (RBD), with some blocking the ability of the RBD to bind human ACE2, while others bind core regions of the RBD to modulate spike stability or ability to fuse to host cell membranes. While these antibodies were being discovered and developed, new variants of SARS-CoV-2 have cropped up in real time, altering the antibody landscape on a moving basis. Over the past year, the search has widened to find antibodies capable of neutralizing the wide array of variants that have arisen, including Alpha, Beta, Gamma, Delta, and Omicron. The recent rise and dominance of the Omicron family of variants, including the rather disparate BA.1 and BA.2 variants, demonstrate the need to continue to find new approaches to neutralize the rapidly evolving SARS-CoV-2 virus. This review highlights both convalescent plasma- and polyclonal antibody-based approaches as well as the top approximately 50 antibodies to SARS-CoV-2, their epitopes, their ability to bind to SARS-CoV-2 variants, and how they are delivered. New approaches to antibody constructs, including single domain antibodies, bispecific antibodies, IgA- and IgM-based antibodies, and modified ACE2-Fc fusion proteins, are also described. Finally, antibodies being developed for palliative care of COVID-19 disease, including the ramifications of cytokine release syndrome (CRS) and acute respiratory distress syndrome (ARDS), are described.
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Affiliation(s)
| | - Zhiqiang Ku
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, The University of Texas Health Sciences Center, Houston, TX USA
| | - Zhiqiang An
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, The University of Texas Health Sciences Center, Houston, TX USA
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22
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Abstract
Despite its heterogeneous phenotypes, sepsis or life-threatening dysfunction in response to infection is often treated empirically. Identifying patient subgroups with unique pathophysiology and treatment response is critical to the advancement of sepsis care. However, phenotyping methods and results are as heterogeneous as the disease itself. This scoping review evaluates the prognostic capabilities and treatment implications of adult sepsis and septic shock phenotyping methods. DATA SOURCES Medline and Embase. STUDY SELECTION We included clinical studies that described sepsis or septic shock and used any clustering method to identify sepsis phenotypes. We excluded conference abstracts, literature reviews, comments, letters to the editor, and in vitro studies. We assessed study quality using a validated risk of bias tool for observational cohort and cross-sectional studies. DATA EXTRACTION We extracted population, methodology, validation, and phenotyping characteristics from 17 studies. DATA SYNTHESIS Sepsis phenotyping methods most frequently grouped patients based on the degree of inflammatory response and coagulopathy using clinical, nongenomic variables. Five articles clustered patients based on genomic or transcriptomic data. Seven articles generated patient subgroups with differential response to sepsis treatments. Cluster clinical characteristics and their associations with mortality and treatment response were heterogeneous across studies, and validity was evaluated in nine of 17 articles, hindering pooled analysis of results and derivation of universal truths regarding sepsis phenotypes, their prognostic capabilities, and their associations with treatment response. CONCLUSIONS Sepsis phenotyping methods can identify high-risk patients and those with high probability of responding well to targeted treatments. Research quality was fair, but achieving generalizability and clinical impact of sepsis phenotyping will require external validation and direct comparison with alternative approaches.
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23
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Kindgen-Milles D, Feldt T, Jensen BEO, Dimski T, Brandenburger T. Why the application of IVIG might be beneficial in patients with COVID-19. THE LANCET RESPIRATORY MEDICINE 2022; 10:e15. [PMID: 35120611 PMCID: PMC8806196 DOI: 10.1016/s2213-2600(21)00549-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022]
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24
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Mazeraud A, Wolff M, Lucas B, Sharshar T. Why the application of IVIG might be beneficial in patients with COVID-19 – Authors' reply. THE LANCET RESPIRATORY MEDICINE 2022; 10:e16. [PMID: 35120612 PMCID: PMC8806197 DOI: 10.1016/s2213-2600(21)00550-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Aurélien Mazeraud
- Service d'Anesthésie-Réanimation, Groupe Hospitalier Université Paris Psychiatrie et Neurosciences, Pôle Neuro, 75014 Paris, France; Department of Neurosiences, Université de Paris, Paris, France.
| | - Michel Wolff
- Service d'Anesthésie-Réanimation, Groupe Hospitalier Université Paris Psychiatrie et Neurosciences, Pôle Neuro, 75014 Paris, France; Department of Neurosiences, Université de Paris, Paris, France
| | - Bruno Lucas
- Institut Cochin, Centre National de la Recherche Scientifique UMR8104, INSERM U1016, Paris, France
| | - Tarek Sharshar
- Service d'Anesthésie-Réanimation, Groupe Hospitalier Université Paris Psychiatrie et Neurosciences, Pôle Neuro, 75014 Paris, France; Department of Neurosiences, Université de Paris, Paris, France
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25
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Stahl K, Bode C, David S. Extrakorporale Behandlungsstrategien der Sepsis. TRANSFUSIONSMEDIZIN 2022. [DOI: 10.1055/a-1557-3201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Zusammenfassung
Hintergrund Die Mortalität der Sepsis bleibt auch im 21. Jahrhundert sehr hoch. Verschiedene adjuvante Strategien zur extrakorporalen Zytokinelimination wurden als zusätzliche
therapeutische Maßnahmen bei Sepsis und septischem Schock untersucht.
Ziele Zusammenfassung einer Auswahl extrakorporaler Blutreinigungstechniken und der aktuellen Erkenntnisse in der klinischen Anwendung mit besonderem Schwerpunkt auf dem
therapeutischen Plasmaaustausch.
Methoden Nicht systematische Literaturrecherche.
Ergebnisse Verschiedene extrakorporale Blutreinigungstechniken mit unterschiedlichen Evidenzniveaus hinsichtlich Zytokinelimination, Verbesserung der Hämodynamik und Verringerung der
Mortalität werden derzeit klinisch eingesetzt. Die am ausführlichsten untersuchten Modalitäten umfassen die hochvolumige Hämofiltration/Dialyse mit und ohne High-Cut-off-Filter sowie
Hämoadsorptionstechniken (einschließlich CytoSorb- und Polymyxin-B-Filter). Trotz teilweise ermutigender Beobachtungen bezüglich der Entfernung proinflammatorischer Zytokine und verbesserten
Hämodynamik zeigten randomisierte Outcome-Studien bislang keinen positiven Einfluss auf das Überleben. Aufgrund der Verwendung von Spenderplasma als Substitutionsflüssigkeit stellt der
therapeutische Plasmaaustausch das einzige Verfahren dar, das neben einer reinen Elimination zusätzlich verbrauchte protektive Faktoren ersetzen kann.
Schlussfolgerungen Die Anwendung extrakorporaler Blutreinigungsmethoden kann für Sepsispatienten außerhalb klinischer Studien bisher nicht empfohlen werden, da derzeit keine Beweise
für ihre Wirksamkeit vorliegen. Zukünftige Untersuchungen sollten darauf abzielen, das Patientenkollektiv hinsichtlich des klinischen Schweregrads, des Zeitpunkts der Intervention und
verschiedener inflammatorischer (Sub-)Phänotypen zu homogenisieren.
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Affiliation(s)
- Klaus Stahl
- Abteilung für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Deutschland
| | - Christian Bode
- Klinik für Anästhesie und operative Intensivmedizin, Universitätsklinikum Bonn, Deutschland
| | - Sascha David
- Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover & Institut für Intensivmedizin, Universitätsspital Zürich, Schweiz
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26
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Ruiz-Rodriguez JC, Plata-Menchaca EP, Chiscano-Camón L, Ruiz-Sanmartin A, Pérez-Carrasco M, Palmada C, Ribas V, Martínez-Gallo M, Hernández-González M, Gonzalez-Lopez JJ, Larrosa N, Ferrer R. Precision medicine in sepsis and septic shock: From omics to clinical tools. World J Crit Care Med 2022; 11:1-21. [PMID: 35433311 PMCID: PMC8788206 DOI: 10.5492/wjccm.v11.i1.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/23/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
Sepsis is a heterogeneous disease with variable clinical course and several clinical phenotypes. As it is associated with an increased risk of death, patients with this condition are candidates for receipt of a very well-structured and protocolized treatment. All patients should receive the fundamental pillars of sepsis management, which are infection control, initial resuscitation, and multiorgan support. However, specific subgroups of patients may benefit from a personalized approach with interventions targeted towards specific pathophysiological mechanisms. Herein, we will review the framework for identifying subpopulations of patients with sepsis, septic shock, and multiorgan dysfunction who may benefit from specific therapies. Some of these approaches are still in the early stages of research, while others are already in routine use in clinical practice, but together will help in the effective generation and safe implementation of precision medicine in sepsis.
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Affiliation(s)
- Juan Carlos Ruiz-Rodriguez
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona 08036, Spain
| | - Luis Chiscano-Camón
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Adolfo Ruiz-Sanmartin
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Marcos Pérez-Carrasco
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
| | - Clara Palmada
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
| | - Vicent Ribas
- Data Analytics in Medicine, Digital Health Unit, Eurecat, Centre Tecnològic de Catalunya, Barcelona 08005, Spain
| | - Mónica Martínez-Gallo
- Immunology Division, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Diagnostic Immunology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Manuel Hernández-González
- Immunology Division, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Diagnostic Immunology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Juan J Gonzalez-Lopez
- Department of Clinical Microbiology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Microbiology and Genetics, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Nieves Larrosa
- Department of Clinical Microbiology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Department of Microbiology and Genetics, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona 08035, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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27
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Zhang J, Zhang H, Sun L. Therapeutic antibodies for COVID-19: is a new age of IgM, IgA and bispecific antibodies coming? MAbs 2022; 14:2031483. [PMID: 35220888 PMCID: PMC8890389 DOI: 10.1080/19420862.2022.2031483] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 12/23/2022] Open
Abstract
Early humoral immune responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are dominated by IgM and IgA antibodies, which greatly contribute to virus neutralization at mucosal sites. Given the essential roles of IgM and IgA in the control and elimination of SARS-CoV-2 infection, the mucosal immunity could be exploited for therapeutic and prophylactic purposes. However, almost all neutralizing antibodies that are authorized for emergency use and under clinical development are IgG antibodies, and no vaccine has been developed to boost mucosal immunity for SARS-CoV-2 infection. In addition to IgM and IgA, bispecific antibodies (bsAbs) combine specificities of two antibodies in one molecule, representing an important alternative to monoclonal antibody cocktails. Here, we summarize the latest advances in studies on IgM, IgA and bsAbs against SARS-CoV-2. The current challenges and future directions in vaccine design and antibody-based therapeutics are also discussed.
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Affiliation(s)
- Jingjing Zhang
- Department of Pathogens and Infectious Disease Prevention and Control, School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107China
| | - Han Zhang
- Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, Yunnan, China, 650118
| | - Litao Sun
- Department of Pathogens and Infectious Disease Prevention and Control, School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107China
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28
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Wiebe F, Handtke S, Wesche J, Schnarre A, Palankar R, Wolff M, Jahn K, Voß F, Weißmüller S, Schüttrumpf J, Greinacher A, Hammerschmidt S. Polyvalent immunoglobulin preparations inhibit pneumolysin-induced platelet destruction. Thromb Haemost 2021; 122:1147-1158. [PMID: 34918314 PMCID: PMC9385248 DOI: 10.1055/a-1723-1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Platelets play an important role in the development and progression of respiratory distress. Functional platelets are known to seal inflammatory endothelial gaps and loss of platelet function has been shown to result in loss of integrity of pulmonary vessels. This leads to fluid accumulation in the pulmonary interstitium, eventually resulting in respiratory distress.
Streptococcus pneumoniae
is one of the major pathogens causing community-acquired pneumonia. Previously, we have shown that its major toxin pneumolysin forms pores in platelet membranes and renders them nonfunctional. In vitro, this process was inhibited by polyvalent intravenous immunoglobulins (IVIGs). In this study, we compared the efficacy of a standard IVIG preparation (IVIG, 98% immunoglobulin G [IgG]; Privigen, CSL Behring, United States) and an IgM/IgA-enriched immunoglobulin preparation (21% IgA, 23% IgM, 56% IgG; trimodulin, Biotest AG, Germany) to inhibit pneumolysin-induced platelet destruction. Platelet destruction and functionality were assessed by flow cytometry, intracellular calcium release, aggregometry, platelet viability, transwell, and flow chamber assays. Overall, both immunoglobulin preparations efficiently inhibited pneumolysin-induced platelet destruction. The capacity to antagonize pneumolysin mainly depended on the final IgG content. As both polyvalent immunoglobulin preparations efficiently prevent pneumolysin-induced platelet destruction and maintain platelet function in vitro, they represent promising candidates for clinical studies on supportive treatment of pneumococcal pneumonia to reduce progression of respiratory distress.
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Affiliation(s)
- Friederike Wiebe
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Handtke
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jan Wesche
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Annabel Schnarre
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Raghavendra Palankar
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Martina Wolff
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Kristin Jahn
- Department of Molecular Genetics and Infection Biology, Universität Greifswald Mathematisch-Naturwissenschaftliche Fakultät, Greifswald, Germany
| | - Franziska Voß
- Department of Molecular Genetics and Infection Biology, Universität Greifswald Mathematisch-Naturwissenschaftliche Fakultät, Greifswald, Germany
| | | | - Jörg Schüttrumpf
- Department of Research & Development, Biotest AG, Dreieich, Germany
| | - Andreas Greinacher
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Universität Greifswald Mathematisch-Naturwissenschaftliche Fakultät, Greifswald, Germany
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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30
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Bohländer F, Weißmüller S, Riehl D, Gutscher M, Schüttrumpf J, Faust S. The Functional Role of IgA in the IgM/IgA-Enriched Immunoglobulin Preparation Trimodulin. Biomedicines 2021; 9:1828. [PMID: 34944644 PMCID: PMC8698729 DOI: 10.3390/biomedicines9121828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
In comparison to human immunoglobulin (Ig) G, antibodies of IgA class are not well investigated. In line with this, the functional role of the IgA component in IgM/IgA-enriched immunoglobulin preparations is also largely unknown. In recent years, powerful anti-pathogenic and immunomodulatory properties of human serum IgA especially on neutrophil function were unraveled. Therefore, the aim of our work is to investigate functional aspects of the trimodulin IgA component, a new plasma-derived polyvalent immunoglobulin preparation containing ~56% IgG, ~23% IgM and ~21% IgA. The functional role of IgA was investigated by analyzing the interaction of IgA with FcαRI, comparing trimodulin with standard intravenous IgG (IVIG) preparation and investigating Fc receptor (FcR)-dependent functions by excluding IgM-mediated effects. Trimodulin demonstrated potent immunomodulatory, as well as anti-pathogenic effects in our neutrophil model (neutrophil-like HL-60 cells). The IgA component of trimodulin was shown to induce a strong FcαRI-dependent inhibitory immunoreceptor tyrosine-based activation motif (ITAMi) signaling, counteract lipopolysaccharide-induced inflammation and mediate phagocytosis of Staphylococcus aureus. The fine-tuned balance between immunomodulatory and anti-pathogenic effects of trimodulin were shown to be dose-dependent. Summarized, our data demonstrate the functional role of IgA in trimodulin, highlighting the importance of this immunoglobulin class in immunoglobulin therapy.
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Affiliation(s)
- Fabian Bohländer
- Department of Analytical Development and Validation, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (F.B.); (D.R.); (M.G.)
| | - Sabrina Weißmüller
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Dennis Riehl
- Department of Analytical Development and Validation, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (F.B.); (D.R.); (M.G.)
| | - Marcus Gutscher
- Department of Analytical Development and Validation, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (F.B.); (D.R.); (M.G.)
| | - Jörg Schüttrumpf
- Corporate R&D, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Stefanie Faust
- Department of Analytical Development and Validation, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (F.B.); (D.R.); (M.G.)
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31
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 831] [Impact Index Per Article: 277.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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32
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1341] [Impact Index Per Article: 447.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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33
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Scott J, Ruchaud-Sparagano MH, Musgrave K, Roy AI, Wright SE, Perry JD, Conway Morris A, Rostron AJ, Simpson AJ. Phosphoinositide 3-Kinase δ Inhibition Improves Neutrophil Bacterial Killing in Critically Ill Patients at High Risk of Infection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 207:1776-1784. [PMID: 34497151 DOI: 10.4049/jimmunol.2000603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/20/2021] [Indexed: 11/19/2022]
Abstract
Acquired neutrophil dysfunction frequently develops during critical illness, independently increasing the risk for intensive care unit-acquired infection. PI3Kδ is implicated in driving neutrophil dysfunction and can potentially be targeted pharmacologically. The aims of this study were to determine whether PI3Kδ inhibition reverses dysfunction in neutrophils from critically ill patients and to describe potential mechanisms. Neutrophils were isolated from blood taken from critically ill patients requiring intubation and mechanical ventilation, renal support, or blood pressure support. In separate validation experiments, neutrophil dysfunction was induced pharmacologically in neutrophils from healthy volunteers. Phagocytosis and bacterial killing assays were performed, and activity of RhoA and protein kinase A (PKA) was assessed. Inhibitors of PI3Kδ, 3-phosphoinositide-dependent protein kinase-1 (PDK1), and PKA were used to determine mechanisms of neutrophil dysfunction. Sixty-six patients were recruited. In the 27 patients (40.9%) with impaired neutrophil function, PI3Kδ inhibition consistently improved function and significantly increased bacterial killing. These findings were validated in neutrophils from healthy volunteers with salbutamol-induced dysfunction and extended to demonstrate that PI3Kδ inhibition restored killing of clinical isolates of nine pathogens commonly associated with intensive care unit-acquired infection. PI3Kδ activation was associated with PDK1 activation, which in turn phosphorylated PKA, which drove phosphorylation and inhibition of the key regulator of neutrophil phagocytosis, RhoA. These data indicate that, in a significant proportion of critically ill patients, PI3Kδ inhibition can improve neutrophil function through PDK1- and PKA-dependent processes, suggesting that therapeutic use of PI3Kδ inhibitors warrants investigation in this setting.
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Affiliation(s)
- Jonathan Scott
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Marie-Hélène Ruchaud-Sparagano
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kathryn Musgrave
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - John D Perry
- Microbiology Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; and
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - A John Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom;
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34
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IgM Immunoglobulin Influences Recovery after Cervical Spinal Cord Injury by Modulating the IgG Autoantibody Response. eNeuro 2021; 8:ENEURO.0491-19.2021. [PMID: 34413082 PMCID: PMC8431822 DOI: 10.1523/eneuro.0491-19.2021] [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: 11/25/2019] [Revised: 06/06/2021] [Accepted: 06/10/2021] [Indexed: 12/24/2022] Open
Abstract
Spinal cord injury (SCI) results in the development of detrimental autoantibodies against the lesioned spinal cord. IgM immunoglobulin maintains homeostasis against IgG-autoantibody responses, but its effect on SCI recovery remains unknown. In the present study we investigated the role of IgM immunoglobulin in influencing recovery after SCI. To this end, we induced cervical SCI at the C6/C7 level in mice that lacked secreted IgM immunoglobulin [IgM-knock-out (KO)] and their wild-type (WT) littermate controls. Overall, the absence of secretory IgM resulted in worse outcomes as compared with WT mice with SCI. At two weeks after injury, IgM-KO mice had significantly more IgG antibodies, which fixed the complement system, in the injured spinal cord parenchyma. In addition to these findings, IgM-KO mice had more parenchymal T-lymphocytes as well as CD11b+ microglia/macrophages, which co-localized with myelin. At 10 weeks after injury, IgM-KO mice showed significant impairment in neurobehavioral recovery, such as deteriorated coordination, reduced hindlimb swing speed and print area. These neurobehavioral detriments were coupled with increased lesional tissue and myelin loss. Taken together, this study provides the first evidence for the importance of IgM immunoglobulin in modulating recovery after SCI and suggests that modulating IgM could be a novel therapeutic approach to enhance recovery after SCI.
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35
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Coloretti I, Berlot G, Busani S, De Rosa FG, Donati A, Forfori F, Grasselli G, Mirabella L, Tascini C, Viale P, Girardis M. Rationale for Polyclonal Intravenous Immunoglobulin Adjunctive Therapy in COVID-19 Patients: Report of a Structured Multidisciplinary Consensus. J Clin Med 2021; 10:jcm10163500. [PMID: 34441796 PMCID: PMC8396919 DOI: 10.3390/jcm10163500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction: Adjunctive therapy with polyclonal intravenous immunoglobins (IVIg) is currently used for preventing or managing infections and sepsis, especially in immunocompromised patients. The pathobiology of COVID-19 and the mechanisms of action of Ig led to the consideration of this adjunctive therapy, including in patients with respiratory failure due to the SARS-CoV-2 infection. This manuscript reports the rationale, the available data and the results of a structured consensus on intravenous Ig therapy in patients with severe COVID-19. Methods: A panel of multidisciplinary experts defined the clinical phenotypes of COVID-19 patients with severe respiratory failure and, after literature review, voted for the agreement on the rationale and the potential role of IVIg therapy for each phenotype. Due to the scarce evidence available, a modified RAND/UCLA appropriateness method was used. Results: Three different phenotypes of COVID-19 patients with severe respiratory failure were identified: patients with an abrupt and dysregulated hyperinflammatory response (early phase), patients with suspected immune paralysis (late phase) and patients with sepsis due to a hospital-acquired superinfection (sepsis by bacterial superinfection). The rationale for intravenous Ig therapy in the early phase was considered uncertain whereas the panelists considered its use in the late phase and patients with sepsis/septic shock by bacterial superinfection appropriate. Conclusion: As with other immunotherapies, IVIg adjunctive therapy may have a potential role in the management of COVID-19 patients. The ongoing trials will clarify the appropriate target population and the true effectiveness.
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Affiliation(s)
- Irene Coloretti
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
| | - Giorgio Berlot
- Anestesia and Intensive Care Department, University Hospital of Trieste, 34127 Trieste, Italy;
| | - Stefano Busani
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
| | | | - Abele Donati
- Anaesthesia and Intensive Care Department, University Hospital of Ancona, 60127 Ancona, Italy;
| | - Francesco Forfori
- Anaesthesia and Intensive Care Department, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Giacomo Grasselli
- Anaesthesia and Intensive Care Department, University Hospital of Milan, 20122 Milano, Italy;
| | - Lucia Mirabella
- Anaesthesia and Intensive Care Department, University Hospital of Foggia, 71122 Foggia, Italy;
| | - Carlo Tascini
- Infectious Disease Department, University Hospital of Udine, 33100 Udine, Italy;
| | - Pierluigi Viale
- Infectious Disease Department, University Hospital of Bologna, 40126 Bologna, Italy;
| | - Massimo Girardis
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
- Correspondence:
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36
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Schmidt C, Weißmüller S, Bohländer F, Germer M, König M, Staus A, Wartenberg-Demand A, Heinz CC, Schüttrumpf J. The Dual Role of a Polyvalent IgM/IgA-Enriched Immunoglobulin Preparation in Activating and Inhibiting the Complement System. Biomedicines 2021; 9:817. [PMID: 34356880 PMCID: PMC8301464 DOI: 10.3390/biomedicines9070817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
Activation of the complement system is important for efficient clearance of a wide variety of pathogens via opsonophagocytosis, or by direct lysis via complement-dependent cytotoxicity (CDC). However, in severe infections dysregulation of the complement system contributes to hyperinflammation. The influence of the novel IgM/IgA-enriched immunoglobulin preparation trimodulin on the complement pathway was investigated in in vitro opsonophagocytosis, binding and CDC assays. Immunoglobulin levels before and after trimodulin treatment were placed in relation to complement assessments in humans. In vitro, trimodulin activates complement and induces opsonophagocytosis, but also interacts with opsonins C3b, C4b and anaphylatoxin C5a in a concentration-dependent manner. This was not observed for standard intravenous IgG preparation (IVIg). Accordingly, trimodulin, but not IVIg, inhibited the downstream CDC pathway and target cell lysis. If applied at a similar concentration range in healthy subjects, trimodulin treatment resulted in C3 and C4 consumption in a concentration-dependent manner, which was extended in patients with severe community-acquired pneumonia. Complement consumption is found to be dependent on underlying immunoglobulin levels, particularly IgM, pinpointing their regulative function in humans. IgM/IgA provide a balancing effect on the complement system. Trimodulin may enhance phagocytosis and opsonophagocytosis in patients with severe infections and prevent excessive pathogen lysis and release of harmful anaphylatoxins.
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Affiliation(s)
- Carolin Schmidt
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (C.S.); (M.K.)
| | - Sabrina Weißmüller
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (C.S.); (M.K.)
| | - Fabian Bohländer
- Department of Analytical Development and Validation, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Matthias Germer
- Preclinical Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Martin König
- Department of Translational Research, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany; (C.S.); (M.K.)
| | - Alexander Staus
- Corporate Biostatistics, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Andrea Wartenberg-Demand
- Corporate Clinical Research & Development, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Corina C. Heinz
- Clinical Strategy & Development, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
| | - Jörg Schüttrumpf
- Corporate R&D, Biotest AG, Landsteinerstraße 5, 63303 Dreieich, Germany;
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37
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"Impact of pentaglobin in severe COVID 19 pneumonia- a prospective study.". Int Immunopharmacol 2021; 99:107968. [PMID: 34304002 PMCID: PMC8270756 DOI: 10.1016/j.intimp.2021.107968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/24/2021] [Accepted: 07/06/2021] [Indexed: 11/25/2022]
Abstract
Background The current COVID-19 pandemic has become a global public health crisis and presents a serious challenge in treatment of severe COVID pneumonia patients. With an imperative need for an effective treatment, we aimed to study the effectiveness of Pentaglobin, an intravenous immunoglobin in the treatment of severe Covid-19 pneumonia patients. Methods This is an open-label non-randomised controlled study. Patients in the study group (n = 17) received Pentaglobin in addition to standard therapy and the control group (n = 19) received only the standard of care treatment. Severity of illness were quantified by severity scores and inflammatory laboratory parameters were compared between the two groups. Results The average length of hospital stay in pentaglobin group were 12.35 ± 6.98 days compared to 10.94 ± 4.62 days in standard treatment group with mean difference of 1.4 days (p value = 0.4). Pentaglobin did not provide an added advantage in terms of reducing the duration of hospital stay. There was no significant difference between both the groups in terms of requirement of invasive ventilation (p = 0.56) and mortality (p = 0.86). CT Severity score (OR = 1.39 95% CI = 1.09–1.77, P = 0.01), APACHE II score (OR = 1.16 95% CI = 0.99–1.35, P = 0.05) and the SOFA score (OR = 2.11 95% CI = 1.13–3.93, P = 0.02) were independent predictors of mortality. Conclusion The administration of pentaglobin in COVID −19 patients has no significant effect in reducing the risk of mechanical ventilation or death, in disease worsening or in reduction of inflammation.
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38
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Bohländer F, Riehl D, Weißmüller S, Gutscher M, Schüttrumpf J, Faust S. Immunomodulation: Immunoglobulin Preparations Suppress Hyperinflammation in a COVID-19 Model via FcγRIIA and FcαRI. Front Immunol 2021; 12:700429. [PMID: 34177967 PMCID: PMC8223875 DOI: 10.3389/fimmu.2021.700429] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/21/2021] [Indexed: 12/13/2022] Open
Abstract
The rapid spread of SARS-CoV-2 has induced a global pandemic. Severe forms of COVID-19 are characterized by dysregulated immune response and "cytokine storm". The role of IgG and IgM antibodies in COVID-19 pathology is reasonably well studied, whereas IgA is neglected. To improve clinical outcome of patients, immune modulatory drugs appear to be beneficial. Such drugs include intravenous immunoglobulin preparations, which were successfully tested in severe COVID-19 patients. Here we established a versatile in vitro model to study inflammatory as well as anti-inflammatory processes by therapeutic human immunoglobulins. We dissect the inflammatory activation on neutrophil-like HL60 cells, using an immune complex consisting of latex beads coated with spike protein of SARS-CoV-2 and opsonized with specific immunoglobulins from convalescent plasma. Our data clarifies the role of Fc-receptor-dependent phagocytosis via IgA-FcαRI and IgG-FcγR for COVID-19 disease followed by cytokine release. We show that COVID-19 associated inflammation could be reduced by addition of human immunoglobulin preparations (IVIG and trimodulin), while trimodulin elicits stronger immune modulation by more powerful ITAMi signaling. Besides IgG, the IgA component of trimodulin in particular, is of functional relevance for immune modulation in this assay setup, highlighting the need to study IgA mediated immune response.
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Affiliation(s)
- Fabian Bohländer
- Department of Analytical Development and Validation, Corporate R&D, Biotest AG, Dreieich, Germany
- Corporate R&D, Biotest AG, Dreieich, Germany
| | - Dennis Riehl
- Department of Analytical Development and Validation, Corporate R&D, Biotest AG, Dreieich, Germany
- Corporate R&D, Biotest AG, Dreieich, Germany
| | - Sabrina Weißmüller
- Corporate R&D, Biotest AG, Dreieich, Germany
- Department of Translational Research, Preclinical Research, Corporate R&D, Biotest AG, Dreieich, Germany
| | - Marcus Gutscher
- Department of Analytical Development and Validation, Corporate R&D, Biotest AG, Dreieich, Germany
- Corporate R&D, Biotest AG, Dreieich, Germany
| | | | - Stefanie Faust
- Department of Analytical Development and Validation, Corporate R&D, Biotest AG, Dreieich, Germany
- Corporate R&D, Biotest AG, Dreieich, Germany
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Pneumolysin induces platelet destruction, not platelet activation, which can be prevented by immunoglobulin preparations in vitro. Blood Adv 2021; 4:6315-6326. [PMID: 33351126 DOI: 10.1182/bloodadvances.2020002372] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 11/05/2020] [Indexed: 01/08/2023] Open
Abstract
Community-acquired pneumonia by primary or superinfections with Streptococcus pneumoniae can lead to acute respiratory distress requiring mechanical ventilation. The pore-forming toxin pneumolysin alters the alveolar-capillary barrier and causes extravasation of protein-rich fluid into the interstitial pulmonary tissue, which impairs gas exchange. Platelets usually prevent endothelial leakage in inflamed pulmonary tissue by sealing inflammation-induced endothelial gaps. We not only confirm that S pneumoniae induces CD62P expression in platelets, but we also show that, in the presence of pneumolysin, CD62P expression is not associated with platelet activation. Pneumolysin induces pores in the platelet membrane, which allow anti-CD62P antibodies to stain the intracellular CD62P without platelet activation. Pneumolysin treatment also results in calcium efflux, increase in light transmission by platelet lysis (not aggregation), loss of platelet thrombus formation in the flow chamber, and loss of pore-sealing capacity of platelets in the Boyden chamber. Specific anti-pneumolysin monoclonal and polyclonal antibodies inhibit these effects of pneumolysin on platelets as do polyvalent human immunoglobulins. In a post hoc analysis of the prospective randomized phase 2 CIGMA trial, we show that administration of a polyvalent immunoglobulin preparation was associated with a nominally higher platelet count and nominally improved survival in patients with severe S pneumoniae-related community-acquired pneumonia. Although, due to the low number of patients, no definitive conclusion can be made, our findings provide a rationale for investigation of pharmacologic immunoglobulin preparations to target pneumolysin by polyvalent immunoglobulin preparations in severe community-acquired pneumococcal pneumonia, to counteract the risk of these patients becoming ventilation dependent. This trial was registered at www.clinicaltrials.gov as #NCT01420744.
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40
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Jarczak D, Kluge S, Nierhaus A. Sepsis-Pathophysiology and Therapeutic Concepts. Front Med (Lausanne) 2021; 8:628302. [PMID: 34055825 PMCID: PMC8160230 DOI: 10.3389/fmed.2021.628302] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition and a global disease burden. Today, the heterogeneous syndrome is defined as severe organ dysfunction caused by a dysregulated host response to infection, with renewed emphasis on immune pathophysiology. Despite all efforts of experimental and clinical research during the last three decades, the ability to positively influence course and outcome of the syndrome remains limited. Evidence-based therapy still consists of basic causal and supportive measures, while adjuvant interventions such as blood purification or targeted immunotherapy largely remain without proof of effectiveness so far. With this review, we aim to provide an overview of sepsis immune pathophysiology, to update the choice of therapeutic approaches targeting different immunological mechanisms in the course of sepsis and septic shock, and to call for a paradigm shift from the pathogen to the host response as a potentially more promising angle.
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Affiliation(s)
- Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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41
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Wu X, Wu J, Wang P, Fang X, Yu Y, Tang J, Xiao Y, Wang M, Li S, Zhang Y, Hu B, Ma T, Li Q, Wang Z, Wu A, Liu C, Dai M, Ma X, Yi H, Kang Y, Wang D, Han G, Zhang P, Wang J, Yuan Y, Wang D, Wang J, Zhou Z, Ren Z, Liu Y, Guan X, Ren J. Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons. Clin Infect Dis 2021; 71:S337-S362. [PMID: 33367581 DOI: 10.1093/cid/ciaa1513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.
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Affiliation(s)
- Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jie Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,BenQ Medical Center, Nanjing Medical University, Nanjing, China
| | - Peige Wang
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueling Fang
- Department of Critical Care Medicine, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianguo Tang
- Department of Emergency Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Yonghong Xiao
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shikuan Li
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiang Li
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiming Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Menghua Dai
- Department of Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Huimin Yi
- Department of Critical Care Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Gang Han
- Department of Gastroenterology, Second Hospital of Jilin University, Changchun, China
| | - Ping Zhang
- Department of General Surgery, First Hospital of Jilin University, Changchun, China
| | - Jianzhong Wang
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yufeng Yuan
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Wang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Jian Wang
- Department of Biliary and Pancreatic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng Zhou
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zeqiang Ren
- Department of General Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuxiu Liu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Barker G, Leeuwenburgh C, Brusko T, Moldawer L, Reddy ST, Guirgis FW. Lipid and Lipoprotein Dysregulation in Sepsis: Clinical and Mechanistic Insights into Chronic Critical Illness. J Clin Med 2021; 10:1693. [PMID: 33920038 PMCID: PMC8071007 DOI: 10.3390/jcm10081693] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
In addition to their well-characterized roles in metabolism, lipids and lipoproteins have pleiotropic effects on the innate immune system. These undergo clinically relevant alterations during sepsis and acute inflammatory responses. High-density lipoprotein (HDL) plays an important role in regulating the immune response by clearing bacterial toxins, supporting corticosteroid release, decreasing platelet aggregation, inhibiting endothelial cell apoptosis, reducing the monocyte inflammatory response, and inhibiting expression of endothelial cell adhesion molecules. It undergoes quantitative as well as qualitative changes which can be measured using the HDL inflammatory index (HII). Pro-inflammatory, or dysfunctional HDL (dysHDL) lacks the ability to perform these functions, and we have also found it to independently predict adverse outcomes and organ failure in sepsis. Another important class of lipids known as specialized pro-resolving mediators (SPMs) positively affect the escalation and resolution of inflammation in a temporal fashion. These undergo phenotypic changes in sepsis and differ significantly between survivors and non-survivors. Certain subsets of sepsis survivors go on to have perilous post-hospitalization courses where this inflammation continues in a low grade fashion. This is associated with immunosuppression in a syndrome of persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The continuous release of tissue damage-related patterns and viral reactivation secondary to immunosuppression feed this chronic cycle of inflammation. Animal data indicate that dysregulation of endogenous lipids and SPMs play important roles in this process. Lipids and their associated pathways have been the target of many clinical trials in recent years which have not shown mortality benefit. These results are limited by patient heterogeneity and poor animal models. Considerations of sepsis phenotypes and novel biomarkers in future trials are important factors to be considered in future research. Further characterization of lipid dysregulation and chronic inflammation during sepsis will aid mortality risk stratification, detection of sepsis, and inform individualized pharmacologic therapies.
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Affiliation(s)
- Grant Barker
- Department of Emergency Medicine, College of Medicine-Jacksonville, University of Florida, 655 West 8th Street, Jacksonville, FL 32209, USA;
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, College of Medicine, University of Florida, Gainesville, FL 32603, USA;
| | - Todd Brusko
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL 32610, USA;
| | - Lyle Moldawer
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL 32608, USA;
| | - Srinivasa T. Reddy
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Faheem W. Guirgis
- Department of Emergency Medicine, College of Medicine-Jacksonville, University of Florida, 655 West 8th Street, Jacksonville, FL 32209, USA;
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Abstract
Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.
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Barberán J, Restrepo R, Cardinal-Fernández P. Community-acquired pneumonia: similarities and differences between European and American guidelines - A narrative review. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2021; 34:72-80. [PMID: 33291864 PMCID: PMC8019462 DOI: 10.37201/req/114.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Community-acquired pneumonia (CAP) is severe disease. Early prescription of an adequate treatment has a positive impact in the CAP outcome. Despite the evidence of existing relevant differences between CAP across geographical areas, general guidelines can be designed to be applied everywhere. Eight years have passed between the publication of the European (EG) and American (AG) CAP guidelines, thus the aim of this narrative review is to compare both guidelines and summarize their recommendations. The main similarity between both guidelines is the antibiotics recommendation with the exception that AG mention new antimicrobials that were not available at the time of EG publication. Both guidelines recommend against routinely adding steroids as an adjuvant treatment. Finally, both guidelines acknowledge that the decision to hospitalize a patient is clinical and should be complemented with an objective tool for risk assessment. EG recommend the CRB-65 while AG recommend the Pneumonia Severity Index (PSI). EG and AG share a similar core of recommendations and only differ in minor issues such as new antibiotics. Likewise, both guidelines recommend against the routine prescription of steroids as an adjuvant therapy.
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Affiliation(s)
| | | | - P Cardinal-Fernández
- Pablo Cardinal-Fernández, Unidad de Cuidados Intensivos - Hospital Universitario HM Sanchinarro, Calle Oña 10, Madrid. Spain.
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45
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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46
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Biagioni E, Tosi M, Berlot G, Castiglione G, Corona A, De Cristofaro MG, Donati A, Feltracco P, Forfori F, Fragranza F, Murino P, Piazza O, Tullo L, Grasselli G, D'Amico R, Girardis M. Adjunctive IgM-enriched immunoglobulin therapy with a personalised dose based on serum IgM-titres versus standard dose in the treatment of septic shock: a randomised controlled trial (IgM-fat trial). BMJ Open 2021; 11:e036616. [PMID: 33574139 PMCID: PMC7880103 DOI: 10.1136/bmjopen-2019-036616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In patients with septic shock, low levels of circulating immunoglobulins are common and their kinetics appear to be related to clinical outcome. The pivotal role of immunoglobulins in the host immune response to infection suggests that additional therapy with polyclonal intravenous immunoglobulins may be a promising option in patients with septic shock. Immunoglobulin preparations enriched with the IgM component have largely been used in sepsis, mostly at standard dosages (250 mg/kg per day), regardless of clinical severity and without any dose adjustment based on immunoglobulin serum titres or other biomarkers. We hypothesised that a personalised dose of IgM enriched preparation based on patient IgM titres and aimed to achieve a specific threshold of IgM titre is more effective in decreasing mortality than a standard dose. METHODS AND ANALYSIS The study is designed as a multicentre, interventional, randomised, single-blinded, prospective, investigator sponsored, two-armed study. Patients with septic shock and IgM titres <60 mg/dL will be randomly assigned to an IgM titre-based treatment or a standard treatment group in a ratio of 1:1. The study will involve 12 Italian intensive care units and 356 patients will be enrolled. Patients assigned to the IgM titre-based treatment will receive a personalised daily dose based on an IgM serum titre aimed at achieving serum titres above 100 mg/dL up to discontinuation of vasoactive drugs or day 7 after enrolment. Patients assigned to the IgM standard treatment group will receive IgM enriched preparation daily for three consecutive days at the standard dose of 250 mg/kg. The primary endpoint will be all-cause mortality at 28 days. ETHICS AND DISSEMINATION The study protocol was approved by the ethics committees of the coordinating centre (Comitato Etico dell'Area Vasta Emilia Nord) and collaborating centres. The results of the trial will be published within 12 months from the end of the study and the steering committee has the right to present them at public symposia and conferences. TRIAL REGISTRATION DETAILS The trial protocol and information documents have received a favourable opinion from the Area Vasta Emilia Nord Ethical Committee on 12 September 2019. The trial protocol has been registered on EudraCT (2018-001613-33) on 18 April 2018 and on ClinicalTrials.gov (NCT04182737) on 2 December 2019.
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Affiliation(s)
- Emanuela Biagioni
- Anesthesia and Intensive Care, University Hospital Modena, Modena, Emilia-Romagna, Italy
| | - Martina Tosi
- Anesthesia and Intensive Care, University Hospital Modena, Modena, Emilia-Romagna, Italy
| | - Giorgio Berlot
- Anesthesia and Intensive Care Unit, Major Hospital of Trieste, Trieste, Friuli-Venezia Giulia, Italy
| | - Giacomo Castiglione
- Anesthesia and Intensive Care Unit, University Hospital Vittorio Emanuele Catania Polyclinic, Catania, Sicilia, Italy
| | - Alberto Corona
- Anesthesia and Intensive Care Unit, Luigi Sacco University Hospital, Milano, Lombardia, Italy
| | | | - Abele Donati
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I G M Lancisi G Salesi, Ancona, Marche, Italy
| | - Paolo Feltracco
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Padova, Padova, Veneto, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care Unit, Pisa University Hospital, Pisa, Toscana, Italy
| | | | - Patrizia Murino
- Anesthesia and Intensive Care Unit, Monaldi Hospital, Napoli, Campania, Italy
| | - Ornella Piazza
- Anesthesia and Intensive Care Unit, University of Salerno, Fisciano, Campania, Italy
| | - Livio Tullo
- Anesthesia and Intensive Care Unit, Foggia University Hospital, Foggia, Puglia, Italy
| | - Giacomo Grasselli
- Anesthesia and Intensive Care Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Lombardia, Italy
| | - Roberto D'Amico
- Medical and Surgical Science, University Hospital Modena, Modena, Emilia-Romagna, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care, University Hospital Modena, Modena, Emilia-Romagna, Italy
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Rombauts A, Abelenda-Alonso G, Cuervo G, Gudiol C, Carratalà J. Role of the inflammatory response in community-acquired pneumonia: clinical implications. Expert Rev Anti Infect Ther 2021; 20:1261-1274. [PMID: 33034228 DOI: 10.1080/14787210.2021.1834848] [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: 12/15/2022]
Abstract
INTRODUCTION Despite adequate antibiotic coverage, community-acquired pneumonia (CAP) remains a leading cause of hospitalization and mortality worldwide. It induces both a local pulmonary and a systemic inflammatory response, particularly significant in severe cases. The intensity of the dysregulated host response varies from patient to patient and has a negative impact on survival and other outcomes. AREAS COVERED This comprehensive review summarizes the pathophysiological aspects of the inflammatory response in CAP, briefly discusses the usefulness of biomarkers, and assesses the clinical evidence for modulating the inflammatory pathways. We searched PubMed for the most relevant studies, reviews, and meta-analysis until August 2020. EXPERT OPINION Notable efforts have been made to identify biomarkers that can accurately differentiate between viral and bacterial etiology, and indeed, to enhance risk stratification in CAP. However, none has proven ideal and no recommended biomarker-guided algorithms exist. Biomarker signatures from proteomic and metabolomic studies could be more useful for such assessments. To date, most studies have produced contradictory results concerning the role of immunomodulatory agents (e.g. corticosteroids, macrolides, and statins) in CAP. Adequately identifying the population who may benefit most from effective modulation of the inflammatory response remains a challenge.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain
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Schirm S, Ahnert P, Berger S, Nouailles G, Wienhold SM, Müller-Redetzky H, Suttorp N, Loeffler M, Witzenrath M, Scholz M. A biomathematical model of immune response and barrier function in mice with pneumococcal lung infection. PLoS One 2020; 15:e0243147. [PMID: 33270742 PMCID: PMC7714238 DOI: 10.1371/journal.pone.0243147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022] Open
Abstract
Pneumonia is one of the leading causes of death worldwide. The course of the disease is often highly dynamic with unforeseen critical deterioration within hours in a relevant proportion of patients. Besides antibiotic treatment, novel adjunctive therapies are under development. Their additive value needs to be explored in preclinical and clinical studies and corresponding therapy schedules require optimization prior to introduction into clinical practice. Biomathematical modeling of the underlying disease and therapy processes might be a useful aid to support these processes. We here propose a biomathematical model of murine immune response during infection with Streptococcus pneumoniae aiming at predicting the outcome of different treatment schedules. The model consists of a number of non-linear ordinary differential equations describing the dynamics and interactions of the pulmonal pneumococcal population and relevant cells of the innate immune response, namely alveolar- and inflammatory macrophages and neutrophils. The cytokines IL-6 and IL-10 and the chemokines CCL2, CXCL1 and CXCL5 are considered as major mediators of the immune response. We also model the invasion of peripheral blood monocytes, their differentiation into macrophages and bacterial penetration through the epithelial barrier causing blood stream infections. We impose therapy effects on this system by modelling antibiotic therapy and treatment with the novel C5a-inactivator NOX-D19. All equations are derived by translating known biological mechanisms into equations and assuming appropriate response kinetics. Unknown model parameters were determined by fitting the predictions of the model to time series data derived from mice experiments with close-meshed time series of state parameters. Parameter fittings resulted in a good agreement of model and data for the experimental scenarios. The model can be used to predict the performance of alternative schedules of combined antibiotic and NOX-D19 treatment. We conclude that we established a comprehensive biomathematical model of pneumococcal lung infection, immune response and barrier function in mice allowing simulations of new treatment schedules. We aim to validate the model on the basis of further experimental data. We also plan the inclusion of further novel therapy principles and the translation of the model to the human situation in the near future.
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Affiliation(s)
- Sibylle Schirm
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Peter Ahnert
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Sarah Berger
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Geraldine Nouailles
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sandra-Maria Wienhold
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Holger Müller-Redetzky
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Markus Loeffler
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Martin Witzenrath
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Markus Scholz
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
- LIFE Research Center of Civilization Diseases, University of Leipzig, Leipzig, Germany
- * E-mail:
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49
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Husain-Syed F, Vadász I, Wilhelm J, Walmrath HD, Seeger W, Birk HW, Jennert B, Dietrich H, Herold S, Trauth J, Tello K, Sander M, Morty RE, Slanina H, Schüttler CG, Ziebuhr J, Kassoumeh S, Ronco C, Ferrari F, Warnatz K, Stahl K, Seeliger B, Hoeper MM, Welte T, David S. Immunoglobulin deficiency as an indicator of disease severity in patients with COVID-19. Am J Physiol Lung Cell Mol Physiol 2020; 320:L590-L599. [PMID: 33237794 PMCID: PMC8057306 DOI: 10.1152/ajplung.00359.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite the pandemic status of COVID-19, there is limited information about host risk factors and treatment beyond supportive care. Immunoglobulin G (IgG) could be a potential treatment target. Our aim was to determine the incidence of IgG deficiency and associated risk factors in a cohort of 62 critically ill patients with COVID-19 admitted to two German ICUs (72.6% male, median age: 61 yr). Thirteen (21.0%) of the patients displayed IgG deficiency (IgG < 7 g/L) at baseline (predominant for the IgG1, IgG2, and IgG4 subclasses). Patients who were IgG-deficient had worse measures of clinical disease severity than those with normal IgG levels (shorter duration from disease onset to ICU admission, lower ratio of [Formula: see text] to [Formula: see text], higher Sequential Organ Failure Assessment score, and higher levels of ferritin, neutrophil-to-lymphocyte ratio, and serum creatinine). Patients who were IgG-deficient were also more likely to have sustained lower levels of lymphocyte counts and higher levels of ferritin throughout the hospital stay. Furthermore, patients who were IgG-deficient compared with those with normal IgG levels displayed higher rates of acute kidney injury (76.9% vs. 26.5%; P = 0.001) and death (46.2% vs. 14.3%; P = 0.012), longer ICU [28 (6-48) vs. 12 (3-18) days; P = 0.012] and hospital length of stay [30 (22-50) vs. 18 (9-24) days; P = 0.004]. Univariable logistic regression showed increasing odds of 90-day overall mortality associated with IgG-deficiency (odds ratio 5.14, 95% confidence interval 1.3-19.9; P = 0.018). IgG deficiency might be common in patients with COVID-19 who are critically ill, and warrants investigation as both a marker of disease severity as well as a potential therapeutic target.
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Affiliation(s)
- Faeq Husain-Syed
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - István Vadász
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, German Center for Lung Research, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany
| | - Jochen Wilhelm
- Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, German Center for Lung Research, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany.,Institute for Lung Health, Justus Liebig University Giessen, Giessen, Germany
| | - Hans-Dieter Walmrath
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Infectious Diseases, Department of Internal Medicine II, Department of Internal Medicine, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Werner Seeger
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Infectious Diseases, Department of Internal Medicine II, Department of Internal Medicine, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, German Center for Lung Research, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany.,Institute for Lung Health, Justus Liebig University Giessen, Giessen, Germany.,Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Horst-Walter Birk
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Birgit Jennert
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Hartmut Dietrich
- Divison of Nephrology, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Susanne Herold
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Division of Infectious Diseases, Department of Internal Medicine II, Department of Internal Medicine, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, German Center for Lung Research, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany
| | - Janina Trauth
- Division of Infectious Diseases, Department of Internal Medicine II, Department of Internal Medicine, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Khodr Tello
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, German Center for Lung Research, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Rory E Morty
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center, Justus Liebig University Giessen, German Center for Lung Research, Giessen, Germany.,The Cardio-Pulmonary Institute, Giessen, Germany.,Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Heiko Slanina
- Institute of Medical Virology, Justus Liebig University Giessen, The German Center for Infection Research, Giessen, Germany
| | - Christian G Schüttler
- Institute of Medical Virology, Justus Liebig University Giessen, The German Center for Infection Research, Giessen, Germany
| | - John Ziebuhr
- Institute of Medical Virology, Justus Liebig University Giessen, The German Center for Infection Research, Giessen, Germany
| | - Shadi Kassoumeh
- Justus Liebig Medical University Medical School, Giessen, Germany
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine (DIMED), Università di Padova, Padua, Italy
| | - Fiorenza Ferrari
- Intensive Care Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Klaus Warnatz
- Center for Chronic Immunodeficiency at Center for Translational Research, Medical Center University of Freiburg, Freiburg, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.,Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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50
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Brandenburg K, Schromm AB, Weindl G, Heinbockel L, Correa W, Mauss K, Martinez de Tejada G, Garidel P. An update on endotoxin neutralization strategies in Gram-negative bacterial infections. Expert Rev Anti Infect Ther 2020; 19:495-517. [PMID: 33210958 DOI: 10.1080/14787210.2021.1834847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gram-negative bacterial infections represent still a severe problem of human health care, regarding the increase in multi-resistance against classical antibiotics and the lack of newly developed antimicrobials. For the fight against these germs, anti-infective agents must overcome and/or bind to the Gram-negative outer membrane consisting of a lipopolysaccharide (LPS, endotoxin) outer leaflet and an inner leaflet from phospholipids, with additional peripheral or integral membrane proteins (OMP's). AREAS COVERED The current article reviews data of existing therapeutic options and summarizes newer approaches for targeting and neutralizing endotoxins, ranging from in vitro over in vivo animal data to clinical applications by using databases such as Medline. EXPERT OPINION Conventional antibiotic treatment of the bacteria leads to their killing, but not necessary LPS neutralization, which may be a severe problem in particular for the systemic pathway. This is the reason why there is an increasing number of therapeutic approaches, which - besides combating whole bacteria - at the same time try to neutralize endotoxin within or outside the bacterial cells mainly responsible for the high inflammation induction in Gram-negative species.
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Affiliation(s)
- Klaus Brandenburg
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Andra B Schromm
- FG Immunobiophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Günther Weindl
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Universität Bonn, Universität Bonn Pharmazeutisches Institut Pharmakologie Und Toxikologie Bonn, Germany
| | - Lena Heinbockel
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Wilmar Correa
- FG Biophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Karl Mauss
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Asklepios-Klinik Hamburg-Altona, Hamburg, Germany
| | - Guillermo Martinez de Tejada
- Department of Microbiology and Parasitology, University of Navarra, E-31008 Pamplona, Spain and Navarra Institute for Health Research (Idisna), Pamplona, Spain.,Department de Microbiologia, Universidad De Navarra, Pamplona, Spain
| | - Patrick Garidel
- Martin-Luther-Universität Halle-Wittenberg, Institut für Chemie, Halle/Saale, Germany
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