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Huang H, Chen J, Dang H, Liu C, Huo J, Fu YQ. Effect of intravenous immunoglobulin on the outcome of children with septic shock in a PICU: a retrospective cohort study. Eur J Pediatr 2023; 182:5315-5323. [PMID: 37733114 DOI: 10.1007/s00431-023-05224-5] [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: 08/07/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 09/22/2023]
Abstract
The therapeutic efficacy of intravenous immuneglobulin (IVIG) on children with septic shock remains uncertain. Therefore, we endeavored to investigate the impact of administering intravenous immunoglobulin (IVIG) in the pediatric intensive care unit (PICU) on patient with septic shock. We retrospectively analyzed the data of children admitted to the PICU due to septic shock from January 2017 to December 2021 in a tertiary pediatric hospital. The main outcome was in-hospital mortality. Total 304 patients were enrolled. There were no significant differences in the PRISM-III score (11 vs. 12, P = 0.907), PIM-3 score (0.08 vs. 0.07, P = 0.544), pSOFA score (10 vs. 10, P = 0.852) between the No IVIG group and the IVIG group. Children who received IVIG required more continuous renal replacement therapy (CRRT) support (43% vs. 24%, P = 0.001) and longer duration of mechanical ventilation (MV) (6 vs. 3 days, P = 0.002), and longer length of stay (LOS) of PICU (7 vs. 4 days, P = 0.001) and LOS of hospital (18 vs. 11 days, P = 0.001) than children who did not receive. The 28-day survival analysis (P = 0.033) showed better survival rates in IVIG group, while the in-hospital mortality (43% vs. 52%, P = 0.136) was no significant difference. In the propensity score matched analysis, 71 pairs were established. The length of CRRT (2 vs. 3 days, P = 0.744), duration of mechanical ventilation (5 vs. 4 days, P = 0.402), LOS of PICU (7 vs. 5 days, P = 0.216), LOS of hospital (18 vs. 13 days, P = 0.290), in-hospital mortality (44% vs. 44%, P = 1.000) and 28-day survival analysis (P = 0.748) were not statistically different. After inverse probability weighted analysis, there was still no difference in mortality between the two groups (51% vs. 48%, P = 0.665). CONCLUSION In children with septic shock, the use of intravenous immunoglobulin as an adjuvant therapy does not reduce in-hospital mortality. WHAT IS KNOWN • Guidelines suggest against the routine use of intravenous immuneglobulin in children with septic shock. Some small observational studies have reported conflicting result. WHAT IS NEW • The use of intravenous immunoglobulin as an adjuvant therapy does not reduce in-hospital mortality in children with septic shock.
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Affiliation(s)
- Haixin Huang
- Department of Critical Care Medicine, Childrens Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Chongqing, 400014, Yuzhong District, China
| | - Jian Chen
- Department of Critical Care Medicine, Childrens Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Chongqing, 400014, Yuzhong District, China
| | - Hongxing Dang
- Department of Critical Care Medicine, Childrens Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Chongqing, 400014, Yuzhong District, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Childrens Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Chongqing, 400014, Yuzhong District, China
| | - Junming Huo
- Department of Critical Care Medicine, Childrens Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Chongqing, 400014, Yuzhong District, China
| | - Yue-Qiang Fu
- Department of Critical Care Medicine, Childrens Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Chongqing, 400014, Yuzhong District, China.
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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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4
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Pan B, Sun P, Pei R, Lin F, Cao H. Efficacy of IVIG therapy for patients with sepsis: a systematic review and meta-analysis. J Transl Med 2023; 21:765. [PMID: 37898763 PMCID: PMC10612304 DOI: 10.1186/s12967-023-04592-8] [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: 09/11/2023] [Accepted: 10/05/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Sepsis is an overwhelming reaction to infection that comes with high morbidity and mortality. It requires urgent interventions in order to improve outcomes. Intravenous immunoglobulins (IVIG) are considered as potential therapy in sepsis patients. Results of trials on IVIG as adjunctive therapy for sepsis have been conflicting due to the variability in population characteristics, country geography and drug dosage form in different studies. METHODS A systematic article search was performed for eligible studies published up to January, 31, 2023, through the PubMed, Embase, Cochrane Library and Chinese National Knowledge Infrastructure database. The included articles were screened by using rigorous inclusion and exclusion criteria. Subgroup analyses were conducted according to different IVIG types, ages and economic regions. All analyses were conducted using Review Manager 5.4. Quality of studies and risk of bias were evaluated. RESULTS In total, 31 randomized controlled trials were included with a sample size of 6,276 participants. IVIG could reduce the mortality (RR 0.86, 95% CI: 0.77-0.95, p = 0.005), the hospital stay (MD - 4.46, 95% CI: - 6.35 to - 2.57, p = 0.00001), and the APACHE II scores (MD - 1.65, 95% CI: - 2.89 to - 0.63, p = 0.001). Additionally, the results showed that IgM-enriched IVIG was effective in treating sepsis (RR 0.55, 95% CI: 0.40 - 0.76; p = 0.0003), while standard IVIG failed to be effective (RR 0.91, 95% CI: 0.81-1.02, p = 0.10). And the effect of IVIG in reducing neonatal mortality was inconclusive (RR 0.93, 95% CI: 0.81-1.05, p = 0.24), but it played a large role in reducing sepsis mortality in adults (RR 0.70, 95% CI: 0.57-0.86, p = 0.0006). Besides, from the subgroup of different economic regions, it indicated that IVIG was effective for sepsis in high-income (RR 0.89, 95% CI: 0.79-0.99, p = 0.03) and middle-income countries (RR 0.49, 95% CI: 0.28-0.84, p = 0.01), while no benefit was demonstrated in low-income countries (RR 0.56, 95% CI: 0.27-1.14, p = 0.11). CONCLUSIONS There is sufficient evidence to support that IVIG reduces sepsis mortality. IgM-enriched IVIG is effective in both adult and neonatal sepsis, while standard IVIG is only effective in adult sepsis. IVIG for sepsis has shown efficacy in high- and middle-income countries, but is still debatable in low-income countries. More RCTs are needed in the future to confirm the true clinical potential of IVIG for sepsis in low-income countries.
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Affiliation(s)
- Bo Pan
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, 610052, China
| | - Pan Sun
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, 610052, China
| | - Renjun Pei
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, 610052, China
| | - Fangzhao Lin
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, 610052, China.
| | - Haijun Cao
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, 610052, China.
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Plasma IgM Levels Differentiate between Survivors and Non-Survivors of Culture-Positive and Culture-Negative Sepsis and SIRS: A Pilot Study. J Clin Med 2021; 10:jcm10225391. [PMID: 34830673 PMCID: PMC8626001 DOI: 10.3390/jcm10225391] [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: 09/11/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Immunoglobulin IgM is important for controlling viral and bacterial infections, and low immunoglobulin levels have been found in sepsis. There is a clear need to stratify sepsis patients according to the presence of an invading organism, compared to no organism identified, and SIRS patients, where organ dysfunction is a result of a non-infective process. The aim of this pilot study in a small cohort of patients with sepsis was to evaluate the association between IgM plasma levels and survival in 47 patients with sepsis and 11 patients diagnosed with organ failure without the identification of a pathogen (SIRS). Patients were admitted to the intensive care unit (ICU) at The Royal Glamorgan Hospital, Llantrisant, UK between 2010 and 2014. We found that low IgM levels were associated with sepsis, but not SIRS. IgM levels did not differ significantly for culture-positive (CP) compared with culture-negative (CN, no organism found) sepsis samples. Kaplan–Meier analysis was used to compare survival curves according to IgM levels, with no significant difference. We observed significantly higher survival in the CP samples when comparing with CN. Cut-off value for IgM (266 μg/mL) for diagnosis of sepsis patients was determined using receiver operator characteristic (ROC) curves with 70% sensitivity, 69% specificity and 92% negative predictive values (NPV), respectively. The corresponding area under the curve (AUC) for the discrimination of sepsis patients was AUC = 0.73, and in a subgroup analysis of CP was AUC = 0.77 and for CN was AUC = 0.79. We confirm IgM as a good diagnostic marker of sepsis. These findings indicate a difference in the pathology between culture-positive versus negative sepsis, SIRS and survival. This indicates that IgM is likely relevant to pathology, because of its role in the early immune response against pathogens, the potentially protective role of natural IgM antibodies, and supports its application in immunoglobulin therapy.
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Busani S, Roat E, Tosi M, Biagioni E, Coloretti I, Meschiari M, Gelmini R, Brugioni L, De Biasi S, Girardis M. Adjunctive Immunotherapy With Polyclonal Ig-M Enriched Immunoglobulins for Septic Shock: From Bench to Bedside. The Rationale for a Personalized Treatment Protocol. Front Med (Lausanne) 2021; 8:616511. [PMID: 33681248 PMCID: PMC7930614 DOI: 10.3389/fmed.2021.616511] [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: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 01/19/2023] Open
Abstract
Septic shock still has a high mortality rate which has not hinted at decreasing in recent years. Unfortunately, randomized trials failed mainly because the septic patient was considered as a homogeneous entity. All this creates a sort of therapeutic impotence in everyday clinical practice in treating patients with septic shock. The need to customize therapy on each patient with sepsis has now become an established necessity. In this scenario, adjuvant therapies can help if interpreted as modulators of the immune system. Indeed, the host's immune response differs from patient to patient based on the virulence of the pathogen, comorbidity, infection site, and prolonged hospitalization. In this review, we summarize the rationale for using immunoglobulins as an adjunctive treatment. Furthermore, we would like to suggest a possible protocol to personalize treatment in the different clinical scenarios of the host's response to serious infectious events.
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Affiliation(s)
- Stefano Busani
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Erika Roat
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martina Tosi
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Emanuela Biagioni
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Gelmini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Brugioni
- Internal Medicine Department, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Sara De Biasi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Nierhaus A, Berlot G, Kindgen-Milles D, Müller E, Girardis M. Best-practice IgM- and IgA-enriched immunoglobulin use in patients with sepsis. Ann Intensive Care 2020; 10:132. [PMID: 33026597 PMCID: PMC7538847 DOI: 10.1186/s13613-020-00740-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/06/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Despite treatment being in line with current guidelines, mortality remains high in those with septic shock. Intravenous immunoglobulins represent a promising therapy to modulate both the pro- and anti-inflammatory processes and can contribute to the elimination of pathogens. In this context, there is evidence of the benefits of immunoglobulin M (IgM)- and immunoglobulin A (IgA)-enriched immunoglobulin therapy for sepsis. This manuscript aims to summarize current relevant data to provide expert opinions on best practice for the use of an IgM- and IgA-enriched immunoglobulin (Pentaglobin) in adult patients with sepsis. Main text Sepsis patients with hyperinflammation and patients with immunosuppression may benefit most from treatment with IgM- and IgA-enriched immunoglobulin (Pentaglobin). Patients with hyperinflammation present with phenotypes that manifest throughout the body, whilst the clinical characteristics of immunosuppression are less clear. Potential biomarkers for hyperinflammation include elevated procalcitonin, interleukin-6, endotoxin activity and C-reactive protein, although thresholds for these are not well-defined. Convenient biomarkers for identifying patients in a stage of immune-paralysis are still matter of debate, though human leukocyte antigen–antigen D related expression on monocytes, lymphocyte count and viral reactivation have been proposed. The timing of treatment is potentially more critical for treatment efficacy in patients with hyperinflammation compared with patients who are in an immunosuppressed stage. Due to the lack of evidence, definitive dosage recommendations for either population cannot be made, though we suggest that patients with hyperinflammation should receive an initial bolus at a rate of up to 0.6 mL (30 mg)/kg/h for 6 h followed by a continuous maintenance rate of 0.2 mL (10 mg)/kg/hour for ≥ 72 h (total dose ≥ 0.9 g/kg). For immunosuppressed patients, dosage is more conservative (0.2 mL [10 mg]/kg/h) for ≥ 72 h, without an initial bolus (total dose ≥ 0.72 g/kg). Conclusions Two distinct populations that may benefit most from Pentaglobin therapy are described in this review. However, further clinical evidence is required to strengthen support for the recommendations given here regarding timing, duration and dosage of treatment.
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Affiliation(s)
- Axel Nierhaus
- University Medical Center Hamburg, Hamburg, Germany. .,Dep. of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Reporting of Organ Support Outcomes in Septic Shock Randomized Controlled Trials: A Methodologic Review-The Sepsis Organ Support Study. Crit Care Med 2020; 47:984-992. [PMID: 30889023 DOI: 10.1097/ccm.0000000000003746] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Many recent randomized controlled trials in the field of septic shock failed to demonstrate a benefit on mortality. Randomized controlled trials increasingly report organ support duration and organ support-free days as primary or secondary outcomes. We conducted a methodologic systematic review to assess how organ support outcomes were defined and reported in septic shock randomized controlled trials. DATA SOURCES MEDLINE via PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science. STUDY SELECTION We included randomized controlled trials published between January 2004 and March 2018 that involved septic shock adults and assessed organ support duration and/or organ support-free days for hemodynamic support, respiratory support, or renal replacement therapy. DATA EXTRACTION For each randomized controlled trial, we extracted the definitions of organ support duration and organ support-free days. We particularly evaluated how nonsurvivors were accounted for. Study authors were contacted to provide any missing information regarding these definitions. DATA SYNTHESIS We included 28 randomized controlled trials. Organ support duration and organ support-free days outcomes were reported in 17 and 15 randomized controlled trials, respectively, for hemodynamic support, 15 and 15 for respiratory support, and five and nine for renal replacement therapy. Nonsurvivors were included in the organ support duration calculation in 13 of 14 randomized controlled trials (93%) for hemodynamic support and nine of 10 (90%) for respiratory support. The organ support-free days definition for hemodynamic support, respiratory support, and renal replacement therapy was reported in six of 15 randomized controlled trials (40%), eight of 15 randomized controlled trials (53%), and six of nine randomized controlled trials (67%) reporting an organ support-free days outcome, respectively. Of these, one half assigned "0" to nonsurvivors, and the other half attributed one point per day alive free of organ support up to a predefined time point. CONCLUSIONS This study highlights the heterogeneity and infrequency of organ support duration/organ support-free days outcome reporting in septic shock trials. When reported, the definitions of these outcome measures and methods of calculation are also infrequently reported, in particular how nonsurvivors were accounted for, which may have an important impact on interpretation.
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Kyriazopoulou E, Giamarellos-Bourboulis EJ. Pharmacological management of sepsis in adults with a focus on the current gold standard treatments and promising adjunctive strategies: evidence from the last five years. Expert Opin Pharmacother 2019; 20:991-1007. [DOI: 10.1080/14656566.2019.1589451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Cui J, Wei X, Lv H, Li Y, Li P, Chen Z, Liu G. The clinical efficacy of intravenous IgM-enriched immunoglobulin (pentaglobin) in sepsis or septic shock: a meta-analysis with trial sequential analysis. Ann Intensive Care 2019; 9:27. [PMID: 30725235 PMCID: PMC6365591 DOI: 10.1186/s13613-019-0501-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/23/2019] [Indexed: 12/13/2022] Open
Abstract
Background Sepsis is characterized by a complex immune response. This meta-analysis evaluated the clinical effectiveness of intravenous IgM-enriched immunoglobulin (IVIgGM) in patients with sepsis and septic shock. Methods Four databases, PubMed, the Cochrane Library, the ISI Web of Knowledge, and Embase, were systematically searched from inception to June 2018 to update the 2013 edition of the Cochrane review by two investigators, who independently selected studies, extracted relevant data, and evaluated study quality. Data were subjected to a meta-analysis and trial sequential analysis (TSA) for the primary and secondary outcomes. Level of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale. Results Nineteen studies comprising 1530 patients were included in this meta-analysis. Pooled analyses showed that the use of IVIgGM reduced the mortality risk of septic patients (relative risk 0.60; 95% confidence interval [CI] 0.52–0.69, I2 = 0%). TSA showed that IVIgGM had a significant effect on mortality. Additionally, the meta-analysis suggested that use of IVIgGM shortened length of mechanical ventilation (mean difference − 3.16 days; 95% CI − 5.71 to − 0.61 days) and did not shorten length of stay in the intensive care unit (mean difference − 0.38 days; 95% CI − 3.55 to 2.80 days). The GRADE scale showed that the certainty of the body of evidence was low for both benefits and IVIgGM. Conclusion Administration of IVIgGM to adult septic patients may be associated with reduced mortality. Treatment effects tended to be smaller or less consistent when including only those studies deemed adequate for each indicator. The available evidence is not clearly sufficient to support the widespread use of IVIgGM in the treatment of sepsis. Trial registration PROSPERO registration number: CRD42018084120. Registered on 11 February 2018. Electronic supplementary material The online version of this article (10.1186/s13613-019-0501-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jie Cui
- Head and Neck Surgery, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, Guangdong Province, People's Republic of China
| | - Xuxia Wei
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong Province, People's Republic of China
| | - Haijin Lv
- Surgical Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong Province, People's Republic of China
| | - Yuntao Li
- Nursing Department, Shaodong County People's Hospital, Shaodong, 422800, Hunan Province, People's Republic of China
| | - Ping Li
- Department of Anesthesia, GuangDong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, Guangdong Province, People's Republic of China
| | - Zhen Chen
- Intensive Care Unit, Shunde Hospital, Southern Medical University, Foshan, 528300, Guangdong Province, People's Republic of China.
| | - Genglong Liu
- Department of Pathology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, Guangdong Province, People's Republic of China.
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Kakoullis L, Pantzaris ND, Platanaki C, Lagadinou M, Papachristodoulou E, Velissaris D. The use of IgM-enriched immunoglobulin in adult patients with sepsis. J Crit Care 2018; 47:30-35. [DOI: 10.1016/j.jcrc.2018.06.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 05/29/2018] [Accepted: 06/02/2018] [Indexed: 01/12/2023]
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12
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Nakamura K, Inokuchi R, Fukushima K, Naraba H, Takahashi Y, Sonoo T, Hashimoto H, Doi K, Morimura N. Single versus divided administration of intravenous immunoglobulin for sepsis: a retrospective and historical control study. Minerva Anestesiol 2018; 85:156-163. [PMID: 29808971 DOI: 10.23736/s0375-9393.18.12344-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) is regarded as effective, theoretically, for sepsis. The IVIG regimen for severe infection covered by Japanese health insurance is administration of 5 g/day for three days: an extremely low dosage. We investigated its effectiveness by comparison between divided dosage and single dosage of 15 g for one day. METHODS Patients who were admitted to our hospital's Emergency Medical Center and treated with IVIG for sepsis were included and were analyzed retrospectively. The dosage regimen was 5 g for three days in the early half period, and 15 g for one day in the latter half period employing the same indication criteria. RESULTS Each group included 57 patients. No significant difference was found in their baseline characteristics, survival probability, or length of mechanical ventilation. However, the ICU stay and hospital stay lengths were shortened significantly by administration of the single dosage regimen. Disseminated intravascular coagulopathy markers and inflammatory indices were improved significantly earlier in the 15 g for one day group. Regarding adverse events, no significant difference was found. CONCLUSIONS For sepsis treatment, single administration of 15 g IVIG for one day improved the condition and inflammation earlier than divided dosage.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan -
| | - Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazutaka Fukushima
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoto Morimura
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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Szakmany T, Heurich-Sevcenco M. Immunomodulation in sepsis-why blunting the response doesn't work? J Infect 2015; 71:147-9. [PMID: 25922288 DOI: 10.1016/j.jinf.2015.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 04/18/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Tamas Szakmany
- Cardiff University, Cardiff, UK; Aneurin Bevan University Health Board, Gwent, UK.
| | - Meike Heurich-Sevcenco
- Institute of Infection & Immunity, Cardiff University, Cardiff, UK; Tenovus Building, Heath Park, Cardiff CF14 4XN, UK.
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14
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Intravenous Immunoglobulin and Mortality in Pneumonia Patients With Septic Shock: An Observational Nationwide Study. Clin Infect Dis 2015; 61:385-92. [DOI: 10.1093/cid/civ307] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/21/2015] [Indexed: 12/22/2022] Open
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15
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Intravenous immunoglobulin use in septic shock patients after emergency laparotomy. J Infect 2015; 71:158-66. [PMID: 25869539 DOI: 10.1016/j.jinf.2015.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/18/2015] [Accepted: 04/03/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The role of intravenous immunoglobulin (IVIG) as an adjunctive treatment for abdominal sepsis remains controversial. METHODS Mechanically ventilated septic shock patients following emergency laparotomy for perforation of the lower intestinal tract were identified in the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2013. The effect of IVIG use on 28-day mortality was evaluated using propensity score and instrumental variable analyses. RESULTS Eligible patients (n = 4919) treated at 845 hospitals were divided into IVIG (n = 2085) and control (n = 2834) groups. Propensity score matching created a matched cohort of 1081pairs with and without IVIG treatment. Although significant mortality differences existed between the IVIG and control groups in the unmatched analysis (20.6% vs. 18.3%; difference, 2.3%; 95% confidence interval [CI], 0.07-4.5), there were no significant differences in the propensity score-matched analysis (20.4% vs. 19.3%; difference, 1.1%; 95% CI, -2.3-4.5). Analysis employing the pattern of hospital IVIG use as an instrumental variable showed that IVIG use was not associated with reduced mortality (difference -2.5; 95% CI, -6.5-1.6). CONCLUSIONS There may be no significant association between IVIG use and mortality in mechanically ventilated septic shock patients after emergency laparotomy.
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Affiliation(s)
- Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan; Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan.
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University, Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan.
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Ates I, Dogan N, Aksoy M, Halıcı Z, Gündogdu C, Keles MS. The protective effects of IgM-enriched immunoglobulin and erythropoietin on the lung and small intestine tissues of rats with induced sepsis: biochemical and histopathological evaluation. PHARMACEUTICAL BIOLOGY 2015; 53:78-84. [PMID: 25243880 DOI: 10.3109/13880209.2014.910535] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
CONTEXT Sepsis continues to be a significant problem for critical care patients. OBJECTIVE To evaluate the protective effects of IgM-enriched immunoglobulin and erythropoietin on pulmonary and small intestine tissues in a rat model of intra-abdominal sepsis induced via the cecal ligation and puncture (CLP) method. MATERIALS AND METHODS Male Sprague-Dawley rats were used. Control group (n = 6): surgical procedure was not performed. Laparotomy was only performed in the sham group (n = 6) and CLP was only performed in the sepsis (CLP) group (n = 30). After erythropoietin (2000 U/kg, intraperitoneal) was given in the sepsis + erythropoietin (CLP + EPO) group (n = 30), IgM-enriched immunoglobulin (600 mg/kg, intraperitoneal) was given in the sepsis + pentaglobin (CLP + PEN) group (n = 30), CLP was created. Intracardiac blood samples were collected for biochemical analysis; lung and small intestine tissue samples were removed for histopathological evaluation. RESULTS Plasma TNF-α levels (pg/ml) were similar among CLP, CLP + EPO, and CLP + PEN groups (204.0 ± 52.4, 198.5 ± 17.3, and 214.6 ± 93.6, respectively). The CLP group had higher plasma IL-1β levels (pg/ml) compared with CLP + EPO and CLP + PEN groups (325.1 ± 134.1, 164.3 ± 25.6, and 186.3 ± 26.0, respectively) (p < 0.05). Rats in CLP + EPO and CLP + PEN groups had abolished histopathologic appearance of lung and small intestine tissues compared with rats in the CLP group. DISCUSSION AND CONCLUSION Our findings support the use of EPO and IgM-enriched immunoglobulin in the prevention of lung and small intestine injuries associated with sepsis.
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Affiliation(s)
- Irem Ates
- Department of Anesthesiology and Reanimation, Palandöken State Hospital , Erzurum , Turkey
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de Montmollin E, Annane D. Year in review 2013: Critical Care--sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:578. [PMID: 25673430 PMCID: PMC4331148 DOI: 10.1186/s13054-014-0578-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review presents key publications from the research field of sepsis published in Critical Care and other relevant journals during 2013. The results of these experimental studies and clinical trials are discussed in the context of current scientific and clinical background. The discussion highlights and summarises articles on four main topics: sepsis pathogenesis, diagnostic and prognostic biomarkers, potential new therapies, and epidemiologic and outcome studies.
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Identification of four novel serum protein biomarkers in sepsis patients encoded by target genes of sepsis-related miRNAs. Clin Sci (Lond) 2014; 126:857-67. [PMID: 24303815 PMCID: PMC4202716 DOI: 10.1042/cs20130301] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The goal of the present study was to identify novel protein biomarkers from the target genes of
six serum miRNAs that we identified previously in patients with sepsis. The target genes were
predicted by bioinformatics analysis; the levels of the respective proteins in the sera of patients
with sepsis were detected by ELISA. ACVR2A (activin A receptor, type IIA),
FOXO1 (forkhead box O1), IHH (Indian hedgehog),
STK4 (serine/threonine kinase 4) and DUSP3 (dual specificity
phosphatase 3) were predicted to be the targets of the six miRNAs, and their encoded proteins were
used for biomarker identification. Levels of ACVR2A (P<0.01) and FOXO1
(P<0.01) were significantly different among normal controls, patients with
sepsis, patients with severe sepsis and patients with septic shock. Furthermore, levels of ACVR2A
(P=0.025), FOXO1 (P<0.001), IHH (P=0.001)
and STK4 (P=0.001) were differentially expressed in survivors and non-survivors.
DUSP3 levels were not significantly different between any groups. Conjoin analysis of the four
differentially expressed proteins showed that the area under the curve of the predictive
probabilities was 0.875 [95% CI (confidence interval): 0.785–0.965], which was higher than
the SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health
Evaluation II) scores. When the value of predictive probabilities was 0.449, the four proteins
yielded a sensitivity of 68% and a specificity of 91%. Dynamic changes in ACVR2A, FOXO1 and IHH
levels showed differential expression between survivors and non-survivors at all time points. On the
basis of a combined analysis of the four identified proteins, their predictive value of 28-day
mortality of patients with sepsis was better than the SOFA or APACHE II scores. Four novel protein biomarkers encoded by the miRNA target genes were identified for patients with
sepsis. The combined analysis of the four proteins indicated that their predictive value for sepsis
prognosis was better than the values for the SOFA score and APACHE II score.
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