Aluminum load in ICU patients during stress ulcer prophylaxis

Pharmacological interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units: a network meta-analysis

OBJECTIVES

To assess the efficacy and safety of pharmacological interventions for preventing upper gastrointestinal (GI) bleeding in people admitted to intensive care units (ICUs).

DESIGN AND SETTING

Systematic review and frequentist network meta-analysis using standard methodological procedures as recommended by Cochrane for screening of records, data extraction and analysis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence.

PARTICIPANTS

Randomised controlled trials involving patients admitted to ICUs for longer than 24 hours were included.

SEARCH METHODS

The Cochrane Gut Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Latin American and Caribbean Health Science Information database (LILACS) databases were searched from August 2017 to March 2022. The search in MEDLINE was updated in April 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP).

MAIN OUTCOME MEASURES

The primary outcome was the prevention of clinically important upper GI bleeding.

RESULTS

We included 123 studies with 46 996 participants. Cimetidine (relative risk (RR) 0.56, 95% CI 0.40 to 0.77, moderate certainty), ranitidine (RR 0.54, 95% CI 0.38 to 0.76, moderate certainty), antacids (RR 0.48, 95% CI 0.33 to 0.68, moderate certainty), sucralfate (RR 0.54, 95% CI 0.39 to 0.75, moderate certainty) and a combination of ranitidine and antacids (RR 0.13, 95% CI 0.03 to 0.62, moderate certainty) are likely effective in preventing upper GI bleeding.The effect of any intervention on the prevention of nosocomial pneumonia, all-cause mortality in the ICU or the hospital, duration of the stay in the ICU, duration of intubation and (serious) adverse events remains unclear.

CONCLUSIONS

Several interventions seem effective in preventing clinically important upper GI bleeding while there is limited evidence for other outcomes. Patient-relevant benefits and harms need to be assessed under consideration of the patients' underlying conditions.

Gallic and Hesperidin Ameliorate Electrolyte Imbalances in AlCl3-Induced Nephrotoxicity in Wistar Rats

Nephrotoxicity is usually characterized by inefficiency of the kidney, thereby causing disruptions to electrolyte balance and blood acidity. This study aimed to evaluate the effect of hesperidin and gallic acid on serum electrolytes and ion pumps in Wistar rats subjected to aluminum chloride (AlCl₃)-induced nephrotoxicity. Thirty Wistar rats were randomly divided into six groups of five animals apiece. Group one served as the negative control and received distilled water while the study lasted. Animals in groups 2–4 received 100 mg/kg/day AlCl₃ throughout the study. Animals in groups 3 and 4 were also administered 100 mg/kg/day gallic acid and 100 mg/kg/day hesperidin, respectively. Groups 5 and 6 were treated with 100 mg/kg/day gallic acid only and 100 mg/kg/day hesperidin only, respectively. Treatments were administered orally via gavage for 28 days with distilled water as the vehicle. Animals were sacrificed after which levels of potassium, calcium, magnesium, phosphate, chloride, and bicarbonate ions were evaluated in the serum, while activities of Na⁺/K⁺ and Ca²⁺/Mg²⁺ ATPases were determined in kidney homogenate. Results showed that AlCl₃ significantly (p < 0.05) inhibited activities of Na⁺/K⁺ and Ca²⁺/Mg²⁺ ATPases in addition to increasing serum levels of potassium, calcium, phosphate, and chloride, with concomitant decrease in serum levels of magnesium and bicarbonate. However, coadministration of AlCl₃ with either gallic acid or hesperidin ameliorated all the disruptions caused by AlCl₃. It could be concluded that gallic acid and hesperidin could be relevant in managing electrolyte imbalances and acidosis occasioned by kidney dysfunction.

Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units

BACKGROUND

Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding.

OBJECTIVES

To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs.

SEARCH METHODS

We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane.

MAIN RESULTS

We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence).

AUTHORS' CONCLUSIONS

This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.

Protective effects of banana pectin against aluminum-induced cognitive impairment and aluminum accumulation in mice

To investigate the effect of pectin on absorption and bio-toxicity of aluminum, pectin extract (100 mg kg^-1 d^-1) from banana pulp was orally administrated to aluminum exposed mice (35 mg kg^-1 d^-1) for 6 weeks. Our result showed that body weight gain of the mice treated with aluminum plus banana pectin was 32.5% higher than that of mice exposed to aluminum alone after 6 weeks of the administration. In both the step-down inhibitory avoidance task and Morris water maze test, memory retention of aluminum-exposed mice was significantly improved by the pectin administration. Treatment with banana pectin effectively prevented absorption of aluminum from the gastrointestinal tract, total aluminum excretion of mice treated with banana pectin plus aluminum was 9.3% higher than that of mice exposed to aluminum alone on the 12th day. Aluminum level in serum, cerebrum, or cerebellum of mice treated with aluminum plus banana pectin was 30.8%, 17.5%, or 17.9% lower than that of mice exposed to aluminum alone on the 42nd day, respectively. In conclusion, banana pectin extract can effectively reduce aluminum toxicity in mice.

Protective effect of resveratrol against aluminum chloride induced nephrotoxicity in rats

OBJECTIVES

To investigate the potential protective effect of resveratrol (RES) on aluminum chloride (AlCl3)-induced nephrotoxicity in rats.

METHODS

This experimental study was conducted from April to June 2015 at the Medical College of King Khalid University, Abha, Kingdom of Saudi Arabia. The experiments were performed on 24 male Wistar rats. The rats were randomly allocated into 4 groups; 1) group A: control rats received only normal saline, 2) group B: received RES dissolved in normal saline, 3) group C: model group and received AlCl3 dissolved in normal saline and 4) group D: RES treated group and received concomitant doses of RES+AlCl3. All treatments were administered for consecutive 40 days. After 40 days of treatments, kidney function tests, oxidative stress parameters and histopathological assay were evaluated.

RESULTS

all findings clearly showed significant deteriorations in kidney function and architectures after AlCl3 exposure. This was accompanied by increased renal oxidative stress and inflammation suggesting strong pro-oxidant activity of AlCl3 in spite of its non-redox status. Resveratrol co-treatment with AlCl3 to the rats showed significant improvement in all biochemical and histological parameters related to kidney function and structure.

CONCLUSION

The findings of the current study showed that RES pre-administration to rats ameliorates renal damage and improves renal function in AlCl3 intoxicated rats in a mechanism related to its antioxidant potential.

Studies on fate and toxicity of nanoalumina in male albino rats

The work aimed to evaluate the nanoalumina toxicity on the histological architecture, some haematological and biochemical aspects in male albino rats, during acute and sublethal experiments. Rats, in acute experiments, were injected with a single-acute dose of 3.9 g or 6.4 g or 8.5 g of aluminium oxide (Al2O3) kg−1, whereas those of sublethal were injected with 1.3 g of Al2O3 kg−1 2 days−1. One-way analysis of variance indicated that injected doses and the experimental periods were significantly affected by haemoglobin (Hb) content; haematocrit value (Hct); white blood cell (WBC) count; blood platelet (Plt) count; mean corpuscular volume (MCV); mean corpuscular Hb (MCH) and MCH concentration (MCHC). In acute experiments, Hct, WBC count, MCV and Plt were significantly higher than the corresponding controls, whereas Hb, MCH and MCHC markedly decreased. In comparison with the related controls after 1, 3 and 7 days post-injection, red blood cell count, Hb, Hct, WBC count, Plt and MCV were significantly increased, but begun to decrease after 14 or/and 28 days and were associated with a marked decrease in MCH and MCHC. In serum of rats injected with acute or sublethal dose, the concentrations of total protein (TP) and total lipid (TL) were significantly lesser than the corresponding controls, whereas the levels of urea, uric acid, creatinine and the activities of aspartate aminotransferase and alanine aminotransferase were markedly increased. The injected doses were directly proportional with all the studied biochemical parameter, except the TL and TP that exhibited a negative correlation. Histologically, the highest acute and sublethal doses of nanoalumina caused hepatic irregular disarray, necrosis to the hepatic and Kupffer cells that are associated with congested blood sinusoids. The renal tissues characterized by the appearance of inter-tubular congestion that is accompanied by the dilation of the vascular glomeruli that completely occupied Bowman’s capsule and accompanied with partial disappearance of the renal tubule’s brush border. The brain showed a progressive degeneration of neurons in both the experiments.

The genotoxic, hepatotoxic, nephrotoxic, haematotoxic and histopathological effects in rats after aluminium chronic intoxication

Aluminium (Al) is used in water purification and is also present in several manufactured foods and medicines. Al is known to induce a broad range of physiological, biochemical and behavioural dysfunctions in laboratory animals and humans. This investigation was carried out to investigate the effects of subchronic exposure to Al (as AlCl3) in rats. Sprague-Dawley rats were randomly separated into two groups. Group 1 rats treated with sodium chloride served as the control, group 2 rats were treated with Al (as AlCl3, 5 mg/kg body weight) intraperitonally for 10 weeks. Animals were killed and blood samples were analyzed for blood serum alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) enzyme activities and creatinine, urea (U) and uric acid (UA) levels for evaluating hepatotoxicity and nephrotoxicity. Blood parameters including red blood cells (RBCs), haemoglobin (Hb) concentration, haematocrit (Ht), platelets (PLTs) and white blood cells (WBCs) were compared between control and experimental group to assess haematoxicity. In order to determine the genotoxicity, the number of micronucleated hepatocytes (MNHEPs) was counted in isolated hepatocytes. In addition, histological alterations in liver and kidney samples were investigated. After exposure with Al, the enzymatic activities of ALP, AST, ALT and LDH, and the levels of U and UA significantly increased. RBC, WBC, PLT, Hb and Ht revealed significant decreases in experimental group compared to the control. AlCl3 caused a significant increase in MNHEPs. Furthermore, severe pathological damages were established in both liver and kidney samples. Subchronic exposure to low doses of Al can produce serious dysfunctions in rat blood, liver and kidney, and exposure to this metal can result in greater damages.

Aluminum is a potential environmental factor for Crohn's disease induction: extended hypothesis

Aluminum (Al) is a common environmental compound with immune-adjuvant activity and granulomatous inflammation inducer. Al exposure in food, additives, air, pharmaceuticals, and water pollution is ubiquitous in Western culture. Crohn's disease (CD) is a chronic relapsing intestinal inflammation in genetically susceptible individuals and is influenced by yet unidentified environmental factors. It is hypothesized, in the present review, that Al is a potential factor for induction or maintaining the inflammation in CD. Epidemiologically, CD incidence is higher in urban areas, where microparticle pollution is prevalent. Al immune activities share many characteristics with the immune pathology of CD: increased antigen presentation and APCs activation, many luminal bacterial or dietary compounds can be adsorbed to the metal and induce Th1 profile activity, promotion of humoral and cellular immune responses, proinflammatory, apoptotic, oxidative activity, and stress-related molecule expression enhancement, affecting intestinal bacterial composition and virulence, granuloma formation, colitis induction in an animal model of CD, and terminal ileum uptake. The Al-bacterial interaction, the microparticles homing the intestine together with the extensive immune activity, put Al as a potential environmental candidate for CD induction and maintenance.