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Siew LY, Lee ZY, Yunos NM, Atan R, Cove ME, Lumlertgul N, Srisawat N, Hasan MS. Outcomes of extracorporeal blood purification with oXiris® membrane in critically ill patients: A systematic review and meta-analysis. J Crit Care 2024; 83:154844. [PMID: 38901069 DOI: 10.1016/j.jcrc.2024.154844] [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: 11/02/2023] [Revised: 04/26/2024] [Accepted: 06/08/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE To evaluate the efficacy of the novel oXiris® membrane in critically ill adult patients. METHODS We systematically searched MEDLINE, EMBASE, and CENTRAL from inception to 01/06/2023 for relevant randomised controlled trials (RCTs) and non-randomised studies of intervention (NRSI). The primary outcome was overall mortality. Random effect meta-analyses were conducted in RevMan 5.4.1. Study quality was evaluated using Cochrane's risk of bias tool. (PROSPERO: CRD42023389198). RESULTS Ten studies (2 RCTs and 8 NRSIs) with 481 patients were included. None had low risk of bias. Treatment using oXiris® was associated with reduced overall mortality (RR 0.78, 95%CI 0.62-0.98; p = 0.03; 6 NRSI). One RCT reported 28-day mortality, finding no significant difference between groups. Besides, pooled NRSIs results showed significant reductions in SOFA scores, norepinephrine dosage, and several inflammatory biomarkers (C-reactive protein [CRP], lactate, and interleukin-6 [IL-6]) post oXiris® treatment. However, other clinical outcomes (ICU and hospital length of stay, mechanical ventilation duration) were similar between groups. CONCLUSION In critically ill patients, the use of oXiris® membrane was associated with reduced overall mortality, norepinephrine dosage, CRP, IL-6, lactate levels, along with improved organ function. However, the certainty of evidence was very low, necessitating high-quality RCTs to further evaluate its efficacy in this population.
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Affiliation(s)
- Li Ying Siew
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rafidah Atan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Matthew Edward Cove
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Nuttha Lumlertgul
- Division of Nephrology, Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Faculty of Medicine, Centre of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Faculty of Medicine, Centre of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Zhao YC, Wang CY, Liu JY, Li JK, Liu HY, Sun ZH, Zhang BK, Yan M. Factors affecting the effectiveness and safety of polymyxin B in the treatment of Gram-negative bacterial infections: A meta-analysis of 96 articles. Int J Antimicrob Agents 2024; 64:107262. [PMID: 38945178 DOI: 10.1016/j.ijantimicag.2024.107262] [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: 01/23/2024] [Revised: 05/19/2024] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
PURPOSE Polymyxin B, with its unique structure and mechanism of action, has emerged as a key therapeutic agent against Gram-negative bacteria. The study aims to explore potential factors to influence its effectiveness and safety. METHODS A model-based meta-analysis of 96 articles was conducted, focusing on factors like dosage, bacterial species, and combined antibiotic therapy. The analysis evaluated mortality rates and incidence rate of renal dysfunction, also employing parametric survival models to assess 30-d survival rates. RESULTS In the study involving 96 articles and 9716 patients, polymyxin B's daily dose showed minimal effect on overall mortality, with high-dose group mortality at 33.57% (95% confidence intervals [CI]: 29.15-38.00) compared to the low-dose group at 35.44% (95% CI: 28.99-41.88), P = 0.64. Mortality significantly varied by bacterial species, with Pseudomonas aeruginosa infections at 58.50% (95% CI: 55.42-63.58). Monotherapy exhibited the highest mortality at 40.25% (95% CI: 34.75-45.76), P < 0.01. Renal dysfunction was more common in high-dose patients at 29.75% (95% CI: 28.52-30.98), with no significant difference across antibiotic regimens, P = 0.54. The 30-d overall survival rate for monotherapy therapy was 63.6% (95% CI: 59.3-67.5) and 70.2% (95% CI: 64.4-76.2) for association therapy with β-lactam drugs. CONCLUSIONS The dosage of polymyxin B does not significantly change death rates, but its effectiveness varies based on the bacterial infection. Certain bacteria like P. aeruginosa are associated with higher mortality. Combining polymyxin B with other antibiotics, especially β-lactam drugs, improves survival rates. Side effects depend on the dose, with lower doses being safer. These findings emphasize the importance of customizing treatment to balance effectiveness and safety.
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Affiliation(s)
- Yi-Chang Zhao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China
| | - Chen-Yu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia-Yi Liu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China
| | - Jia-Kai Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China
| | - Huai-Yuan Liu
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China; China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Zhi-Hua Sun
- International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China; China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Bi-Kui Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China
| | - Miao Yan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; International Research Center for Precision Medicine, Transformative Technology and Software Services, Changsha, Hunan, China.
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Wang P, Xie C, Zhang Y, Li H, Lu Y, Sun L, Hu X, Nie T, Li C, Li G, Lu X, Pang J, Yang X, Yu L, Li X, Wang X, You X. Negatively charged nanodiscs for the reduction of toxicity and enhanced efficacy of polymyxin B against Acinetobacter baumannii sepsis. Acta Biomater 2024; 184:323-334. [PMID: 38901753 DOI: 10.1016/j.actbio.2024.06.017] [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: 03/14/2024] [Revised: 05/27/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
The treatment of sepsis caused by multidrug-resistant (MDR) Gram-negative bacterial infections remains challenging. With these pathogens exhibiting resistance to carbapenems and new generation cephalosporins, the traditional antibiotic polymyxin B (PMB) has reemerged as a critical treatment option. However, its severe neurotoxicity and nephrotoxicity greatly limit the clinical application. Therefore, we designed negatively charged high-density lipoprotein (HDL) mimicking nanodiscs as a PMB delivery system, which can simultaneously reduce toxicity and enhance drug efficacy. The negative charge prevented the PMB release in physiological conditions and binding to cell membranes, significantly reducing toxicity in mammalian cells and mice. Notably, nanodisc-PMB exhibits superior efficacy than free PMB in sepsis induced by carbapenem-resistant Acinetobacter baumannii (CRAB) strains. Nanodisc-PMB shows promise as a treatment for carbapenem-resistant Gram-negative bacterial sepsis, especially caused by Acinetobacter baumannii, and the nanodiscs could be repurposed for other toxic antibiotics as an innovative delivery system. STATEMENT OF SIGNIFICANCE: Multidrug-resistant Gram-negative bacteria, notably carbapenem-resistant Acinetobacter baumannii, currently pose a substantial challenge due to the scarcity of effective treatments, rendering Polymyxins a last-resort antibiotic option. However, their therapeutic application is significantly limited by severe neurotoxic and nephrotoxic side effects. Prevailing polymyxin delivery systems focus on either reducing toxicity or enhancing bioavailability yet fail to simultaneously achieve both. In this scenario, we have developed a distinctive HDL-mimicking nanodisc for polymyxin B, which not only significantly reduces toxicity but also improves efficacy against Gram-negative bacteria, especially in sepsis caused by CRAB. This research offers an innovative drug delivery system for polymyxin B. Such advancement could notably improve the therapeutic landscape and make a significant contribution to the arsenal against these notorious pathogens.
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Affiliation(s)
- Penghe Wang
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Chunyang Xie
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Youwen Zhang
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Haibin Li
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Yun Lu
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Lang Sun
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Xinxin Hu
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Tongying Nie
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Congran Li
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Guoqing Li
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Xi Lu
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Jing Pang
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Xinyi Yang
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Liyan Yu
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China
| | - Xue Li
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China.
| | - Xiukun Wang
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China.
| | - Xuefu You
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China; Division for Medicinal Microorganisms Related Strains, CAMS Collection Center of Pathogenic Microorganisms, Beijing 100050, China; State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100050, China.
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4
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Li C, Zhang J, Yang P, Wang R, Chen T, Li L. The role of polymyxin B-immobilized hemoperfusion in reducing mortality and enhancing hemodynamics in patients with sepsis and septic shock: A systematic review and meta-analysis. Heliyon 2024; 10:e33735. [PMID: 39040355 PMCID: PMC11261863 DOI: 10.1016/j.heliyon.2024.e33735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/17/2024] [Accepted: 06/26/2024] [Indexed: 07/24/2024] Open
Abstract
Purpose Polymyxin B-immobilized hemoperfusion (PMX-HP) is a therapeutic strategy for removing circulating endotoxins from patients with sepsis or septic shock. However, the survival advantage of PMX-HP treatment remains controversial for patients with sepsis/septic shock. Therefore, this study collected all the clinical trials to assess the effect and the safety of PMX-HP treatment. Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for eligible trials fromtheir inception through June 30, 2023. All clinical trials that investigated the effect of polymyxin B hemoperfusion in patients who died with sepsis or septic shock within 28-day mortality were eligible. The Cochrane Risk of Bias Assessment instrument and the ROBINS-I tool were used to assess the risk of bias. Results A total of 30 trials, including 25680 adult patients, were included. PMX-HP decreased 28-day mortality (OR 0.75, 95 % CI 0.65-0.88; p<0.00001). Subgroup analysis revealed that 28-day mortality was significantly reduced after PMX-HP treatment in the mixed infection site group and in the age under 70 years old group. PMX-HP might also lower endotoxin levels (MD -1.22, 95 % CI -1.62 - 0.81, p < 0.00001) and improve SOFA scores (MD -2.11, 95 % CI -3.80- 0.43, p = 0.01). PMX-HP was not linked to the development of significant adverse events (p = 0. 05). Conclusion Our findings suggest that PMX-HP therapy can reduce 28-day mortality in individuals with sepsis or septic shock. The therapeutic effect may be due to the ability of PMX-HP to lower endotoxin levels and enhance hemodynamics. However, further assessment of the clinical effects of PMX-HP on sepsis or septic shock is required.
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Affiliation(s)
- Chao Li
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinlian Zhang
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ranran Wang
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Chen
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lixia Li
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Jang JH, Choi E, Kim T, Yeo HJ, Jeon D, Kim YS, Cho WH. Navigating the Modern Landscape of Sepsis: Advances in Diagnosis and Treatment. Int J Mol Sci 2024; 25:7396. [PMID: 39000503 PMCID: PMC11242529 DOI: 10.3390/ijms25137396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024] Open
Abstract
Sepsis poses a significant threat to human health due to its high morbidity and mortality rates worldwide. Traditional diagnostic methods for identifying sepsis or its causative organisms are time-consuming and contribute to a high mortality rate. Biomarkers have been developed to overcome these limitations and are currently used for sepsis diagnosis, prognosis prediction, and treatment response assessment. Over the past few decades, more than 250 biomarkers have been identified, a few of which have been used in clinical decision-making. Consistent with the limitations of diagnosing sepsis, there is currently no specific treatment for sepsis. Currently, the general treatment for sepsis is conservative and includes timely antibiotic use and hemodynamic support. When planning sepsis-specific treatment, it is important to select the most suitable patient, considering the heterogeneous nature of sepsis. This comprehensive review summarizes current and evolving biomarkers and therapeutic approaches for sepsis.
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Affiliation(s)
- Jin Ho Jang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Eunjeong Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Taehwa Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Hye Ju Yeo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Doosoo Jeon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Yun Seong Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Woo Hyun Cho
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
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Cho A, Oh SY, Lee H, Ryu HG. VASOPRESSOR REDUCTION EFFECT OF POLYMYXIN B HEMOPERFUSION IN PATIENTS WITH PERITONITIS-INDUCED SEPTIC SHOCK: A PROPENSITY SCORE-MATCHED ANALYSIS. Shock 2024; 62:69-73. [PMID: 38661146 DOI: 10.1097/shk.0000000000002375] [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: 04/26/2024]
Abstract
ABSTRACT Background : This study aimed to evaluate the effect of polymyxin B hemoperfusion (PMX-HP) in patients with peritonitis-induced septic shock who still required high-dose vasopressors after surgical source control. Methods : This retrospective study included adult patients admitted to the surgical intensive care unit (ICU) at Seoul National University Hospital between July 2014 and February 2021 who underwent major abdominal surgery to control the source of sepsis. Patients were divided into two groups based on whether PMX-HP was applied after surgery or not. The primary and secondary endpoints were the vasopressor reduction effect, and in-ICU mortality, respectively. Propensity score matching was performed to compare the vasopressor reduction effect. Results : A total of 338 patients met the inclusion criteria, of which 23 patients underwent PMX-HP postoperatively, whereas 315 patients did not during the study period. Serum norepinephrine concentration decreased over time regardless of whether PMX-HP was applied. However, it decreased more rapidly in the PMX-HP(+) group than in the PMX-HP(-) group. There were no significant differences in demographics including age, sex, body mass index, and most underlying comorbidities between the two groups. Risk factors for in-ICU mortality were identified by comparing patient characteristics and perioperative factors between the two groups using multivariate analysis. Conclusion : For patients with peritonitis-induced septic shock, PMX-HP rapidly reduces the requirement of vasopressors immediately after surgery but does not reduce in-ICU mortality. This effect could potentially accelerate recovery from shock, reduce sequelae from vasopressors, and ultimately improve quality of life after discharge.
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Affiliation(s)
- Ara Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | - Hannah Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Ramasco F, Nieves-Alonso J, García-Villabona E, Vallejo C, Kattan E, Méndez R. Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies. J Pers Med 2024; 14:176. [PMID: 38392609 PMCID: PMC10890552 DOI: 10.3390/jpm14020176] [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: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Jesús Nieves-Alonso
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Esther García-Villabona
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Vallejo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Eduardo Kattan
- Departamento de Medicina Intensiva del Adulto, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
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Bellomo R, Mehta RL, Forni LG, Zarbock A, Ostermann M, Ronco C. Hemoadsorption. Clin J Am Soc Nephrol 2024; 19:01277230-990000000-00339. [PMID: 38214917 PMCID: PMC11168820 DOI: 10.2215/cjn.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/09/2024] [Indexed: 01/13/2024]
Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital; Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ravindra L. Mehta
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Lui G. Forni
- Department of Critical Care, Royal Surrey Hospital Foundation Trust, Guilford, United Kingdom
- Faculty of Health Sciences, University of Surrey, Guilford, United Kingdom
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital, Muenster, Germany
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Claudio Ronco
- Department of Medicine, University of Padua, Padua, Italy
- International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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9
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Chen JJ, Lai PC, Lee TH, Huang YT. Blood Purification for Adult Patients With Severe Infection or Sepsis/Septic Shock: A Network Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2023; 51:1777-1789. [PMID: 37470680 PMCID: PMC10645104 DOI: 10.1097/ccm.0000000000005991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVES This study aimed to conduct a comprehensive and updated systematic review with network meta-analysis (NMA) to assess the outcome benefits of various blood purification modalities for adult patients with severe infection or sepsis. DATA SOURCES We conducted a search of PubMed, MEDLINE, clinical trial registries, Cochrane Library, and Embase databases with no language restrictions. STUDY SELECTION Only randomized controlled trials (RCTs) were selected. DATA EXTRACTION The primary outcome was overall mortality. The secondary outcomes were the length of mechanical ventilation (MV) days and ICU stay, incidence of acute kidney injury (AKI), and kidney replacement therapy requirement. DATA SYNTHESIS We included a total of 60 RCTs with 4,595 participants, comparing 16 blood purification modalities with 17 interventions. Polymyxin-B hemoperfusion (relative risk [RR]: 0.70; 95% CI, 0.57-0.86) and plasma exchange (RR: 0.61; 95% CI, 0.42-0.91) were associated with low mortality (very low and low certainty of evidence, respectively). Because of the presence of high clinical heterogeneity and intransitivity, the potential benefit of polymyxin-B hemoperfusion remained inconclusive. The analysis of secondary outcomes was limited by the scarcity of available studies. HA330 with high-volume continuous venovenous hemofiltration (CVVH), HA330, and standard-volume CVVH were associated with shorter ICU stay. HA330 with high-volume CVVH, HA330, and standard-volume CVVH were beneficial in reducing MV days. None of the interventions showed a significant reduction in the incidence of AKI or the need for kidney replacement therapy. CONCLUSIONS Our NMA suggests that plasma exchange and polymyxin-B hemoperfusion may provide potential benefits for adult patients with severe infection or sepsis/septic shock when compared with standard care alone, but most comparisons were based on low or very low certainty evidence. The therapeutic effect of polymyxin-B hemoperfusion remains uncertain. Further RCTs are required to identify the specific patient population that may benefit from extracorporeal blood purification.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou Main Branch, Taoyuan City, Taiwan
| | - Pei-Chun Lai
- Education Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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10
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Gräfe C, Weidhase L, Liebchen U, Weigand MA, Scharf C. [Hemoperfusion in anesthesia and intensive care medicine: benefits, risks, and evidence for different systems]. DIE ANAESTHESIOLOGIE 2023; 72:843-851. [PMID: 37707564 DOI: 10.1007/s00101-023-01341-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies. OBJECTIVE The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany. METHOD To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies. RESULTS In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is a relevant risk, especially when used in patients with sepsis. DISCUSSION Various adsorption systems can eliminate different known and unknown substances. Currently, there is a lack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or a recommendation against the use can be given.
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Affiliation(s)
- Caroline Gräfe
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Lorenz Weidhase
- Interdisziplinäre internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Uwe Liebchen
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christina Scharf
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
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11
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Tomlinson G, Al-Khafaji A, Conrad SA, Factora FNF, Foster DM, Galphin C, Gunnerson KJ, Khan S, Kohli-Seth R, McCarthy P, Meena NK, Pearl RG, Rachoin JS, Rains R, Seneff M, Tidswell M, Walker PM, Kellum JA. Bayesian methods: a potential path forward for sepsis trials. Crit Care 2023; 27:432. [PMID: 37940985 PMCID: PMC10634134 DOI: 10.1186/s13054-023-04717-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Given the success of recent platform trials for COVID-19, Bayesian statistical methods have become an option for complex, heterogenous syndromes like sepsis. However, study design will require careful consideration of how statistical power varies using Bayesian methods across different choices for how historical data are incorporated through a prior distribution and how the analysis is ultimately conducted. Our objective with the current analysis is to assess how different uses of historical data through a prior distribution, and type of analysis influence results of a proposed trial that will be analyzed using Bayesian statistical methods. METHODS We conducted a simulation study incorporating historical data from a published multicenter, randomized clinical trial in the US and Canada of polymyxin B hemadsorption for treatment of endotoxemic septic shock. Historical data come from a 179-patient subgroup of the previous trial of adult critically ill patients with septic shock, multiple organ failure and an endotoxin activity of 0.60-0.89. The trial intervention consisted of two polymyxin B hemoadsorption treatments (2 h each) completed within 24 h of enrollment. RESULTS In our simulations for a new trial of 150 patients, a range of hypothetical results were observed. Across a range of baseline risks and treatment effects and four ways of including historical data, we demonstrate an increase in power with the use of clinically defensible incorporation of historical data. In one possible trial result, for example, with an observed reduction in risk of mortality from 44 to 37%, the probability of benefit is 96% with a fixed weight of 75% on prior data and 90% with a commensurate (adaptive-weighting) prior; the same data give an 80% probability of benefit if historical data are ignored. CONCLUSIONS Using Bayesian methods and a biologically justifiable use of historical data in a prior distribution yields a study design with higher power than a conventional design that ignores relevant historical data. Bayesian methods may be a viable option for trials in critical care medicine where beneficial treatments have been elusive.
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Affiliation(s)
- George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health, Shreveport, LA, USA
| | - Faith N F Factora
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Claude Galphin
- Southeast Renal Research Institute, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Sobia Khan
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul McCarthy
- West Virginia University, Heart & Vascular Institute, Morgantown, WV, USA
| | - Nikhil K Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ronald Rains
- Pulmonary Associates, Univ of Colorado Health-Memorial Hospital, Colorado Springs, CO, USA
| | - Michael Seneff
- Department of Anesthesia and Critical Care, George Washington University Hospital, Washington, DC, USA
| | - Mark Tidswell
- Pulmonary and Critical Care Division, Baystate Medical Center, Springfield, MA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
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12
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Whitehead B, Antennuci F, Boysen AT, Nejsum P. Polymyxin B inhibits pro-inflammatory effects of E. coli outer membrane vesicles whilst increasing immune cell uptake and clearance. J Antibiot (Tokyo) 2023; 76:360-364. [PMID: 37016014 DOI: 10.1038/s41429-023-00615-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
Polymyxin B (PMB) is a peptide based antibiotic that binds the lipid A moiety of lipopolysaccharide (LPS) with a resultant bactericidal effect. The interaction of PMB with LPS presented on outer membrane vesicles (OMVs) is not fully known, however, a sacrificial role of OMVs in protecting bacterial cells by sequestering PMB has been described. Here we assess the ability of PMB to neutralize the immune-stimulatory properties of OMVs whilst modulating the uptake of OMVs in human immune cells. We show for the first time that PMB increases immune cell uptake of Escherichia coli derived OMVs whilst inhibiting TNF and IL-1β production. Therefore, we present a potential new role for PMB in the neutralization of OMVs via LPS masking and increased immune cell uptake.
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Affiliation(s)
- Bradley Whitehead
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Fabio Antennuci
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anders T Boysen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Nejsum
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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13
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Mendibaev MS, Rabotinsky SE. Pharmacological methods for blood stabilization in the extracorporeal circuit (review of literature). MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2023. [DOI: 10.24884/2078-5658-2023-20-1-81-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
We summarize the possible benefits and risks of using various anticoagulants during hemoperfusion. Clotting in the extracorporeal circuit can lead to a decrease in the effectiveness of therapy, additional workload, risk to the patient and economic losses. At the same time, relatively excessive anticoagulation against the background of existing hemostasis disorders can lead to severe hemorrhagic complications, which in turn worsen the prognosis of patients. The article describes the causes of heparin resistance, the main techniques for overcoming it, and provides practical guidelines for anticoagulant therapy during hemoperfusion. It is well known that routine methods of monitoring hemostasis (such as platelet count, activated partial thromboplastin time) are unable to assess the balance of pro/anticoagulants. The authors have proposed a reasonable personalized approach to anticoagulant therapy of extracorporeal blood purification depending on the pathology in patient and thromboelastography (TEG) data, and antithrombin III levels.
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14
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Shoji H, Ferrer R. Potential survival benefit and early recovery from organ dysfunction with polymyxin B hemoperfusion: perspectives from a real-world big data analysis and the supporting mechanisms of action. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC9207853 DOI: 10.1186/s44158-022-00056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Endotoxin (ET) removal therapy with polymyxin B-immobilized fiber column hemoperfusion (PMX-HP) has been used for the treatment of septic shock. Some observational studies reported clinical benefits, particularly in specific subgroups of patients. However, larger randomized controlled trial results have been disappointing.
Main body
The four studies that revealed the survival benefit of PMX-HP were based on the Japanese Diagnosis Procedure Combination (DPC) national inpatient database (J-DPC study). Nevertheless, one J-DPC study and a randomized controlled trial (RCT) conducted in France evaluated PMX-HP in patients with abdominal septic shock and did not report a significant survival benefit. In both studies, the severity of illness was too low to find substantial significant differences in mortality. The results of the J-DPC studies further suggest that some subpopulations of patients could benefit from PMX-HP. Based on these results, this review revisited prior RCTs and other large-scale studies on PMX-HP. In addition, four J-DPC studies and one large-scale study reported a survival benefit with PMX-HP. A secondary analysis of the EUPHRATES trial, the most recent double-blinded RCT of PMX-HP conducted in North America, suggested a survival benefit in patients with high levels of endotoxemia. In the J-DPC studies and the EUPHRATES trial, ventilator-free days, vasoactive drug-free days, and renal replacement-free days were significantly improved in the PMX-HP groups. These findings suggest that PMX-HP can contribute to early recovery from organ dysfunction. The reduction of supportive care likely provides important health and economic benefits for managing patients with septic shock. Finally, the blood levels of mediators or biomarkers related to respiratory, cardiovascular, and renal dysfunction have been reported to be normalized with PMX-HP.
Conclusions
These results support the biological rationale for the improvement in organ dysfunction observed in the J-DPC studies and other large-scale studies, including the EUPHRATES trial. Real-world evidence from large data sets suggests an appropriate patient population that are likely to benefit from the utility of PMX-HP for septic shock.
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15
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Ronco C, Bellomo R. Hemoperfusion: technical aspects and state of the art. Crit Care 2022; 26:135. [PMID: 35549999 PMCID: PMC9097563 DOI: 10.1186/s13054-022-04009-w] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Blood purification through the removal of plasma solutes by adsorption to beads of charcoal or resins contained in a cartridge (hemoperfusion) has a long and imperfect history. Developments in production and coating technology, however, have recently increased the biocompatibility of sorbents and have spurred renewed interest in hemoperfusion. Methods We performed a narrative assessment of the literature with focus on the technology, characteristics, and principles of hemoperfusion. We assessed publications in ex vivo, animal, and human studies. We synthesized such literature in a technical and state-of-the-art summary. Results Early hemoperfusion studies were hampered by bioincompatibility. Recent technology, however, has improved its safety. Hemoperfusion has been used with positive effects in chronic dialysis and chronic liver disease. It has also demonstrated extraction of a variety of toxins and drugs during episodes of overdose. Trials with endotoxin binding polymyxin B have shown mixed results in septic shock and are under active investigation. The role of non-selective hemoperfusion in sepsis or inflammation remains. Although new technologies have made sorbents more biocompatible, the research agenda in the field remains vast. Conclusion New sorbents markedly differ from those used in the past because of greater biocompatibility and safety. Initial studies of novel sorbent-based hemoperfusion show some promise in specific chronic conditions and some acute states. Systematic studies of novel sorbent-based hemoperfusion are now both necessary and justified.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy.,Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia. .,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia. .,Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia. .,Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, VIC, 3084, Australia. .,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.
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16
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The Rationale and Current Status of Endotoxin Adsorption in the Treatment of Septic Shock. J Clin Med 2022; 11:jcm11030619. [PMID: 35160068 PMCID: PMC8836955 DOI: 10.3390/jcm11030619] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 02/05/2023] Open
Abstract
Lipopolysaccharide, the main component of the outer membrane of Gram-negative bacteria is a highly potent endotoxin responsible for organ dysfunction in sepsis. It is present in the blood stream not only in Gram-negative infections, but also in Gram-positive and fungal infections, presumably due to sepsis-related disruption of the intestinal barrier. Various pathways, both extra- and intracellular, are involved in sensing endotoxin and non-canonical activation of caspase-mediated pyroptosis is considered to have a major role in sepsis pathophysiology. Endotoxin induces specific pathological alterations in several organs, which contributes to poor outcomes. The adverse consequences of endotoxin in the circulation support the use of anti-endotoxin therapies, yet more than 30 years of experience with endotoxin adsorption therapies have not provided clear evidence in favor of this treatment modality. The results of small studies support timely endotoxin removal guided by measuring the levels of endotoxin; unfortunately, this has not been proven in large, randomized studies. The presence of endotoxemia can be demonstrated in the majority of patients with COVID-19, yet only case reports and case series describing the effects of endotoxin removal in these patients have been published to date. The place of blood purification therapies in the treatment of septic shock has not yet been determined.
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17
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Abstract
PURPOSE OF REVIEW Sepsis and septic shock are life-threatening diseases with high mortality. Although efforts have made to improve the survivals, the outcomes are still frustrating. Blood purification was thought to be a promising adjunctive therapy to regulate the excessive cytokine storm or to reduce the endotoxin activity caused by sepsis. Critically ill COVID-19 characterized with the similar disease to sepsis may also benefit from blood purification. RECENT FINDINGS The recent studies mainly focused on hemadsorption materials. The results of the clinical trials showed a tendency in decrease of cytokine levels and endotoxin activity and improvement in haemodynamics. However, the results were controversial. More evidence about blood purification in sepsis and COVID-19 are needed from currently ongoing trials and future well designed trials. SUMMARY The blood purification therapy demonstrated the tendency in decrease of cytokines and endotoxin activity in different degree according to the current studies. However, the effect on mortality and haemodynamics is still in controversy. Further well designed, large sample sized studies should focus on the timing of initiating blood purification, the appropriate indications and the optimal type of blood purification membrane or cartridge to provide more evidence for clinical practice.
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18
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Payen D, Dupuis C, Deckert V, Pais de Barros JP, Rérole AL, Lukaszewicz AC, Coudroy R, Robert R, Lagrost L. Endotoxin Mass Concentration in Plasma Is Associated With Mortality in a Multicentric Cohort of Peritonitis-Induced Shock. Front Med (Lausanne) 2021; 8:749405. [PMID: 34778311 PMCID: PMC8586519 DOI: 10.3389/fmed.2021.749405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/06/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives: To investigate the association of plasma LPS mass with mortality and inflammation in patients with peritonitis-induced septic shock (SS). Design: Longitudinal endotoxin and inflammatory parameters in a multicentric cohort of SS. Patients: Protocolized post-operative parameters of 187 SS patients collected at T1 (12 h max post-surgery) and T4 (24 h after T1). Intervention: Post-hoc analysis of ABDOMIX trial. Measurements and Results: Plasma concentration of LPS mass as determined by HPLC-MS/MS analysis of 3-hydroxymyristate, activity of phospholipid transfer protein (PLTP), lipids, lipoproteins, IL-6, and IL-10. Cohort was divided in low (LLPS) and high (HLPS) LPS levels. The predictive value for mortality was tested by multivariate analysis. HLPS and LLPS had similar SAPSII (58 [48.5; 67]) and SOFA (8 [6.5; 9]), but HLPS showed higher death and LPS to PLTP ratio (p < 0.01). LPS was stable in HLPS, but it increased in LLPS with a greater decrease in IL-6 (p < 0.01). Dead patients had a higher T1 LPS (p = 0.02), IL-6 (<0.01), IL-10 (=0.01), and day 3 SOFA score (p = 0.01) than survivors. In the group of SAPSII > median, the risk of death in HLPS (38%) was higher than in LLPS (24%; p < 0.01). The 28-day death was associated only with SAPSII (OR 1.06 [1.02; 1.09]) and HLPS (OR 2.47 [1; 6.11]) in the multivariate model. In HLPS group, high PLTP was associated with lower plasma levels of IL-6 (p = 0.02) and IL-10 (p = 0.05). Conclusions: Combination of high LPS mass concentration and high SAPS II is associated with elevated mortality in peritonitis-induced SS patients.
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Affiliation(s)
- Didier Payen
- UFR de Médecine Lariboisière-Saint-Louis, University Paris 7 Denis Diderot, Paris, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Valérie Deckert
- Inserm, LNC-UMR1231, Dijon, France.,University Bourgogne-Franche Comté, LNC-UMR1231, Dijon, France.,LabEx LipSTIC, FCS Bourgogne-France Comté, Dijon, France
| | - Jean-Paul Pais de Barros
- Inserm, LNC-UMR1231, Dijon, France.,University Bourgogne-Franche Comté, LNC-UMR1231, Dijon, France.,LabEx LipSTIC, FCS Bourgogne-France Comté, Dijon, France
| | - Anne-Laure Rérole
- Inserm, LNC-UMR1231, Dijon, France.,University Bourgogne-Franche Comté, LNC-UMR1231, Dijon, France.,LabEx LipSTIC, FCS Bourgogne-France Comté, Dijon, France.,CHU Dijon, Service de la Recherche, Dijon, France
| | | | - Remi Coudroy
- Department of Medical Intensive Care, La Miléterie University Hospital, Poitiers University, Poitiers, France
| | - René Robert
- Department of Medical Intensive Care, La Miléterie University Hospital, Poitiers University, Poitiers, France
| | - Laurent Lagrost
- Inserm, LNC-UMR1231, Dijon, France.,University Bourgogne-Franche Comté, LNC-UMR1231, Dijon, France.,LabEx LipSTIC, FCS Bourgogne-France Comté, Dijon, France.,CHU Dijon, Service de la Recherche, Dijon, France
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19
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Honore PM, Redant S, Preseau T, Moorthamers S, Kaefer K, Barreto Gutierrez L, Attou R, Gallerani A, De Bels D. Studying polymyxin B-immobilized hemoperfusion therapy to remove endotoxin in infection with GN bacteria has conflicting results: We are not sure! J Crit Care 2021; 65:228-229. [PMID: 34252651 DOI: 10.1016/j.jcrc.2021.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Patrick M Honore
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium; Faculty of Medicine of the ULB University, Belgium.
| | - Sebastien Redant
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Thierry Preseau
- Emergency Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Sofie Moorthamers
- Emergency Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Keitiane Kaefer
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | | | - Rachid Attou
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Andrea Gallerani
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - David De Bels
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
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Nebulized Colistin in Ventilator-Associated Pneumonia and Tracheobronchitis: Historical Background, Pharmacokinetics and Perspectives. Microorganisms 2021; 9:microorganisms9061154. [PMID: 34072189 PMCID: PMC8227626 DOI: 10.3390/microorganisms9061154] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
Clinical evidence suggests that nebulized colistimethate sodium (CMS) has benefits for treating lower respiratory tract infections caused by multidrug-resistant Gram-negative bacteria (GNB). Colistin is positively charged, while CMS is negatively charged, and both have a high molecular mass and are hydrophilic. These physico-chemical characteristics impair crossing of the alveolo-capillary membrane but enable the disruption of the bacterial wall of GNB and the aggregation of the circulating lipopolysaccharide. Intravenous CMS is rapidly cleared by glomerular filtration and tubular excretion, and 20-25% is spontaneously hydrolyzed to colistin. Urine colistin is substantially reabsorbed by tubular cells and eliminated by biliary excretion. Colistin is a concentration-dependent antibiotic with post-antibiotic and inoculum effects. As CMS conversion to colistin is slower than its renal clearance, intravenous administration can lead to low plasma and lung colistin concentrations that risk treatment failure. Following nebulization of high doses, colistin (200,000 international units/24h) lung tissue concentrations are > five times minimum inhibitory concentration (MIC) of GNB in regions with multiple foci of bronchopneumonia and in the range of MIC breakpoints in regions with confluent pneumonia. Future research should include: (1) experimental studies using lung microdialysis to assess the PK/PD in the interstitial fluid of the lung following nebulization of high doses of colistin; (2) superiority multicenter randomized controlled trials comparing nebulized and intravenous CMS in patients with pandrug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis; (3) non-inferiority multicenter randomized controlled trials comparing nebulized CMS to intravenous new cephalosporines/ß-lactamase inhibitors in patients with extensive drug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis.
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Therapeutic Rationale for Endotoxin Removal with Polymyxin B Immobilized Fiber Column (PMX) for Septic Shock. Int J Mol Sci 2021; 22:ijms22042228. [PMID: 33672437 PMCID: PMC7926968 DOI: 10.3390/ijms22042228] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Endotoxin removal therapy with polymyxin B immobilized fiber column (PMX) has been clinically applied for sepsis and septic shock patients since 1994. The effectiveness and usefulness of this therapy have been demonstrated for more than a quarter of a century. However, a documented survival benefit has not yet been demonstrable in a large, multicenter, randomized and controlled trial. Following the findings derived from a large sepsis clinical trial with PMX in North America, a new trial is ongoing to determine if PMX has a long-term survival benefit when administered to septic patients. Another approach to support a survival benefit from intervention with PMX is to utilize a detailed analysis available from a large clinical data base. The endotoxin adsorption capacity of PMX columns in vitro and the effectiveness of PMX columns can be further demonstrable in animal models. The capability of PMX and details of its mechanism of action to intervene in the sepsis cascade and impede organ dysfunction in septic patients is not fully understood. The surface antigen expression in monocytes and neutrophils are improved after PMX therapy. Immunomodulatory effects as a result of endotoxin removal and/or other mechanisms of action have been suggested. These effects and other potential immune effects may explain some of the improved effects upon organ dysfunction of sepsis and septic shock patients. Endotoxemia may be involved in the pathophysiology of other diseases than sepsis. A rapid diagnostic method to detect and target endotoxemia could allow us to practice precision medicine and expand the clinical indications of endotoxin removal therapy.
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