Respuesta inflamatoria y apoptosis en la lesión pulmonar aguda

Sepsis-induced acute respiratory distress syndrome with fatal outcome is associated to increased serum transforming growth factor beta-1 levels

BACKGROUND

TGF-β1 is a promoter of pulmonary fibrosis in many chronic inflammatory diseases. TGF-β1 circulating levels in patients with sepsis-induced Acute Respiratory Distress Syndrome (ARDS) have not been established.

METHODS

In this prospective pilot cohort study, serum bioactive TGF-β1 concentration, determined by sandwich ELISA, was analyzed in 52 patients who fulfilled criteria for septic shock at admission and on days 3 and 7.

RESULTS

Of the 52 patients enrolled in the study, 46.1% fulfilled the criteria for ARDS on admission. At ICU admission, there were not statistical differences in TGF-β1 concentrations between septic shock patients with or without ARDS. After 7 days of follow-up in ICU, circulating TGF-β1 levels were significantly higher in patients with sepsis and ARDS than in those without ARDS [55.47 (35.04-79.48 pg/ml) versus 31.65 (22.89-45.63 pg/ml), respectively] (p = 0.002). Furthermore, in septic shock associated ARDS patients, TGF-β1 levels were significantly higher in nonsurvivors than in survivors [85.23 (78.19-96.30 pg/ml) versus 36.41 (30.21-55.47 pg/ml), respectively] (p = 0.006) on day 7 of ICU follow-up.

CONCLUSIONS

In patients with septic shock, persistent ARDS is accompanied with increased circulating TGF-β1 levels. Furthermore, ARDS patients with fatal outcome show higher TGF-β1 concentrations than survivors. These results suggest the relevance of TGF-β1 levels found in the pathogenesis of persistent sepsis-induced ARDS.

[High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta-analysis]

OBJECTIVE

To perform a systematic review and meta-analysis of the literature to evaluate the effects of high PEEP versus conventional PEEP on mortality and on the risk of barotrauma in patients with the acute respiratory distress syndrome (ARDS).

SOURCE OF DATA

Computer search of Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, Cochrane library (CDSR, DARE, CCTR), ISI Proceedings, Current Contents, and Web of Science, as well as manual search of selected references.

SELECTION OF STUDIES

Controlled random clinical trials published after NAECC (1994) that evaluated the effect of two levels of PEEP and that reported the mortality and incidence of barotrauma in the series.

DATA EXTRACTION

By two investigators working independently, with discrepancies resolved by group consensus. Contingency tables were elaborated and the RRs with corresponding confidence intervals were obtained for each study.

RESULTS

Four articles were selected for the meta-analysis of mortality and three for the meta-analysis of barotrauma. No effects of PEEP level on mortality were found (RR 0.73, 95% CI: 0.49 to 1.10) or on the incidence of barotrauma (RR 0.50, 95% CI: 0.14 to 1.73). However, an analysis of the studies in which PEEP was individualized in function of Pflex showed a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82) (p=0.001)

CONCLUSIONS

The use of high or conventional PEEP in function of oxygenation does not affect mortality or the incidence of barotrauma in patients with ARDS. However, there might be a decrease in mortality associated to high PEEP individualized in function of the pulmonary mechanics of each patient.

Methylmercury Induces Alveolar Macrophages Apoptosis

Through the use of a scanning electronic microscope, it was found that alveolar macrophages treated with 10 μM of methylmercury for 24 h showed a decrease of surface microvilli, and those treated with 15 μM of methylmercury underwent deformity and subsequent cell death. To investigate their death patterns, DNA was aspirated from alveolar macrophages and analyzed by electrophoresis. It was discovered that the DNA ladder phenomenon became more obvious as the methylmercury increased in concentration. When 5 mM EGTA was used to eliminate calcium ions, a decrease of the ladder phenomenon was observed. Zinc at 1 mM had a similar inhibitory effect. Moreover, an apoptosis peak was observed on flow cytometry analysis of DNA stained with propidium iodide. Alveolar macrophages stained with Hoechst 33342 demonstrated apoptotic bodies induced by methylmercury. The above data indicate that methylmercury can induce a typical apoptosis in alveolar macrophages. Continuing onto the study of the mechanism of apoptosis as induced by methylmercury in alveolar macrophages, it was discovered that methylmercury could increase the intracellular calcium ion concentration and decrease the pH in alveolar macrophages. To find out which endonuclease was responsible for the methylmercury-induced DNA fragmentation of alveolar macrophages, the nuclear proteins of alveolar macrophages was aspirated and tested under different pH values and in conditions with or without calcium ions, and it was discovered that the endonuclease was calcium dependent without relations to pH values.