1
|
Cheng W, Zhang J, Li D, Lei X, Wang H, Cui N. CTLA-4 expression on CD4 + lymphocytes in patients with sepsis-associated immunosuppression and its relationship to mTOR mediated autophagic-lysosomal disorder. Front Immunol 2024; 15:1396157. [PMID: 39104530 PMCID: PMC11298341 DOI: 10.3389/fimmu.2024.1396157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024] Open
Abstract
Background The aim of this study was to clarify the relationship between expression level of CTLA-4 on CD4+ T cells and sepsis-associated immunosuppression (SAI), and to elucidate the possible mechanism of mTOR pathway mediated autophagic-lysosomal disorder in regulating CTLA-4 expression. Methods We enrolled 63 sepsis patients admitted to our ICU between January 1 and June 30, 2023. Peripheral blood mononuclear cells were isolated from the patients within 24 hours of recruitment. Expression levels of mTOR, P62, LC3II, and CTLA-4 on circulating CD4+ T lymphocytes were quantitated using flow cytometry. The association of these markers and relationship between CTLA-4 expression and the incidence of SAI and 28-day mortality were comprehensively analyzed. Results Compared with non-immunosuppressed patients with sepsis, patients with SAI had a higher 28-day mortality rate (37.5% vs 13.0%, P=0.039) and higher CTLA-4 mean fluorescence intensity (MFI) on CD4+ T cells (328.7 versus 78.7, P<0.0001). CTLA-4 MFI on CD4+ cells was independently associated with the occurrence of SAI (95% confidence interval: 1.00-1.14, P=0.044). In patients with sepsis and SAI, non-survivors had higher CTLA-4 expression than survivors (sepsis: 427.5 versus 130.6, P=0.002; and SAI: 506.7 versus 225.2, P<0.0001). The sensitivity and specificity of CTLA-4 MFI at predicting 28-day mortality in patients with SAI was 100% and 80% respectively with the cutoff value of 328.7 and the area under the curve of 0.949. The MFI of mTOR, P62, and LC3II on CD4+ T cells were statistically higher in patients with SAI than in non-immunosuppressed patients (267.2 versus 115.9, P<0.0001; 314.8 versus 173.7, P<0.0001; and 184.7 versus 1123.5, P=0.012, respectively); P62 and LC3II were markedly higher in non-survivors than in survivors of sepsis (302.9 versus 208.9, P=0.039; and 244.3 versus 122.8, P<0.0001 respectively). The expression of CTLA-4 statistically correlated with that of LC3II in patients with sepsis, patients with SAI, and patients with SAI who did not survive (correlation coefficient: 0.69, 0.68, and 0.73, respectively, P<0.0001). Conclusions CTLA-4 overexpression on CD4+ T cells was markedly associated with the incidence of SAI and had great relevance to 28-day mortality. mTOR pathway mediated autophagic-lysosomal disorder showed significant association with CTLA-4 expression.
Collapse
Affiliation(s)
- Wei Cheng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiahui Zhang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Dongkai Li
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xianli Lei
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hao Wang
- Department of Critical Care Medicine, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| |
Collapse
|
2
|
Coman O, Grigorescu BL, Huțanu A, Bacârea A, Văsieșiu AM, Fodor RȘ, Stoica F, Azamfirei L. The Role of Programmed Cell Death 1/Programmed Death Ligand 1 (PD-1/PD-L1) Axis in Sepsis-Induced Apoptosis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1174. [PMID: 39064603 PMCID: PMC11278887 DOI: 10.3390/medicina60071174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Sepsis involves a dysregulated host response, characterized by simultaneous immunosuppression and hyperinflammation. Initially, there is the release of pro-inflammatory factors and immune system dysfunction, followed by persistent immune paralysis leading to apoptosis. This study investigates sepsis-induced apoptosis and its pathways, by assessing changes in PD-1 and PD-L1 serum levels, CD4+ and CD8+ T cells, and Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) severity scores. Materials and Methods: This prospective, observational, single-centre study enrolled 87 sepsis patients admitted to the intensive care unit at the County Emergency Clinical Hospital in Târgu Mureș, Romania. We monitored the parameters on day 1 (the day sepsis or septic shock was diagnosed as per the Sepsis-3 Consensus) and day 5. Results: Our study found a statistically significant variation in the SOFA score for the entirety of the patients between the studied days (p = 0.001), as well as for the studied patient groups: sepsis, septic shock, survivors, and non-survivors (p = 0.001, p = 0.003, p = 0.01, p = 0.03). On day 1, we found statistically significant correlations between CD8+ cells and PD-1 (p = 0.02) and PD-L1 (p = 0.04), CD4+ and CD8+ cells (p < 0.0001), SOFA and APACHE II scores (p < 0.0001), and SOFA and APACHE II scores and PD-L1 (p = 0.001 and p = 0.01). On day 5, we found statistically significant correlations between CD4+ and CD8+ cells and PD-L1 (p = 0.03 and p = 0.0099), CD4+ and CD8+ cells (p < 0.0001), and SOFA and APACHE II scores (p < 0.0001). Conclusions: The reduction in Th CD4+ and Tc CD8+ lymphocyte subpopulations were evident from day 1, indicating that apoptosis is a crucial factor in the progression of sepsis and septic shock. The increased expression of the PD-1/PD-L1 axis impairs costimulatory signalling, leading to diminished T cell responses and lymphopenia, thereby increasing the susceptibility to nosocomial infections.
Collapse
Affiliation(s)
- Oana Coman
- Department of Simulation Applied in Medicine, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania;
| | - Bianca-Liana Grigorescu
- Department of Anaesthesiology and Intensive Therapy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania; (R.Ș.F.); (L.A.)
| | - Adina Huțanu
- Department of Laboratory Medicine, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania;
- Center for Advanced Medical and Pharmaceutical Research, Immunology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania
| | - Anca Bacârea
- Department of Pathophysiology, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania;
| | - Anca Meda Văsieșiu
- Department of Infectious Disease, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania;
| | - Raluca Ștefania Fodor
- Department of Anaesthesiology and Intensive Therapy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania; (R.Ș.F.); (L.A.)
| | - Florin Stoica
- Clinic of Internal Medicine II, Emergency County Hospital, 540136 Targu Mures, Romania;
| | - Leonard Azamfirei
- Department of Anaesthesiology and Intensive Therapy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, 540142 Targu Mures, Romania; (R.Ș.F.); (L.A.)
| |
Collapse
|
3
|
Kim MJ, Choi EJ, Choi EJ. Evolving Paradigms in Sepsis Management: A Narrative Review. Cells 2024; 13:1172. [PMID: 39056754 PMCID: PMC11274781 DOI: 10.3390/cells13141172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Sepsis, a condition characterized by life-threatening organ dysfunction due to a dysregulated host response to infection, significantly impacts global health, with mortality rates varying widely across regions. Traditional therapeutic strategies that target hyperinflammation and immunosuppression have largely failed to improve outcomes, underscoring the need for innovative approaches. This review examines the development of therapeutic agents for sepsis, with a focus on clinical trials addressing hyperinflammation and immunosuppression. It highlights the frequent failures of these trials, explores the underlying reasons, and outlines current research efforts aimed at bridging the gap between theoretical advancements and clinical applications. Although personalized medicine and phenotypic categorization present promising directions, this review emphasizes the importance of understanding the complex pathogenesis of sepsis and developing targeted, effective therapies to enhance patient outcomes. By addressing the multifaceted nature of sepsis, future research can pave the way for more precise and individualized treatment strategies, ultimately improving the management and prognosis of sepsis patients.
Collapse
Affiliation(s)
- Min-Ji Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Republic of Korea;
| | - Eun-Joo Choi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu 42472, Republic of Korea;
| | - Eun-Jung Choi
- Department of Anatomy, School of Medicine, Daegu Catholic University, Duryugongwon-ro 17gil, Nam-gu, Daegu 42472, Republic of Korea
| |
Collapse
|
4
|
Shaker NS, Sahib HB, Tahseen NJ. Anti-cytokine Storm Activity of Fraxin, Quercetin, and their Combination on Lipopolysaccharide-Induced Cytokine Storm in Mice: Implications in COVID-19. IRANIAN JOURNAL OF MEDICAL SCIENCES 2024; 49:322-331. [PMID: 38751871 PMCID: PMC11091274 DOI: 10.30476/ijms.2023.98947.3102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/02/2023] [Accepted: 08/28/2023] [Indexed: 05/18/2024]
Abstract
Background Cytokine release syndrome (CRS) is the leading cause of mortality in advanced stages of coronavirus patients. This study examined the prophylactic effects of fraxin, quercetin, and a combination of fraxin+quercetin (FQ) on lipopolysaccharide-induced mice. Methods Sixty mice were divided into six groups (n=10) as follows: control, LPS only, fraxin (120 mg/Kg), quercetin (100 mg/Kg), dexamethasone (5 mg/Kg), and FQ. All treatments were administered intraperitoneally (IP) one hour before induction by LPS (5 mg/Kg) IP injection. Twenty-four hours later, the mice were euthanized. Interleukin one beta (IL-1β), interleukin 6 (IL-6), and tumor necrosis factor-alpha (TNF-α) were quantified using an enzyme-linked immunosorbent assay (ELISA), and lung and kidney tissues were examined for histopathological alterations. This study was conducted at Al-Nahrain University, Baghdad, Iraq, in 2022. Results FQ reduced IL-1β (P<0.001). All treatments significantly suppressed IL-6, fraxin, quercetin, dexamethasone, and FQ, all with P<0.001. The TNF-α level was reduced more with dexamethasone (P<0.001) and quercetin (P<0.001). Histopathological scores were significantly reduced mainly by quercetin and FQ in the lungs with scores of 12.30±0.20 (P=0.093), and 15.70±0.20 (P=0.531), respectively. The scores were 13±0.26 (P=0.074) and 15±0.26 (P=0.222) for quercetin and FQ in the kidneys, respectively. Conclusion All used treatments reduced proinflammatory cytokine levels and protected against LPS-induced tissue damage.
Collapse
Affiliation(s)
- Nada Sahib Shaker
- Department of Pharmacology and Toxicology, Mustansiriyah University, College of Pharmacy, Baghdad, Iraq
| | - Hayder B Sahib
- Dean of College of Pharmacy, Al-Nahrain University, Baghdad, Iraq
| | | |
Collapse
|
5
|
Fang W, Chai C, Lu J. The causal effects of circulating cytokines on sepsis: a Mendelian randomization study. PeerJ 2024; 12:e16860. [PMID: 38313013 PMCID: PMC10838533 DOI: 10.7717/peerj.16860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/09/2024] [Indexed: 02/06/2024] Open
Abstract
Background In observational studies, sepsis and circulating levels of cytokines have been associated with unclear causality. This study used Mendelian randomization (MR) to identify the causal direction between circulating cytokines and sepsis in a two-sample study. Methods An MR analysis was performed to estimate the causal effect of 41 cytokines on sepsis risk. The inverse-variance weighted random-effects method, the weighted median-based method, and MR-Egger were used to analyze the data. Heterogeneity and pleiotropy were assessed using MR-Egger regression and Cochran's Q statistic. Results Genetically predicted beta-nerve growth factor (OR = 1.12, 95% CI [1.037-1.211], P = 0.004) increased the risk of sepsis, while RANTES (OR = 0.92, 95% CI [0.849-0.997], P = 0.041) and fibroblast growth factor (OR = 0.869, 95% CI [0.766-0.986], P = 0.029) reduced the risk of sepsis. These findings were robust in extensive sensitivity analyses. There was no clear association between the other cytokines and sepsis risk. Conclusion The findings of this study demonstrate that beta-nerve growth factor, RANTES, and fibroblast growth factor contribute to sepsis risk. Investigations into potential mechanisms are warranted.
Collapse
Affiliation(s)
- Weijun Fang
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China, Wuhan, China
| | - Chen Chai
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China, Wuhan, China
| | - Jiawei Lu
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China, Wuhan, China
| |
Collapse
|
6
|
Chen H, Wang J, Ding K, Xu J, Yang Y, Tang C, Zhou Y, Yu W, Wang H, Huang Q, Li B, Kuang D, Wu D, Luo Z, Gao J, Zhao Y, Liu J, Peng X, Lu S, Liu H. Gastrointestinal microbiota and metabolites possibly contribute to distinct pathogenicity of SARS-CoV-2 proto or its variants in rhesus monkeys. Gut Microbes 2024; 16:2334970. [PMID: 38563680 PMCID: PMC10989708 DOI: 10.1080/19490976.2024.2334970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
Gastrointestinal (GI) infection is evidenced with involvement in COVID-19 pathogenesis caused by SARS-CoV-2. However, the correlation between GI microbiota and the distinct pathogenicity of SARS-CoV-2 Proto and its emerging variants remains unclear. In this study, we aimed to determine if GI microbiota impacted COVID-19 pathogenesis and if the effect varied between SARS-CoV-2 Proto and its variants. We performed an integrative analysis of histopathology, microbiomics, and transcriptomics on the GI tract fragments from rhesus monkeys infected with SARS-CoV-2 proto or its variants. Based on the degree of pathological damage and microbiota profile in the GI tract, five of SARS-CoV-2 strains were classified into two distinct clusters, namely, the clusters of Alpha, Beta and Delta (ABD), and Proto and Omicron (PO). Notably, the abundance of potentially pathogenic microorganisms increased in ABD but not in the PO-infected rhesus monkeys. Specifically, the high abundance of UCG-002, UCG-005, and Treponema in ABD virus-infected animals positively correlated with interleukin, integrins, and antiviral genes. Overall, this study revealed that infection-induced alteration of GI microbiota and metabolites could increase the systemic burdens of inflammation or pathological injury in infected animals, especially in those infected with ABD viruses. Distinct GI microbiota and metabolite profiles may be responsible for the differential pathological phenotypes of PO and ABD virus-infected animals. These findings improve our understanding the roles of the GI microbiota in SARS-CoV-2 infection and provide important information for the precise prevention, control, and treatment of COVID-19.
Collapse
Affiliation(s)
- Hongyu Chen
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Junbin Wang
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Kaiyun Ding
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Jingwen Xu
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Yun Yang
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Cong Tang
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Yanan Zhou
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Wenhai Yu
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Haixuan Wang
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Qing Huang
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Bai Li
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Dexuan Kuang
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Daoju Wu
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Zhiwu Luo
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Jiahong Gao
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Yuan Zhao
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Jiansheng Liu
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Xiaozhong Peng
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
- Institute of Laboratory Animal Sciences, IMBCAMS & PUMC, Beijing, China
- Institute of Basic Medical Sciences, IMBCAMS & PUMC, Beijing, China
| | - Shuaiyao Lu
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| | - Hongqi Liu
- Institute of Medical biology, Chinese Academy of Medical Sciences and Peking Union Medical School (IMBCAMS & PUMC), Kunming, Yunnan, China
| |
Collapse
|
7
|
Hamilton FW, Thomas M, Arnold D, Palmer T, Moran E, Mentzer AJ, Maskell N, Baillie K, Summers C, Hingorani A, MacGowan A, Khandaker GM, Mitchell R, Davey Smith G, Ghazal P, Timpson NJ. Therapeutic potential of IL6R blockade for the treatment of sepsis and sepsis-related death: A Mendelian randomisation study. PLoS Med 2023; 20:e1004174. [PMID: 36716318 PMCID: PMC9925069 DOI: 10.1371/journal.pmed.1004174] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 02/13/2023] [Accepted: 01/13/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Sepsis is characterised by dysregulated, life-threatening immune responses, which are thought to be driven by cytokines such as interleukin 6 (IL-6). Genetic variants in IL6R known to down-regulate IL-6 signalling are associated with improved Coronavirus Disease 2019 (COVID-19) outcomes, a finding later confirmed in randomised trials of IL-6 receptor antagonists (IL6RAs). We hypothesised that blockade of IL6R could also improve outcomes in sepsis. METHODS AND FINDINGS We performed a Mendelian randomisation (MR) analysis using single nucleotide polymorphisms (SNPs) in and near IL6R to evaluate the likely causal effects of IL6R blockade on sepsis (primary outcome), sepsis severity, other infections, and COVID-19 (secondary outcomes). We weighted SNPs by their effect on CRP and combined results across them in inverse variance weighted meta-analysis, proxying the effect of IL6RA. Our outcomes were measured in UK Biobank, FinnGen, the COVID-19 Host Genetics Initiative (HGI), and the GenOSept and GainS consortium. We performed several sensitivity analyses to test assumptions of our methods, including utilising variants around CRP and gp130 in a similar analysis. In the UK Biobank cohort (N = 486,484, including 11,643 with sepsis), IL6R blockade was associated with a decreased risk of our primary outcome, sepsis (odds ratio (OR) = 0.80; 95% confidence interval (CI) 0.66 to 0.96, per unit of natural log-transformed CRP decrease). The size of this effect increased with severity, with larger effects on 28-day sepsis mortality (OR = 0.74; 95% CI 0.47 to 1.15); critical care admission with sepsis (OR = 0.48, 95% CI 0.30 to 0.78) and critical care death with sepsis (OR = 0.37, 95% CI 0.14 to 0.98). Similar associations were seen with severe respiratory infection: OR for pneumonia in critical care 0.69 (95% CI 0.49 to 0.97) and for sepsis survival in critical care (OR = 0.22; 95% CI 0.04 to 1.31) in the GainS and GenOSept consortium, although this result had a large degree of imprecision. We also confirm the previously reported protective effect of IL6R blockade on severe COVID-19 (OR = 0.69, 95% CI 0.57 to 0.84) in the COVID-19 HGI, which was of similar magnitude to that seen in sepsis. Sensitivity analyses did not alter our primary results. These results are subject to the limitations and assumptions of MR, which in this case reflects interpretation of these SNP effects as causally acting through blockade of IL6R, and reflect lifetime exposure to IL6R blockade, rather than the effect of therapeutic IL6R blockade. CONCLUSIONS IL6R blockade is causally associated with reduced incidence of sepsis. Similar but imprecisely estimated results supported a causal effect also on sepsis related mortality and critical care admission with sepsis. These effects are comparable in size to the effect seen in severe COVID-19, where IL-6 receptor antagonists were shown to improve survival. These data suggest that a randomised trial of IL-6 receptor antagonists in sepsis should be considered.
Collapse
Affiliation(s)
- Fergus W. Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
- Infection Science, North Bristol NHS Trust, Bristol, United Kingdom
| | - Matt Thomas
- Intensive Care Unit, North Bristol NHS Trust, Bristol, United Kingdom
| | - David Arnold
- Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom
| | - Tom Palmer
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| | - Ed Moran
- Infection Science, North Bristol NHS Trust, Bristol, United Kingdom
| | - Alexander J. Mentzer
- Wellcome Centre For Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom
| | - Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Charlotte Summers
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Aroon Hingorani
- UCL Institute for Cardiovascular Science, University College London, London, United Kingdom
- UCL BHF Research Accelerator, University College London, London, United Kingdom
- Health Data Research UK, London, United Kingdom
| | | | - Golam M. Khandaker
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| | - Ruth Mitchell
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| | - George Davey Smith
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| | - Peter Ghazal
- Project Sepsis, Cardiff University, Cardiff, United Kingdom
| | - Nicholas J. Timpson
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| |
Collapse
|
8
|
Athale J, Busch LM, O'Grady NP. Cytokine Release Syndrome and Sepsis: Analogous Clinical Syndromes with Distinct Causes and Challenges in Management. Infect Dis Clin North Am 2022; 36:735-748. [PMID: 36328633 PMCID: PMC9641544 DOI: 10.1016/j.idc.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both cytokine release syndrome (CRS) and sepsis are clinical syndromes rather than distinct diseases and share considerable overlap. It can often be challenging to distinguish between the two, but it is important given the availability of targeted treatment options. In addition, several other clinical syndromes overlap with CRS and sepsis, further making it difficult to differentiate them. This has particularly been highlighted in the recent coronavirus disease-2019 pandemic. As we start to understand the differences in the inflammatory markers and presentations in these syndromes, hopefully we will be able to enhance treatment and improve outcomes.
Collapse
Affiliation(s)
- Janhavi Athale
- Department of Critical Care Medicine, Division of Hematology and Oncology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Lindsay M Busch
- Department of Medicine, Emory University Hospital, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health, Room 2-2734, Bethesda, MD 20892-1662, USA.
| |
Collapse
|
9
|
Korayem GB, Aljuhani O, Altebainawi AF, Shaya AIA, Alnajjar LI, Alissa A, Aldhaeefi M, Kensara R, Al Muqati H, Alhuwahmel A, Alhuthaili O, Vishwakarma R, Aldardeer N, Eljaaly K, Alharbi A, Harbi SA, Katheri AA, Bekairy AMA, Aljedai A, Al Sulaiman K. The safety and effectiveness of tocilizumab in older adult critically ill patients with COVID-19: a multicenter, cohort study. Int J Infect Dis 2022; 122:252-259. [PMID: 35605948 PMCID: PMC9121644 DOI: 10.1016/j.ijid.2022.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/21/2022] [Accepted: 05/16/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Evidence supports tocilizumab (TCZ) benefit and safety in adult patients with severe COVID-19. However, its effectiveness in critically ill older adult patients remains questionable. Thus, the study aimed to evaluate the safety and effectiveness of TCZ in older critically ill patients with COVID-19. METHODS A multicenter, retrospective study for all critically ill older adults (aged ≥65 years) with confirmed COVID-19 infection and admitted to the intensive care units (ICUs). Eligible patients were categorized into two groups based on TCZ use during ICU stay (control vs TCZ). Propensity score (PS) matching was used (1:1 ratio) based on the selected criteria. The primary outcome was the in-hospital mortality. RESULTS A total of 368 critically ill older adult patients were included in the study. Fifty one patients (13.8%) received TCZ. The in-hospital mortality was lower in the TCZ group (HR 0.41; 95% CI 0.22-0.76, P-value = 0.005). Patients who received TCZ had lower odds of respiratory failure requiring mechanical ventilation (OR [95% CI]: 0.32 [0.10-0.98], P-value = 0.04). No statistically significant differences were found between the two groups for 30-days mortality, ventilator-free days, length of stay, and complications during ICU stay. CONCLUSION Tocilizumab use in critically ill older adult patients with COVID-19 is associated with lower in-hospital mortality and a similar safety profile.
Collapse
Affiliation(s)
- Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P. O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali F. Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Ministry of Health, Saudi Arabia
| | - Abdulrahman I. Al Shaya
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Lina I. Alnajjar
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P. O. Box 84428, Riyadh 11671, Saudi Arabia,Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Abdulrahman Alissa
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Mohammed Aldhaeefi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Raed Kensara
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hessa Al Muqati
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdulmohsen Alhuwahmel
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Omar Alhuthaili
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Namareq Aldardeer
- Pharmaceutical Care Services, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia,College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Aisha Alharbi
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Shmeylan Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulmalik Al Katheri
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulkareem M. Al Bekairy
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmed Aljedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia,Corresponding author: Khalid A. Al Sulaiman, Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC)-Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS); PO Box 22490, 11426, Riyadh, Saudi Arabia
| |
Collapse
|
10
|
Gharamti AA, Samara O, Monzon A, Montalbano G, Scherger S, DeSanto K, Chastain DB, Sillau S, Montoya JG, Franco-Paredes C, Henao-Martínez AF, Shapiro L. Proinflammatory cytokines levels in sepsis and healthy volunteers, and tumor necrosis factor-alpha associated sepsis mortality: A systematic review and meta-analysis. Cytokine 2022; 158:156006. [PMID: 36044827 DOI: 10.1016/j.cyto.2022.156006] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/09/2022] [Accepted: 08/05/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Sepsis is a global health challenge associated with significant morbidity and mortality. Detrimental sepsis effects are attributed to excessive inflammation or a "cytokine storm." However, anti-inflammation therapies have failed to lower sepsis mortality. We aim to characterize levels of key inflammatory cytokines in patients with sepsis and compare levels with those in healthy individuals and relate tumor necrosis factor (TNF) α levels to patient characteristics and outcomes. METHODS We performed a systematic review and meta-analysis. Medline, Embase, Cochrane Library, and Web of Science Core Collection databases were searched between 1985 and May 2020. Analysis was restricted to studies in English. We included randomized controlled trials (RCTs), controlled trials, cohort studies, case series, and cross-sectional studies that reported mean levels of cytokines in the circulation thought to be relevant for sepsis pathogenesis. We also evaluated concentrations of these cytokines in healthy individuals. The Quality in Prognosis Studies tool was used to assess the methodological quality of included studies. We extracted summary data from published reports. Data analyses were performed using a random-effects model to estimate pooled odds ratios (OR) with 95% confidence intervals for cytokine levels and mortality. This systematic review is registered in PROSPERO (CRD42020179800). FINDINGS We identified 3654 records, and 104 studies were included with a total of 3250 participants. The pooled estimated mean TNFα concentration in sepsis patients was 58.4 pg/ml (95% Confidence Interval or CI 39.8-85.8 pg/ml), and in healthy individuals was 5.5 pg/ml (95% CI 3.8-8.0 pg/ml). Pooled estimate means for IL-1β and IFN-γ in sepsis patients were 21.8 pg/ml and 63.3 pg/ml, respectively. Elevated TNFα concentrations associated with increased 28-day sepsis mortality (p = 0.001). In subgroup analyses, we did not detect an association between TNFα levels and sepsis source, sepsis severity, or sequential organ failure assessment (SOFA) score. A TNF-α cutoff level ≥14.7 pg/ml separated sepsis patients from healthy individuals with a sensitivity of 82.6%, a specificity of 91.7%, and a likelihood ratio of 9.9. INTERPRETATION Sepsis mean TNFα concentration is increased approximately 10-fold compared to mean concentration in healthy individuals, and TNFα associated with sepsis mortality but not sepsis severity. The concept that elevated cytokines cause sepsis should be revisited in the context of these data. FUNDING None.
Collapse
Affiliation(s)
- Amal A Gharamti
- Department of Internal Medicine, Yale University, Waterbury Hospital, Waterbury, CT, USA
| | - Omar Samara
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anthony Monzon
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gabrielle Montalbano
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sias Scherger
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Stefan Sillau
- Department of Neurology and Department of Biostatistics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jose G Montoya
- Dr. Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto, CA, USA
| | - Carlos Franco-Paredes
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Hospital Infantil de México, Federico Gómez, Mexico City, Mexico
| | - Andrés F Henao-Martínez
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leland Shapiro
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| |
Collapse
|
11
|
Senousy SR, El-Daly M, Ibrahim ARN, Khalifa MMA, Ahmed ASF. Effect of Celecoxib and Infliximab against Multiple Organ Damage Induced by Sepsis in Rats: A Comparative Study. Biomedicines 2022; 10:biomedicines10071613. [PMID: 35884918 PMCID: PMC9312943 DOI: 10.3390/biomedicines10071613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 12/30/2022] Open
Abstract
In cases of sepsis, the immune system responds with an uncontrolled release of proinflammatory cytokines and reactive oxygen species. The lungs, kidneys, and liver are among the early impacted organs during sepsis and are a direct cause of mortality. The aim of this study was to compare the effects of infliximab (IFX) and celecoxib (CLX) on septic rats that went through a cecal ligation and puncture (CLP) surgery to induce sepsis. This study included four groups: sham, CLP (untreated), and CLP-treated with CLX or IFX. The administration of “low dose” CLX or IFX was performed after 2 h following the induction of sepsis. Twenty-four hours following the induction of sepsis, the rats were sacrificed and blood samples were collected to evaluate kidney, liver, and lung injuries. MDA and NOx content, in addition to SOD activity and GSH levels, were evaluated in the tissue homogenates of each group. Tissue samples were also investigated histopathologically. In a separate experiment, the same groups were employed to evaluate the survival of septic rats in a 7-day observation period. The results of this study showed that treatment with either CLX or IFX ameliorated the three organs’ damage compared to septic-untreated rats, decreased oxidative stress, enhanced the antioxidant defense, and reduced serum cytokines. As a result, a higher survival rate resulted: 62.5% and 37.5% after the administration of CLX and IFX, respectively, compared to 0% in the CLP group after 7 days. No significant differences were observed between the two agents in all measured parameters. Histopathological examination confirmed the observed results. In conclusion, CLX and IFX ameliorated lung, kidney, and liver injuries associated with sepsis through anti-inflammatory and antioxidant actions, which correlated to the increase in survival observed with both of them.
Collapse
Affiliation(s)
- Shaymaa Ramzy Senousy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia 61511, Egypt; (S.R.S.); (M.E.-D.); (M.M.A.K.); (A.-S.F.A.)
| | - Mahmoud El-Daly
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia 61511, Egypt; (S.R.S.); (M.E.-D.); (M.M.A.K.); (A.-S.F.A.)
| | - Ahmed R. N. Ibrahim
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia
- Department of Biochemistry, Faculty of Pharmacy, Minia University, Minia 61511, Egypt
- Correspondence: ; Tel.: +96-65-5408-8979
| | - Mohamed Montaser A. Khalifa
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia 61511, Egypt; (S.R.S.); (M.E.-D.); (M.M.A.K.); (A.-S.F.A.)
| | - Al-Shaimaa F. Ahmed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia 61511, Egypt; (S.R.S.); (M.E.-D.); (M.M.A.K.); (A.-S.F.A.)
| |
Collapse
|
12
|
Besedovsky HO, Del Rey A. To protect or to kill: A persisting Darwinian immune dilemma. Brain Behav Immun 2022; 103:205-214. [PMID: 35470014 DOI: 10.1016/j.bbi.2022.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/06/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022] Open
Abstract
The immune system, which evolved as a protective system, can paradoxically mediate lethal effects when it is over-activated. These effects can be traced back to infected insects and are mainly mediated by phylogenetically old cytokines that have been found already in starfishes and sponges. We hypothesize that these anti-homeostatic effects are important for restricting the cumulative risk of transmission of highly mutating environmental pathogens that may endanger species, particularly when they start to originate and expand. Considering the Darwinian view that evolution is a permanent process, this anti-homeostatic program is preserved and expressed even when there is no risk for the species. Here, we review these aspects and discuss how evolutionary-imposed anti-homeostatic immune programs are expressed during acute and chronic human diseases, which can be further aggravated in the absence of medical interventions. The relevance of early identification of ancestral biomarkers that predict a shift from protective to deleterious immune outcomes is emphasized.
Collapse
Affiliation(s)
- Hugo O Besedovsky
- Research Group Immunophysiology, Division Neurophysiology, Institute of Physiology and Pathophysiology, Medical Faculty, Philipps University, Marburg, Germany.
| | - Adriana Del Rey
- Research Group Immunophysiology, Division Neurophysiology, Institute of Physiology and Pathophysiology, Medical Faculty, Philipps University, Marburg, Germany
| |
Collapse
|
13
|
Liu Y, Kuang D, Li D, Yang J, Yan J, Xia Y, Zhang F, Cao H. Roles of the gut microbiota in severe SARS-CoV-2 infection. Cytokine Growth Factor Rev 2022; 63:98-107. [PMID: 35131164 PMCID: PMC8802135 DOI: 10.1016/j.cytogfr.2022.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 12/11/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. The pathophysiological mechanisms linking gut dysbiosis and severe SARS-CoV-2 infection are poorly understood, although gut microbiota disorders are related to severe SARS-CoV-2 infections. The roles of the gut microbiota in severe SARS-CoV-2 infection were compared with those in respiratory viral infection, which is an easily understood and enlightening analogy. Secondary bacterial infections caused by immune disorders and antibiotic abuse can lead to dysregulation of the gut microbiota in patients with respiratory viral infections. The gut microbiota can influence the progression of respiratory viral infections through metabolites and the immune response, which is known as the gut–lung axis. Angiotensin-converting enzyme 2 is expressed in both the lungs and the small intestine, which may be a bridge between the lung and the gut. Similarly, SARS-CoV-2 infection has been shown to disturb the gut microbiota, which may be the cause of cytokine storms. Bacteria in the gut, lung, and other tissues and respiratory viruses can be considered microecosystems and may exert overall effects on the host. By referencing respiratory viral infections, this review focused on the mechanisms involved in the interaction between SARS-CoV-2 infections and the gut microbiota and provides new strategies for the treatment or prevention of severe SARS-CoV-2 infections by improving gut microbial homeostasis.
Collapse
|
14
|
Amer M, Kamel AM, Bawazeer M, Maghrabi K, Butt A, Dahhan T, Kseibi E, Khurshid SM, Abujazar M, Alghunaim R, Rabee M, Abualkhair M, Al-Janoubi A, AlFirm AT, Gajic O, Walkey AJ, Mosier JM, Zabolotskikh IB, Gavidia OY, Teruel SY, Bernstein MA, Boman K, Kumar VK, Bansal V, Kashyap R. Clinical characteristics and outcomes of critically ill mechanically ventilated COVID-19 patients receiving interleukin-6 receptor antagonists and corticosteroid therapy: a preliminary report from a multinational registry. Eur J Med Res 2021; 26:117. [PMID: 34600589 PMCID: PMC8487342 DOI: 10.1186/s40001-021-00591-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Interleukin-6 receptor antagonists (IL-6RAs) and steroids are emerging immunomodulatory therapies for severe and critical coronavirus disease (COVID-19). In this preliminary report, we aim to describe the epidemiology, clinical characteristics, and outcomes of adult critically ill COVID-19 patients, requiring invasive mechanical ventilation (iMV), and receiving IL-6RA and steroids therapy over the last 11 months. MATERIALS AND METHODS International, multicenter, cohort study derived from Viral Infection and Respiratory Illness University Study registry and conducted through Discovery Network, Society of Critical Care Medicine. Data were collected between March 01, 2020, and January 10, 2021. RESULTS Of 860 patients who met eligibility criteria, 589 received steroids, 170 IL-6RAs, and 101 combinations. Patients who received IL-6RAs were younger (median age of 57.5 years vs. 61.1 and 61.8 years in the steroids and combination groups, respectively). The median C-reactive protein level was > 75 mg/L, indicating a hyperinflammatory phenotype. The median daily steroid dose was 7.5 mg dexamethasone or equivalent (interquartile range: 6-14 mg); 80.8% and 19.2% received low-dose and high-dose steroids, respectively. Of the patients who received IL-6RAs, the majority received one dose of tocilizumab and sarilumab (dose range of 600-800 mg for tocilizumab and 200-400 mg for sarilumab). Regarding the timing of administration, we observed that steroid and IL-6RA administration on day 0 of ICU admission was only 55.6% and 39.5%, respectively. By day 28, when compared with steroid use alone, IL-6RA use was associated with an adjusted incidence rate ratio (aIRR) of 1.12 (95% confidence interval [CI] 0.88, 1.4) for ventilator-free days, while combination therapy was associated with an aIRR of 0.83 (95% CI 0.6, 1.14). IL-6RA use was associated with an adjusted odds ratio (aOR) of 0.68 (95% CI 0.44, 1.07) for the 28-day mortality rate, while combination therapy was associated with an aOR of 1.07 (95% CI 0.67, 1.70). Liver dysfunction was higher in IL-6RA group (p = 0.04), while the bacteremia rate did not differ among groups. CONCLUSIONS Discordance was observed between the registry utilization patterns (i.e., timing of steroids and IL-6RA administration) and new evidence from the recent randomized controlled trials and guideline recommendations. These data will help us to identify areas of improvement in prescribing patterns and enhance our understanding of IL-6RA safety with different steroid regimens. Further studies are needed to evaluate the drivers of hospital-level variation and their impact on clinical outcomes. Trial registration ClinicalTrials.gov: NCT04486521. Registered on July 2020.
Collapse
Affiliation(s)
- Marwa Amer
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Saudi Arabia.
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Ahmed M Kamel
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Giza, Egypt
| | - Mohammed Bawazeer
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Maghrabi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abid Butt
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Talal Dahhan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Eiad Kseibi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Syed Moazzum Khurshid
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Abujazar
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Razan Alghunaim
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Saudi Arabia
| | - Muath Rabee
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maal Abualkhair
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali Al-Janoubi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abeer Turki AlFirm
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | | | - Karen Boman
- Society of Critical Care Medicine, Mount Prospect, USA
| | | | | | | |
Collapse
|
15
|
Cytokine Blockade in Coronavirus Disease 2019: Keeping an Open Mind. Crit Care Explor 2021; 3:e0424. [PMID: 34036275 PMCID: PMC8133097 DOI: 10.1097/cce.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|