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Simpson CE, Ledford JG, Liu G. Application of Metabolomics across the Spectrum of Pulmonary and Critical Care Medicine. Am J Respir Cell Mol Biol 2024; 71:1-9. [PMID: 38547373 PMCID: PMC11225873 DOI: 10.1165/rcmb.2024-0080ps] [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: 02/19/2024] [Accepted: 03/28/2024] [Indexed: 07/02/2024] Open
Abstract
In recent years, metabolomics, the systematic study of small-molecule metabolites in biological samples, has yielded fresh insights into the molecular determinants of pulmonary diseases and critical illness. The purpose of this article is to orient the reader to this emerging field by discussing the fundamental tenets underlying metabolomics research, the tools and techniques that serve as foundational methodologies, and the various statistical approaches to analysis of metabolomics datasets. We present several examples of metabolomics applied to pulmonary and critical care medicine to illustrate the potential of this avenue of research to deepen our understanding of pathophysiology. We conclude by reviewing recent advances in the field and future research directions that stand to further the goal of personalizing medicine to improve patient care.
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Affiliation(s)
- Catherine E. Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Julie G. Ledford
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona; and
| | - Gang Liu
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Willmann K, Moita LF. Physiologic disruption and metabolic reprogramming in infection and sepsis. Cell Metab 2024; 36:927-946. [PMID: 38513649 DOI: 10.1016/j.cmet.2024.02.013] [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: 11/05/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/23/2024]
Abstract
Effective responses against severe systemic infection require coordination between two complementary defense strategies that minimize the negative impact of infection on the host: resistance, aimed at pathogen elimination, and disease tolerance, which limits tissue damage and preserves organ function. Resistance and disease tolerance mostly rely on divergent metabolic programs that may not operate simultaneously in time and space. Due to evolutionary reasons, the host initially prioritizes the elimination of the pathogen, leading to dominant resistance mechanisms at the potential expense of disease tolerance, which can contribute to organ failure. Here, we summarize our current understanding of the role of physiological perturbations resulting from infection in immune response dynamics and the metabolic program requirements associated with resistance and disease tolerance mechanisms. We then discuss how insight into the interplay of these mechanisms could inform future research aimed at improving sepsis outcomes and the potential for therapeutic interventions.
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Affiliation(s)
- Katharina Willmann
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Luis F Moita
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
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De Backer D, Deutschman CS, Hellman J, Myatra SN, Ostermann M, Prescott HC, Talmor D, Antonelli M, Pontes Azevedo LC, Bauer SR, Kissoon N, Loeches IM, Nunnally M, Tissieres P, Vieillard-Baron A, Coopersmith CM. Surviving Sepsis Campaign Research Priorities 2023. Crit Care Med 2024; 52:268-296. [PMID: 38240508 DOI: 10.1097/ccm.0000000000006135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. DESIGN Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. METHODS Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. RESULTS A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? CONCLUSIONS Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Sepsis Research Lab, the Feinstein Institutes for Medical Research, Manhasset, NY
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio-Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Leinster, Dublin, Ireland
| | | | - Pierre Tissieres
- Pediatric Intensive Care, Neonatal Medicine and Pediatric Emergency, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Vieillard-Baron
- Service de Medecine Intensive Reanimation, Hopital Ambroise Pare, Universite Paris-Saclay, Le Kremlin-Bicêtre, France
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Johansson PI, Henriksen HH, Karvelsson ST, Rolfsson Ó, Schønemann-Lund M, Bestle MH, McGarrity S. LASSO regression shows histidine and sphingosine 1 phosphate are linked to both sepsis mortality and endothelial damage. Eur J Med Res 2024; 29:71. [PMID: 38245777 PMCID: PMC10799523 DOI: 10.1186/s40001-023-01612-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
Sepsis is a major cause of death worldwide, with a mortality rate that has remained stubbornly high. The current gold standard of risk stratifying sepsis patients provides limited mechanistic insight for therapeutic targeting. An improved ability to predict sepsis mortality and to understand the risk factors would allow better treatment targeting. Sepsis causes metabolic dysregulation in patients; therefore, metabolomics offers a promising tool to study sepsis. It is also known that that in sepsis endothelial cells affecting their function regarding blood clotting and vascular permeability. We integrated metabolomics data from patients admitted to an intensive care unit for sepsis, with commonly collected clinical features of their cases and two measures of endothelial function relevant to blood vessel function, platelet endothelial cell adhesion molecule and soluble thrombomodulin concentrations in plasma. We used least absolute shrinkage and selection operator penalized regression, and pathway enrichment analysis to identify features most able to predict 30-day survival. The features important to sepsis survival include carnitines, and amino acids. Endothelial proteins in plasma also predict 30-day mortality and the levels of these proteins also correlate with a somewhat overlapping set of metabolites. Overall metabolic dysregulation, particularly in endothelial cells, may be a contributory factor to sepsis response. By exploring sepsis metabolomics data in conjunction with clinical features and endothelial proteins we have gained a better understanding of sepsis risk factors.
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Affiliation(s)
- Pär I Johansson
- CAG Center for Endotheliomics, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne H Henriksen
- CAG Center for Endotheliomics, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Óttar Rolfsson
- Biomedical Center, University of Iceland, Reykjavik, Iceland
| | - Martin Schønemann-Lund
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital - North Zealand, Hillerod, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital - North Zealand, Hillerod, Denmark
| | - Sarah McGarrity
- Biomedical Center, University of Iceland, Reykjavik, Iceland.
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Jennaro TS, Puskarich MA, Flott TL, McLellan LA, Jones AE, Pai MP, Stringer KA. Kidney function as a key driver of the pharmacokinetic response to high-dose L-carnitine in septic shock. Pharmacotherapy 2023; 43:1240-1250. [PMID: 37775945 PMCID: PMC10841498 DOI: 10.1002/phar.2882] [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: 05/12/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
STUDY OBJECTIVE Levocarnitine (L-carnitine) has shown promise as a metabolic-therapeutic for septic shock, where mortality approaches 40%. However, high-dose (≥ 6 grams) intravenous supplementation results in a broad range of serum concentrations. We sought to describe the population pharmacokinetics (PK) of high-dose L-carnitine, test various estimates of kidney function, and assess the correlation of PK parameters with pre-treatment metabolites in describing drug response for patients with septic shock. DESIGN Population PK analysis was done with baseline normalized concentrations using nonlinear mixed effect models in the modeling platform Monolix. Various estimates of kidney function, patient demographics, dose received, and organ dysfunction were tested as population covariates. DATA SOURCE We leveraged serum samples and metabolomics data from a phase II trial of L-carnitine in vasopressor-dependent septic shock. Serum was collected at baseline (T0); end-of-infusion (T12); and 24, 48, and 72 h after treatment initiation. PATIENTS AND INTERVENTION Patients were adaptively randomized to receive intravenous L-carnitine (6 grams, 12 grams, or 18 grams) or placebo. MEASUREMENTS AND MAIN RESULTS The final dataset included 542 serum samples from 130 patients randomized to L-carnitine. A two-compartment model with linear elimination and a fixed volume of distribution (17.1 liters) best described the data and served as a base structural model. Kidney function estimates as a covariate on the elimination rate constant (k) reliably improved model fit. Estimated glomerular filtration rate (eGFR), based on the 2021 Chronic Kidney Disease Epidemiology collaboration (CKD-EPI) equation with creatinine and cystatin C, outperformed creatinine clearance (Cockcroft-Gault) and older CKD-EPI equations that use an adjustment for self-identified race. CONCLUSIONS High-dose L-carnitine supplementation is well-described by a two-compartment population PK model in patients with septic shock. Kidney function estimates that leverage cystatin C provided superior model fit. Future investigations into high-dose L-carnitine supplementation should consider baseline metabolic status and dose adjustments based on renal function over a fixed or weight-based dosing paradigm.
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Affiliation(s)
- Theodore S. Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Thomas L. Flott
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura A. McLellan
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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