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Perrella A, Geen O, Ahuja M, Scott S, Kaushik R, Ferrante LE, Brummel NE, Muscedere J, Rochwerg B. Exploring the Impact of Age, Frailty, and Multimorbidity on the Effect of ICU Interventions: A Systematic Review of Randomized Controlled Trials. Crit Care Med 2024; 52:e463-e472. [PMID: 38661459 DOI: 10.1097/ccm.0000000000006315] [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: 04/26/2024]
Abstract
OBJECTIVES To date, age, frailty, and multimorbidity have been used primarily to inform prognosis in older adults. It remains uncertain, however, whether these patient factors may also predict response to critical care interventions or treatment outcomes. DATA SOURCES We conducted a systematic search of top general medicine and critical care journals for randomized controlled trials (RCTs) examining critical care interventions published between January 1, 2011, and December 31, 2021. STUDY SELECTION We included RCTs of critical care interventions that examined any one of three subgroups-age, frailty, or multimorbidity. We excluded cluster RCTs, studies that did not report interventions in an ICU, and studies that did not report data examining subgroups of age, frailty, or multimorbidity. DATA EXTRACTION We collected study characteristics (single vs. multicountry enrollment, single vs. multicenter enrollment, funding, sample size, intervention, comparator, primary outcome and secondary outcomes, length of follow-up), study population (inclusion and exclusion criteria, average age in intervention and comparator groups), and subgroup data. We used the Instrument for assessing the Credibility of Effect Modification Analyses instrument to evaluate the credibility of subgroup findings. DATA SYNTHESIS Of 2037 unique citations, we included 48 RCTs comprising 50,779 total participants. Seven (14.6%) RCTs found evidence of statistically significant effect modification based on age, whereas none of the multimorbidity or frailty subgroups found evidence of statistically significant subgroup effect. Subgroup credibility ranged from very low to moderate. CONCLUSIONS Most critical care RCTs do not examine for subgroup effects by frailty or multimorbidity. Although age is more commonly considered, the cut-point is variable, and relative effect modification is rare. Although interventional effects are likely similar across age groups, shared decision-making based on individual patient preferences must remain a priority. RCTs focused specifically on critically ill older adults or those living with frailty and/or multimorbidity are crucial to further address this research question.
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Affiliation(s)
- Andrew Perrella
- Department of Medicine, Division of Geriatric Medicine, McMaster University, Hamilton, ON, Canada
| | - Olivia Geen
- Department of Medicine, Division of Geriatric Medicine, Trillium Health Partners, Mississauga, ON, Canada
| | - Manan Ahuja
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephanie Scott
- Department of Pediatrics, Western University, London, ON, Canada
| | - Ramya Kaushik
- Department of Medicine, Yale University, New Haven, CT
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Nathan E Brummel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - John Muscedere
- Department of Critical Care Medicine, Queens University, Kingston, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Malinczak CA, Burns Naas LA, Clark A, Conze D, DiNovi M, Kaminski N, Kruger C, Lönnerdal B, Lukacs NW, Merker R, Peterson R. Workshop report: A study roadmap to evaluate the safety of recombinant human lactoferrin expressed in Komagataella phaffii intended as an ingredient in conventional foods - Recommendations of a scientific expert panel. Food Chem Toxicol 2024; 190:114817. [PMID: 38880466 DOI: 10.1016/j.fct.2024.114817] [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: 04/09/2024] [Revised: 06/03/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024]
Abstract
Human milk lactoferrin (hmLF) is a glycoprotein with well-known effects on immune function. Helaina Inc. has used a glycoengineered yeast, Komatagaella phaffii, to produce recombinant human lactoferrin (Helaina rhLF, Effera™) that is structurally similar to hmLF with intended uses as a food ingredient. However, earlier FDA reviews of rhLF were withdrawn due to insufficient safety data and unanswered safety questions the experts and FDA raised about the immunogenicity/immunotoxicity risks of orally ingested rhLF. Helaina organized a panel of leading scientists to build and vet a safety study roadmap containing the studies and safety endpoints needed to address these questions. Panelists participated in a one-day virtual workshop in June 2023 and ensuing discussions through July 2023. Relevant workshop topics included physicochemical properties of LF, regulatory history of bovine LF and rhLF as food ingredients in the FDA's generally recognized as safe (GRAS) program, and synopses of publicly available studies on the immunogenicity/alloimmunization, immunotoxicology, iron homeostasis, and absorption, distribution, metabolism, and excretion of rhLF. Panelists concluded that the safety study roadmap addresses the unanswered safety questions and the intended safe use of rhLF as a food ingredient for adults and agreed on broad applications of the roadmap to assess the safety and support GRAS of other recombinant milk proteins with immunomodulatory functions.
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Affiliation(s)
| | | | | | | | | | - Norbert Kaminski
- Department of Pharmacology & Toxicology, Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, USA.
| | | | - Bo Lönnerdal
- Department of Internal Medicine, University of California, Davis, CA, USA.
| | - Nicholas W Lukacs
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, USA.
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3
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Vishwanath-Deutsch R, Dallas DC, Besada-Lombana P, Katz L, Conze D, Kruger C, Clark AJ, Peterson R, Malinczak CA. A review of the safety evidence on recombinant human lactoferrin for use as a food ingredient. Food Chem Toxicol 2024; 189:114727. [PMID: 38735359 DOI: 10.1016/j.fct.2024.114727] [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: 04/11/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
Published studies on the glycosylation, absorption, distribution, metabolism, excretion, and safety outcomes of orally ingested recombinant human lactoferrin (rhLF) were reviewed in the context of unanswered safety questions, including alloimmunization, allergenicity, and immunotoxicity potential of rhLF during repeated exposure. The primary objective was to summarize current safety data of rhLF produced in transgenic host expression systems. Overall, results from animal and human studies showed that rhLF was well tolerated and safe. Animal data showed no significant toxicity-related outcomes among any safety or tolerability endpoints. The no observed adverse effect levels (NOAEL) were at the highest level tested in both iron-desaturated and -saturated forms of rhLF. Although one study reported outcomes of rhLF on immune parameters, no animal studies directly assessed immunogenicity or immunotoxicity from a safety perspective. Data from human studies were primarily reported as adverse events (AE). They showed no or fewer rhLF-related AE compared to control and no evidence of toxicity, dose-limiting toxicities, or changes in iron status in various subpopulations. However, no human studies evaluated the immunomodulatory potential of rhLF as a measure of safety. Following this review, a roadmap outlining preclinical and clinical studies with relevant safety endpoints was developed to address the unanswered safety questions.
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Affiliation(s)
| | - David C Dallas
- Nutrition Program, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, and Department of Food Science and Technology, Oregon State University, Corvallis, OR, USA.
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4
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Safabakhsh M, Imani H, Shahinfar H, Mohammadpour M, Rohani P, Shab-Bidar S. Efficacy of dietary supplements on mortality and clinical outcomes in adults with sepsis and septic shock: A systematic review and network meta-analysis. Clin Nutr 2024; 43:1299-1307. [PMID: 38663051 DOI: 10.1016/j.clnu.2024.03.030] [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: 01/18/2024] [Revised: 03/19/2024] [Accepted: 03/29/2024] [Indexed: 05/31/2024]
Abstract
AIM The aim of this network meta-analysis (NMA) was to investigate the effects of different dietary supplements on the mortality and clinical status of adults with sepsis. METHODS We searched PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials until February 2023. The inclusion criteria were: 1) randomized controlled trials (RCT)s; 2) adults suffering sepsis or septic shock; 3) evaluation of short- or long-mortality; and 4) publications between 1994 and 2023. The general information of studies and details of interventions were extracted. The primary outcome was short-term mortality (<90 days), and the secondary outcomes were long-term mortality (≥90 days), length of ICU and hospital stays, and duration of mechanical ventilation (MV). The risk of bias of RCTs was assessed using the Cochrane risk of bias tool 2 (ROB2). A random effect NMA was performed to rank the effect of each intervention using a frequentist approach. RESULTS Finally, 56 RCTs with 5957 participants met the criteria. Approximately, one-third of RCTs were low risk of bias. NMA analysis revealed that there was no treatment more effective in short- or long-term mortality than control or other interventions, except for magnesium (RR: 0.33, 95% CI: 0.14, 0.79; GRADE = low) and vitamin C (RR: 0.81, 95% CI: 0.67, 0.99; low certainty evidence), which had beneficial effects on short-term mortality. Moreover, eicosapentaenoic acid, gamma-linolenic acid, and antioxidants (EPA + GLA + AOs) combination was the most effective, and magnesium, vitamin D and vitamin C were the other effective approaches in terms of duration of MV, and ICU length of stay. There was no beneficial dietary supplement for hospital stay in these patients. CONCLUSIONS In septic patients, none of the dietary supplements had a substantial effect on mortality except for magnesium and vitamin C, which were linked to lower short-term mortality with low certainty of evidence. Further investigation into high-quality studies with the use of dietary supplements for sepsis should be highly discouraged.
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Affiliation(s)
- Maryam Safabakhsh
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Hossein Imani
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Hossein Shahinfar
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Division of Pediatric Intensive Care Unit, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pejman Rohani
- Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research Institute for Children Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran; Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran.
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5
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Giamarellos-Bourboulis EJ, Aschenbrenner AC, Bauer M, Bock C, Calandra T, Gat-Viks I, Kyriazopoulou E, Lupse M, Monneret G, Pickkers P, Schultze JL, van der Poll T, van de Veerdonk FL, Vlaar APJ, Weis S, Wiersinga WJ, Netea MG. The pathophysiology of sepsis and precision-medicine-based immunotherapy. Nat Immunol 2024; 25:19-28. [PMID: 38168953 DOI: 10.1038/s41590-023-01660-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Sepsis remains a major cause of morbidity and mortality in both low- and high-income countries. Antibiotic therapy and supportive care have significantly improved survival following sepsis in the twentieth century, but further progress has been challenging. Immunotherapy trials for sepsis, mainly aimed at suppressing the immune response, from the 1990s and 2000s, have largely failed, in part owing to unresolved patient heterogeneity in the underlying immune disbalance. The past decade has brought the promise to break this blockade through technological developments based on omics-based technologies and systems medicine that can provide a much larger data space to describe in greater detail the immune endotypes in sepsis. Patient stratification opens new avenues towards precision medicine approaches that aim to apply immunotherapies to sepsis, on the basis of precise biomarkers and molecular mechanisms defining specific immune endotypes. This approach has the potential to lead to the establishment of immunotherapy as a successful pillar in the treatment of sepsis for future generations.
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Affiliation(s)
- Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Anna C Aschenbrenner
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Bonn, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Christoph Bock
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Medical University of Vienna, Institute of Artificial Intelligence, Center for Medical Data Science, Vienna, Austria
| | - Thierry Calandra
- Service of Immunology and Allergy and Center of Human Immunology Lausanne, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Irit Gat-Viks
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Mihaela Lupse
- Infectious Diseases Hospital, University of Medicine and Pharmacy 'Iuliu Hatieganu', Cluj-Napoca, Romania
| | - Guillaume Monneret
- Joint Research Unit HCL-bioMérieux, EA 7426 'Pathophysiology of Injury-Induced Immunosuppression' (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon, bioMérieux), Lyon, France
- Immunology Laboratory, Edouard Herriot Hospital - Hospices Civils de Lyon, Lyon, France
| | - Peter Pickkers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joachim L Schultze
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Bonn, Germany
- PRECISE Platform for Single Cell Genomics and Epigenomics, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) and the University of Bonn, Bonn, Germany
- Genomics and Immunoregulation, Life & Medical Sciences (LIMES) Institute, University of Bonn, Bonn, Germany
| | - Tom van der Poll
- Division of Infectious Diseases, Amsterdam University Medical Centers (Amsterdam UMC), Center for Experimental and Molecular Medicine (CEMM), University of Amsterdam, Amsterdam, The Netherlands
| | - Frank L van de Veerdonk
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology L.E.C.A. Amsterdam Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute-HKI, Jena, Germany
| | - W Joost Wiersinga
- Division of Infectious Diseases, Amsterdam University Medical Centers (Amsterdam UMC), Center for Experimental and Molecular Medicine (CEMM), University of Amsterdam, Amsterdam, The Netherlands
| | - Mihai G Netea
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
- Genomics and Immunoregulation, Life & Medical Sciences (LIMES) Institute, University of Bonn, Bonn, Germany.
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
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Li W, Cornelius V, Finfer S, Venkatesh B, Billot L. Adaptive designs in critical care trials: a simulation study. BMC Med Res Methodol 2023; 23:236. [PMID: 37853343 PMCID: PMC10585789 DOI: 10.1186/s12874-023-02049-6] [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: 04/18/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Adaptive clinical trials are growing in popularity as they are more flexible, efficient and ethical than traditional fixed designs. However, notwithstanding their increased use in assessing treatments for COVID-19, their use in critical care trials remains limited. A better understanding of the relative benefits of various adaptive designs may increase their use and interpretation. METHODS Using two large critical care trials (ADRENAL. CLINICALTRIALS gov number, NCT01448109. Updated 12-12-2017; NICE-SUGAR. CLINICALTRIALS gov number, NCT00220987. Updated 01-29-2009), we assessed the performance of three frequentist and two bayesian adaptive approaches. We retrospectively re-analysed the trials with one, two, four, and nine equally spaced interims. Using the original hypotheses, we conducted 10,000 simulations to derive error rates, probabilities of making an early correct and incorrect decision, expected sample size and treatment effect estimates under the null scenario (no treatment effect) and alternative scenario (a positive treatment effect). We used a logistic regression model with 90-day mortality as the outcome and the treatment arm as the covariate. The null hypothesis was tested using a two-sided significance level (α) at 0.05. RESULTS Across all approaches, increasing the number of interims led to a decreased expected sample size. Under the null scenario, group sequential approaches provided good control of the type-I error rate; however, the type I error rate inflation was an issue for the Bayesian approaches. The Bayesian Predictive Probability and O'Brien-Fleming approaches showed the highest probability of correctly stopping the trials (around 95%). Under the alternative scenario, the Bayesian approaches showed the highest overall probability of correctly stopping the ADRENAL trial for efficacy (around 91%), whereas the Haybittle-Peto approach achieved the greatest power for the NICE-SUGAR trial. Treatment effect estimates became increasingly underestimated as the number of interims increased. CONCLUSIONS This study confirms the right adaptive design can reach the same conclusion as a fixed design with a much-reduced sample size. The efficiency gain associated with an increased number of interims is highly relevant to late-phase critical care trials with large sample sizes and short follow-up times. Systematically exploring adaptive methods at the trial design stage will aid the choice of the most appropriate method.
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Affiliation(s)
- W Li
- MRC Biostatistics Unit, East Forvie Building, University of Cambridge, Cambridge, CB2 0QY, UK.
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK.
| | - V Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Woodlane, London, W12 7RH, UK
| | - S Finfer
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
- Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - B Venkatesh
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - L Billot
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
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Kaczyńska K, Jampolska M, Wojciechowski P, Sulejczak D, Andrzejewski K, Zając D. Potential of Lactoferrin in the Treatment of Lung Diseases. Pharmaceuticals (Basel) 2023; 16:192. [PMID: 37259341 PMCID: PMC9960651 DOI: 10.3390/ph16020192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 11/07/2023] Open
Abstract
Lactoferrin (LF) is a multifunctional iron-binding glycoprotein that exhibits a variety of properties, such as immunomodulatory, anti-inflammatory, antimicrobial, and anticancer, that can be used to treat numerous diseases. Lung diseases continue to be the leading cause of death and disability worldwide. Many of the therapies currently used to treat these diseases have limited efficacy or are associated with side effects. Therefore, there is a constant pursuit for new drugs and therapies, and LF is frequently considered a therapeutic agent and/or adjunct to drug-based therapies for the treatment of lung diseases. This article focuses on a review of the existing and most up-to-date literature on the contribution of the beneficial effects of LF on the treatment of lung diseases, including asthma, viral infections, cystic fibrosis, or lung cancer, among others. Although in vitro and in vivo studies indicate significant potency of LF in the treatment of the listed diseases, only in the case of respiratory tract infections do human studies seem to confirm them by demonstrating the effectiveness of LF in reducing episodes of illness and shortening the recovery period. For lung cancer, COVID-19 and sepsis, the reports are conflicting, and for other diseases, there is a paucity of human studies conclusively confirming the beneficial effects of LF.
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Affiliation(s)
- Katarzyna Kaczyńska
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Monika Jampolska
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Piotr Wojciechowski
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Dorota Sulejczak
- Department of Experimental Pharmacology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Kryspin Andrzejewski
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
| | - Dominika Zając
- Department of Respiration Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5 St., 02-106 Warsaw, Poland
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Ong R, Cornish J, Wen J. Nanoparticular and other carriers to deliver lactoferrin for antimicrobial, antibiofilm and bone-regenerating effects: a review. Biometals 2022; 36:709-727. [PMID: 36512300 PMCID: PMC9745744 DOI: 10.1007/s10534-022-00455-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/27/2022] [Indexed: 12/15/2022]
Abstract
Bone and joint infections are a rare but serious problem worldwide. Lactoferrin’s antimicrobial and antibiofilm activity coupled with its bone-regenerating effects may make it suitable for improving bone and joint infection treatment. However, free lactoferrin (LF) has highly variable oral bioavailability in humans due to potential for degradation in the stomach and small intestine. It also has a short half-life in blood plasma. Therefore, encapsulating LF in nanocarriers may slow degradation in the gastrointestinal tract and enhance LF absorption, stability, permeability and oral bioavailability. This review will summarize the literature on the encapsulation of LF into liposomes, solid lipid nanoparticles, nanostructured lipid carriers, polymeric micro and nanoparticles and hydroxyapatite nanocrystals. The fabrication, characterization, advantages, disadvantages and applications of each system will be discussed and compared.
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Affiliation(s)
- Ray Ong
- grid.9654.e0000 0004 0372 3343Faculty of Medical and Health Sciences, School of Medicine, The University of Auckland, Auckland, 1142 New Zealand
| | - Jillian Cornish
- grid.9654.e0000 0004 0372 3343Faculty of Medical and Health Sciences, School of Medicine, The University of Auckland, Auckland, 1142 New Zealand
| | - Jingyuan Wen
- grid.9654.e0000 0004 0372 3343Faculty of Medical and Health Sciences, School of Medicine, The University of Auckland, Auckland, 1142 New Zealand
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Avalos-Gómez C, Ramírez-Rico G, Ruiz-Mazón L, Sicairos NL, Serrano-Luna J, de la Garza M. Lactoferrin: An Effective Weapon in the Battle Against Bacterial Infections. Curr Pharm Des 2022; 28:3243-3260. [PMID: 36284379 DOI: 10.2174/1381612829666221025153216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 09/27/2022] [Indexed: 01/28/2023]
Abstract
The emergence of multidrug-resistant bacterial strains with respect to commercially available antimicrobial drugs has marked a watershed in treatment therapies to fight pathogens and has stimulated research on alternative remedies. Proteins of the innate immune system of mammals have been highlighted as potentially yielding possible treatment options for infections. Lactoferrin (Lf) is one of these proteins; interestingly, no resistance to it has been found. Lf is a conserved cationic nonheme glycoprotein that is abundant in milk and is also present in low quantities in mucosal secretions. Moreover, Lf is produced and secreted by the secondary granules of neutrophils at infection sites. Lf is a molecule of approximately 80 kDa that displays multiple functions, such as antimicrobial, anti-viral, anti-inflammatory, and anticancer actions. Lf can synergize with antibiotics, increasing its potency against bacteria. Lactoferricins (Lfcins) are peptides resulting from the N-terminal end of Lf by proteolytic cleavage with pepsin. They exhibit several anti-bacterial effects similar to those of the parental glycoprotein. Synthetic analog peptides exhibiting potent antimicrobial properties have been designed. The aim of this review is to update understanding of the structure and effects of Lf and Lfcins as anti-bacterial compounds, focusing on the mechanisms of action in bacteria and the use of Lf in treatment of infections in patients, including those studies where no significant differences were found. Lf could be an excellent option for prevention and treatment of bacterial diseases, mainly in combined therapies with antibiotics or other antimicrobials.
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Affiliation(s)
- Christian Avalos-Gómez
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ciudad de Mexico, Mexico
| | - Gerardo Ramírez-Rico
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ciudad de Mexico, Mexico.,Facultad de Estudios Superiores Cuautitlán, Universidad Nacional Autónoma de México (UNAM), Km 2.5 Carretera Cuautitlán- Teoloyucan, Cuautitlán Izcalli, 54714, Mexico
| | - Lucero Ruiz-Mazón
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ciudad de Mexico, Mexico
| | - Nidia León Sicairos
- Departamento de Investigación, Hospital Pediátrico de Sinaloa, Unidad de Investigación, Facultad de Medicina, Universidad Autónoma de Sinaloa, Mexico
| | - Jesús Serrano-Luna
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ciudad de Mexico, Mexico
| | - Mireya de la Garza
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del IPN, Ciudad de Mexico, Mexico
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The End of “One Size Fits All” Sepsis Therapies: Toward an Individualized Approach. Biomedicines 2022; 10:biomedicines10092260. [PMID: 36140361 PMCID: PMC9496597 DOI: 10.3390/biomedicines10092260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 12/20/2022] Open
Abstract
Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection, remains a major challenge for clinicians and trialists. Despite decades of research and multiple randomized clinical trials, a specific therapeutic for sepsis is not available. The evaluation of therapeutics targeting components of host response anomalies in patients with sepsis has been complicated by the inability to identify those in this very heterogeneous population who are more likely to benefit from a specific intervention. Additionally, multiple and diverse host response aberrations often co-exist in sepsis, and knowledge of which dysregulated biological organ system or pathway drives sepsis-induced pathology in an individual patient is limited, further complicating the development of effective therapies. Here, we discuss the drawbacks of previous attempts to develop sepsis therapeutics and delineate a future wherein interventions will be based on the host response profile of a patient.
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Karakike E, Scicluna BP, Roumpoutsou M, Mitrou I, Karampela N, Karageorgos A, Psaroulis K, Massa E, Pitsoulis A, Chaloulis P, Pappa E, Schrijver IT, Frantzeskaki F, Lada M, Dauby N, De Bels D, Floros I, Anisoglou S, Antoniadou E, Patrani M, Vlachogianni G, Mouloudi E, Antoniadou A, Grimaldi D, Roger T, Wiersinga WJ, Tsangaris I, Giamarellos-Bourboulis EJ. Effect of intravenous clarithromycin in patients with sepsis, respiratory and multiple organ dysfunction syndrome: a randomized clinical trial. Crit Care 2022; 26:183. [PMID: 35717241 PMCID: PMC9206755 DOI: 10.1186/s13054-022-04055-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/08/2022] [Indexed: 12/29/2022] Open
Abstract
Background Clarithromycin may act as immune-regulating treatment in sepsis and acute respiratory dysfunction syndrome. However, clinical evidence remains inconclusive. We aimed to evaluate whether clarithromycin improves 28-day mortality among patients with sepsis, respiratory and multiple organ dysfunction syndrome. Methods We conducted a multicenter, randomized, clinical trial in patients with sepsis. Participants with ratio of partial oxygen pressure to fraction of inspired oxygen less than 200 and more than 3 SOFA points from systems other than the respiratory function were enrolled between December 2017 and September 2019. Patients were randomized to receive 1 gr of clarithromycin or placebo intravenously once daily for 4 consecutive days. The primary endpoint was 28-day all-cause mortality. Secondary outcomes were 90-day mortality; sepsis response (defined as at least 25% decrease in SOFA score by day 7); sepsis recurrence; and differences in peripheral blood cell populations and leukocyte transcriptomics. Results Fifty-five patients were allocated to each arm. By day 28, 27 (49.1%) patients in the clarithromycin and 25 (45.5%) in the placebo group died (risk difference 3.6% [95% confidence interval (CI) − 15.7 to 22.7]; P = 0.703, adjusted OR 1.03 [95%CI 0.35–3.06]; P = 0.959). There were no statistical differences in 90-day mortality and sepsis response. Clarithromycin was associated with lower incidence of sepsis recurrence (OR 0.21 [95%CI 0.06–0.68]; P = 0.012); significant increase in monocyte HLA-DR expression; expansion of non-classical monocytes; and upregulation of genes involved in cholesterol homeostasis. Serious and non-serious adverse events were equally distributed. Conclusions Clarithromycin did not reduce mortality among patients with sepsis with respiratory and multiple organ dysfunction. Clarithromycin was associated with lower sepsis recurrence, possibly through a mechanism of immune restoration. Clinical trial registration clinicaltrials.gov identifier NCT03345992 registered 17 November 2017; EudraCT 2017-001056-55. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04055-4.
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12
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Li D, Hu Z, He Q, Guo Y, Chong Y, Xu J, Qin L. Lactoferrin Alleviates Acute Alcoholic Liver Injury by Improving Redox-Stress Response Capacity in Female C57BL/6J Mice. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2021; 69:14856-14867. [PMID: 34873911 DOI: 10.1021/acs.jafc.1c06813] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Lactoferrin (Lf) can attenuate alcoholic liver injury (ALI) in male mice; however, the effects of Lf on acute ALI in female mice are still unknown. Female C57BL/6J mice were randomly divided into four groups and fed with different diets for 4 weeks: an AIN-93G diet for control (CON) and ethanol (EtOH) groups; an AIN-93G diet with 0.4 and 4% casein replaced by Lf for low-dose Lf (LLf) and high-dose Lf (HLf) groups. Acute ALI was induced by intragastric administration of ethanol (4.8 g/kgbw) every 12 h continuously for three times. HLf had obvious alleviating effects on acute ALI. Lf pretreatment did not affect hepatic alcohol metabolism key enzymes. Meanwhile, the ethanol-induced hepatic reactive oxygen species level increase was not ameliorated by Lf. Metabolomics and bioinformatics analysis results suggested an important role of redox-stress response capacity (RRC). Western blots showed HLf-promoted AKT and AMP-activated protein kinase activations and upregulated Nrf2 and LC3-II expressions, which was associated with RRC improvement. In summary, HLf could prevent acute ALI in female mice, and RRC likely played an important role.
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Affiliation(s)
- Deming Li
- Department of Nutrition and Food Hygiene, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
| | - Zhiqiang Hu
- Department of Nutrition and Food Hygiene, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
| | - Qian He
- Department of Nutrition and Food Hygiene, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
| | - Yaxin Guo
- Department of Nutrition and Food Hygiene, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
| | - Yu Chong
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
| | - Jiaying Xu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
| | - Liqiang Qin
- Department of Nutrition and Food Hygiene, School of Public Health, Medical College of Soochow University, 199 Renai Road, Suzhou, Jiangsu 215123, China
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13
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How to Combat Gram-Negative Bacteria Using Antimicrobial Peptides: A Challenge or an Unattainable Goal? Antibiotics (Basel) 2021; 10:antibiotics10121499. [PMID: 34943713 PMCID: PMC8698890 DOI: 10.3390/antibiotics10121499] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 12/16/2022] Open
Abstract
Antimicrobial peptides (AMPs) represent a promising and effective alternative for combating pathogens, having some advantages compared to conventional antibiotics. However, AMPs must also contend with complex and specialised Gram-negative bacteria envelops. The variety of lipopolysaccharide and phospholipid composition in Gram-negative bacteria strains and species are decisive characteristics regarding their susceptibility or resistance to AMPs. Such biological and structural barriers have created delays in tuning AMPs to deal with Gram-negative bacteria. This becomes even more acute because little is known about the interaction AMP–Gram-negative bacteria and/or AMPs’ physicochemical characteristics, which could lead to obtaining selective molecules against Gram-negative bacteria. As a consequence, available AMPs usually have highly associated haemolytic and/or cytotoxic activity. Only one AMP has so far been FDA approved and another two are currently in clinical trials against Gram-negative bacteria. Such a pessimistic panorama suggests that efforts should be concentrated on the search for new molecules, designs and strategies for combating infection caused by this type of microorganism. This review has therefore been aimed at describing the currently available AMPs for combating Gram-negative bacteria, exploring the characteristics of these bacteria’s cell envelop hampering the development of new AMPs, and offers a perspective regarding the challenges for designing new AMPs against Gram-negative bacteria.
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14
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Sousa SA, Feliciano JR, Pita T, Soeiro CF, Mendes BL, Alves LG, Leitão JH. Bacterial Nosocomial Infections: Multidrug Resistance as a Trigger for the Development of Novel Antimicrobials. Antibiotics (Basel) 2021; 10:antibiotics10080942. [PMID: 34438992 PMCID: PMC8389044 DOI: 10.3390/antibiotics10080942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022] Open
Abstract
Nosocomial bacterial infections are associated with high morbidity and mortality, posing a huge burden to healthcare systems worldwide. The ongoing COVID-19 pandemic, with the raised hospitalization of patients and the increased use of antimicrobial agents, boosted the emergence of difficult-to-treat multidrug-resistant (MDR) bacteria in hospital settings. Therefore, current available antibiotic treatments often have limited or no efficacy against nosocomial bacterial infections, and novel therapeutic approaches need to be considered. In this review, we analyze current antibacterial alternatives under investigation, focusing on metal-based complexes, antimicrobial peptides, and antisense antimicrobial therapeutics. The association of new compounds with older, commercially available antibiotics and the repurposing of existing drugs are also revised in this work.
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Affiliation(s)
- Sílvia A. Sousa
- Department of Bioengineering, IBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; (J.R.F.); (T.P.); (C.F.S.); (B.L.M.)
- Associate Laboratory i4HB—Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal
- Correspondence: (S.A.S.); (J.H.L.); Tel.: +351-218417688 (J.H.L.)
| | - Joana R. Feliciano
- Department of Bioengineering, IBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; (J.R.F.); (T.P.); (C.F.S.); (B.L.M.)
- Associate Laboratory i4HB—Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal
| | - Tiago Pita
- Department of Bioengineering, IBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; (J.R.F.); (T.P.); (C.F.S.); (B.L.M.)
- Associate Laboratory i4HB—Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal
| | - Catarina F. Soeiro
- Department of Bioengineering, IBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; (J.R.F.); (T.P.); (C.F.S.); (B.L.M.)
| | - Beatriz L. Mendes
- Department of Bioengineering, IBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; (J.R.F.); (T.P.); (C.F.S.); (B.L.M.)
- Centro de Química Estrutural, Instituto Superior Técnico, Universidade de Lisboa, 1049-001 Lisboa, Portugal
| | - Luis G. Alves
- Centro de Química Estrutural, Associação do Instituto Superior Técnico para a Investigação e Desenvolvimento, 1049-003 Lisboa, Portugal;
| | - Jorge H. Leitão
- Department of Bioengineering, IBB-Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; (J.R.F.); (T.P.); (C.F.S.); (B.L.M.)
- Associate Laboratory i4HB—Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal
- Correspondence: (S.A.S.); (J.H.L.); Tel.: +351-218417688 (J.H.L.)
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15
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Sienkiewicz M, Jaśkiewicz A, Tarasiuk A, Fichna J. Lactoferrin: an overview of its main functions, immunomodulatory and antimicrobial role, and clinical significance. Crit Rev Food Sci Nutr 2021; 62:6016-6033. [PMID: 33685299 DOI: 10.1080/10408398.2021.1895063] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lactoferrin (LF), a glycoprotein found in mucosal secretions, is characterized by a wide range of functions, including immunomodulatory and anti-inflammatory activities. Moreover, several investigations confirmed that LF displays high effectiveness against multiple bacteria and viruses and may be regarded as a potential inhibitor of enveloped viruses, such as presently prevailing SARS-CoV-2. In our review, we discuss available studies about LF functions and bioavailability of different LF forms in in vitro and in vivo models. Moreover, we characterize the potential benefits and side effects of LF use; we also briefly summarize the latest clinical trials examining LF application. Finally, we point potential role of LF in inflammatory bowel disease and indicate its use as a marker for disease severity.
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Affiliation(s)
- Michał Sienkiewicz
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| | - Andrzej Jaśkiewicz
- Institute of Food Technology and Analysis, Faculty of Biotechnology and Food Sciences, Lodz University of Technology, Lodz, Poland
| | - Aleksandra Tarasiuk
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
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16
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Ryu M, Park J, Yeom JH, Joo M, Lee K. Rediscovery of antimicrobial peptides as therapeutic agents. J Microbiol 2021; 59:113-123. [PMID: 33527313 DOI: 10.1007/s12275-021-0649-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 02/07/2023]
Abstract
In recent years, the occurrence of antibiotic-resistant pathogens is increasing rapidly. There is growing concern as the development of antibiotics is slower than the increase in the resistance of pathogenic bacteria. Antimicrobial peptides (AMPs) are promising alternatives to antibiotics. Despite their name, which implies their antimicrobial activity, AMPs have recently been rediscovered as compounds having antifungal, antiviral, anticancer, antioxidant, and insecticidal effects. Moreover, many AMPs are relatively safe from toxic side effects and the generation of resistant microorganisms due to their target specificity and complexity of the mechanisms underlying their action. In this review, we summarize the history, classification, and mechanisms of action of AMPs, and provide descriptions of AMPs undergoing clinical trials. We also discuss the obstacles associated with the development of AMPs as therapeutic agents and recent strategies formulated to circumvent these obstacles.
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Affiliation(s)
- Minkyung Ryu
- Department of Life Science, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - Jaeyeong Park
- Department of Life Science, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - Ji-Hyun Yeom
- Department of Life Science, Chung-Ang University, Seoul, 06974, Republic of Korea.
| | - Minju Joo
- Department of Life Science, Chung-Ang University, Seoul, 06974, Republic of Korea.
| | - Kangseok Lee
- Department of Life Science, Chung-Ang University, Seoul, 06974, Republic of Korea.
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17
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Zlatina K, Galuska SP. The N-glycans of lactoferrin: more than just a sweet decoration. Biochem Cell Biol 2021; 99:117-127. [DOI: 10.1139/bcb-2020-0106] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nearly all extracellular proteins undergo post-translational modification with sugar chains during their transit through the endoplasmic reticulum and the Golgi apparatus. These “sweet” modifications not only influence the activity of its carrier protein, but they themselves often have bioactivity, independent of the carrier function. Lactoferrin belongs to the group of glycoproteins and is modified with several different N-glycans. This minireview summarizes several studies dealing with the diverse glycosylation patterns of lactoferrin from different origins, and the potential impact of these post-translational modifications on the functionality of lactoferrin. A special emphasis is placed on the differences between human and bovine lactoferrin, because the latter form is often selected for the development of novel therapeutic approaches in humans. For this reason, the potential impact of the bovine-specific glycosylation patterns on the observed heterogeneous effects of lactoferrin in humans is discussed within this minireview.
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Affiliation(s)
- Kristina Zlatina
- Institute of Reproductive Biology, Leibniz Institute for Farm Animal Biology (FBN), Wilhelm-Stahl-Allee 2, 18196 Dummerstorf, Germany
- Institute of Reproductive Biology, Leibniz Institute for Farm Animal Biology (FBN), Wilhelm-Stahl-Allee 2, 18196 Dummerstorf, Germany
| | - Sebastian P. Galuska
- Institute of Reproductive Biology, Leibniz Institute for Farm Animal Biology (FBN), Wilhelm-Stahl-Allee 2, 18196 Dummerstorf, Germany
- Institute of Reproductive Biology, Leibniz Institute for Farm Animal Biology (FBN), Wilhelm-Stahl-Allee 2, 18196 Dummerstorf, Germany
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18
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Brandenburg K, Schromm AB, Weindl G, Heinbockel L, Correa W, Mauss K, Martinez de Tejada G, Garidel P. An update on endotoxin neutralization strategies in Gram-negative bacterial infections. Expert Rev Anti Infect Ther 2020; 19:495-517. [PMID: 33210958 DOI: 10.1080/14787210.2021.1834847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gram-negative bacterial infections represent still a severe problem of human health care, regarding the increase in multi-resistance against classical antibiotics and the lack of newly developed antimicrobials. For the fight against these germs, anti-infective agents must overcome and/or bind to the Gram-negative outer membrane consisting of a lipopolysaccharide (LPS, endotoxin) outer leaflet and an inner leaflet from phospholipids, with additional peripheral or integral membrane proteins (OMP's). AREAS COVERED The current article reviews data of existing therapeutic options and summarizes newer approaches for targeting and neutralizing endotoxins, ranging from in vitro over in vivo animal data to clinical applications by using databases such as Medline. EXPERT OPINION Conventional antibiotic treatment of the bacteria leads to their killing, but not necessary LPS neutralization, which may be a severe problem in particular for the systemic pathway. This is the reason why there is an increasing number of therapeutic approaches, which - besides combating whole bacteria - at the same time try to neutralize endotoxin within or outside the bacterial cells mainly responsible for the high inflammation induction in Gram-negative species.
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Affiliation(s)
- Klaus Brandenburg
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Andra B Schromm
- FG Immunobiophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Günther Weindl
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Universität Bonn, Universität Bonn Pharmazeutisches Institut Pharmakologie Und Toxikologie Bonn, Germany
| | - Lena Heinbockel
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Wilmar Correa
- FG Biophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Karl Mauss
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Asklepios-Klinik Hamburg-Altona, Hamburg, Germany
| | - Guillermo Martinez de Tejada
- Department of Microbiology and Parasitology, University of Navarra, E-31008 Pamplona, Spain and Navarra Institute for Health Research (Idisna), Pamplona, Spain.,Department de Microbiologia, Universidad De Navarra, Pamplona, Spain
| | - Patrick Garidel
- Martin-Luther-Universität Halle-Wittenberg, Institut für Chemie, Halle/Saale, Germany
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19
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Chang R, Ng TB, Sun WZ. Lactoferrin as potential preventative and adjunct treatment for COVID-19. Int J Antimicrob Agents 2020; 56:106118. [PMID: 32738305 PMCID: PMC7390755 DOI: 10.1016/j.ijantimicag.2020.106118] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/01/2020] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
Lactoferrin (Lf) is a naturally occurring, pleiotropic, non-toxic glycoprotein. Lf has broad-spectrum antiviral, immunomodulatory and anti-inflammatory effects. Lf shows in vitro antiviral activity against SARS-CoV, which is likely similar against SARS-CoV-2 via the same mechanism. Lf's immunomodulatory and anti-inflammatory effects may be especially relevant as a potential adjunct for severe COVID-19.
The coronavirus disease 2019 (COVID-19) pandemic is rapidly advancing across the globe despite drastic public and personal health measures. Antivirals and nutritional supplements have been proposed as potentially useful against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus that causes COVID-19, but few have been clinically established. Lactoferrin (Lf) is a naturally occurring, non-toxic glycoprotein that is orally available as a nutritional supplement and has established in vitro antiviral efficacy against a wide range of viruses, including SARS-CoV, a closely related coronavirus to SARS-CoV-2. Furthermore, Lf possesses unique immunomodulatory and anti-inflammatory effects that may be especially relevant to the pathophysiology of severe COVID-19 cases. Here we review the underlying biological mechanisms of Lf as an antiviral and immune regulator, and propose its unique potential as a preventative and adjunct treatment for COVID-19. We hope that further research and development of Lf nutritional supplementation would establish its role for COVID-19.
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Affiliation(s)
- Raymond Chang
- Institute of East-West Medicine, 102 E 30th Street, New York, NY 10016, USA.
| | - Tzi Bun Ng
- Chinese University of Hong Kong, Shatin, N.T., Hong Kong
| | - Wei-Zen Sun
- Institute of East-West Medicine, 102 E 30th Street, New York, NY 10016, USA; National Taiwan University Hospital, 7 Chung Shan S. Road., Taipei, Taiwan
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20
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Mitri C, Xu Z, Bardin P, Corvol H, Touqui L, Tabary O. Novel Anti-Inflammatory Approaches for Cystic Fibrosis Lung Disease: Identification of Molecular Targets and Design of Innovative Therapies. Front Pharmacol 2020; 11:1096. [PMID: 32848733 PMCID: PMC7396676 DOI: 10.3389/fphar.2020.01096] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/06/2020] [Indexed: 12/19/2022] Open
Abstract
Cystic fibrosis (CF) is the most common genetic disorder among Caucasians, estimated to affect more than 70,000 people in the world. Severe and persistent bronchial inflammation and chronic bacterial infection, along with airway mucus obstruction, are hallmarks of CF lung disease and participate in its progression. Anti-inflammatory therapies are, therefore, of particular interest for CF lung disease. Furthermore, a better understanding of the molecular mechanisms involved in airway infection and inflammation in CF has led to the development of new therapeutic approaches that are currently under evaluation by clinical trials. These new strategies dedicated to CF inflammation are designed to treat different dysregulated aspects such as oxidative stress, cytokine secretion, and the targeting of dysregulated pathways. In this review, we summarize the current understanding of the cellular and molecular mechanisms that contribute to abnormal lung inflammation in CF, as well as the new anti-inflammatory strategies proposed to CF patients by exploring novel molecular targets and novel drug approaches.
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Affiliation(s)
- Christie Mitri
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Zhengzhong Xu
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France.,Yangzhou University, Yangzhou, China
| | - Pauline Bardin
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Harriet Corvol
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France.,Département de Pédiatrie Respiratoire, Hôpital Trousseau, AP-HP, Paris, France
| | - Lhousseine Touqui
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France.,Equipe Mucoviscidose et Bronchopathies Chroniques, Département Santé Globale, Institut Pasteur, Paris, France
| | - Olivier Tabary
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France
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21
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Carbone F, Montecucco F, Sahebkar A. Current and emerging treatments for neonatal sepsis. Expert Opin Pharmacother 2020; 21:549-556. [PMID: 32011188 DOI: 10.1080/14656566.2020.1721464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction: Mortality due to sepsis is still prevalent, peaking at extreme ages of life including infancy. Despite many efforts, the peculiarity of the infant immune system has limited further advances in its treatment. Indeed, neonates experience a dramatic physiological transition from immune tolerance to the maternal antigens to functional maturity. Such a transition is extremely dynamic, as is the pathophysiology of infant sepsis, which is dependent on many infant, maternal, and environmental factors.Areas covered: In this review, the authors critically update and summarize the current paradigm of immunomodulation in infant sepsis. They confirm how exogenous stimulation of the immune system through intravenous immunoglobulin, colony stimulating factors, and granulocyte transfusion have failed to impact on the prognosis of infant sepsis. They also strongly support the beneficial effects of supplementation/replacement therapies with products naturally contained within maternal milk as well as antioxidant compounds.Expert opinion: Breastfeeding is beneficial against sepsis. Knowledge of the neonatal immune system is indeed too limited to effectively strengthen immune response by exogenous interventions, especially in preterm and low-birth-weight infants. Awareness of this limitation should pave the way for future studies (e.g. gender- and omics-based) aimed at better characterizing the infant immune system and promoting a more tailored approach.
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Affiliation(s)
- Federico Carbone
- First Clinic of Internal Medicine Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino Genoa - Italian Cardiovascular Network, Genoa, Italy
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa - Italian Cardiovascular Network, Genoa, Italy.,First Clinic of Internal Medicine, Department of Internal Medicine and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - Amirhossein Sahebkar
- Halal Research Center of IRI, FDA, Tehran, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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22
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Which Multicenter Randomized Controlled Trials in Critical Care Medicine Have Shown Reduced Mortality? A Systematic Review. Crit Care Med 2019; 47:1680-1691. [DOI: 10.1097/ccm.0000000000004000] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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23
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Prevention of Nosocomial Infections in Critically Ill Patients With Lactoferrin: A Randomized, Double-Blind, Placebo-Controlled Study. Crit Care Med 2019; 46:1450-1456. [PMID: 30015668 DOI: 10.1097/ccm.0000000000003294] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To obtain preliminary evidence for the efficacy of lactoferrin as a preventative measure for nosocomial infections and inform the conduct of a definitive study. DESIGN Phase 2, multicenter, randomized, double-blind, placebo-controlled study. SETTING Medical-surgical ICUs. PATIENTS Adult, critically ill patients receiving invasive mechanical ventilation. INTERVENTIONS Randomized, eligible, consenting patients expected to require invasive mechanical ventilation more than 48 hours received lactoferrin both enterally and via an oral swab or a placebo of sterile water for up to 28 days. MEASUREMENTS AND MAIN RESULTS Of the 214 patients who were randomized, 212 received at least one dose of the intervention and were analyzed (107 lactoferrin and 105 placebo). Protocol adherence was 87.5%. Patients receiving lactoferrin were older (mean [SD], 66.3 [13.5] vs 62.5 [16.2] yr), had a higher Acute Physiology and Chronic Health Evaluation II score (26.8 [7.8] vs 23.5 [7.9]), and need for vasopressors (79% vs 70%). Antibiotic-free days (17.3 [9.0] vs 18.5 [7.1]; p = 0.91) and nosocomial infections (0.3 [0.7] vs 0.4 [0.6] per patient; p = 0.48) did not differ between lactoferrin and placebo groups, respectively. Clinical outcomes for lactoferrin versus placebo were as follows: ICU length of stay (14.5 [18.0] vs 15.0 [37.3] d; p = 0.82), hospital length of stay (25.0 [25.9] vs 28.1 [44.6] d; p = 0.57), hospital mortality (41.1% vs 30.5%; p = 0.11), and 90-day mortality (44.9% vs 32.4%; p = 0.06). Biomarker levels did not differ between the groups. CONCLUSIONS Lactoferrin did not improve the primary outcome of antibiotic-free days, nor any of the secondary outcomes. Our data do not support the conduct of a larger phase 3 trial.
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Vincent JL, Sakr Y. Clinical trial design for unmet clinical needs: a spotlight on sepsis. Expert Rev Clin Pharmacol 2019; 12:893-900. [DOI: 10.1080/17512433.2019.1643235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jean-Louis Vincent
- Dept of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
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Luhr R, Cao Y, Söderquist B, Cajander S. Trends in sepsis mortality over time in randomised sepsis trials: a systematic literature review and meta-analysis of mortality in the control arm, 2002-2016. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:241. [PMID: 31269976 PMCID: PMC6610784 DOI: 10.1186/s13054-019-2528-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/24/2019] [Indexed: 12/25/2022]
Abstract
Background Epidemiologic data have shown an increasing incidence and declining mortality rate in sepsis. However, confounding effects due to differences in disease classification might have contributed to these trends. To assess if a declining mortality over time could be supported by data derived from high-quality prospective studies, we performed a meta-analysis using data from randomised controlled trials (RCTs) on sepsis. The primary aim was to assess whether the mortality in sepsis trials has changed over time. The secondary aim was to investigate how many of the included trials could show efficacy of the studied intervention regarding 28-day mortality. Methods We searched PubMed for RCTs enrolling patients with severe sepsis and septic shock, published between 2002 and 2016. The included trials were assessed for quality and sorted by date of first inclusion. A meta-analysis was performed to synthesise data from the individual sepsis trials. Results Of 418 eligible articles, 44 RCTs on sepsis were included in the analysis, enrolling 13,315 patients in the usual care arm between 1991 and 2013. In this time period, mortality decreased by 0.42% annually (p = 0.04) to give a total decline of 9.24%. In subgroup analyses with adjustments for APACHE II, SAPS II and SOFA scores, the observed time trend was not significant (p = 0.45, 0.23 and 0.98 respectively). Only four of the included trials showed any efficacy with regard to mortality. Conclusions Data from RCTs show a declining trend in 28-day mortality in severe sepsis and septic shock patients during the years from 1991 to 2013. However, when controlling for severity at study inclusion, there was no significant change in mortality over time. The number of trials presenting new treatment options was low. Trial registration PROSPERO CRD42018091100. Registered 27 August 2018. Electronic supplementary material The online version of this article (10.1186/s13054-019-2528-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert Luhr
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182, Örebro, Sweden.,Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Bo Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden.,Department of Infectious Diseases, Örebro University Hospital, 70182, Örebro, Sweden
| | - Sara Cajander
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden. .,Department of Infectious Diseases, Örebro University Hospital, 70182, Örebro, Sweden.
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Pammi M, Abrams SA. Enteral lactoferrin for the treatment of sepsis and necrotizing enterocolitis in neonates. Cochrane Database Syst Rev 2019; 5:CD007138. [PMID: 31077334 PMCID: PMC6511233 DOI: 10.1002/14651858.cd007138.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Neonatal sepsis and necrotizing enterocolitis (NEC) cause significant neonatal mortality and morbidity despite appropriate antibiotic therapy. Enhancing host defense and modulating inflammation by using lactoferrin as an adjunct to antibiotics in the treatment of sepsis, NEC, or both, may improve clinical outcomes. OBJECTIVES The primary objective was to assess safety and efficacy of oral lactoferrin as an adjunct to antibiotics in the treatment of neonates with suspected or confirmed sepsis, NEC, or both. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 9), MEDLINE via PubMed, PREMEDLINE, (1966 to 20 September 2018) Embase (1980 to 20 September 2018), and CINAHL (1982 to 20 September 2018). We also searched clinical trial databases, conference proceedings, the reference lists of retried articles and clinical trials, and the authors' personal files. SELECTION CRITERIA We included randomized or quasi-randomized controlled trials evaluating enteral lactoferrin (at any dose or duration), used as an adjunct to antibiotic therapy, compared with antibiotic therapy alone (with or without placebo) or other adjuncts to antibiotic therapy to treat neonates at any gestational age up to 44 weeks' postmenstrual age with confirmed or suspected sepsis or necrotizing enterocolitis (Bell's Stage II or III). DATA COLLECTION AND ANALYSIS We used the standardized methods of Cochrane Neonatal for conducting a systematic review and for assessing the methodological quality of studies (neonatal.cochrane.org/en/index.html). The titles and the abstracts of studies identified by the search strategy were independently assessed by the two review authors and full text versions were obtained for assessment if necessary. Forms were designed to record trial inclusion/exclusion and data extraction. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS We did not identify any eligible trials evaluating lactoferrin for the treatment of neonatal sepsis or NEC. AUTHORS' CONCLUSIONS Implications for practice: currently there is no evidence to support or refute the use of enteral lactoferrin, as an adjunct to antibiotic therapy, for the treatment of neonatal sepsis or necrotizing enterocolitis. IMPLICATIONS FOR RESEARCH given the lack of efficacy of enteral lactoferrin for preventing late-onset sepsis and necrotizing enterocolitis, evaluation of enteral lactoferrin as an adjunctive agent for treatment of sepsis or necrotizing enterocolitis does not appear to be a research priority.
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Affiliation(s)
- Mohan Pammi
- Baylor College of MedicineSection of Neonatology, Department of Pediatrics6621, Fannin, MC.WT 6‐104HoustonTexasUSA77030
| | - Steven A Abrams
- Dell Medical School, The University of Texas at AustinDepartment of PediatricsAustinTexasUSA
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27
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Nwafor DC, Brichacek AL, Mohammad AS, Griffith J, Lucke-Wold BP, Benkovic SA, Geldenhuys WJ, Lockman PR, Brown CM. Targeting the Blood-Brain Barrier to Prevent Sepsis-Associated Cognitive Impairment. J Cent Nerv Syst Dis 2019; 11:1179573519840652. [PMID: 31007531 PMCID: PMC6456845 DOI: 10.1177/1179573519840652] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/21/2019] [Indexed: 12/17/2022] Open
Abstract
Sepsis is a systemic inflammatory disease resulting from an infection. This disorder affects 750 000 people annually in the United States and has a 62% rehospitalization rate. Septic symptoms range from typical flu-like symptoms (eg, headache, fever) to a multifactorial syndrome known as sepsis-associated encephalopathy (SAE). Patients with SAE exhibit an acute altered mental status and often have higher mortality and morbidity. In addition, many sepsis survivors are also burdened with long-term cognitive impairment. The mechanisms through which sepsis initiates SAE and promotes long-term cognitive impairment in septic survivors are poorly understood. Due to its unique role as an interface between the brain and the periphery, numerous studies support a regulatory role for the blood-brain barrier (BBB) in the progression of acute and chronic brain dysfunction. In this review, we discuss the current body of literature which supports the BBB as a nexus which integrates signals from the brain and the periphery in sepsis. We highlight key insights on the mechanisms that contribute to the BBB's role in sepsis which include neuroinflammation, increased barrier permeability, immune cell infiltration, mitochondrial dysfunction, and a potential barrier role for tissue non-specific alkaline phosphatase (TNAP). Finally, we address current drug treatments (eg, antimicrobials and intravenous immunoglobulins) for sepsis and their potential outcomes on brain function. A comprehensive understanding of these mechanisms may enable clinicians to target specific aspects of BBB function as a therapeutic tool to limit long-term cognitive impairment in sepsis survivors.
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Affiliation(s)
- Divine C Nwafor
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Allison L Brichacek
- Immunology and Microbial Pathogenesis, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Afroz S Mohammad
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Jessica Griffith
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Brandon P Lucke-Wold
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Stanley A Benkovic
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Werner J Geldenhuys
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Paul R Lockman
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Candice M Brown
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Immunology and Microbial Pathogenesis, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Center for Basic and Translational Stroke Research, Rockefeller Neuroscience Institute, Health Sciences Center, West Virginia University, Morgantown, WV, USA
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Kyriazopoulou E, Giamarellos-Bourboulis EJ. Pharmacological management of sepsis in adults with a focus on the current gold standard treatments and promising adjunctive strategies: evidence from the last five years. Expert Opin Pharmacother 2019; 20:991-1007. [DOI: 10.1080/14656566.2019.1589451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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van Werkhoven CH, Harbarth S, Bonten MJM. Adaptive designs in clinical trials in critically ill patients: principles, advantages and pitfalls. Intensive Care Med 2018; 45:678-682. [PMID: 30377740 PMCID: PMC6483961 DOI: 10.1007/s00134-018-5426-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/17/2018] [Indexed: 12/20/2022]
Affiliation(s)
- C H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - S Harbarth
- Infection Control Program and WHO Collaborating Center, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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30
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Telang S. Lactoferrin: A Critical Player in Neonatal Host Defense. Nutrients 2018; 10:nu10091228. [PMID: 30181493 PMCID: PMC6165050 DOI: 10.3390/nu10091228] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/30/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022] Open
Abstract
Newborn infants are at a high risk for infection due to an under-developed immune system, and human milk has been shown to exhibit substantial anti-infective properties that serve to bolster neonatal defenses against multiple infections. Lactoferrin is the dominant whey protein in human milk and has been demonstrated to perform a wide array of antimicrobial and immunomodulatory functions and play a critical role in protecting the newborn infant from infection. This review summarizes data describing the structure and important functions performed by lactoferrin in protecting the neonate from infection and contributing to the maturation of the newborn innate and adaptive immune systems. We also briefly discuss clinical trials examining the utility of lactoferrin supplementation in the prevention of sepsis and necrotizing enterocolitis in newborn infants. The data reviewed provide rationale for the continuation of studies to examine the effects of lactoferrin administration on the prevention of sepsis in the neonate.
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Affiliation(s)
- Sucheta Telang
- Division of Neonatology, Department of Pediatrics, University of Louisville, Louisville, KY 40202, USA.
- Division of Hematology/Oncology, Department of Medicine, James Graham Brown Cancer Center, University of Louisville, Louisville, KY 40202, USA.
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31
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MacManus CF, Collins CB, Nguyen TT, Alfano RW, Jedlicka P, de Zoeten EF. VEN-120, a Recombinant Human Lactoferrin, Promotes a Regulatory T Cell [Treg] Phenotype and Drives Resolution of Inflammation in Distinct Murine Models of Inflammatory Bowel Disease. J Crohns Colitis 2017; 11:1101-1112. [PMID: 28472424 PMCID: PMC5881664 DOI: 10.1093/ecco-jcc/jjx056] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease [IBD] is characterised by a disruption of immune homeostasis, which is tightly regulated to protect against harmful pathogens yet not react to commensal antigens. Animal studies indicate that regulatory T cells [Treg] modulate the immune response to prevent IBD development. Lactoferrin [LF] is an endogenous anti-inflammatory pleiotropic protein secreted at high concentrations in colostrum and at mucosal sites. However, the effect of LF on specific T lymphocyte populations has not been studied. Here, we identify a novel mechanism by which a recombinant human LF, VEN-120, regulates T cell populations in health and disease. METHODS Two murine models of intestinal inflammation, the dextran sodium sulphate colitis model and the TNFΔARE/+ model of ileitis, were used to study the anti-inflammatory and T cell modulating ability of VEN-120. Flow cytometry was used to evaluate T cell populations within the lamina propria and mesenteric lymph nodes, and to evaluate the effect of VEN-120 on CD4+ T cells in vitro. RESULTS VEN-120 reduced inflammation in both models of IBD, accompanied by increased Tregs in the intestinal lamina propria. Treatment of CD4+ T cells in vitro resulted in an upregulation of Treg genes and skewing towards a Treg population. This in vitro T cell skewing translated to an increase of Treg homing to the intestinal lamina propria and associated lymph tissue in healthy mice. CONCLUSIONS These data provide a novel immunological mechanism by which VEN-120 modulates T cells to restrict inflammatory T cell-driven disease.
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Affiliation(s)
- Christopher F MacManus
- Ventria Biosciences, Fort Collins, CO, USA,Corresponding author: Christopher MacManus, Ventria Bioscience, 320 E. Vine Dr., Fort Collins, CO 80524, USA. Tel.: 970-407-1239;
| | - Colm B Collins
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tom T Nguyen
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Paul Jedlicka
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Edwin F de Zoeten
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Muscedere J, Maslove D, Boyd JG, O'Callaghan N, Lamontagne F, Reynolds S, Albert M, Hall R, McGolrick D, Jiang X, Day AG. Prevention of nosocomial infections in critically ill patients with lactoferrin (PREVAIL study): study protocol for a randomized controlled trial. Trials 2016; 17:474. [PMID: 27681799 PMCID: PMC5041570 DOI: 10.1186/s13063-016-1590-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/02/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Nosocomial infections remain an important source of morbidity, mortality, and increased health care costs in hospitalized patients. This is particularly problematic in intensive care units (ICUs) because of increased patient vulnerability due to the underlying severity of illness and increased susceptibility from utilization of invasive therapeutic and monitoring devices. Lactoferrin (LF) and the products of its breakdown have multiple biological effects, which make its utilization of interest for the prevention of nosocomial infections in the critically ill. METHODS/DESIGN This is a phase II randomized, multicenter, double-blinded trial to determine the effect of LF on antibiotic-free days in mechanically ventilated, critically ill, adult patients in the ICU. Eligible, consenting patients will be randomized to receive either LF or placebo. The treating clinician will remain blinded to allocation during the study; blinding will be maintained by using opaque syringes and containers. The primary outcome will be antibiotic-free days, defined as the number of days alive and free of antibiotics 28 days after randomization. Secondary outcomes will include: antibiotic utilization, adjudicated diagnosis of nosocomial infection (longer than 72 h of admission to ICU), hospital and ICU length of stay, change in organ function after randomization, hospital and 90-day mortality, incidence of tracheal colonization, changes in gastrointestinal permeability, and immune function. Outcomes to inform the conduct of a larger definitive trial will also be evaluated, including feasibility as determined by recruitment rates and protocol adherence. DISCUSSION The results from this study are expected to provide insight into a potential novel therapeutic use for LF in critically ill adult patients. Further, analysis of study outcomes will inform a future, large-scale phase III randomized controlled trial powered on clinically important outcomes related to the use of LF. TRIAL REGISTRATION The trial was registered at www.ClinicalTrials.gov on 18 November 2013. TRIAL REGISTRATION NUMBER NCT01996579 .
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Affiliation(s)
- John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada. .,Kingston General Hospital, Room 5-411, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2 V3, Canada.
| | - David Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - John Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Nicole O'Callaghan
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Francois Lamontagne
- Centre de recherché du CHU de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Steven Reynolds
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Martin Albert
- Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Division of Critical Care Medicine, Critical Care and Medicine Departments, Université de Montréal, Montréal, QC, Canada
| | - Rick Hall
- Department of Critical Care Medicine, Dalhousie University and the Nova Scotia Health Authority, Halifax, NS, Canada
| | - Danielle McGolrick
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Kingston General Hospital, Room 5-411, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2 V3, Canada
| | - Andrew G Day
- Kingston General Hospital, Room 5-411, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2 V3, Canada
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Abstract
Anti-microbial peptides (AMPs) were originally thought to exert protecting actions against bacterial infection by disintegrating bacterial membranes. Upon identification of internal bacterial targets, the view changed and moved toward inhibition of prokaryote-specific biochemical processes. However, the level of none of these activities can explain the robust efficacy of some of these peptides in animal models of systemic and cutaneous infections. A rapidly growing panel of reports suggests that AMPs, now called host-defense peptides (HDPs), act through activating the immune system of the host. This includes recruitment and activation of macrophages and mast cells, inducing chemokine production and altering NF-κB signaling processes. As a result, both pro- and anti-inflammatory responses are elevated together with activation of innate and adaptive immunity mechanisms, wound healing, and apoptosis. HDPs sterilize the systemic circulation and local injury sites significantly more efficiently than pure single-endpoint in vitro microbiological or biochemical data would suggest and actively aid recovering from tissue damage after or even without bacterial infections. However, the multiple and, often opposing, immunomodulatory functions of HDPs require exceptional care in therapeutic considerations.
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Affiliation(s)
- Laszlo Otvos
- 1 Olpe LLC, Audubon, PA, USA
- 2 Institute of Medical Microbiology , Semmelweis University , Budapest, Hungary
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Battersby AJ, Khara J, Wright VJ, Levy O, Kampmann B. Antimicrobial Proteins and Peptides in Early Life: Ontogeny and Translational Opportunities. Front Immunol 2016; 7:309. [PMID: 27588020 PMCID: PMC4989132 DOI: 10.3389/fimmu.2016.00309] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/29/2016] [Indexed: 12/18/2022] Open
Abstract
While developing adaptive immune responses, young infants are especially vulnerable to serious infections, including sepsis, meningitis, and pneumonia. Antimicrobial proteins and peptides (APPs) are key effectors that function as broad-spectrum anti-infectives. This review seeks to summarize the clinically relevant functional qualities of APPs and the increasing clinical trial evidence for their use to combat serious infections in infancy. Levels of APPs are relatively low in early life, especially in infants born preterm or with low birth weight (LBW). There are several rationales for the potential clinical utility of APPs in the prevention and treatment of infections in infants: (a) APPs may be most helpful in those with reduced levels; (b) during sepsis microbial products signal via pattern recognition receptors causing potentially harmful inflammation that APPs may counteract; and (c) in the era of antibiotic resistance, development of new anti-infective strategies is essential. Evidence supports the potential clinical utility of exogenous APPs to reduce infection-related morbidity in infancy. Further studies should characterize the ontogeny of antimicrobial activity in mucosal and systemic compartments, and examine the efficacy of exogenous-APP formulations to inform translational development of APPs for infant groups.
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Affiliation(s)
- Anna J Battersby
- Academic Paediatrics, Imperial College London, London, UK; Medical Research Council (MRC) Unit, Vaccines and Immunity Theme, Fajara, Gambia
| | - Jasmeet Khara
- Academic Paediatrics, Imperial College London, London, UK; Department of Pharmacy, National University of Singapore, Singapore
| | | | - Ofer Levy
- Precision Vaccines Program, Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Beate Kampmann
- Academic Paediatrics, Imperial College London, London, UK; Medical Research Council (MRC) Unit, Vaccines and Immunity Theme, Fajara, Gambia
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Pettilä V, Hjortrup PB, Jakob SM, Wilkman E, Perner A, Takala J. Control groups in recent septic shock trials: a systematic review. Intensive Care Med 2016; 42:1912-1921. [PMID: 27448676 DOI: 10.1007/s00134-016-4444-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/04/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The interpretation of septic shock trial data is profoundly affected by patients, control intervention, co-interventions and selected outcome measures. We evaluated the reporting of control groups in recent septic shock trials. METHODS We searched for original articles presenting randomized clinical trials (RCTs) in adult septic shock patients from 2006 to 2016. We included RCTs focusing on septic shock patients with at least two parallel groups and at least 50 patients in the control group. We selected and evaluated data items regarding patients, control group characteristics, and mortality outcomes, and calculated a data completeness score to provide an overall view of quality of reporting. RESULTS A total of 24 RCTs were included (mean n = 287 patients and 71 % of eligible patients were randomized). Of the 24 studies, 14 (58 %) presented baseline data on vasopressors and 58 % the proportion of patients with elevated lactate values. Five studies (21 %) provided data to estimate the proportion of septic shock patients fulfilling the Sepsis-3 definition. The mean data completeness score was 19 out of 36 (range 8-32). Of 18 predefined control group characteristics, a mean of 8 (range 2-17) were reported. Only 2 (8 %) trials provided adequate data to confirm that their control group treatment represented usual care. CONCLUSIONS Recent trials in septic shock provide inadequate data on the control group treatment and hemodynamic values. We propose a standardized trial dataset to be created and validated, comprising characteristics of patient population, interventions administered, hemodynamic values achieved, surrogate organ dysfunction, and mortality outcomes, to allow better analysis and interpretation of future trial results.
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Affiliation(s)
- Ville Pettilä
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Peter Buhl Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Erika Wilkman
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- CRIC, Center of Research for Intensive Care, Copenhagen, Denmark
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Mayeur S, Spahis S, Pouliot Y, Levy E. Lactoferrin, a Pleiotropic Protein in Health and Disease. Antioxid Redox Signal 2016; 24:813-36. [PMID: 26981846 DOI: 10.1089/ars.2015.6458] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
SIGNIFICANCE Lactoferrin (Lf) is a nonheme iron-binding glycoprotein strongly expressed in human and bovine milk and it plays many functions during infancy such as iron homeostasis and defense against microorganisms. In humans, Lf is mainly expressed in mucosal epithelial and immune cells. Growing evidence suggests multiple physiological roles for Lf after weaning. RECENT ADVANCES The aim of this review is to highlight the recent advances concerning multifunctional Lf activities. CRITICAL ISSUES First, we will provide an overview of the mechanisms related to Lf intrinsic synthesis or intestinal absorption as well as its interaction with a wide spectrum of mammalian receptors and distribution in organs and cell types. Second, we will discuss the large variety of its physiological functions such as iron homeostasis, transportation, immune regulation, oxidative stress, inflammation, and apoptosis while specifying the mechanisms of action. Third, we will focus on its recent physiopathology implication in metabolic disorders, including obesity, type 2 diabetes, and cardiovascular diseases. Additional efforts are necessary before suggesting the potential use of Lf as a diagnostic marker or as a therapeutic tool. FUTURE DIRECTIONS The main sources of Lf in human cardiometabolic disorders should be clarified to identify new perspectives for future research and develop new strategies using Lf in therapeutics. Antioxid. Redox Signal. 24, 813-836.
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Affiliation(s)
- Sylvain Mayeur
- 1 Research Centre, CHU Ste-Justine, Université de Montréal , Montreal, Canada .,2 Institute of Nutraceuticals and Functional Foods (INAF) , Université Laval, Quebec, Canada
| | - Schohraya Spahis
- 1 Research Centre, CHU Ste-Justine, Université de Montréal , Montreal, Canada .,2 Institute of Nutraceuticals and Functional Foods (INAF) , Université Laval, Quebec, Canada .,3 Department of Nutrition, Université de Montréal , Montreal, Canada
| | - Yves Pouliot
- 3 Department of Nutrition, Université de Montréal , Montreal, Canada
| | - Emile Levy
- 1 Research Centre, CHU Ste-Justine, Université de Montréal , Montreal, Canada .,2 Institute of Nutraceuticals and Functional Foods (INAF) , Université Laval, Quebec, Canada .,3 Department of Nutrition, Université de Montréal , Montreal, Canada
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Tsaganos T, Giamarellos-Bourboulis EJ. Novel immunotherapeutic strategies for pyelonephritis. Immunotherapy 2016; 8:89-96. [DOI: 10.2217/imt.15.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute pyelonephritis is an infection of the renal parenchyma and renal pelvis. When it is caused by a typical pathogen in an immunocompetent female patient with normal urinary tract, it is considered uncomplicated. In all other cases, sepsis is the most worrisome complication. In the event of sepsis, patients should be hospitalized and treated aggressively with antibiotics, intravenous fluids and agents that enhance the immune response of the host. In this review, we summarize findings from immunomodulatory interventions in experimental studies of acute pyelonephritis and the application of these interventions into clinical practice. Vaccine against bacterial virulence factors and agents aiming to modulate the immune response of the host belong to these interventions and they are discussed.
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Affiliation(s)
- Thomas Tsaganos
- 4th Department of Internal Medicine, National & Kapodistrian University of Athens, Medical School, ATTIKON University Hospital, 1 Rimini Str, 12462 Athens, Greece
| | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National & Kapodistrian University of Athens, Medical School, ATTIKON University Hospital, 1 Rimini Str, 12462 Athens, Greece
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Han D, Shang W, Wang G, Sun L, Zhang Y, Wen H, Xu L. Ulinastatin- and thymosin α1-based immunomodulatory strategy for sepsis: A meta-analysis. Int Immunopharmacol 2015; 29:377-382. [PMID: 26522590 DOI: 10.1016/j.intimp.2015.10.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 10/19/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This meta-analysis was performed to evaluate the efficacy of ulinastatin (UTI) and thymosin α1 (Tα1) based immunomodulatory strategy in sepsis patients. METHODS A systematic search was made of MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases. Randomized clinical trials on treatment of sepsis with the combination of ulinastatin and Tα1, compared with placebo, were reviewed. Studies were pooled to relative risk (RR) and weighted mean differences (WMD), with 95% confidence interval (CI). RESULTS Six trials (enrolling 915 participants) met the inclusion criteria. Compared with placebo, the combination of ulinastatin and Tα1 presented significant effects on 28-day all-cause mortality (RR 0.67; 95% CI 0.57 to 0.80), 90-day all-cause mortality (RR 0.75; 95% CI 0.61 to 0.93), TNF-α (WMD -73.86ng/L; 95% CI -91.00 to -56.73ng/L), IL-6 (WMD -55.04ng/L; 95% CI -61.22 to -48.85ng/L), and duration of mechanical ventilation (WMD -2.26days; 95% CI -2.79 to -1.73days). CONCLUSIONS Immunomodulatory therapy that combines ulinastatin and Tα1 significantly improves all-cause mortality, inflammatory mediators and duration of mechanical ventilation in subjects with sepsis.
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Affiliation(s)
- Dong Han
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, PR China.
| | - Wenli Shang
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, PR China
| | - Guizuo Wang
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, PR China
| | - Li Sun
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, PR China
| | - Yingying Zhang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710004, PR China
| | - Hongxia Wen
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, PR China
| | - Lingbin Xu
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710068, PR China
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