1
|
Atreya MR, Huang M, Moore AR, Zheng H, Hasin-Brumshtein Y, Fitzgerald JC, Weiss SL, Cvijanovich NZ, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Thomas NJ, Quasney M, Dahmer MK, Baines T, Haileselassie B, Lautz AJ, Stanski NL, Standage SW, Kaplan JM, Zingarelli B, Sahay R, Zhang B, Sweeney TE, Khatri P, Sanchez-Pinto LN, Kamaleswaran R. Identification and transcriptomic assessment of latent profile pediatric septic shock phenotypes. Crit Care 2024; 28:246. [PMID: 39014377 PMCID: PMC11253460 DOI: 10.1186/s13054-024-05020-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 07/05/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Sepsis poses a grave threat, especially among children, but treatments are limited owing to heterogeneity among patients. We sought to test the clinical and biological relevance of pediatric septic shock subclasses identified using reproducible approaches. METHODS We performed latent profile analyses using clinical, laboratory, and biomarker data from a prospective multi-center pediatric septic shock observational cohort to derive phenotypes and trained a support vector machine model to assign phenotypes in an internal validation set. We established the clinical relevance of phenotypes and tested for their interaction with common sepsis treatments on patient outcomes. We conducted transcriptomic analyses to delineate phenotype-specific biology and inferred underlying cell subpopulations. Finally, we compared whether latent profile phenotypes overlapped with established gene-expression endotypes and compared survival among patients based on an integrated subclassification scheme. RESULTS Among 1071 pediatric septic shock patients requiring vasoactive support on day 1 included, we identified two phenotypes which we designated as Phenotype 1 (19.5%) and Phenotype 2 (80.5%). Membership in Phenotype 1 was associated with ~ fourfold adjusted odds of complicated course relative to Phenotype 2. Patients belonging to Phenotype 1 were characterized by relatively higher Angiopoietin-2/Tie-2 ratio, Angiopoietin-2, soluble thrombomodulin (sTM), interleukin 8 (IL-8), and intercellular adhesion molecule 1 (ICAM-1) and lower Tie-2 and Angiopoietin-1 concentrations compared to Phenotype 2. We did not identify significant interactions between phenotypes, common treatments, and clinical outcomes. Transcriptomic analysis revealed overexpression of genes implicated in the innate immune response and driven primarily by developing neutrophils among patients designated as Phenotype 1. There was no statistically significant overlap between established gene-expression endotypes, reflective of the host adaptive response, and the newly derived phenotypes, reflective of the host innate response including microvascular endothelial dysfunction. However, an integrated subclassification scheme demonstrated varying survival probabilities when comparing patient endophenotypes. CONCLUSIONS Our research underscores the reproducibility of latent profile analyses to identify pediatric septic shock phenotypes with high prognostic relevance. Pending validation, an integrated subclassification scheme, reflective of the different facets of the host response, holds promise to inform targeted intervention among those critically ill.
Collapse
Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45627, USA.
| | - Min Huang
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew R Moore
- Stanford Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA, USA
| | - Hong Zheng
- Stanford Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA, USA
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | | | | | - Scott L Weiss
- Nemours Children's Health, Wilmington, DE, 19803, USA
| | | | | | - Parag N Jain
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, Orange, CA, 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN, 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN, 55404, USA
| | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA, 17033, USA
| | - Michael Quasney
- C.S Mott Children's Hospital, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Mary K Dahmer
- C.S Mott Children's Hospital, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Torrey Baines
- University of Florida Health Children's Hospital, Gainesville, FL, 32610, USA
| | | | - Andrew J Lautz
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45627, USA
| | - Natalja L Stanski
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45627, USA
| | - Stephen W Standage
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45627, USA
| | - Jennifer M Kaplan
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45627, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45627, USA
| | - Rashmi Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | | | - Purvesh Khatri
- Stanford Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA, USA
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Department of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, 30322, USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, 30322, USA
| |
Collapse
|
2
|
Jariyasakoolroj T, Chattipakorn SC, Chattipakorn N. Potential biomarkers used for risk estimation of pediatric sepsis-associated organ dysfunction and immune dysregulation. Pediatr Res 2024:10.1038/s41390-024-03289-y. [PMID: 38834784 DOI: 10.1038/s41390-024-03289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/03/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
Pediatric sepsis is a serious issue globally and is a significant cause of illness and death among infants and children. Refractory septic shock and multiple organ dysfunction syndrome are the primary causes of mortality in children with sepsis. However, there is incomplete understanding of mechanistic insight of sepsis associated organ dysfunction. Biomarkers present during the body's response to infection-related inflammation can be used for screening, diagnosis, risk stratification/prognostication, and/or guidance in treatment decision-making. Research on biomarkers in children with sepsis can provide information about the risk of poor outcomes and sepsis-related organ dysfunction. This review focuses on clinically used biomarkers associated with immune dysregulation and organ dysfunction in pediatric sepsis, which could be useful for developing precision medicine strategies in pediatric sepsis management in the future. IMPACT: Sepsis is a complex syndrome with diverse clinical presentations, where organ dysfunction is a key factor in morbidity and mortality. Early detection of organ complications is vital in sepsis management, and potential biomarkers offer promise for precision medicine in pediatric cases. Well-designed studies are needed to identify phase-specific biomarkers and improve outcomes through more precise management.
Collapse
Affiliation(s)
- Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| |
Collapse
|
3
|
Cajander S, Kox M, Scicluna BP, Weigand MA, Mora RA, Flohé SB, Martin-Loeches I, Lachmann G, Girardis M, Garcia-Salido A, Brunkhorst FM, Bauer M, Torres A, Cossarizza A, Monneret G, Cavaillon JM, Shankar-Hari M, Giamarellos-Bourboulis EJ, Winkler MS, Skirecki T, Osuchowski M, Rubio I, Bermejo-Martin JF, Schefold JC, Venet F. Profiling the dysregulated immune response in sepsis: overcoming challenges to achieve the goal of precision medicine. THE LANCET. RESPIRATORY MEDICINE 2024; 12:305-322. [PMID: 38142698 DOI: 10.1016/s2213-2600(23)00330-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 12/26/2023]
Abstract
Sepsis is characterised by a dysregulated host immune response to infection. Despite recognition of its significance, immune status monitoring is not implemented in clinical practice due in part to the current absence of direct therapeutic implications. Technological advances in immunological profiling could enhance our understanding of immune dysregulation and facilitate integration into clinical practice. In this Review, we provide an overview of the current state of immune profiling in sepsis, including its use, current challenges, and opportunities for progress. We highlight the important role of immunological biomarkers in facilitating predictive enrichment in current and future treatment scenarios. We propose that multiple immune and non-immune-related parameters, including clinical and microbiological data, be integrated into diagnostic and predictive combitypes, with the aid of machine learning and artificial intelligence techniques. These combitypes could form the basis of workable algorithms to guide clinical decisions that make precision medicine in sepsis a reality and improve patient outcomes.
Collapse
Affiliation(s)
- Sara Cajander
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Matthijs Kox
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Brendon P Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, Mater Dei hospital, University of Malta, Msida, Malta; Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raquel Almansa Mora
- Department of Cell Biology, Genetics, Histology and Pharmacology, University of Valladolid, Valladolid, Spain
| | - Stefanie B Flohé
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ignacio Martin-Loeches
- St James's Hospital, Dublin, Ireland; Hospital Clinic, Institut D'Investigacions Biomediques August Pi i Sunyer, Universidad de Barcelona, Barcelona, Spain
| | - Gunnar Lachmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany
| | - Massimo Girardis
- Department of Intensive Care and Anesthesiology, University Hospital of Modena, Modena, Italy
| | - Alberto Garcia-Salido
- Hospital Infantil Universitario Niño Jesús, Pediatric Critical Care Unit, Madrid, Spain
| | - Frank M Brunkhorst
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Antoni Torres
- Pulmonology Department. Hospital Clinic of Barcelona, University of Barcelona, Ciberes, IDIBAPS, ICREA, Barcelona, Spain
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Guillaume Monneret
- Immunology Laboratory, Hôpital E Herriot - Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon-1, Hôpital E Herriot, Lyon, France
| | | | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, The University of Edinburgh, Edinburgh, UK
| | | | - Martin Sebastian Winkler
- Department of Anesthesiology and Intensive Care, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Tomasz Skirecki
- Department of Translational Immunology and Experimental Intensive Care, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marcin Osuchowski
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Ignacio Rubio
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Jesus F Bermejo-Martin
- Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain; School of Medicine, Universidad de Salamanca, Salamanca, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabienne Venet
- Immunology Laboratory, Hôpital E Herriot - Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Inserm U1111, CNRS, UMR5308, Ecole Normale Supeérieure de Lyon, Universiteé Claude Bernard-Lyon 1, Lyon, France.
| |
Collapse
|
4
|
Sankar J, Agarwal S, Goyal A, Kabra SK, Lodha R. Pediatric Sepsis Phenotypes and Outcome: 5-Year Retrospective Cohort Study in a Single Center in India (2017-2022). Pediatr Crit Care Med 2024; 25:e186-e192. [PMID: 38305702 DOI: 10.1097/pcc.0000000000003449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES To describe mortality associated with different clinical phenotypes of sepsis in children. DESIGN Retrospective study. SETTING PICU of a tertiary care center in India from 2017 to 2022. PATIENTS Six hundred twelve children (from 2 mo to 17 yr old) with a retrospectively applied diagnosis of sepsis using 2020 guidance. METHODS The main outcome was mortality associated with sepsis subtypes. Other analyses included assessment of risk factors, requirement for organ support, and PICU resources used by sepsis phenotype. Clinical data were recorded on a predesigned proforma. INTERVENTIONS None. MEASUREMENTS AND RESULTS Of the 612 children identified, there were 382 (62%) with sepsis but no multiple organ failure (NoMOF), 48 (8%) with thrombocytopenia-associated MOF (TAMOF), 140 (23%) with MOF without thrombocytopenia, and 40 (6.5%) with sequential MOF (SMOF). Mortality was higher in the SMOF (20/40 [50%]), MOF (62/140 [44%]) and TAMOF (20/48 [42%]) groups, compared with NoMOF group (82/382 [21%] [ p < 0.001]). The requirement for organ support and PICU resources was higher in all phenotypes with MOF as compared with those without MOF. On multivariable analysis elevated lactate and having MOF were associated with greater odds of mortality. CONCLUSIONS In this single-center experience of sepsis in India, we found that sepsis phenotypes having MOF were associated with mortality and the requirement of PICU resources. Prospective studies in different regions of the world will help identify a classification of pediatric sepsis that is more widely applicable.
Collapse
Affiliation(s)
- Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | |
Collapse
|
5
|
Atreya MR, Piraino G, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Thomas NJ, Baines T, Haileselassie B, Zingarelli B. SERUM HUMANIN IN PEDIATRIC SEPTIC SHOCK-ASSOCIATED MULTIPLE-ORGAN DYSFUNCTION SYNDROME. Shock 2024; 61:83-88. [PMID: 37917869 PMCID: PMC10842252 DOI: 10.1097/shk.0000000000002266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
ABSTRACT Background: Multiple-organ dysfunction syndrome disproportionately contributes to pediatric sepsis morbidity. Humanin (HN) is a small peptide encoded by mitochondrial DNA and thought to exert cytoprotective effects in endothelial cells and platelets. We sought to test the association between serum HN (sHN) concentrations and multiple-organ dysfunction syndrome in a prospectively enrolled cohort of pediatric septic shock. Methods: Human MT-RNR2 ELISA was used to determine sHN concentrations on days 1 and 3. The primary outcome was thrombocytopenia-associated multiorgan failure (TAMOF). Secondary outcomes included individual organ dysfunctions on day 7. Associations across pediatric sepsis biomarker (PERSEVERE)-based mortality risk strata and correlation with platelet and markers of endothelial activation were tested. Results: One hundred forty subjects were included in this cohort, of whom 39 had TAMOF. The concentration of sHN was higher on day 1 relative to day 3 and among those with TAMOF phenotype in comparison to those without. However, the association between sHN and TAMOF phenotype was not significant after adjusting for age and illness severity in multivariate models. In secondary analyses, sHN was associated with presence of day 7 sepsis-associated acute kidney injury ( P = 0.049). Furthermore, sHN was higher among those with high PERSEVERE-mortality risk strata and correlated with platelet counts and several markers of endothelial activation. Conclusion: Future investigation is necessary to validate the association between sHN and sepsis-associated acute kidney injury among children with septic shock. Furthermore, mechanistic studies that elucidate the role of HN may lead to therapies that promote organ recovery through restoration of mitochondrial homeostasis among those critically ill.
Collapse
Affiliation(s)
| | - Giovanna Piraino
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, 45229, OH, USA
| | | | | | - Scott L Weiss
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, Orange, CA 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN 55404, USA
| | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA 17033, USA
| | - Torrey Baines
- University of Florida Health Shands Children's Hospital, Gainesville, FL 32610, USA
| | | | | |
Collapse
|
6
|
Atreya MR, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Abulebda K, Lutfi R, Nowak J, Thomas NJ, Baines T, Quasney M, Haileselassie B, Sahay R, Zhang B, Alder MN, Stanski NL, Goldstein SL. Revisiting Post-ICU Admission Fluid Balance Across Pediatric Sepsis Mortality Risk Strata: A Secondary Analysis of a Prospective Observational Cohort Study. Crit Care Explor 2024; 6:e1027. [PMID: 38234587 PMCID: PMC10793970 DOI: 10.1097/cce.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Post-ICU admission cumulative positive fluid balance (PFB) is associated with increased mortality among critically ill patients. We sought to test whether this risk varied across biomarker-based risk strata upon adjusting for illness severity, presence of severe acute kidney injury (acute kidney injury), and use of continuous renal replacement therapy (CRRT) in pediatric septic shock. DESIGN Ongoing multicenter prospective observational cohort. SETTING Thirteen PICUs in the United States (2003-2023). PATIENTS Six hundred and eighty-one children with septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cumulative percent PFB between days 1 and 7 (days 1-7 %PFB) was determined. Primary outcome of interest was complicated course defined as death or persistence of greater than or equal to two organ dysfunctions by day 7. Pediatric Sepsis Biomarker Risk Model (PERSEVERE)-II biomarkers were used to assign mortality probability and categorize patients into high mortality (n = 91), intermediate mortality (n = 134), and low mortality (n = 456) risk strata. Cox proportional hazard regression models with adjustment for PERSEVERE-II mortality probability, presence of sepsis-associated acute kidney injury on day 3, and use of CRRT, demonstrated that time-dependent variable days 1-7%PFB was independently associated with an increased hazard of complicated course. Risk-stratified analyses revealed that each 10% increase in days 1-7 %PFB was associated with increased hazard of complicated course only among patients with high mortality risk strata (adjusted hazard ratio 1.24 (95% CI, 1.08-1.43), p = 0.003). However, this association was not causally mediated by PERSEVERE-II biomarkers. CONCLUSIONS Our data demonstrate the influence of cumulative %PFB on the risk of complicated course in pediatric septic shock. Contrary to our previous report, this risk was largely driven by patients categorized as having a high mortality risk based on PERSEVERE-II biomarkers. Incorporation of such prognostic enrichment tools in randomized trials of restrictive fluid management or early initiation of de-escalation strategies may inform targeted application of such interventions among at-risk patients.
Collapse
Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Julie C Fitzgerald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott L Weiss
- Department of Pediatrics, Nemours Children's Hospital, Wilmington, DE
| | | | - Parag N Jain
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Kamal Abulebda
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, IN
| | - Riad Lutfi
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, IN
| | - Jeffrey Nowak
- Department of Pediatrics, Children's Hospital and Clinics of Minnesota, Minneapolis, MN
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, PA
| | - Torrey Baines
- Department of Pediatrics, University of Florida Health Shands Children's Hospital, Gainesville, FL
| | - Michael Quasney
- Department of Pediatrics, CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI
| | | | - Rashmi Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
| | - Matthew N Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Natalja L Stanski
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Nephrology, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH
| |
Collapse
|
7
|
Stanski NL, Basu RK, Cvijanovich NZ, Fitzgerald JC, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Thomas NJ, Baines T, Haileselassie B, Weiss SL, Atreya MR, Lautz AJ, Zingarelli B, Standage SW, Kaplan J, Chawla LS, Goldstein SL. External validation of the modified sepsis renal angina index for prediction of severe acute kidney injury in children with septic shock. Crit Care 2023; 27:463. [PMID: 38017578 PMCID: PMC10683237 DOI: 10.1186/s13054-023-04746-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/18/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) occurs commonly in pediatric septic shock and increases morbidity and mortality. Early identification of high-risk patients can facilitate targeted intervention to improve outcomes. We previously modified the renal angina index (RAI), a validated AKI prediction tool, to improve specificity in this population (sRAI). Here, we prospectively assess sRAI performance in a separate cohort. METHODS A secondary analysis of a prospective, multicenter, observational study of children with septic shock admitted to the pediatric intensive care unit from 1/2019 to 12/2022. The primary outcome was severe AKI (≥ KDIGO Stage 2) on Day 3 (D3 severe AKI), and we compared predictive performance of the sRAI (calculated on Day 1) to the original RAI and serum creatinine elevation above baseline (D1 SCr > Baseline +). Original renal angina fulfillment (RAI +) was defined as RAI ≥ 8; sepsis renal angina fulfillment (sRAI +) was defined as RAI ≥ 20 or RAI 8 to < 20 with platelets < 150 × 103/µL. RESULTS Among 363 patients, 79 (22%) developed D3 severe AKI. One hundred forty (39%) were sRAI + , 195 (54%) RAI + , and 253 (70%) D1 SCr > Baseline + . Compared to sRAI-, sRAI + had higher risk of D3 severe AKI (RR 8.9, 95%CI 5-16, p < 0.001), kidney replacement therapy (KRT) (RR 18, 95%CI 6.6-49, p < 0.001), and mortality (RR 2.5, 95%CI 1.2-5.5, p = 0.013). sRAI predicted D3 severe AKI with an AUROC of 0.86 (95%CI 0.82-0.90), with greater specificity (74%) than D1 SCr > Baseline (36%) and RAI + (58%). On multivariable regression, sRAI + retained associations with D3 severe AKI (aOR 4.5, 95%CI 2.0-10.2, p < 0.001) and need for KRT (aOR 5.6, 95%CI 1.5-21.5, p = 0.01). CONCLUSIONS Prediction of severe AKI in pediatric septic shock is important to improve outcomes, allocate resources, and inform enrollment in clinical trials examining potential disease-modifying therapies. The sRAI affords more accurate and specific prediction than context-free SCr elevation or the original RAI in this population.
Collapse
Affiliation(s)
- Natalja L Stanski
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Rajit K Basu
- Division of Critical Care Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | | | - Julie C Fitzgerald
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael T Bigham
- Akron Children's Hospital, 214 W Bowery St., Akron, OH, 44308, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Drive, Hershey, PA, 17033, USA
| | - Torrey Baines
- University of Florida Health Shands Children's Hospital, 1600 South West Archer Rd, Gainesville, FL, 32608, USA
| | | | - Scott L Weiss
- Nemours Children's Health, 1600 Rockland Rd, Wilmington, DE, 19803, USA
| | - Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Stephen W Standage
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center San Diego, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| |
Collapse
|
8
|
Bodilly L, Williamson L, Lahni P, Alder MN, Haslam DB, Kaplan JM. Obesity Alters cytokine signaling and gut microbiome in septic mice. Innate Immun 2023; 29:161-170. [PMID: 37802127 PMCID: PMC10621470 DOI: 10.1177/17534259231205959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023] Open
Abstract
Sepsis is a leading cause of mortality. Plasma cytokine levels may identify those at increased risk of mortality from sepsis. Our aim was to understand how obesity alters cytokine levels during early sepsis and its correlation with survival. Six-week-old C57BL/6 male mice were randomized to control (non-obese) or high fat diet (obese) for 5-7 weeks. Sepsis was induced by cecal ligation and perforation (CLP). Cytokine levels were measured from cheek bleeds 8 h after CLP, and mice were monitored for survival. Other cohorts were sacrificed 1 h after CLP for plasma and tissue. Septic obese mice had higher survival. At 8 h after sepsis, obese mice had higher adiponectin, leptin, and resistin but lower TNFα and IL-6 compared to non-obese mice. When stratified by 24-h survival, adipokines were not significantly different in obese and non-obese mice. TNFα and IL-6 were higher in non-obese, compared to obese, mice that died within 24 h of sepsis. Diet and to sepsis significantly impacted the cecal microbiome. IL-6 is a prognostic biomarker during early sepsis in non-obese and obese mice. A plausible mechanism for the survival difference in non-obese and obese mice may be the difference in gut microbiome and its evolution during sepsis.
Collapse
Affiliation(s)
- Lauren Bodilly
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Lauren Williamson
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew N. Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David B. Haslam
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer M. Kaplan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
9
|
Abstract
BACKGROUND Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, with extremely high mortality. Notably, sepsis is a heterogeneous syndrome characterized by a vast, multidimensional array of clinical and biologic features, which has hindered advances in the therapeutic field beyond the current standards. DATA SOURCES We used PubMed to search the subject-related medical literature by searching for the following single and/or combination keywords: sepsis, heterogeneity, personalized treatment, host response, infection, epidemiology, mortality, incidence, age, children, sex, comorbidities, gene susceptibility, infection sites, bacteria, fungi, virus, host response, organ dysfunction and management. RESULTS We found that host factors (age, biological sex, comorbidities, and genetics), infection etiology, host response dysregulation and multiple organ dysfunctions can all result in different disease manifestations, progression, and response to treatment, which make it difficult to effectively treat and manage sepsis patients. CONCLUSIONS Herein, we have summarized contributing factors to sepsis heterogeneity, including host factors, infection etiology, host response dysregulation, and multiple organ dysfunctions, from the key elements of pathogenesis of sepsis. An in-depth understanding of the factors that contribute to the heterogeneity of sepsis will help clinicians understand the complexity of sepsis and enable researchers to conduct more personalized clinical studies for homogenous patients.
Collapse
Affiliation(s)
- Wei Wang
- Department of Pediatrics, ShengJing Hospital of China Medical University, No. 36, SanHao Street, Shenyang City, Liaoning Province, 110004, China
| | - Chun-Feng Liu
- Department of Pediatrics, ShengJing Hospital of China Medical University, No. 36, SanHao Street, Shenyang City, Liaoning Province, 110004, China.
| |
Collapse
|
10
|
Stanski NL, Pode Shakked N, Zhang B, Cvijanovich NZ, Fitzgerald JC, Jain PN, Schwarz AJ, Nowak J, Weiss SL, Allen GL, Thomas NJ, Haileselassie B, Goldstein SL. Serum renin and prorenin concentrations predict severe persistent acute kidney injury and mortality in pediatric septic shock. Pediatr Nephrol 2023; 38:3099-3108. [PMID: 36939916 PMCID: PMC10588759 DOI: 10.1007/s00467-023-05930-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Studies in critically ill adults demonstrate associations between serum renin concentrations (a proposed surrogate for renin-angiotensin-aldosterone system dysregulation) and poor outcomes, but data in critically ill children are lacking. We assessed serum renin + prorenin concentrations in children with septic shock to determine their predictive ability for acute kidney injury (AKI) and mortality. METHODS We conducted a secondary analysis of a multicenter observational study of children aged 1 week to 18 years admitted to 14 pediatric intensive care units (PICUs) with septic shock and residual serum available for renin + prorenin measurement. Primary outcomes were development of severe persistent AKI (≥ KDIGO stage 2 for ≥ 48 h) in the first week and 28-day mortality. RESULTS Among 233 patients, day 1 median renin + prorenin concentration was 3436 pg/ml (IQR 1452-6567). Forty-two (18%) developed severe persistent AKI and 32 (14%) died. Day 1 serum renin + prorenin predicted severe persistent AKI with an AUROC of 0.75 (95% CI 0.66-0.84, p < 0.0001; optimal cutoff 6769 pg/ml) and mortality with an AUROC of 0.79 (95% CI 0.69-0.89, p < 0.0001; optimal cutoff 6521 pg/ml). Day 3/day 1 (D3:D1) renin + prorenin ratio had an AUROC of 0.73 (95% CI 0.63-0.84, p < 0.001) for mortality. On multivariable regression, day 1 renin + prorenin > optimal cutoff retained associations with severe persistent AKI (aOR 6.8, 95% CI 3.0-15.8, p < 0.001) and mortality (aOR 6.9, 95% CI 2.2-20.9, p < 0.001). Similarly, D3:D1 renin + prorenin > optimal cutoff was associated with mortality (aOR 7.6, 95% CI 2.5-23.4, p < 0.001). CONCLUSIONS Children with septic shock have very elevated serum renin + prorenin concentrations on PICU admission, and these concentrations, as well as their trend over the first 72 h, predict severe persistent AKI and mortality. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Naomi Pode Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | | | - Julie C Fitzgerald
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Jeffrey Nowak
- Children's Minnesota, 2525 Chicago Ave, Minneapolis, MN, 55404, USA
| | - Scott L Weiss
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Dr, Hershey, PA, 17033, USA
| | | | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| |
Collapse
|
11
|
Atreya MR, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Thomas NJ, Quasney M, Haileselassie B, Baines TD, Zingarelli B. SERUM SOLUBLE ENDOGLIN IN PEDIATRIC SEPTIC SHOCK-ASSOCIATED MULTIPLE ORGAN DYSFUNCTION SYNDROME. Shock 2023; 60:379-384. [PMID: 37493567 PMCID: PMC10529838 DOI: 10.1097/shk.0000000000002183] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
ABSTRACT Background: Endothelial activation is a key driver of multiple organ dysfunction syndrome (MODS). Soluble endoglin (sENG) is expressed by mature and progenitor endothelial cells and thought to have angiogenic properties. We sought to determine the association between sENG and pediatric sepsis-associated MODS. Methods: Prospective observational study of pediatric septic shock. Primary outcome of interest was complicated course-a composite of death by (or) MODS on day 7 of illness. Secondary outcomes included individual organ dysfunctions. Endothelial biomarkers including sENG were measured using multiplex Luminex assays among patients with existing data on the Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) data. Multivariable regression was used to test the independent association between sENG and clinical outcomes. Serum sENG concentrations across PERSEVERE-II mortality risk strata and correlations with established markers of endothelial dysfunction were determined. Results: Three hundred six critically ill children with septic shock were included. Serum sENG concentrations were higher among those with primary and secondary outcomes of interest, with the exception of acute neurological dysfunction. Soluble endoglin was independently associated with increased odds of complicated course (adjusted odds ratio, 1.53; 95% confidence interval, 1.02-2.27; P = 0.038) and acute renal dysfunction (adjusted odds ratio, 1.84; 95% confidence interval, 1.18-2.876; P = 0.006). Soluble endoglin demonstrated graded responses across PERSEVERE-II risk strata and was positively correlated with endothelial biomarkers, except angiopoietin-1. Conclusions: Serum sENG is independently associated with complicated course and acute renal dysfunction in pediatric septic shock. Future studies are required to validate our observational data, and mechanistic studies are necessary to elucidate whether endoglin plays an organ-specific role in the development or resolution of acute renal dysfunction in sepsis.
Collapse
Affiliation(s)
- Mihir R. Atreya
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, 45229, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | | | | | - Scott L. Weiss
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Parag N. Jain
- Texas Children’s Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | | | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Jeffrey Nowak
- Children’s Hospital and Clinics of Minnesota, Minneapolis, MN 55404, USA
| | - Neal J. Thomas
- Penn State Hershey Children’s Hospital, Hershey, PA 17033, USA
| | - Michael Quasney
- CS Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Torrey D. Baines
- University of Florida Health Shands Children’s Hospital, Gainesville, FL 32610, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, 45229, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | | |
Collapse
|
12
|
Atreya MR, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Allen GL, Thomas NJ, Grunwell JR, Baines T, Quasney M, Haileselassie B, Alder MN, Goldstein SL, Stanski NL. Prognostic and predictive value of endothelial dysfunction biomarkers in sepsis-associated acute kidney injury: risk-stratified analysis from a prospective observational cohort of pediatric septic shock. Crit Care 2023; 27:260. [PMID: 37400882 PMCID: PMC10318688 DOI: 10.1186/s13054-023-04554-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/28/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Sepsis-associated acute kidney injury (SA-AKI) is associated with high morbidity, with no current therapies available beyond continuous renal replacement therapy (CRRT). Systemic inflammation and endothelial dysfunction are key drivers of SA-AKI. We sought to measure differences between endothelial dysfunction markers among children with and without SA-AKI, test whether this association varied across inflammatory biomarker-based risk strata, and develop prediction models to identify those at highest risk of SA-AKI. METHODS Secondary analyses of prospective observational cohort of pediatric septic shock. Primary outcome of interest was the presence of ≥ Stage II KDIGO SA-AKI on day 3 based on serum creatinine (D3 SA-AKI SCr). Biomarkers including those prospectively validated to predict pediatric sepsis mortality (PERSEVERE-II) were measured in Day 1 (D1) serum. Multivariable regression was used to test the independent association between endothelial markers and D3 SA-AKI SCr. We conducted risk-stratified analyses and developed prediction models using Classification and Regression Tree (CART), to estimate risk of D3 SA-AKI among prespecified subgroups based on PERSEVERE-II risk. RESULTS A total of 414 patients were included in the derivation cohort. Patients with D3 SA-AKI SCr had worse clinical outcomes including 28-day mortality and need for CRRT. Serum soluble thrombomodulin (sTM), Angiopoietin-2 (Angpt-2), and Tie-2 were independently associated with D3 SA-AKI SCr. Further, Tie-2 and Angpt-2/Tie-2 ratios were influenced by the interaction between D3 SA-AKI SCr and risk strata. Logistic regression demonstrated models predictive of D3 SA-AKI risk performed optimally among patients with high- or intermediate-PERSEVERE-II risk strata. A 6 terminal node CART model restricted to this subgroup of patients had an area under the receiver operating characteristic curve (AUROC) 0.90 and 0.77 upon tenfold cross-validation in the derivation cohort to distinguish those with and without D3 SA-AKI SCr and high specificity. The newly derived model performed modestly in a unique set of patients (n = 224), 84 of whom were deemed high- or intermediate-PERSEVERE-II risk, to distinguish those patients with high versus low risk of D3 SA-AKI SCr. CONCLUSIONS Endothelial dysfunction biomarkers are independently associated with risk of severe SA-AKI. Pending validation, incorporation of endothelial biomarkers may facilitate prognostic and predictive enrichment for selection of therapeutics in future clinical trials among critically ill children.
Collapse
Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA.
| | | | | | - Scott L Weiss
- Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | | | - Parag N Jain
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, Orange, CA, 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN, 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN, 55404, USA
| | | | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA, 17033, USA
| | | | - Torrey Baines
- University of Florida Health Shands Children's Hospital, Gainesville, FL, 32610, USA
| | - Michael Quasney
- CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI, 48109, USA
| | | | - Matthew N Alder
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
- Division of Nephrology, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, 45229, USA
| | - Natalja L Stanski
- Division of Critical Care Medicine, MLC2005, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| |
Collapse
|
13
|
Ishaque S, Famularo ST, Saleem AF, Siddiqui NUR, Kazi Z, Parkar S, Hotwani A, Thomas NJ, Thompson JM, Lahni P, Varisco B, Yehya N. Biomarker-Based Risk Stratification in Pediatric Sepsis From a Low-Middle Income Country. Pediatr Crit Care Med 2023; 24:563-573. [PMID: 37092821 PMCID: PMC10317305 DOI: 10.1097/pcc.0000000000003244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Most biomarker studies of sepsis originate from high-income countries, whereas mortality risk is higher in low- and middle-income countries. The second version of the Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) has been validated in multiple North American PICUs for prognosis. Given differences in epidemiology, we assessed the performance of PERSEVERE-II in septic children from Pakistan, a low-middle income country. Due to uncertainty regarding how well PERSEVERE-II would perform, we also assessed the utility of other select biomarkers reflecting endotheliopathy, coagulopathy, and lung injury. DESIGN Prospective cohort study. SETTING PICU in Aga Khan University Hospital in Karachi, Pakistan. PATIENTS Children (< 18 yr old) meeting pediatric modifications of adult Sepsis-3 criteria between November 2020 and February 2022 were eligible. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma was collected within 24 hours of admission and biomarkers quantified. The area under the receiver operating characteristic curve for PERSEVERE-II to discriminate 28-day mortality was determined. Additional biomarkers were compared between survivors and nonsurvivors and between subjects with and without acute respiratory distress syndrome. In 86 subjects (20 nonsurvivors, 23%), PERSEVERE-II discriminated mortality (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.72-0.94) and stratified the cohort into low-, medium-, and high-risk of mortality. Biomarkers reflecting endotheliopathy (angiopoietin 2, intracellular adhesion molecule 1) increased across worsening risk strata. Angiopoietin 2, soluble thrombomodulin, and plasminogen activator inhibitor 1 were higher in nonsurvivors, and soluble receptor for advanced glycation end-products and surfactant protein D were higher in children meeting acute respiratory distress syndrome criteria. CONCLUSIONS PERSEVERE-II performs well in septic children from Aga Khan University Hospital, representing the first validation of PERSEVERE-II in a low-middle income country. Patients possessed a biomarker profile comparable to that of sepsis from high-income countries, suggesting that biomarker-based enrichment strategies may be effective in this setting.
Collapse
Affiliation(s)
- Sidra Ishaque
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Stephen Thomas Famularo
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ali Faisal Saleem
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | | | - Zaubina Kazi
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Sadia Parkar
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA
| | - Jill Marie Thompson
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Patrick Lahni
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Brian Varisco
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
14
|
Mount MC, Remy KE. Help Wanted for Sepsis: Biomarkers in Low- and Middle-Income Countries Please Apply. Pediatr Crit Care Med 2023; 24:619-621. [PMID: 37409899 PMCID: PMC10421290 DOI: 10.1097/pcc.0000000000003278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Michael C. Mount
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Kenneth E. Remy
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children’s Hospital, Cleveland, OH
- Department of Medicine, Case Western University School of Medicine, University Hospitals of Cleveland, Cleveland, OH
| |
Collapse
|
15
|
Atreya MR, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Abulebda K, Lutfi R, Nowak J, Thomas NJ, Baines T, Quasney M, Haileselassie B, Sahay R, Zhang B, Alder M, Stanski N, Goldstein S. Revisiting post-ICU admission fluid balance across pediatric sepsis mortality risk strata: A secondary analyses from a prospective observational cohort study. RESEARCH SQUARE 2023:rs.3.rs-3117188. [PMID: 37461591 PMCID: PMC10350118 DOI: 10.21203/rs.3.rs-3117188/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Introduction Post-ICU admission cumulative positive fluid balance (PFB) is associated with increased mortality among critically ill patients. We sought to test whether this risk varied across biomarker-based risk strata upon adjusting for illness severity, presence of severe acute kidney injury (AKI), and use of renal replacement therapy (CRRT) in pediatric septic shock. Design Ongoing multi-center prospective observational cohort. Setting Thirteen pediatric ICUs in the United States (2003-2023). Patients Six hundred and eighty-one children with septic shock. Interventions None. Measurements and Main Results Cumulative percent positive fluid balance between day 1-7 (Day 1-7%PFB) was determined. Primary outcome of interest was complicated course defined as death or persistence of ≥ 2 organ dysfunctions by day 7. PERSEVERE-II biomarkers were used to assign mortality probability and categorize patients into high (n = 91), intermediate (n = 134), and low (n = 456) mortality risk strata. Cox proportional hazard regression models with adjustment for PERSEVERE-II mortality probability, presence of sepsis associated acute kidney injury (SA-AKI) on Day 3, and any use of CRRT, demonstrated that time-dependent variable Day 1-7%PFB was independently associated with increased hazard of complicated course in the cohort. Risk stratified analyses revealed that each 10% increase in Day 1-7%PFB was independently associated with increased hazard of complicated course among patients with high mortality risk strata (adj HR of 1.24 (95%CI: 1.08-1.42), p = 0.002), but not among those categorized as intermediate- or low- mortality risk. Conclusions Our data demonstrate the independent influence of cumulative %PFB on the risk of complicated course. Contrary to our previous report, this risk was largely driven by patients categorized as having a high-mortality risk based on PERSEVERE-II biomarkers. Further research is necessary to determine whether this subset of patients may benefit from targeted deployment of restrictive fluid management or early initiation of de-escalation therapies upon resolution of shock.
Collapse
Affiliation(s)
| | | | | | - Scott L Weiss
- 5. Nemours Children's Hospital, Wilmington, DE, 19803, USA
| | | | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Kamal Abulebda
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN 55404, USA
| | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA 17033, USA
| | - Torrey Baines
- University of Florida Health Shands Children's Hospital, Gainesville, FL 32610, USA
| | - Michael Quasney
- CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI 48109, USA
| | | | | | - Bin Zhang
- Cincinnati Children's Hospital Medical Center
| | | | | | | |
Collapse
|
16
|
Benscoter AL, Alten JA, Atreya MR, Cooper DS, Byrnes JW, Nelson DP, Ollberding NJ, Wong HR. Biomarker-based risk model to predict persistent multiple organ dysfunctions after congenital heart surgery: a prospective observational cohort study. Crit Care 2023; 27:193. [PMID: 37210541 PMCID: PMC10199562 DOI: 10.1186/s13054-023-04494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is an important cause of post-operative morbidity and mortality for children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Dysregulated inflammation is widely regarded as a key contributor to bypass-related MODS pathobiology, with considerable overlap of pathways associated with septic shock. The pediatric sepsis biomarker risk model (PERSEVERE) is comprised of seven protein biomarkers of inflammation and reliably predicts baseline risk of mortality and organ dysfunction among critically ill children with septic shock. We aimed to determine if PERSEVERE biomarkers and clinical data could be combined to derive a new model to assess the risk of persistent CPB-related MODS in the early post-operative period. METHODS This study included 306 patients < 18 years old admitted to a pediatric cardiac ICU after surgery requiring cardiopulmonary bypass (CPB) for congenital heart disease. Persistent MODS, defined as dysfunction of two or more organ systems on postoperative day 5, was the primary outcome. PERSEVERE biomarkers were collected 4 and 12 h after CPB. Classification and regression tree methodology were used to derive a model to assess the risk of persistent MODS. RESULTS The optimal model containing interleukin-8 (IL-8), chemokine ligand 3 (CCL3), and age as predictor variables had an area under the receiver operating characteristic curve (AUROC) of 0.86 (0.81-0.91) for differentiating those with or without persistent MODS and a negative predictive value of 99% (95-100). Ten-fold cross-validation of the model yielded a corrected AUROC of 0.75 (0.68-0.84). CONCLUSIONS We present a novel risk prediction model to assess the risk for development of multiple organ dysfunction after pediatric cardiac surgery requiring CPB. Pending prospective validation, our model may facilitate identification of a high-risk cohort to direct interventions and studies aimed at improving outcomes via mitigation of post-operative organ dysfunction.
Collapse
Affiliation(s)
- Alexis L Benscoter
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
| | - Jeffrey A Alten
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Mihir R Atreya
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - David S Cooper
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Jonathan W Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David P Nelson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Hector R Wong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
17
|
Lindell RB, Meyer NJ. Interrogating the sepsis host immune response using cytomics. Crit Care 2023; 27:93. [PMID: 36941659 PMCID: PMC10027588 DOI: 10.1186/s13054-023-04366-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
Collapse
Affiliation(s)
- Robert B Lindell
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nuala J Meyer
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Center for Translational Lung Biology and Lung Biology Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
18
|
Tsakiroglou M, Evans A, Pirmohamed M. Leveraging transcriptomics for precision diagnosis: Lessons learned from cancer and sepsis. Front Genet 2023; 14:1100352. [PMID: 36968610 PMCID: PMC10036914 DOI: 10.3389/fgene.2023.1100352] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
Diagnostics require precision and predictive ability to be clinically useful. Integration of multi-omic with clinical data is crucial to our understanding of disease pathogenesis and diagnosis. However, interpretation of overwhelming amounts of information at the individual level requires sophisticated computational tools for extraction of clinically meaningful outputs. Moreover, evolution of technical and analytical methods often outpaces standardisation strategies. RNA is the most dynamic component of all -omics technologies carrying an abundance of regulatory information that is least harnessed for use in clinical diagnostics. Gene expression-based tests capture genetic and non-genetic heterogeneity and have been implemented in certain diseases. For example patients with early breast cancer are spared toxic unnecessary treatments with scores based on the expression of a set of genes (e.g., Oncotype DX). The ability of transcriptomics to portray the transcriptional status at a moment in time has also been used in diagnosis of dynamic diseases such as sepsis. Gene expression profiles identify endotypes in sepsis patients with prognostic value and a potential to discriminate between viral and bacterial infection. The application of transcriptomics for patient stratification in clinical environments and clinical trials thus holds promise. In this review, we discuss the current clinical application in the fields of cancer and infection. We use these paradigms to highlight the impediments in identifying useful diagnostic and prognostic biomarkers and propose approaches to overcome them and aid efforts towards clinical implementation.
Collapse
Affiliation(s)
- Maria Tsakiroglou
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- *Correspondence: Maria Tsakiroglou,
| | - Anthony Evans
- Computational Biology Facility, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
19
|
Klowak JA, Bijelić V, Barrowman N, Menon K. The Association of Corticosteroids and Pediatric Sepsis Biomarker Risk Model (PERSEVERE)-II Biomarker Risk Stratification With Mortality in Pediatric Septic Shock. Pediatr Crit Care Med 2023; 24:186-193. [PMID: 36562614 DOI: 10.1097/pcc.0000000000003117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Mortality risk stratification may identify a subset of children who benefit from or are harmed by corticosteroid administration. The Pediatric Sepsis Biomarker Risk Model (PERSEVERE)-II score is a biomarker-based mortality risk stratification tool for pediatric sepsis. Our objective was to assess the association of corticosteroid administration with 28-day mortality within different levels of baseline mortality risk (PERSEVERE-II) in a cohort of children with septic shock. DESIGN We performed a secondary analysis using prospectively collected data (January 2015 to December 2018). SETTING PICUs in 13 tertiary care, academic centers in the United States. PATIENTS Children with septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed the association of corticosteroid administration within PERSEVERE-II risk score categories and 28-day mortality, ICU-free days, and maximum failed organs in children with septic shock. We analyzed a total of 461 patients (215 with corticosteroids exposure, 246 without corticosteroid exposure) with an average age of 7.1 years (interquartile range, 2.2-13.6 yr). In the subgroup of patients with a high PERSEVERE-II score, corticosteroid administration was associated with an increased adjusted risk of 28-day mortality (odds ratio [OR] 4.10 [95% CI 1.70-9.86]; p = 0.002), but not in the low risk group (OR 0.20 [95% CI 0.02-1.73]; p = 0.15). A significant interaction between PERSEVERE-II score and corticosteroids was seen for both secondary outcomes complicated course ( p = 0.01) and maximum failed organs ( p < 0.001). Corticosteroid exposure was associated with fewer ICU-free days ( p < 0.0001). CONCLUSIONS In our multicenter observational study, corticosteroid administration was associated with increased mortality in a subgroup of children with a high PERSEVERE-II risk score.
Collapse
Affiliation(s)
- Jennifer A Klowak
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Vid Bijelić
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Kusum Menon
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| |
Collapse
|
20
|
Affiliation(s)
- Jerry J Zimmerman
- Pediatric Critical Care Medicine, Seattle Children's Hospital, Harborview Medical Center, Department of Pediatrics, University of Washington, School of Medicine, Seattle, WA
| |
Collapse
|
21
|
Qin Y, Caldino Bohn RI, Sriram A, Kernan KF, Carcillo JA, Kim S, Park HJ. Refining empiric subgroups of pediatric sepsis using machine-learning techniques on observational data. Front Pediatr 2023; 11:1035576. [PMID: 36793336 PMCID: PMC9923004 DOI: 10.3389/fped.2023.1035576] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/05/2023] [Indexed: 01/31/2023] Open
Abstract
Sepsis contributes to 1 of every 5 deaths globally with 3 million per year occurring in children. To improve clinical outcomes in pediatric sepsis, it is critical to avoid "one-size-fits-all" approaches and to employ a precision medicine approach. To advance a precision medicine approach to pediatric sepsis treatments, this review provides a summary of two phenotyping strategies, empiric and machine-learning-based phenotyping based on multifaceted data underlying the complex pediatric sepsis pathobiology. Although empiric and machine-learning-based phenotypes help clinicians accelerate the diagnosis and treatments, neither empiric nor machine-learning-based phenotypes fully encapsulate all aspects of pediatric sepsis heterogeneity. To facilitate accurate delineations of pediatric sepsis phenotypes for precision medicine approach, methodological steps and challenges are further highlighted.
Collapse
Affiliation(s)
- Yidi Qin
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rebecca I. Caldino Bohn
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Aditya Sriram
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Soyeon Kim
- Division of Pediatric Pulmonary Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Hyun Jung Park
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
22
|
Benscoter AL, Alten JA, Atreya MR, Cooper DS, Byrnes JW, Nelson DP, Ollberding NJ, Wong HR. Biomarker-based risk model to predict persistent multiple organ dysfunctions after congenital heart surgery â€" A prospective observational cohort study. RESEARCH SQUARE 2023:rs.3.rs-2488327. [PMID: 36747744 PMCID: PMC9901021 DOI: 10.21203/rs.3.rs-2488327/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Multiple organ dysfunction syndrome (MODS) is an important cause of post-operative morbidity and mortality for children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Dysregulated inflammation is widely regarded as a key contributor to bypass-related MODS pathobiology, with considerable overlap of pathways associated with septic shock. The pediatric sepsis biomarker risk model (PERSEVERE) is comprised of seven protein biomarkers of inflammation, and reliably predicts baseline risk of mortality and organ dysfunction among critically ill children with septic shock. We aimed to determine if PERSEVERE biomarkers and clinical data could be combined to derive a new model to assess the risk of persistent CPB-related MODS in the early post-operative period. Methods: This study included 306 patients <18 years old admitted to a pediatric cardiac ICU after surgery requiring cardiopulmonary bypass (CPB) for congenital heart disease. Persistent MODS, defined as dysfunction of two or more organ systems on postoperative day 5, was the primary outcome. PERSEVERE biomarkers were collected 4 and 12 hours after CPB. Classification and Regression Tree methodology was used to derive a model to assess the risk of persistent MODS. Results: The optimal model containing interleukin-8 (IL-8), chemokine ligand 3 (CCL3), and age as predictor variables, had an area under the receiver operating characteristic curve (AUROC) of 0.86 (0.81-0.91) for differentiating those with or without persistent MODS, and a negative predictive value of 99% (95-100). Ten-fold cross-validation of the model yielded a corrected AUROC of 0.75. Conclusions: We present a novel risk prediction model to assess the risk for development of multiple organ dysfunction after pediatric cardiac surgery requiring CPB. Pending prospective validation, our model may facilitate identification of a high-risk cohort to direct interventions and studies aimed at improving outcomes via mitigation of post-operative organ dysfunction. Clinical Trial Registration Number: This study does not meet criteria for a clinical trial per the WHO International Clinical Trials Registry Platform as no intervention was performed.
Collapse
Affiliation(s)
- Alexis L. Benscoter
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
| | - Jeffrey A. Alten
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
| | - Mihir R. Atreya
- University of Cincinnati, Cincinnati Children’s Hospital Medical Center
| | - David S. Cooper
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
| | | | | | | | - Hector R. Wong
- University of Cincinnati, Cincinnati Children’s Hospital Medical Center
| |
Collapse
|
23
|
Atreya MR, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Allen GL, Thomas NJ, Grunwell JR, Baines T, Quasney M, Haileselassie B, Lindsell CJ, Alder MN, Wong HR. Integrated PERSEVERE and endothelial biomarker risk model predicts death and persistent MODS in pediatric septic shock: a secondary analysis of a prospective observational study. Crit Care 2022; 26:210. [PMID: 35818064 PMCID: PMC9275255 DOI: 10.1186/s13054-022-04070-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/21/2022] [Indexed: 11/12/2022] Open
Abstract
Background Multiple organ dysfunction syndrome (MODS) is a critical driver of sepsis morbidity and mortality in children. Early identification of those at risk of death and persistent organ dysfunctions is necessary to enrich patients for future trials of sepsis therapeutics. Here, we sought to integrate endothelial and PERSEVERE biomarkers to estimate the composite risk of death or organ dysfunctions on day 7 of septic shock. Methods We measured endothelial dysfunction markers from day 1 serum among those with existing PERSEVERE data. TreeNet® classification model was derived incorporating 22 clinical and biological variables to estimate risk. Based on relative variable importance, a simplified 6-biomarker model was developed thereafter. Results Among 502 patients, 49 patients died before day 7 and 124 patients had persistence of MODS on day 7 of septic shock. Area under the receiver operator characteristic curve (AUROC) for the newly derived PERSEVEREnce model to predict death or day 7 MODS was 0.93 (0.91–0.95) with a summary AUROC of 0.80 (0.76–0.84) upon tenfold cross-validation. The simplified model, based on IL-8, HSP70, ICAM-1, Angpt2/Tie2, Angpt2/Angpt1, and Thrombomodulin, performed similarly. Interaction between variables—ICAM-1 with IL-8 and Thrombomodulin with Angpt2/Angpt1—contributed to the models’ predictive capabilities. Model performance varied when estimating risk of individual organ dysfunctions with AUROCS ranging from 0.91 to 0.97 and 0.68 to 0.89 in training and test sets, respectively. Conclusions The newly derived PERSEVEREnce biomarker model reliably estimates risk of death or persistent organ dysfunctions on day 7 of septic shock. If validated, this tool can be used for prognostic enrichment in future pediatric trials of sepsis therapeutics. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04070-5.
Collapse
|
24
|
Cao I, Lippmann N, Thome UH. The Value of Perinatal Factors, Blood Biomarkers and Microbiological Colonization Screening in Predicting Neonatal Sepsis. J Clin Med 2022; 11:5837. [PMID: 36233706 PMCID: PMC9571877 DOI: 10.3390/jcm11195837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/22/2022] [Accepted: 09/28/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Neonatal sepsis is one of the most important causes of elevated morbidity and mortality rates in neonatal intensive care units worldwide. While the clinical manifestations of neonatal sepsis tend to be nonspecific, its rapid development and life-threatening potential call for reliable markers for early detection. Methods: We conducted a retrospective single-center study including all neonates suspected of having developed neonatal sepsis from 2013 to 2016. Perinatal and clinical characteristics as well as microbiological and laboratory findings were evaluated. Neonatal sepsis was defined as either culture-proven sepsis (positive blood culture) or clinical sepsis (at least one symptom and elevated C-reactive protein (CRP) concentrations within 72 h with negative blood culture). We further differentiated between early-onset (EOS) and late-onset (LOS) sepsis. Results: Microbiological colonization screening by throat and rectal swabs frequently did not detect the organism that subsequently caused the sepsis. Depending on the age of the newborn with sepsis (EOS or LOS), associations between different anamnestic and clinical factors (prenatal or postnatal ones) were found. In particular, the central−peripheral temperature difference showed a strong association with LOS. Laboratory results useful for the early detection of neonatal sepsis included interleukin-6 (IL-6) and CRP concentrations. Conclusions: Elevated IL-6 >100 ng/L was a strong marker for neonatal sepsis. When choosing the antibiotics for treatment, data from microbiological colonization screening should be considered but not solely relied on. Some indicators of infection also depended on postnatal age.
Collapse
Affiliation(s)
- Isabel Cao
- Divison of Neonatology, Center for Pediatric Research, University Hospital for Children, Liebigstraße 20a, 04103 Leipzig, Germany
| | - Norman Lippmann
- Institute for Medical Microbiology and Virology, University of Leipzig, 04103 Leipzig, Germany
| | - Ulrich H. Thome
- Divison of Neonatology, Center for Pediatric Research, University Hospital for Children, Liebigstraße 20a, 04103 Leipzig, Germany
| |
Collapse
|
25
|
Fink EL, Kochanek PM, Panigrahy A, Beers SR, Berger RP, Bayir H, Pineda J, Newth C, Topjian AA, Press CA, Maddux AB, Willyerd F, Hunt EA, Siems A, Chung MG, Smith L, Wenger J, Doughty L, Diddle JW, Patregnani J, Piantino J, Walson KH, Balakrishnan B, Meyer MT, Friess S, Maloney D, Rubin P, Haller TL, Treble-Barna A, Wang C, Clark RRSB, Fabio A. Association of Blood-Based Brain Injury Biomarker Concentrations With Outcomes After Pediatric Cardiac Arrest. JAMA Netw Open 2022; 5:e2230518. [PMID: 36074465 PMCID: PMC9459665 DOI: 10.1001/jamanetworkopen.2022.30518] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Families and clinicians have limited validated tools available to assist in estimating long-term outcomes early after pediatric cardiac arrest. Blood-based brain-specific biomarkers may be helpful tools to aid in outcome assessment. OBJECTIVE To analyze the association of blood-based brain injury biomarker concentrations with outcomes 1 year after pediatric cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS The Personalizing Outcomes After Child Cardiac Arrest multicenter prospective cohort study was conducted in pediatric intensive care units at 14 academic referral centers in the US between May 16, 2017, and August 19, 2020, with the primary investigators blinded to 1-year outcomes. The study included 120 children aged 48 hours to 17 years who were resuscitated after cardiac arrest, had pre-cardiac arrest Pediatric Cerebral Performance Category scores of 1 to 3 points, and were admitted to an intensive care unit after cardiac arrest. EXPOSURE Cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was an unfavorable outcome (death or survival with a Vineland Adaptive Behavior Scales, third edition, score of <70 points) at 1 year after cardiac arrest. Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCH-L1), neurofilament light (NfL), and tau concentrations were measured in blood samples from days 1 to 3 after cardiac arrest. Multivariate logistic regression and area under the receiver operating characteristic curve (AUROC) analyses were performed to examine the association of each biomarker with outcomes on days 1 to 3. RESULTS Among 120 children with primary outcome data available, the median (IQR) age was 1.0 (0-8.5) year; 71 children (59.2%) were male. A total of 5 children (4.2%) were Asian, 19 (15.8%) were Black, 81 (67.5%) were White, and 15 (12.5%) were of unknown race; among 110 children with data on ethnicity, 11 (10.0%) were Hispanic, and 99 (90.0%) were non-Hispanic. Overall, 70 children (58.3%) had a favorable outcome, and 50 children (41.7%) had an unfavorable outcome, including 43 deaths. On days 1 to 3 after cardiac arrest, concentrations of all 4 measured biomarkers were higher in children with an unfavorable vs a favorable outcome at 1 year. After covariate adjustment, NfL concentrations on day 1 (adjusted odds ratio [aOR], 5.91; 95% CI, 1.82-19.19), day 2 (aOR, 11.88; 95% CI, 3.82-36.92), and day 3 (aOR, 10.22; 95% CI, 3.14-33.33); UCH-L1 concentrations on day 2 (aOR, 11.27; 95% CI, 3.00-42.36) and day 3 (aOR, 7.56; 95% CI, 2.11-27.09); GFAP concentrations on day 2 (aOR, 2.31; 95% CI, 1.19-4.48) and day 3 (aOR, 2.19; 95% CI, 1.19-4.03); and tau concentrations on day 1 (aOR, 2.44; 95% CI, 1.14-5.25), day 2 (aOR, 2.28; 95% CI, 1.31-3.97), and day 3 (aOR, 2.04; 95% CI, 1.16-3.57) were associated with an unfavorable outcome. The AUROC models were significantly higher with vs without the addition of NfL on day 2 (AUROC, 0.932 [95% CI, 0.877-0.987] vs 0.871 [95% CI, 0.793-0.949]; P = .02) and day 3 (AUROC, 0.921 [95% CI, 0.857-0.986] vs 0.870 [95% CI, 0.786-0.953]; P = .03). CONCLUSIONS AND RELEVANCE In this cohort study, blood-based brain injury biomarkers, especially NfL, were associated with an unfavorable outcome at 1 year after pediatric cardiac arrest. Additional evaluation of the accuracy of the association between biomarkers and neurodevelopmental outcomes beyond 1 year is needed.
Collapse
Affiliation(s)
- Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel P. Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hülya Bayir
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Children’s Neuroscience Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jose Pineda
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Christopher Newth
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia
| | - Craig A. Press
- Department of Pediatrics and Neurology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia
| | - Aline B. Maddux
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
| | | | - Elizabeth A. Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Ashley Siems
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Melissa G. Chung
- Department of Pediatrics, Divisions of Pediatric Neurology and Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lincoln Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jesse Wenger
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lesley Doughty
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - J. Wesley Diddle
- Department of Pediatrics, Children’s National Hospital, District of Columbia
| | - Jason Patregnani
- Department of Pediatrics, Barbara Bush Children’s Hospital, Portland, Maine
| | - Juan Piantino
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - Binod Balakrishnan
- Department of Pediatrics, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Michael T. Meyer
- Department of Pediatrics, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Stuart Friess
- Department of Pediatrics, St Louis Children’s Hospital, St Louis, Missouri
| | - David Maloney
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pamela Rubin
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tamara L. Haller
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amery Treble-Barna
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chunyan Wang
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert R. S. B. Clark
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
26
|
Kamps NN, Banks R, Reeder RW, Berg RA, Newth CJ, Pollack MM, Meert KL, Carcillo JA, Mourani PM, Sorenson S, Varni JW, Cengiz P, Zimmerman JJ. The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock. Pediatr Crit Care Med 2022; 23:687-697. [PMID: 35695852 PMCID: PMC9444900 DOI: 10.1097/pcc.0000000000003009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes. DESIGN Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity. SETTING Twelve academic PICUs in the United States. PATIENTS Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212). CONCLUSIONS This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.
Collapse
Affiliation(s)
- Nicole N Kamps
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Russell Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Murray M Pollack
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Peter M Mourani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Samuel Sorenson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - James W Varni
- Department of Pediatrics, Texas A&M University, College Station, TX
| | - Pelin Cengiz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
27
|
Samprathi A, Samprathi M, Reddy M. Presepsin: Hope in the Quest for the Holy Grail. Indian J Crit Care Med 2022; 26:664-666. [PMID: 35836630 PMCID: PMC9237159 DOI: 10.5005/jp-journals-10071-24251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
How to cite this article: Samprathi A, Samprathi M, Reddy M. Presepsin: Hope in the Quest for the Holy Grail. Indian J Crit Care Med 2022;26(6):664-666.
Collapse
Affiliation(s)
- Abhishek Samprathi
- Department of Critical Care Medicine, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Madhusudan Samprathi
- Department of Pediatrics, All India Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Mounika Reddy
- Department of Pediatrics, All India Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
28
|
Qin Y, Kernan KF, Fan Z, Park HJ, Kim S, Canna SW, Kellum JA, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Michael Dean J, Carcillo JA. Machine learning derivation of four computable 24-h pediatric sepsis phenotypes to facilitate enrollment in early personalized anti-inflammatory clinical trials. Crit Care 2022; 26:128. [PMID: 35526000 PMCID: PMC9077858 DOI: 10.1186/s13054-022-03977-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy-induced thrombocytopenia-associated multiple organ failure and hyperinflammatory macrophage activation syndrome are important causes of late pediatric sepsis mortality that are often missed or have delayed diagnosis. The National Institutes of General Medical Science sepsis research working group recommendations call for application of new research approaches in extant clinical data sets to improve efficiency of early trials of new sepsis therapies. Our objective is to apply machine learning approaches to derive computable 24-h sepsis phenotypes to facilitate personalized enrollment in early anti-inflammatory trials targeting these conditions. METHODS We applied consensus, k-means clustering analysis to our extant PHENOtyping sepsis-induced Multiple organ failure Study (PHENOMS) dataset of 404 children. 24-hour computable phenotypes are derived using 25 available bedside variables including C-reactive protein and ferritin. RESULTS Four computable phenotypes (PedSep-A, B, C, and D) are derived. Compared to all other phenotypes, PedSep-A patients (n = 135; 2% mortality) were younger and previously healthy, with the lowest C-reactive protein and ferritin levels, the highest lymphocyte and platelet counts, highest heart rate, and lowest creatinine (p < 0.05); PedSep-B patients (n = 102; 12% mortality) were most likely to be intubated and had the lowest Glasgow Coma Scale Score (p < 0.05); PedSep-C patients (n = 110; mortality 10%) had the highest temperature and Glasgow Coma Scale Score, least pulmonary failure, and lowest lymphocyte counts (p < 0.05); and PedSep-D patients (n = 56, 34% mortality) had the highest creatinine and number of organ failures, including renal, hepatic, and hematologic organ failure, with the lowest platelet counts (p < 0.05). PedSep-D had the highest likelihood of developing thrombocytopenia-associated multiple organ failure (Adj OR 47.51 95% CI [18.83-136.83], p < 0.0001) and macrophage activation syndrome (Adj OR 38.63 95% CI [13.26-137.75], p < 0.0001). CONCLUSIONS Four computable phenotypes are derived, with PedSep-D being optimal for enrollment in early personalized anti-inflammatory trials targeting thrombocytopenia-associated multiple organ failure and macrophage activation syndrome in pediatric sepsis. A computer tool for identification of individual patient membership ( www.pedsepsis.pitt.edu ) is provided. Reproducibility will be assessed at completion of two ongoing pediatric sepsis studies.
Collapse
Affiliation(s)
- Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Zhenjiang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Soyeon Kim
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott W Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Russell Banks
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Ron W Reeder
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Holubkov
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel A Notterman
- University of Utah, Salt Lake City, UT, USA
- Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
| |
Collapse
|
29
|
In Memoriam: Hector R. Wong, MD (1963-2022). Pediatr Crit Care Med 2022; 23:341-343. [PMID: 35583615 DOI: 10.1097/pcc.0000000000002939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
30
|
Yehya N, Fitzgerald JC, Hayes K, Zhang D, Bush J, Koterba N, Chen F, Tuluc F, Teachey DT, Balamuth F, Lacey SF, Melenhorst JJ, Weiss SL. Temperature Trajectory Sub-phenotypes and the Immuno-Inflammatory Response in Pediatric Sepsis. Shock 2022; 57:645-651. [PMID: 35066512 PMCID: PMC9117394 DOI: 10.1097/shk.0000000000001906] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Heterogeneity has hampered sepsis trials, and sub-phenotyping may assist with enrichment strategies. However, biomarker-based strategies are difficult to operationalize. Four sub-phenotypes defined by distinct temperature trajectories in the first 72 h have been reported in adult sepsis. Given the distinct epidemiology of pediatric sepsis, the existence and relevance of temperature trajectory-defined sub-phenotypes in children is unknown. We aimed to classify septic children into de novo sub-phenotypes derived from temperature trajectories in the first 72 h, and compare cytokine, immune function, and immunometabolic markers across subgroups. METHODS This was a secondary analysis of a prospective cohort of 191 critically ill septic children recruited from a single academic pediatric intensive care unit. We performed group-based trajectory modeling using temperatures over the first 72 h of sepsis to identify latent profiles. We then used mixed effects regression to determine if temperature trajectory-defined sub-phenotypes were associated with cytokine levels, immune function, and mitochondrial respiration. RESULTS We identified four temperature trajectory-defined sub-phenotypes: hypothermic, normothermic, hyperthermic fast-resolvers, and hyperthermic slow-resolvers. Hypothermic patients were less often previously healthy and exhibited lower levels of pro- and anti-inflammatory cytokines and chemokines. Hospital mortality did not differ between hypothermic children (17%) and other sub-phenotypes (3-11%; P = 0.26). CONCLUSIONS Critically ill septic children can be categorized into temperature trajectory-defined sub-phenotypes that parallel adult sepsis. Hypothermic children exhibit a blunted cytokine and chemokine profile. Group-based trajectory modeling has utility for identifying subtypes of clinical syndromes by incorporating readily available longitudinal data, rather than relying on inputs from a single timepoint.
Collapse
Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katie Hayes
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donglan Zhang
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jenny Bush
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Natalka Koterba
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fang Chen
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Florin Tuluc
- Flow Cytometry Research Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David T Teachey
- Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fran Balamuth
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Simon F Lacey
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jan Joseph Melenhorst
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
31
|
Beitler JR, Thompson BT, Baron RM, Bastarache JA, Denlinger LC, Esserman L, Gong MN, LaVange LM, Lewis RJ, Marshall JC, Martin TR, McAuley DF, Meyer NJ, Moss M, Reineck LA, Rubin E, Schmidt EP, Standiford TJ, Ware LB, Wong HR, Aggarwal NR, Calfee CS. Advancing precision medicine for acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:107-120. [PMID: 34310901 PMCID: PMC8302189 DOI: 10.1016/s2213-2600(21)00157-0] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/29/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous clinical syndrome. Understanding of the complex pathways involved in lung injury pathogenesis, resolution, and repair has grown considerably in recent decades. Nevertheless, to date, only therapies targeting ventilation-induced lung injury have consistently proven beneficial, and despite these gains, ARDS morbidity and mortality remain high. Many candidate therapies with promise in preclinical studies have been ineffective in human trials, probably at least in part due to clinical and biological heterogeneity that modifies treatment responsiveness in human ARDS. A precision medicine approach to ARDS seeks to better account for this heterogeneity by matching therapies to subgroups of patients that are anticipated to be most likely to benefit, which initially might be identified in part by assessing for heterogeneity of treatment effect in clinical trials. In October 2019, the US National Heart, Lung, and Blood Institute convened a workshop of multidisciplinary experts to explore research opportunities and challenges for accelerating precision medicine in ARDS. Topics of discussion included the rationale and challenges for a precision medicine approach in ARDS, the roles of preclinical ARDS models in precision medicine, essential features of cohort studies to advance precision medicine, and novel approaches to clinical trials to support development and validation of a precision medicine strategy. In this Position Paper, we summarise workshop discussions, recommendations, and unresolved questions for advancing precision medicine in ARDS. Although the workshop took place before the COVID-19 pandemic began, the pandemic has highlighted the urgent need for precision therapies for ARDS as the global scientific community grapples with many of the key concepts, innovations, and challenges discussed at this workshop.
Collapse
Affiliation(s)
- Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Loren C Denlinger
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michelle N Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lisa M LaVange
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA; Berry Consultants, LLC, Austin, TX; Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Thomas R Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast and Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lora A Reineck
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | - Eric P Schmidt
- Division of Pulmonary Sciences and Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Theodore J Standiford
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Neil R Aggarwal
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
32
|
Su GY, Fan CN, Fang BL, Xie ZD, Qian SY. Comparison between hospital- and community-acquired septic shock in children: a single-center retrospective cohort study. World J Pediatr 2022; 18:734-745. [PMID: 35737181 PMCID: PMC9556399 DOI: 10.1007/s12519-022-00574-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND We explored the differences in baseline characteristics, pathogens, complications, outcomes, and risk factors between children with hospital-acquired septic shock (HASS) and community-acquired septic shock (CASS) in the pediatric intensive care unit (PICU). METHODS This retrospective study enrolled children with septic shock at the PICU of Beijing Children's Hospital from January 1, 2016, to December 31, 2019. The patients were followed up until 28 days after shock or death and were divided into the HASS and CASS group. Logistic regression analysis was used to identify risk factors for mortality. RESULTS A total of 298 children were enrolled. Among them, 65.9% (n = 91) of HASS patients had hematologic/oncologic diseases, mainly with Gram-negative bacterial bloodstream infections (47.3%). Additionally, 67.7% (n = 207) of CASS patients had no obvious underlying disease, and most experienced Gram-positive bacterial infections (30.9%) of the respiratory or central nervous system. The 28-day mortality was 62.6% and 32.7% in the HASS and CASS groups, respectively (P < 0.001). Platelet [odds ratio (OR) = 0.996, 95% confidence interval (CI) = 0.992-1.000, P = 0.028], positive pathogen detection (OR = 3.557, 95% CI = 1.307-9.684, P = 0.013), and multiple organ dysfunction syndrome (OR = 10.953, 95% CI = 1.974-60.775, P = 0.006) were risk factors for 28-day mortality in HASS patients. Lactate (OR = 1.104, 95% CI = 1.022-1.192, P = 0.012) and mechanical ventilation (OR = 8.114, 95% CI = 1.806-36.465, P = 0.006) were risk factors for 28-day mortality in patients with CASS. CONCLUSIONS The underlying diseases, pathogens, complications, prognosis, and mortality rates varied widely between the HASS and CASS groups. The predictors of 28-day mortality were different between HASS and CASS pediatric patients with septic shock.
Collapse
Affiliation(s)
- Guo-Yun Su
- grid.24696.3f0000 0004 0369 153XPediatric Intensive Care Unit, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, No. 56 Nan-Li-Shi Road, Beijing, 100045 China ,grid.506261.60000 0001 0706 7839Research Unit of Critical Infection in Children, Chinese Academy of Medical Sciences (DIFMS), 2019-I2M-5-026, Beijing, China
| | - Chao-Nan Fan
- grid.24696.3f0000 0004 0369 153XPediatric Intensive Care Unit, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, No. 56 Nan-Li-Shi Road, Beijing, 100045 China ,grid.506261.60000 0001 0706 7839Research Unit of Critical Infection in Children, Chinese Academy of Medical Sciences (DIFMS), 2019-I2M-5-026, Beijing, China
| | - Bo-Liang Fang
- grid.24696.3f0000 0004 0369 153XPediatric Intensive Care Unit, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, No. 56 Nan-Li-Shi Road, Beijing, 100045 China ,grid.506261.60000 0001 0706 7839Research Unit of Critical Infection in Children, Chinese Academy of Medical Sciences (DIFMS), 2019-I2M-5-026, Beijing, China
| | - Zheng-De Xie
- grid.506261.60000 0001 0706 7839Research Unit of Critical Infection in Children, Chinese Academy of Medical Sciences (DIFMS), 2019-I2M-5-026, Beijing, China ,grid.24696.3f0000 0004 0369 153XBeijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, Research Unit of Critical Infection in Children, Chinese Academy of Medical Sciences, 2019RU016, Laboratory of Infection and Virology, Beijing Pediatric Research Institute, Beijing Children’s Hospital, National Center for Children’s Health, Capital Medical University, Beijing, China
| | - Su-Yun Qian
- Pediatric Intensive Care Unit, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nan-Li-Shi Road, Beijing, 100045, China. .,Research Unit of Critical Infection in Children, Chinese Academy of Medical Sciences (DIFMS), 2019-I2M-5-026, Beijing, China.
| |
Collapse
|
33
|
Hall MW, Carcillo JA, Cornell T. Immune System Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S91-S98. [PMID: 34970674 PMCID: PMC9166150 DOI: 10.1542/peds.2021-052888n] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Immune system dysfunction is poorly represented in pediatric organ dysfunction definitions. OBJECTIVE To evaluate evidence for criteria that define immune system dysfunction in critically ill children and associations with adverse outcomes and develop consensus criteria for the diagnosis of immune system dysfunction in critically ill children. DATA SOURCES We conducted electronic searches of PubMed and Embase from January 1992 to January 2020, using medical subject heading terms and text words to define immune system dysfunction and outcomes of interest. STUDY SELECTION Studies of critically ill children with an abnormality in leukocyte numbers or function that is currently measurable in the clinical laboratory in which researchers assessed patient-centered outcomes were included. Studies of adults or premature infants, animal studies, reviews and commentaries, case series (≤10 subjects), and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from eligible studies into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS We identified the following criteria for immune system dysfunction: (1) peripheral absolute neutrophil count <500 cells/μL, (2) peripheral absolute lymphocyte count <1000 cells/μL, (3) reduction in CD4+ lymphocyte count or percentage of total lymphocytes below age-specific thresholds, (4) monocyte HLA-DR expression <30%, or (5) reduction in ex vivo whole blood lipopolysaccharide-induced TNFα production capacity below manufacturer-provided thresholds. LIMITATIONS Many measures of immune system function are currently limited to the research environment. CONCLUSIONS We present consensus criteria for the diagnosis of immune system dysfunction in critically ill children.
Collapse
Affiliation(s)
- Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, College of Medicine, The Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh and Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Timothy Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| |
Collapse
|
34
|
Massaud-Ribeiro L, Silami PHNC, Lima-Setta F, Prata-Barbosa A. Pediatric Sepsis Research: Where Are We and Where Are We Going? Front Pediatr 2022; 10:829119. [PMID: 35223703 PMCID: PMC8873512 DOI: 10.3389/fped.2022.829119] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/20/2022] [Indexed: 01/15/2023] Open
Abstract
Sepsis continues to be one of the leading causes of admission to the Pediatric Intensive Care Unit, representing a great challenge for researchers and healthcare staff. This mini review aims to assess research on pediatric sepsis over the years. Of the 2,698 articles retrieved from the Scopus database, the 100 most cited were selected (50 published since 2000 and 50 published since 2016). The most cited studies, published in the 21st century, are highlighted, with their main findings and perspectives.
Collapse
Affiliation(s)
- Letícia Massaud-Ribeiro
- Pediatric Intensive Care Unit, Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Pediatric Intensive Care Unit, Department of Pediatrics, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Pedro Henrique Nunes Costa Silami
- Pediatric Intensive Care Unit, Department of Pediatrics, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Estadual da Criança, Rio de Janeiro, Brazil
| | - Fernanda Lima-Setta
- Pediatric Intensive Care Unit, Department of Pediatrics, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Department of Pediatrics, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - Arnaldo Prata-Barbosa
- Department of Pediatrics, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| |
Collapse
|
35
|
Lautz AJ, Wong HR, Ryan TD, Statile CJ. Pediatric Sepsis Biomarker Risk Model Biomarkers and Estimation of Myocardial Dysfunction in Pediatric Septic Shock. Pediatr Crit Care Med 2022; 23:e20-e28. [PMID: 34560770 PMCID: PMC8738125 DOI: 10.1097/pcc.0000000000002830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Sepsis-associated myocardial dysfunction is common in pediatric septic shock and negatively impacts outcomes. Early estimation of sepsis-associated myocardial dysfunction risk has the potential to inform clinical care and improve clinical trial design. The Pediatric Sepsis Biomarker Risk Model II is validated as a biomarker-based enrichment algorithm to discriminate children with septic shock with high baseline mortality probability. The objectives were to determine if Pediatric Sepsis Biomarker Risk Model biomarkers are associated with risk for sepsis-associated myocardial dysfunction in pediatric septic shock and to develop a biomarker-based model to reliably estimate sepsis-associated myocardial dysfunction risk. DESIGN Secondary analysis of prospective cohort study. SETTING Single-center, quaternary-care PICU. PATIENTS Children less than 18 years old admitted to the PICU from 2003 to 2018 who had Pediatric Sepsis Biomarker Risk Model biomarkers measured for determination of Pediatric Sepsis Biomarker Risk Model II mortality probability and an echocardiogram performed within 48 hours of septic shock identification. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric Sepsis Biomarker Risk Model II mortality probability was calculated from serum biomarker concentrations and admission platelet count. Echocardiograms were reread by a single cardiologist blinded to Pediatric Sepsis Biomarker Risk Model II data, and sepsis-associated myocardial dysfunction was defined as left ventricular ejection fraction less than 45% for primary analyses. Multivariable logistic regression analyzed the association of Pediatric Sepsis Biomarker Risk Model II mortality probability with sepsis-associated myocardial dysfunction. Classification and regression tree methodology was employed to derive a Pediatric Sepsis Biomarker Risk Model biomarker-based model for sepsis-associated myocardial dysfunction. Thirty-two of 181 children with septic shock demonstrated sepsis-associated myocardial dysfunction. Pediatric Sepsis Biomarker Risk Model II mortality probability was independently associated with sepsis-associated myocardial dysfunction (odds ratio, 1.45; 95% CI, 1.17-1.81; p = 0.001). Modeling with Pediatric Sepsis Biomarker Risk Model biomarkers estimated sepsis-associated myocardial dysfunction risk with an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.85-0.95). Upon 10-fold cross-validation, the derived model had a summary area under the receiver operating characteristic curve of 0.74. Model characteristics were similar when sepsis-associated myocardial dysfunction was defined by both low left ventricular ejection fraction and abnormal global longitudinal strain. CONCLUSIONS A newly derived Pediatric Sepsis Biomarker Risk Model biomarker-based model reliably estimates risk of sepsis-associated myocardial dysfunction in pediatric septic shock, but independent prospective validation is needed.
Collapse
Affiliation(s)
- Andrew J. Lautz
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine
| | - Hector R. Wong
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine
| | - Thomas D. Ryan
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Cardiology
| | - Christopher J. Statile
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Cardiology
| |
Collapse
|
36
|
Pediatric sepsis biomarkers for prognostic and predictive enrichment. Pediatr Res 2022; 91:283-288. [PMID: 34127800 PMCID: PMC8202042 DOI: 10.1038/s41390-021-01620-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 12/29/2022]
Abstract
Sepsis is a major public health problem in children throughout the world. Given that the treatment guidelines emphasize early recognition, there is interest in developing biomarkers of sepsis, and most attention is focused on diagnostic biomarkers. While there is a need for ongoing discovery and development of diagnostic biomarkers for sepsis, this review will focus on less well-known applications of sepsis biomarkers. Among patients with sepsis, the biomarkers can give information regarding the risk of poor outcome from sepsis, risk of sepsis-related organ dysfunction, and subgroups of patients with sepsis who share underlying biological features potentially amenable to targeted therapeutics. These types of biomarkers, beyond the traditional concept of diagnosis, address the important concepts of prognostic and predictive enrichment, which are key components of bringing the promise of precision medicine to the bedside of children with sepsis.
Collapse
|
37
|
Workman JK, Chambers A, Miller C, Larsen GY, Lane RD. Best practices in pediatric sepsis: building and sustaining an evidence-based pediatric sepsis quality improvement program. Hosp Pract (1995) 2021; 49:413-421. [PMID: 34404310 DOI: 10.1080/21548331.2021.1966252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pediatric sepsis is a common problem worldwide and is associated with significant morbidity and mortality. Best practice recommendations have been published by both the American College of Critical Care Medicine and the Surviving Sepsis Campaign to guide the recognition and treatment of pediatric sepsis. However, implementation of these recommendations can be challenging due to the complexity of the care required and intensity of resources needed to successfully implement programs. This paper outlines the experience with implementation of a pediatric sepsis quality improvement program at Primary Children's Hospital, a free-standing, quaternary care children's hospital in Salt Lake City. The hospital has implemented sepsis projects across multiple care settings. Challenges, lessons learned, and suggestions for implementation are described.PLAIN LANGUAGE SUMMARYSepsis is a life-threatening condition that results from an inappropriate response to an infection by the body's immune system. All children are potentially susceptible to sepsis, with nearly 8,000 children dying from the disease in the US each year. Sepsis is a complicated disease, and several international groups have published guidelines to help hospital teams treat children with sepsis appropriately. However, because recognizing and treating sepsis in children is challenging and takes a coordinated effort from many different types of healthcare team members, following the international sepsis guidelines effectively can be difficult and resource intensive. This paper describes how one children's hospital (Primary Children's Hospital in Salt Lake City, Utah) approached the challenge of implementing pediatric sepsis guidelines, some lessons learned from their experience, and suggestions for others interested in implementing sepsis guidelines for children.
Collapse
Affiliation(s)
- Jennifer K Workman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Amber Chambers
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christopher Miller
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gitte Y Larsen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Roni D Lane
- Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
38
|
Bashir DA, Da Q, Pradhan S, Sekhar N, Valladolid C, Lam F, Guffey D, Goldman J, Desai MS, Cruz MA, Allen C, Nguyen TC, Vijayan KV. Secretion of von Willebrand Factor and Suppression of ADAMTS-13 Activity by Markedly High Concentration of Ferritin. Clin Appl Thromb Hemost 2021; 27:1076029621992128. [PMID: 33539188 PMCID: PMC7868463 DOI: 10.1177/1076029621992128] [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] [Indexed: 12/14/2022] Open
Abstract
Hyperferritinemia is associated with poor outcomes in critically ill patients with sepsis, hemophagocytic lymphohistiocytosis (HLH), macrophage activation syndromes (MAS) and coronavirus disease 19 (COVID-19). Autopsies of hyperferritinemic patients that succumbed to either sepsis, HLH, MAS or COVID-19 have revealed disseminated microvascular thromboses with von Willebrand factor (VWF)-, platelets-, and/or fibrin-rich microthrombi. It is unknown whether high plasma ferritin concentration actively promotes microvascular thrombosis, or merely serves as a prognostic biomarker in these patients. Here, we show that secretion of VWF from human umbilical vein endothelial cells (HUVEC) is significantly enhanced by 100,000 ng/ml of recombinant ferritin heavy chain protein (FHC). Ferritin fraction that was isolated by size exclusion chromatography from the plasma of critically ill HLH patients promoted VWF secretion from HUVEC, compared to similar fraction from non-critically ill control plasma. Furthermore, recombinant FHC moderately suppressed the activity of VWF cleaving metalloprotease ADAMTS-13. These observations suggest that a state of marked hyperferritinemia could promote thrombosis and organ injury by inducing endothelial VWF secretion and reducing the ADAMTS-13 activity.
Collapse
Affiliation(s)
- Dalia A Bashir
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
| | - Qi Da
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Subhashree Pradhan
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Nitin Sekhar
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christian Valladolid
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fong Lam
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Jordana Goldman
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Miguel A Cruz
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Carl Allen
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Trung C Nguyen
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
| | - K Vinod Vijayan
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
39
|
Wang Q, Huang J, Chen X, Wang J, Fang F. Transcriptomic markers in pediatric septic shock prognosis: an integrative analysis of gene expression profiles. ACTA ACUST UNITED AC 2021; 54:e10152. [PMID: 33503200 PMCID: PMC7836399 DOI: 10.1590/1414-431x202010152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 09/25/2020] [Indexed: 12/13/2022]
Abstract
The goal of this study was to identify potential transcriptomic markers in
pediatric septic shock prognosis by an integrative analysis of multiple public
microarray datasets. Using the R software and bioconductor packages, we
performed a statistical analysis to identify differentially expressed (DE) genes
in pediatric septic shock non-survivors, and further performed functional
interpretation (enrichment analysis and co-expression network construction) and
classification quality evaluation of the DE genes identified. Four microarray
datasets (3 training datasets and 1 testing dataset, 252 pediatric patients with
septic shock in total) were collected for the integrative analysis. A total of
32 DE genes (18 upregulated genes; 14 downregulated genes) were identified in
pediatric septic shock non-survivors. Enrichment analysis revealed that those DE
genes were strongly associated with acute inflammatory response to antigenic
stimulus, response to yeast, and defense response to bacterium. A support vector
machine classifier (non-survivors vs survivors) was also
trained based on DE genes. In conclusion, the DE genes identified in this study
are suggested as candidate transcriptomic markers for pediatric septic shock
prognosis and provide novel insights into the progression of pediatric septic
shock.
Collapse
Affiliation(s)
- Qian Wang
- Anesthesiology Department, Children's Hospital of Soochow University, Suzhou, China
| | - Jie Huang
- Department of Cardiology, Children's Hospital of Soochow University, Suzhou, China
| | - Xia Chen
- Anesthesiology Department, Children's Hospital of Soochow University, Suzhou, China
| | - Jian Wang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| | - Fang Fang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| |
Collapse
|
40
|
Wong HR, Reeder RW, Banks R, Berg RA, Meert KL, Hall MW, McQuillen PS, Mourani PM, Chima RS, Sorenson S, Varni JW, McGalliard J, Zimmerman JJ. Biomarkers for Estimating Risk of Hospital Mortality and Long-Term Quality-of-Life Morbidity After Surviving Pediatric Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation Investigation. Pediatr Crit Care Med 2021; 22:8-15. [PMID: 33003178 PMCID: PMC7790971 DOI: 10.1097/pcc.0000000000002572] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Life After Pediatric Sepsis Evaluation investigation recently reported that one-third of children who survive sepsis experience significant health-related quality-of-life impairment compared with baseline at 1 year after hospitalization. Pediatric Sepsis Biomarker Risk Model is a multibiomarker tool for estimating baseline risk of mortality among children with septic shock. We determined if the Pediatric Sepsis Biomarker Risk Model biomarkers have predictive capacity for estimating the risk of hospital mortality and long-term health-related quality-of-life morbidity among children with community-acquired septic shock. DESIGN Secondary analysis. SETTING Twelve academic PICUs. PATIENTS A subset of Life After Pediatric Sepsis Evaluation subjects (n = 173) with available blood samples. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three predefined outcomes from the Life After Pediatric Sepsis Evaluation investigation were evaluated: all-cause hospital mortality (n = 173), and the composite outcome of mortality or persistent, serious deterioration of health-related quality of life (> 25% below baseline) among surviving children at 1 month (n = 125) or 3 months (n = 117). Pediatric Sepsis Biomarker Risk Model had an area under the receiver operating characteristic curve of 0.73 (95% CI, 0.59-0.87; p = 0.002) for estimating the risk of hospital mortality and was independently associated with increased odds of hospital mortality. In multivariable analyses, Pediatric Sepsis Biomarker Risk Model was not independently associated with increased odds of the composite outcome of mortality or deterioration of persistent, serious deterioration health-related quality of life greater than 25% below baseline. A new decision tree using the Pediatric Sepsis Biomarker Risk Model biomarkers had an area under the receiver operating characteristic curve of 0.87 (95% CI, 0.80-0.95) for estimating the risk of persistent, serious deterioration health-related quality of life at 3 months among children who survived septic shock. CONCLUSIONS Pediatric Sepsis Biomarker Risk Model had modest performance for estimating hospital mortality in an external cohort of children with community-acquired septic shock. The Pediatric Sepsis Biomarker Risk Model biomarkers appear to have utility for estimating the risk of persistent, serious deterioration of health-related quality of life up to 3 months after surviving septic shock. These findings suggest an opportunity to develop a clinical tool for early assignment of risk for long-term health-related quality-of-life morbidity among children who survive septic shock.
Collapse
Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | - Patrick S McQuillen
- Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | | | - Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Julie McGalliard
- Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Jerry J Zimmerman
- Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
41
|
Editor's Choice Articles for January. Pediatr Crit Care Med 2021; 22:3-4. [PMID: 33410643 DOI: 10.1097/pcc.0000000000002634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
42
|
Zimmerman JJ, Banks R, Berg RA, Zuppa A, Newth CJ, Wessel D, Pollack MM, Meert KL, Hall MW, Quasney M, Sapru A, Carcillo JA, McQuillen PS, Mourani PM, Wong H, Chima RS, Holubkov R, Coleman W, Sorenson S, Varni JW, McGalliard J, Haaland W, Whitlock K, Dean JM, Reeder RW. Critical Illness Factors Associated With Long-Term Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock. Crit Care Med 2020; 48:319-328. [PMID: 32058369 DOI: 10.1097/ccm.0000000000004122] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES A companion article reports the trajectory of long-term mortality and significant health-related quality of life disability among children encountering septic shock. In this article, the investigators examine critical illness factors associated with these adverse outcomes. DESIGN Prospective, cohort-outcome study, conducted 2013-2017. SETTING Twelve United States academic PICUs. PATIENTS Critically ill children, 1 month to 18 years, with community-acquired septic shock requiring vasoactive-inotropic support. INTERVENTIONS Illness severity, organ dysfunction, and resource utilization data were collected during PICU admission. Change from baseline health-related quality of life at the month 3 follow-up was assessed by parent proxy-report employing the Pediatric Quality of Life Inventory or the Stein-Jessop Functional Status Scale. MEASUREMENTS AND MAIN RESULTS In univariable modeling, critical illness variables associated with death and/or persistent, serious health-related quality of life deterioration were candidates for multivariable modeling using Bayesian information criterion. The most clinically relevant multivariable models were selected among models with near-optimal statistical fit. Three months following septic shock, 346 of 389 subjects (88.9%) were alive and 43 of 389 had died (11.1%); 203 of 389 (52.2%) had completed paired health-related quality of life surveys. Pediatric Risk of Mortality, cumulative Pediatric Logistic Organ Dysfunction scores, PICU and hospital durations of stay, maximum and cumulative vasoactive-inotropic scores, duration of mechanical ventilation, need for renal replacement therapy, extracorporeal life support or cardiopulmonary resuscitation, and appearance of pathologic neurologic signs were associated with adverse outcomes in univariable models. In multivariable regression analysis (odds ratio [95% CI]), summation of daily Pediatric Logistic Organ Dysfunction scores, 1.01/per point (1.01-1.02), p < 0.001; highest vasoactive-inotropic score, 1.02/per point (1.00-1.04), p = 0.003; and any acute pathologic neurologic sign/event, 5.04 (2.15-12.01), p < 0.001 were independently associated with death or persistent, serious deterioration of health-related quality of life at month 3. CONCLUSIONS AND RELEVANCE Biologically plausible factors related to sepsis-associated critical illness organ dysfunction and its treatment were associated with poor outcomes at month 3 follow-up among children encountering septic shock.
Collapse
Affiliation(s)
- Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Russell Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J Newth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA
| | - David Wessel
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Murray M Pollack
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
| | - Mark W Hall
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Michael Quasney
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M Mourani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Colorado, Denver, CO
| | - Hector Wong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH
| | - Ranjit S Chima
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH
| | - Richard Holubkov
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Whitney Coleman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Samuel Sorenson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - James W Varni
- Department of Landscape Architecture and Urban Planning, Texas A&M University, College Station, TX
| | - Julie McGalliard
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Wren Haaland
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathryn Whitlock
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - J Michael Dean
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | |
Collapse
|
43
|
Abstract
Supplemental Digital Content is available in the text. Objectives: Circulatory dysfunction has been associated with mortality in children with septic shock. However, the mortality risk attributable to myocardial dysfunction per se has not been established, and the association between myocardial dysfunction and mortality is confounded by illness severity. The objective was to determine if sepsis-associated myocardial dysfunction defined by low left ventricular ejection fraction or global longitudinal strain is associated with mortality in pediatric septic shock after adjusting for baseline mortality probability. Design: Retrospective, observational study. Setting: Single-center, quaternary-care PICU. Patients: Children less than 18 years old admitted to the PICU from 2003 to 2018 who had an echocardiogram performed within 48 hours of septic shock identification and Pediatric Sepsis Biomarker Risk Model II data available. Interventions: None. Measurements and Main Results: All echocardiograms were reread by a cardiologist blinded to patient data for left ventricular ejection fraction and global longitudinal strain. Low left ventricular ejection fraction was defined as less than 45%, and low global longitudinal strain was defined as greater than z score of –2 for body surface area. Multivariable logistic regression separately analyzed the associations of low left ventricular ejection fraction and low global longitudinal strain with mortality, adjusting for Pediatric Sepsis Biomarker Risk Model II mortality risk. A post hoc logistic regression analyzed the association of left ventricular ejection fraction as a continuous variable with mortality, where linearity was maintained for left ventricular ejection fraction less than 65%. Eighteen percent of 181 children had low left ventricular ejection fraction. After adjusting for baseline mortality risk, low left ventricular ejection fraction remained independently associated with mortality (odds ratio, 4.4 [1.0–19.8]; p = 0.0497). Likewise, left ventricular ejection fraction was associated with mortality (odds ratio, 0.96 [0.93–0.99]; p = 0.037) on multivariable analysis for left ventricular ejection fraction less than 65%. Thirty-six percent of 169 children had low global longitudinal strain, and low global longitudinal strain was also independently associated with mortality (odds ratio, 4.6 [1.2–18.0]; p = 0.027). Conclusions: Sepsis-associated myocardial dysfunction, whether defined by low left ventricular ejection fraction or low global longitudinal strain, is an independent risk factor for mortality in pediatric septic shock after accounting for the confounding effects of septic shock severity.
Collapse
|
44
|
Cruz AT, Lane RD, Balamuth F, Aronson PL, Ashby DW, Neuman MI, Souganidis ES, Alpern ER, Schlapbach LJ. Updates on pediatric sepsis. J Am Coll Emerg Physicians Open 2020; 1:981-993. [PMID: 33145549 PMCID: PMC7593454 DOI: 10.1002/emp2.12173] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.
Collapse
Affiliation(s)
- Andrea T. Cruz
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Roni D. Lane
- Division of Pediatric Emergency Medicinethe University of Utah Primary Children's HospitalSalt Lake CityUtahUSA
| | - Fran Balamuth
- Division of Emergency MedicineDepartment of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Paul L. Aronson
- Section of Pediatric Emergency MedicineDepartments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - David W. Ashby
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Mark I. Neuman
- Division of Emergency MedicineDepartment of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Ellie S. Souganidis
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Elizabeth R. Alpern
- Division of Emergency MedicineDepartment of PediatricsAnn & Robert H. Lurie Children's HospitalFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Luregn J. Schlapbach
- Department of Intensive Care Medicine and Neonatologyand Children's Research CenterUniversity Children's Hospital of ZurichUniversity of ZurichZurichSwitzerland
- Paediatric Critical Care Research GroupThe University of Queensland and Queensland Children's HospitalBrisbaneQueenslandAustralia
| |
Collapse
|
45
|
Wong HR, Caldwell JT, Cvijanovich NZ, Weiss SL, Fitzgerald JC, Bigham MT, Jain PN, Schwarz A, Lutfi R, Nowak J, Allen GL, Thomas NJ, Grunwell JR, Baines T, Quasney M, Haileselassie B, Lindsell CJ. Prospective clinical testing and experimental validation of the Pediatric Sepsis Biomarker Risk Model. Sci Transl Med 2020; 11:11/518/eaax9000. [PMID: 31723040 DOI: 10.1126/scitranslmed.aax9000] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/05/2019] [Accepted: 09/27/2019] [Indexed: 12/20/2022]
Abstract
Sepsis remains a major public health problem with no major therapeutic advances over the last several decades. The clinical and biological heterogeneity of sepsis have limited success of potential new therapies. Accordingly, there is considerable interest in developing a precision medicine approach to inform more rational development, testing, and targeting of new therapies. We previously developed the Pediatric Sepsis Biomarker Risk Model (PERSEVERE) to estimate mortality risk and proposed its use as a prognostic enrichment tool in sepsis clinical trials; prognostic enrichment selects patients based on mortality risk independent of treatment. Here, we show that PERSEVERE has excellent performance in a diverse cohort of children with septic shock with potential for use as a predictive enrichment strategy; predictive enrichment selects patients based on likely response to treatment. We demonstrate that the PERSEVERE biomarkers are reliably associated with mortality in mice challenged with experimental sepsis, thus providing an opportunity to test precision medicine strategies in the preclinical setting. Using this model, we tested two clinically feasible therapeutic strategies, guided by the PERSEVERE-based enrichment, and found that mice identified as high risk for mortality had a greater bacterial burden and could be rescued by higher doses of antibiotics. The association between higher pathogen burden and higher mortality risk was corroborated among critically ill children with septic shock. This bedside to bench to bedside approach provides proof of principle for PERSEVERE-guided application of precision medicine in sepsis.
Collapse
Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - J Timothy Caldwell
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH 45229, USA
| | | | - Scott L Weiss
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | | | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Adam Schwarz
- Children's Hospital of Orange County, Orange, CA 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN 55404, USA
| | | | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA 17033, USA
| | | | - Torrey Baines
- University of Florida Health Shands Children's Hospital, Gainesville, FL 32610, USA
| | - Michael Quasney
- CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI 48109, USA
| | | | | |
Collapse
|
46
|
Abbas M, El-Manzalawy Y. Machine learning based refined differential gene expression analysis of pediatric sepsis. BMC Med Genomics 2020; 13:122. [PMID: 32859206 PMCID: PMC7453705 DOI: 10.1186/s12920-020-00771-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/19/2020] [Indexed: 12/18/2022] Open
Abstract
Background Differential expression (DE) analysis of transcriptomic data enables genome-wide analysis of gene expression changes associated with biological conditions of interest. Such analysis often provides a wide list of genes that are differentially expressed between two or more groups. In general, identified differentially expressed genes (DEGs) can be subject to further downstream analysis for obtaining more biological insights such as determining enriched functional pathways or gene ontologies. Furthermore, DEGs are treated as candidate biomarkers and a small set of DEGs might be identified as biomarkers using either biological knowledge or data-driven approaches. Methods In this work, we present a novel approach for identifying biomarkers from a list of DEGs by re-ranking them according to the Minimum Redundancy Maximum Relevance (MRMR) criteria using repeated cross-validation feature selection procedure. Results Using gene expression profiles for 199 children with sepsis and septic shock, we identify 108 DEGs and propose a 10-gene signature for reliably predicting pediatric sepsis mortality with an estimated Area Under ROC Curve (AUC) score of 0.89. Conclusions Machine learning based refinement of DE analysis is a promising tool for prioritizing DEGs and discovering biomarkers from gene expression profiles. Moreover, our reported 10-gene signature for pediatric sepsis mortality may facilitate the development of reliable diagnosis and prognosis biomarkers for sepsis.
Collapse
Affiliation(s)
- Mostafa Abbas
- Department of Imaging Science and Innovation, Geisinger Health System, Danville, PA, 17822, USA
| | - Yasser El-Manzalawy
- Department of Imaging Science and Innovation, Geisinger Health System, Danville, PA, 17822, USA. .,Department of Biomedical and Translational Informatics, Geisinger Health System, Danville, PA, 17822, USA.
| |
Collapse
|
47
|
Z Oikonomakou M, Gkentzi D, Gogos C, Akinosoglou K. Biomarkers in pediatric sepsis: a review of recent literature. Biomark Med 2020; 14:895-917. [PMID: 32808806 DOI: 10.2217/bmm-2020-0016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/12/2020] [Indexed: 01/10/2023] Open
Abstract
Sepsis remains the leading cause of death in infants and children worldwide. Prompt diagnosis and monitoring of infection is pivotal to guide therapy and optimize outcomes. No single biomarker has so far been identified to accurately diagnose sepsis, monitor response and predict severity. We aimed to assess existing evidence of available sepsis biomarkers, and their utility in pediatric population. C-reactive protein and procalcitonin remain the most extensively evaluated and used biomarkers. However, biomarkers related to endothelial damage, vasodilation, oxidative stress, cytokines/chemokines and cell bioproducts have also been identified, often with regard to the site of infection and etiologic pathogen; still, with controversial utility. A multi-biomarker model driven by genomic tools could establish a personalized approach in future disease management.
Collapse
Affiliation(s)
| | - Despoina Gkentzi
- Department of Pediatrics, University Hospital of Patras, Rio 26504, Greece
| | - Charalambos Gogos
- Department of Internal Medicine & Infectious Diseases, University Hospital of Patras, Rio 26504, Greece
| | - Karolina Akinosoglou
- Department of Internal Medicine & Infectious Diseases, University Hospital of Patras, Rio 26504, Greece
| |
Collapse
|
48
|
|
49
|
Abstract
Biomarker panels have the potential to advance the field of critical care medicine by stratifying patients according to prognosis and/or underlying pathophysiology. This article discusses the discovery and validation of biomarker panels, along with their translation to the clinical setting. The current literature on the use of biomarker panels in sepsis, acute respiratory distress syndrome, and acute kidney injury is reviewed.
Collapse
Affiliation(s)
- Susan R Conway
- Division of Critical Care Medicine, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA.
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati Children's Research Foundation, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
50
|
Bulatova YY, Maltabarova NA, Zhumabayev MB, Li TA, Ivanova MP. Modern Diagnostics of Sepsis and Septic Shock in Children. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/7879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|