1
|
Robey RC, Logue C, Caird CA, Hansel J, Hellyer TP, Simpson J, Dark P, Mathioudakis AG, Felton T. Immunomodulatory drugs in sepsis: a systematic review and meta-analysis. Anaesthesia 2024; 79:869-879. [PMID: 38523060 DOI: 10.1111/anae.16263] [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] [Accepted: 02/05/2024] [Indexed: 03/26/2024]
Abstract
Dysregulation of the host immune response has a central role in the pathophysiology of sepsis. There has been much interest in immunomodulatory drugs as potential therapeutic adjuncts in sepsis. We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the safety and clinical effectiveness of immunomodulatory drugs as adjuncts to standard care in the treatment of adults with sepsis. Our primary outcomes were serious adverse events and all-cause mortality. Fifty-six unique, eligible randomised controlled trials were identified, assessing a range of interventions including cytokine inhibitors; anti-inflammatories; immune cell stimulators; platelet pathway inhibitors; and complement inhibitors. At 1-month follow-up, the use of cytokine inhibitors was associated with a decreased risk of serious adverse events, based on 11 studies involving 7138 patients (RR (95%CI) 0.95 (0.90-1.00), I2 = 0%). The only immunomodulatory drugs associated with an increased risk of serious adverse events were toll-like receptor 4 antagonists (RR (95%CI) 1.18 (1.04-1.34), I2 = 0% (two trials, 567 patients)). Based on 18 randomised controlled trials, involving 11,075 patients, cytokine inhibitors reduced 1-month mortality (RR (95%CI) 0.88 (0.78-0.98), I2 = 57%). Mortality reduction was also shown in the subgroup of 13 randomised controlled trials that evaluated anti-tumour necrosis factor α interventions (RR (95%CI) 0.93 (0.87-0.99), I2 = 0%). Anti-inflammatory drugs had the largest apparent effect on mortality at 2 months at any dose (two trials, 228 patients, RR (95%CI) 0.64 (0.51-0.80), I2 = 0%) and at 3 months at any dose (three trials involving 277 patients, RR (95%CI) 0.67 (0.55-0.81), I2 = 0%). These data indicate that, except for toll-like receptor 4 antagonists, there is no evidence of safety concerns for the use of immunomodulatory drugs in sepsis, and they may show some short-term mortality benefit for selected drugs.
Collapse
Affiliation(s)
- R C Robey
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - C Logue
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - C A Caird
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Hansel
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - T P Hellyer
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - P Dark
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Critical Care Unit, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK
| | - A G Mathioudakis
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - T Felton
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
2
|
Jang JH, Choi E, Kim T, Yeo HJ, Jeon D, Kim YS, Cho WH. Navigating the Modern Landscape of Sepsis: Advances in Diagnosis and Treatment. Int J Mol Sci 2024; 25:7396. [PMID: 39000503 PMCID: PMC11242529 DOI: 10.3390/ijms25137396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024] Open
Abstract
Sepsis poses a significant threat to human health due to its high morbidity and mortality rates worldwide. Traditional diagnostic methods for identifying sepsis or its causative organisms are time-consuming and contribute to a high mortality rate. Biomarkers have been developed to overcome these limitations and are currently used for sepsis diagnosis, prognosis prediction, and treatment response assessment. Over the past few decades, more than 250 biomarkers have been identified, a few of which have been used in clinical decision-making. Consistent with the limitations of diagnosing sepsis, there is currently no specific treatment for sepsis. Currently, the general treatment for sepsis is conservative and includes timely antibiotic use and hemodynamic support. When planning sepsis-specific treatment, it is important to select the most suitable patient, considering the heterogeneous nature of sepsis. This comprehensive review summarizes current and evolving biomarkers and therapeutic approaches for sepsis.
Collapse
Affiliation(s)
- Jin Ho Jang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Eunjeong Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Taehwa Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Hye Ju Yeo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Doosoo Jeon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Yun Seong Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Woo Hyun Cho
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| |
Collapse
|
3
|
Slim MA, van Mourik N, Bakkerus L, Fuller K, Acharya L, Giannidis T, Dionne JC, Oczkowski SJW, Netea MG, Pickkers P, Giamarellos-Bourboulis EJ, Müller MCA, van der Poll T, Wiersinga WJ, Vlaar APJ, van Vught LA. Towards personalized medicine: a scoping review of immunotherapy in sepsis. Crit Care 2024; 28:183. [PMID: 38807151 PMCID: PMC11134696 DOI: 10.1186/s13054-024-04964-6] [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: 03/13/2024] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
Despite significant progress in our understanding of the pathophysiology of sepsis and extensive clinical research, there are few proven therapies addressing the underlying immune dysregulation of this life-threatening condition. The aim of this scoping review is to describe the literature evaluating immunotherapy in adult patients with sepsis, emphasizing on methods providing a "personalized immunotherapy" approach, which was defined as the classification of patients into a distinct subgroup or subphenotype, in which a patient's immune profile is used to guide treatment. Subgroups are subsets of sepsis patients, based on any cut-off in a variable. Subphenotypes are subgroups that can be reliably discriminated from other subgroup based on data-driven assessments. Included studies were randomized controlled trials and cohort studies investigating immunomodulatory therapies in adults with sepsis. Studies were identified by searching PubMed, Embase, Cochrane CENTRAL and ClinicalTrials.gov, from the first paper available until January 29th, 2024. The search resulted in 15,853 studies. Title and abstract screening resulted in 1409 studies (9%), assessed for eligibility; 771 studies were included, of which 282 (37%) were observational and 489 (63%) interventional. Treatment groups included were treatments targeting the innate immune response, the complement system, coagulation and endothelial dysfunction, non-pharmalogical treatment, pleiotropic drugs, immunonutrition, concomitant treatments, Traditional Chinese Medicine, immunostimulatory cytokines and growth factors, intravenous immunoglobulins, mesenchymal stem cells and immune-checkpoint inhibitors. A personalized approach was incorporated in 70 studies (9%). Enrichment was applied using cut-offs in temperature, laboratory, biomarker or genetic variables. Trials often showed conflicting results, possibly due to the lack of patient stratification or the potential influence of severity and timing on immunomodulatory therapy results. When a personalized approach was applied, trends of clinical benefit for several interventions emerged, which hold promise for future clinical trials using personalized immunotherapy.
Collapse
Affiliation(s)
- Marleen A Slim
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands.
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Niels van Mourik
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieke Bakkerus
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Lydia Acharya
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Simon J W Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Lu H. Inflammatory liver diseases and susceptibility to sepsis. Clin Sci (Lond) 2024; 138:435-487. [PMID: 38571396 DOI: 10.1042/cs20230522] [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: 09/03/2023] [Revised: 01/09/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
Patients with inflammatory liver diseases, particularly alcohol-associated liver disease and metabolic dysfunction-associated fatty liver disease (MAFLD), have higher incidence of infections and mortality rate due to sepsis. The current focus in the development of drugs for MAFLD is the resolution of non-alcoholic steatohepatitis and prevention of progression to cirrhosis. In patients with cirrhosis or alcoholic hepatitis, sepsis is a major cause of death. As the metabolic center and a key immune tissue, liver is the guardian, modifier, and target of sepsis. Septic patients with liver dysfunction have the highest mortality rate compared with other organ dysfunctions. In addition to maintaining metabolic homeostasis, the liver produces and secretes hepatokines and acute phase proteins (APPs) essential in tissue protection, immunomodulation, and coagulation. Inflammatory liver diseases cause profound metabolic disorder and impairment of energy metabolism, liver regeneration, and production/secretion of APPs and hepatokines. Herein, the author reviews the roles of (1) disorders in the metabolism of glucose, fatty acids, ketone bodies, and amino acids as well as the clearance of ammonia and lactate in the pathogenesis of inflammatory liver diseases and sepsis; (2) cytokines/chemokines in inflammatory liver diseases and sepsis; (3) APPs and hepatokines in the protection against tissue injury and infections; and (4) major nuclear receptors/signaling pathways underlying the metabolic disorders and tissue injuries as well as the major drug targets for inflammatory liver diseases and sepsis. Approaches that focus on the liver dysfunction and regeneration will not only treat inflammatory liver diseases but also prevent the development of severe infections and sepsis.
Collapse
Affiliation(s)
- Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, U.S.A
| |
Collapse
|
5
|
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: 7] [Impact Index Per Article: 7.0] [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
|
6
|
Levy E, Reilly JP. Pharmacologic Treatments in Acute Respiratory Failure. Crit Care Clin 2024; 40:275-289. [PMID: 38432696 DOI: 10.1016/j.ccc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure relies on supportive care using non-invasive and invasive oxygen and ventilatory support. Pharmacologic therapies for the most severe form of respiratory failure, acute respiratory distress syndrome (ARDS), are limited. This review focuses on the most promising therapies for ARDS, targeting different mechanisms that contribute to dysregulated inflammation and resultant hypoxemia. Significant heterogeneity exists within the ARDS population. Treatment requires prompt recognition of ARDS and an understanding of which patients may benefit most from specific pharmacologic interventions. The key to finding effective pharmacotherapies for ARDS may rely on deeper understanding of pathophysiology and bedside identification of ARDS subphenotypes.
Collapse
Affiliation(s)
- Elizabeth Levy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA.
| |
Collapse
|
7
|
Levine AR, Calfee CS. Subphenotypes of Acute Respiratory Distress Syndrome: Advancing Towards Precision Medicine. Tuberc Respir Dis (Seoul) 2024; 87:1-11. [PMID: 37675452 PMCID: PMC10758309 DOI: 10.4046/trd.2023.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common cause of severe hypoxemia defined by the acute onset of bilateral non-cardiogenic pulmonary edema. The diagnosis is made by defined consensus criteria. Supportive care, including prevention of further injury to the lungs, is the only treatment that conclusively improves outcomes. The inability to find more advanced therapies is due, in part, to the highly sensitive but relatively non-specific current syndromic consensus criteria, combining a heterogenous population of patients under the umbrella of ARDS. With few effective therapies, the morality rate remains 30% to 40%. Many subphenotypes of ARDS have been proposed to cluster patients with shared combinations of observable or measurable traits. Subphenotyping patients is a strategy to overcome heterogeneity to advance clinical research and eventually identify treatable traits. Subphenotypes of ARDS have been proposed based on radiographic patterns, protein biomarkers, transcriptomics, and/or machine-based clustering of clinical and biological variables. Some of these strategies have been reproducible across patient cohorts, but at present all have practical limitations to their implementation. Furthermore, there is no agreement on which strategy is the most appropriate. This review will discuss the current strategies for subphenotyping patients with ARDS, including the strengths and limitations, and the future directions of ARDS subphenotyping.
Collapse
Affiliation(s)
- Andrea R. Levine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
8
|
Kim YT, Huh JW, Choi YH, Yoon HK, Nguyen TT, Chun E, Jeong G, Park S, Ahn S, Lee WK, Noh YW, Lee KS, Ahn HS, Lee C, Lee SM, Kim KS, Suh GJ, Jeon K, Kim S, Jin M. Highly secreted tryptophanyl tRNA synthetase 1 as a potential theranostic target for hypercytokinemic severe sepsis. EMBO Mol Med 2024; 16:40-63. [PMID: 38177528 PMCID: PMC10883277 DOI: 10.1038/s44321-023-00004-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 01/06/2024] Open
Abstract
Despite intensive clinical and scientific efforts, the mortality rate of sepsis remains high due to the lack of precise biomarkers for patient stratification and therapeutic guidance. Secreted human tryptophanyl-tRNA synthetase 1 (WARS1), an endogenous ligand for Toll-like receptor (TLR) 2 and TLR4 against infection, activates the genes that signify the hyperinflammatory sepsis phenotype. High plasma WARS1 levels stratified the early death of critically ill patients with sepsis, along with elevated levels of cytokines, chemokines, and lactate, as well as increased numbers of absolute neutrophils and monocytes, and higher Sequential Organ Failure Assessment (SOFA) scores. These symptoms were recapitulated in severely ill septic mice with hypercytokinemia. Further, injection of WARS1 into mildly septic mice worsened morbidity and mortality. We created an anti-human WARS1-neutralizing antibody that suppresses proinflammatory cytokine expression in marmosets with endotoxemia. Administration of this antibody into severe septic mice attenuated cytokine storm, organ failure, and early mortality. With antibiotics, the antibody almost completely prevented fatalities. These data imply that blood-circulating WARS1-guided anti-WARS1 therapy may provide a novel theranostic strategy for life-threatening systemic hyperinflammatory sepsis.
Collapse
Affiliation(s)
- Yoon Tae Kim
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun Hui Choi
- R&D Center, MirimGENE, Incheon, Republic of Korea
| | | | | | - Eunho Chun
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Geunyeol Jeong
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Sunyoung Park
- Lee Gil Ya Cancer and Diabetes Institute, Gachon University, Incheon, Republic of Korea
| | - Sungwoo Ahn
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
| | - Won-Kyu Lee
- New Drug Development Center, Osong Medical Innovation Foundation, Cheongju, Republic of Korea
| | - Young-Woock Noh
- New Drug Development Center, Osong Medical Innovation Foundation, Cheongju, Republic of Korea
| | - Kyoung Sun Lee
- Non-Clinical Evaluation Center, Osong Medical Innovation Foundation, Cheongju, Republic of Korea
| | - Hee-Sung Ahn
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Cheolju Lee
- Chemical & Biological Integrative Research Center, Korea Institute of Science and Technology, Seoul, Republic of Korea
| | - Sang Min Lee
- Department of Internal Medicine, Gil Medical Center, College of Medicine, Gachon University, Incheon, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sunghoon Kim
- Medicinal Bioconvergence Research Center, Institute for Artificial Intelligence and Biomedical Research, The interdisciplinary graduate program in integrative biotechnology, College of Pharmacy & College of Medicine, Gangnam Severance Hospital, Yonsei University, Incheon, Republic of Korea
| | - Mirim Jin
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea.
- R&D Center, MirimGENE, Incheon, Republic of Korea.
- Lee Gil Ya Cancer and Diabetes Institute, Gachon University, Incheon, Republic of Korea.
- Department of Microbiology, College of Medicine, Gachon University, Incheon, Republic of Korea.
| |
Collapse
|
9
|
Xie S, Li J, Lyu F, Xiong Q, Gu P, Chen Y, Chen M, Bao J, Zhang X, Wei R, Deng Y, Wang H, Zeng Z, Chen Z, Deng Y, Lian Z, Zhao J, Gong W, Chen Y, Liu KX, Duan Y, Jiang Y, Zhou HW, Chen P. Novel tripeptide RKH derived from Akkermansia muciniphila protects against lethal sepsis. Gut 2023; 73:78-91. [PMID: 37553229 DOI: 10.1136/gutjnl-2023-329996] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/30/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE The pathogenesis of sepsis is complex, and the sepsis-induced systemic proinflammatory phase is one of the key drivers of organ failure and consequent mortality. Akkermansia muciniphila (AKK) is recognised as a functional probiotic strain that exerts beneficial effects on the progression of many diseases; however, whether AKK participates in sepsis pathogenesis is still unclear. Here, we evaluated the potential contribution of AKK to lethal sepsis development. DESIGN Relative abundance of gut microbial AKK in septic patients was evaluated. Cecal ligation and puncture (CLP) surgery and lipopolysaccharide (LPS) injection were employed to establish sepsis in mice. Non-targeted and targeted metabolomics analysis were used for metabolites analysis. RESULTS We first found that the relative abundance of gut microbial AKK in septic patients was significantly reduced compared with that in non-septic controls. Live AKK supplementation, as well as supplementation with its culture supernatant, remarkably reduced sepsis-induced mortality in sepsis models. Metabolomics analysis and germ-free mouse validation experiments revealed that live AKK was able to generate a novel tripeptide Arg-Lys-His (RKH). RKH exerted protective effects against sepsis-induced death and organ damage. Furthermore, RKH markedly reduced sepsis-induced inflammatory cell activation and proinflammatory factor overproduction. A mechanistic study revealed that RKH could directly bind to Toll-like receptor 4 (TLR4) and block TLR4 signal transduction in immune cells. Finally, we validated the preventive effects of RKH against sepsis-induced systemic inflammation and organ damage in a piglet model. CONCLUSION We revealed that a novel tripeptide, RKH, derived from live AKK, may act as a novel endogenous antagonist for TLR4. RKH may serve as a novel potential therapeutic approach to combat lethal sepsis after successfully translating its efficacy into clinical practice.
Collapse
Affiliation(s)
- Shihao Xie
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Department of Critical Care Medicine, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Jiaxin Li
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Department of Critical Care Medicine, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Fengyuan Lyu
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Qingming Xiong
- Department of Anesthesiology, The First People's Hospital of Foshan, Foshan, China
| | - Peng Gu
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Yuqi Chen
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Meiling Chen
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Jingna Bao
- Department of Critical Care Medicine, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Xianglong Zhang
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Rongjuan Wei
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Youpeng Deng
- Department of Infectious Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Hongzheng Wang
- Department of Infectious Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yongqiang Deng
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Zhuoshi Lian
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, China
| | - Jie Zhao
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, China
| | - Wei Gong
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Ye Chen
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Ke-Xuan Liu
- Departmentof Anesthesiology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yi Duan
- Department of Infectious Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Yong Jiang
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Hong-Wei Zhou
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Peng Chen
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Proteomics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| |
Collapse
|
10
|
Bode C, Weis S, Sauer A, Wendel-Garcia P, David S. Targeting the host response in sepsis: current approaches and future evidence. Crit Care 2023; 27:478. [PMID: 38057824 PMCID: PMC10698949 DOI: 10.1186/s13054-023-04762-6] [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: 09/13/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
Sepsis, a dysregulated host response to infection characterized by organ failure, is one of the leading causes of death worldwide. Disbalances of the immune response play an important role in its pathophysiology. Patients may develop simultaneously or concomitantly states of systemic or local hyperinflammation and immunosuppression. Although a variety of effective immunomodulatory treatments are generally available, attempts to inhibit or stimulate the immune system in sepsis have failed so far to improve patients' outcome. The underlying reason is likely multifaceted including failure to identify responders to a specific immune intervention and the complex pathophysiology of organ dysfunction that is not exclusively caused by immunopathology but also includes dysfunction of the coagulation system, parenchymal organs, and the endothelium. Increasing evidence suggests that stratification of the heterogeneous population of septic patients with consideration of their host response might led to treatments that are more effective. The purpose of this review is to provide an overview of current studies aimed at optimizing the many facets of host response and to discuss future perspectives for precision medicine approaches in sepsis.
Collapse
Affiliation(s)
- Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll Institute-HKI, Jena, Germany
| | - Andrea Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Pedro Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
11
|
Ardila SM, Weeks HM, Dahmer MK, Kaciroti N, Quasney M, Sapru A, Curley MAQ, Flori HR. A Targeted Analysis of Serial Cytokine Measures and Nonpulmonary Organ System Failure in Children With Acute Respiratory Failure: Individual Measures and Trajectories Over Time. Pediatr Crit Care Med 2023; 24:727-737. [PMID: 37195096 PMCID: PMC10524322 DOI: 10.1097/pcc.0000000000003286] [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: 05/18/2023]
Abstract
OBJECTIVES There is a need for research exploring the temporal trends of nonpulmonary organ dysfunction (NPOD) and biomarkers in order to identify unique predictive or prognostic phenotypes. We examined the associations between the number and trajectories of NPODs and plasma biomarkers of early and late inflammatory cascade activation, specifically plasma interleukin-1 receptor antagonist (IL-1ra) and interleukin-8 (IL-8), respectively, in the setting of acute respiratory failure (ARF). DESIGN Secondary analysis of the Randomized Evaluation for Sedation Titration for Respiratory Failure clinical trial and Biomarkers in Acute Lung Injury (BALI) ancillary study. SETTING Multicenter. PATIENTS Intubated pediatric patients with ARF. INTERVENTIONS NPODs were evaluated against plasma IL-1ra and IL-8 levels on individual days (1 to 4 d after intubation) and longitudinally across days. MEASUREMENTS AND MAIN RESULTS Within the BALI cohort, 432 patients had at least one value for IL-1ra or IL-8 within days 0 through 5. 36.6% had a primary diagnosis of pneumonia, 18.5% had a primary diagnosis of sepsis and 8.1% died. Multivariable logistic regression models showed that increasing levels of both plasma IL-1ra and IL-8 were statistically significantly associated with increasing numbers of NPODs (IL-1ra: days 1-3; IL-8: days 1-4), independent of sepsis diagnosis, severity of oxygenation defect, age, and race/ethnicity. Longitudinal trajectory analysis identified four distinct NPOD trajectories and seven distinct plasma IL-1ra and IL-8 trajectories. Multivariable ordinal logistic regression revealed that specific IL-1ra and IL-8 trajectory groups were associated with greater NPOD trajectory group ( p = 0.004 and p < 0.0001, respectively), independent of severity of oxygenation defect, age, sepsis diagnosis, and race/ethnicity. CONCLUSIONS Both the inflammatory biomarkers and number of NPODs exhibit distinct trajectories over time with strong associations with one another. These biomarkers and their trajectory patterns may be useful in evaluating the severity of multiple organ dysfunction syndrome in critically ill children and identifying those phenotypes with time-sensitive, treatable traits.
Collapse
Affiliation(s)
- Silvia M Ardila
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Heidi M Weeks
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Niko Kaciroti
- Center for Human Growth and Development, University of Michigan, Ann Arbor, MI
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Michael Quasney
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Martha A Q Curley
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI
- Center for Human Growth and Development, University of Michigan, Ann Arbor, MI
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
- Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| |
Collapse
|
12
|
Fadanni GP, Calixto JB. Recent progress and prospects for anti-cytokine therapy in preclinical and clinical acute lung injury. Cytokine Growth Factor Rev 2023; 71-72:13-25. [PMID: 37481378 DOI: 10.1016/j.cytogfr.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 07/24/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous cause of respiratory failure that has a rapid onset, a high mortality rate, and for which there is no effective pharmacological treatment. Current evidence supports a critical role of excessive inflammation in ARDS, resulting in several cytokines, cytokine receptors, and proteins within their downstream signalling pathways being putative therapeutic targets. However, unsuccessful trials of anti-inflammatory drugs have thus far hindered progress in the field. In recent years, the prospects of precision medicine and therapeutic targeting of cytokines coevolving into effective treatments have gained notoriety. There is an optimistic and growing understanding of ARDS subphenotypes as well as advances in treatment strategies and clinical trial design. Furthermore, large trials of anti-cytokine drugs in patients with COVID-19 have provided an unprecedented amount of information that could pave the way for therapeutic breakthroughs. While current clinical and nonclinical ARDS research suggest relatively limited potential in monotherapy with anti-cytokine drugs, combination therapy has emerged as an appealing strategy and may provide new perspectives on finding safe and effective treatments. Accurate evaluation of these drugs, however, also relies on well-founded experimental research and the implementation of biomarker-guided stratification in future trials. In this review, we provide an overview of anti-cytokine therapy for acute lung injury and ARDS, highlighting the current preclinical and clinical evidence for targeting the main cytokines individually and the therapeutic prospects for combination therapy.
Collapse
Affiliation(s)
- Guilherme Pasetto Fadanni
- Centre of Innovation and Preclinical Studies (CIEnP), Florianópolis, Santa Catarina, Brazil; Department of Pharmacology, Centre of Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil.
| | - João Batista Calixto
- Centre of Innovation and Preclinical Studies (CIEnP), Florianópolis, Santa Catarina, Brazil; Department of Pharmacology, Centre of Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil.
| |
Collapse
|
13
|
Vigneron C, Py BF, Monneret G, Venet F. The double sides of NLRP3 inflammasome activation in sepsis. Clin Sci (Lond) 2023; 137:333-351. [PMID: 36856019 DOI: 10.1042/cs20220556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 03/02/2023]
Abstract
Sepsis is defined as a life-threatening organ dysfunction induced by a dysregulated host immune response to infection. Immune response induced by sepsis is complex and dynamic. It is schematically described as an early dysregulated systemic inflammatory response leading to organ failures and early deaths, followed by the development of persistent immune alterations affecting both the innate and adaptive immune responses associated with increased risk of secondary infections, viral reactivations, and late mortality. In this review, we will focus on the role of NACHT, leucin-rich repeat and pyrin-containing protein 3 (NLRP3) inflammasome in the pathophysiology of sepsis. NLRP3 inflammasome is a multiproteic intracellular complex activated by infectious pathogens through a two-step process resulting in the release of the pro-inflammatory cytokines IL-1β and IL-18 and the formation of membrane pores by gasdermin D, inducing a pro-inflammatory form of cell death called pyroptosis. The role of NLRP3 inflammasome in the pathophysiology of sepsis can be ambivalent. Indeed, although it might protect against sepsis when moderately activated after initial infection, excessive NLRP3 inflammasome activation can induce dysregulated inflammation leading to multiple organ failure and death during the acute phase of the disease. Moreover, this activation might become exhausted and contribute to post-septic immunosuppression, driving impaired functions of innate and adaptive immune cells. Targeting the NLRP3 inflammasome could thus be an attractive option in sepsis either through IL-1β and IL-18 antagonists or through inhibition of NLRP3 inflammasome pathway downstream components. Available treatments and results of first clinical trials will be discussed.
Collapse
Affiliation(s)
- Clara Vigneron
- Centre International de Recherche en Infectiologie (CIRI), Univ Lyon, Inserm, U1111, Université Claude Bernard-Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Bénédicte F Py
- Centre International de Recherche en Infectiologie (CIRI), Univ Lyon, Inserm, U1111, Université Claude Bernard-Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Guillaume Monneret
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux), Joint Research Unit HCL-bioMérieux, Edouard Herriot Hospital, Lyon, France
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Fabienne Venet
- Centre International de Recherche en Infectiologie (CIRI), Univ Lyon, Inserm, U1111, Université Claude Bernard-Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| |
Collapse
|
14
|
Martinez GS, Ostadgavahi AT, Al-Rafat AM, Garduno A, Cusack R, Bermejo-Martin JF, Martin-Loeches I, Kelvin D. Model-interpreted outcomes of artificial neural networks classifying immune biomarkers associated with severe infections in ICU. Front Immunol 2023; 14:1137850. [PMID: 36969221 PMCID: PMC10034398 DOI: 10.3389/fimmu.2023.1137850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionMillions of deaths worldwide are a result of sepsis (viral and bacterial) and septic shock syndromes which originate from microbial infections and cause a dysregulated host immune response. These diseases share both clinical and immunological patterns that involve a plethora of biomarkers that can be quantified and used to explain the severity level of the disease. Therefore, we hypothesize that the severity of sepsis and septic shock in patients is a function of the concentration of biomarkers of patients.MethodsIn our work, we quantified data from 30 biomarkers with direct immune function. We used distinct Feature Selection algorithms to isolate biomarkers to be fed into machine learning algorithms, whose mapping of the decision process would allow us to propose an early diagnostic tool.ResultsWe isolated two biomarkers, i.e., Programmed Death Ligand-1 and Myeloperoxidase, that were flagged by the interpretation of an Artificial Neural Network. The upregulation of both biomarkers was indicated as contributing to increase the severity level in sepsis (viral and bacterial induced) and septic shock patients.DiscussionIn conclusion, we built a function considering biomarker concentrations to explain severity among sepsis, sepsis COVID, and septic shock patients. The rules of this function include biomarkers with known medical, biological, and immunological activity, favoring the development of an early diagnosis system based in knowledge extracted from artificial intelligence.
Collapse
Affiliation(s)
- Gustavo Sganzerla Martinez
- Laboratory of Emerging Infectious Diseases, Department of Immunology and Microbiology, Dalhousie University, Halifax, NS, Canada
- Department of Pediatrics, Izaak Walton Killan (IWK) Health Center, CCfV, Halifax, NS, Canada
- *Correspondence: David Kelvin, ; Gustavo Sganzerla Martinez,
| | - Ali Toloue Ostadgavahi
- Laboratory of Emerging Infectious Diseases, Department of Immunology and Microbiology, Dalhousie University, Halifax, NS, Canada
- Department of Pediatrics, Izaak Walton Killan (IWK) Health Center, CCfV, Halifax, NS, Canada
| | - Abdullah Mahmud Al-Rafat
- Laboratory of Emerging Infectious Diseases, Department of Immunology and Microbiology, Dalhousie University, Halifax, NS, Canada
- Department of Pediatrics, Izaak Walton Killan (IWK) Health Center, CCfV, Halifax, NS, Canada
| | - Alexis Garduno
- Department of Clinical Medicine, Trinity College, University of Dublin, Dublin, Ireland
| | - Rachael Cusack
- Department of Clinical Medicine, Trinity College, University of Dublin, Dublin, Ireland
| | - Jesus Francisco Bermejo-Martin
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Gerencia Regional de Salud de Castilla y León, Paseo de San Vicente, Salamanca, Spain
- Universidad de Salamanca, C. Alfonso X el Sabio, s/n, Salamanca, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), CB22/06/00035, Instituto de Salud Carlos III, Avenida de Monforte de Lemos, Madrid, Spain
| | | | - David Kelvin
- Laboratory of Emerging Infectious Diseases, Department of Immunology and Microbiology, Dalhousie University, Halifax, NS, Canada
- Department of Pediatrics, Izaak Walton Killan (IWK) Health Center, CCfV, Halifax, NS, Canada
- *Correspondence: David Kelvin, ; Gustavo Sganzerla Martinez,
| |
Collapse
|
15
|
Integrating biology into clinical trial design. Curr Opin Crit Care 2023; 29:26-33. [PMID: 36580371 DOI: 10.1097/mcc.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Critical care medicine revolves around syndromes, such as acute respiratory distress syndrome (ARDS), sepsis and acute kidney injury. Few interventions have shown to be effective in large clinical trials, likely because of between-patient heterogeneity. Translational evidence suggests that more homogeneous biological subgroups can be identified and that differential treatment effects exist. Integrating biological considerations into clinical trial design is therefore an important frontier of critical care research. RECENT FINDINGS The pathophysiology of critical care syndromes involves a multiplicity of processes, which emphasizes the difficulty of integrating biology into clinical trial design. Biological assessment can be integrated into clinical trials using predictive enrichment at trial inclusion, time-dependent variation to better understand treatment effects and biological markers as surrogate outcomes. SUMMARY Integrating our knowledge on biological heterogeneity into clinical trial design, which has revolutionized other medical fields, could serve as a solution to implement personalized treatment in critical care syndromes. Changing the trial design by using predictive enrichment, incorporation of the evaluation of time-dependent changes and biological markers as surrogate outcomes may improve the likelihood of detecting a beneficial effect from targeted therapeutic interventions and the opportunity to test multiple lines of treatment per patient.
Collapse
|
16
|
Abstract
Heterogeneity in sepsis and acute respiratory distress syndrome (ARDS) is increasingly being recognized as one of the principal barriers to finding efficacious targeted therapies. The advent of multiple high-throughput biological data ("omics"), coupled with the widespread access to increased computational power, has led to the emergence of phenotyping in critical care. Phenotyping aims to use a multitude of data to identify homogenous subgroups within an otherwise heterogenous population. Increasingly, phenotyping schemas are being applied to sepsis and ARDS to increase understanding of these clinical conditions and identify potential therapies. Here we present a selective review of the biological phenotyping schemas applied to sepsis and ARDS. Further, we outline some of the challenges involved in translating these conceptual findings to bedside clinical decision-making tools.
Collapse
Affiliation(s)
- Pratik Sinha
- Division of Clinical & Translational Research and Division of Critical Care, Department of Anesthesia, Washington University, St. Louis, Missouri, USA;
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine; Center for Translational Lung Biology; and Lung Biology Institute, University of Pennsylvania Perelman School of Medicine; Philadelphia, Pennsylvania, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
17
|
Use of Mendelian randomization to better understand and treat sepsis. Intensive Care Med 2022; 48:1638-1641. [PMID: 36104530 PMCID: PMC9473480 DOI: 10.1007/s00134-022-06778-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/02/2022] [Indexed: 11/22/2022]
|
18
|
Leligdowicz A, Harhay MO, Calfee CS. Immune Modulation in Sepsis, ARDS, and Covid-19 - The Road Traveled and the Road Ahead. NEJM EVIDENCE 2022; 1:EVIDra2200118. [PMID: 38319856 DOI: 10.1056/evidra2200118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Immune Modulation in Sepsis, ARDS, and Covid-19Leligdowicz et al. consider the history and future of immunomodulating therapies in sepsis and ARDS, including ARDS due to Covid-19, and remark on the larger challenge of clinical research on therapies for syndromes with profound clinical and biologic heterogeneity.
Collapse
Affiliation(s)
- Aleksandra Leligdowicz
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada
- Robarts Research Institute, Western University, London, ON, Canada
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco
| |
Collapse
|
19
|
Hong Y, Chen L, Sun J, Xing L, Yang Y, Jin X, Cai H, Dong L, Zhou L, Zhang Z. Single-cell transcriptome profiling reveals heterogeneous neutrophils with prognostic values in sepsis. iScience 2022; 25:105301. [PMID: 36304125 PMCID: PMC9593767 DOI: 10.1016/j.isci.2022.105301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/16/2022] [Accepted: 09/29/2022] [Indexed: 11/20/2022] Open
Abstract
Neutrophils constitute the largest proportion of nucleated peripheral blood cells, and neutrophils have substantial heterogeneity. We profiled nearly 300,000 human peripheral blood cells in this study using single-cell RNA sequencing. A large proportion (>50%) of these cells were annotated as neutrophils. Neutrophils were further clustered into four subtypes, including Neu1, Neu2, Neu3, and Neu4. Neu1 is characterized by high expression of MMP9, HP, and RGL4. Neu1 was associated with septic shock and significantly correlated with the sequential organ failure assessment (SOFA) score. A gene expression module in Neu1 named Neu1_C (characterized by expression of NFKBIA, CXCL8, G0S2, and FTH1) was highly predictive of septic shock with an area under the curve of 0.81. The results were extensively validated in external bulk datasets by using single-cell deconvolution methods. In summary, our study establishes a general framework for studying neutrophil-related mechanisms, prognostic biomarkers, and potential therapeutic targets for septic shock. Neutrophils were clustered into four subtypes, including Neu1, Neu2, Neu3, and Neu4 Neu1 was associated with septic shock Neu1 was correlated with the sequential organ failure assessment (SOFA) score A gene expression module in Neu1 named Neu1_C was highly predictive of septic shock
Collapse
Affiliation(s)
- Yucai Hong
- Department of Emergency Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Lin Chen
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Jian Sun
- Department of Critical Care Medicine, Lishui Center Hospital, Lishui, Zhejiang 323000, China
| | - Lifeng Xing
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yi Yang
- Department of Emergency Medicine, The Second Hospital of Jiaxing, Jiaxing, 314000, P.R.China
| | - Xiaohong Jin
- Department of Emergency Medicine, The Affiliated Wenling Hospital of Wenzhou Medical University, Wenling 317500, Zhejiang Province, China
| | - Huabo Cai
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Lianlian Dong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Liping Zhou
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China,Key Laboratory of Digital Technology in Medical Diagnostics Of Zhejiang Province, Hangzhou, Zhejiang, China,Corresponding author
| |
Collapse
|
20
|
Williamson SF, Grayling MJ, Mander AP, Noor NM, Savage JS, Yap C, Wason JMS. Subgroup analyses in randomized controlled trials frequently categorized continuous subgroup information. J Clin Epidemiol 2022; 150:72-79. [PMID: 35788399 DOI: 10.1016/j.jclinepi.2022.06.017] [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: 03/29/2022] [Revised: 06/15/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES To investigate how subgroup analyses of published Randomized Controlled Trials (RCTs) are performed when subgroups are created from continuous variables. METHODS We carried out a review of RCTs published in 2016-2021 that included subgroup analyses. Information was extracted on whether any of the subgroups were based on continuous variables and, if so, how they were analyzed. RESULTS Out of 428 reviewed papers, 258 (60.4%) reported RCTs with a subgroup analysis. Of these, 178/258 (69%) had at least one subgroup formed from a continuous variable and 14/258 (5.4%) were unclear. The vast majority (169/178, 94.9%) dichotomized the continuous variable and treated the subgroup as categorical. The most common way of dichotomizing was using a pre-specified cutpoint (129/169, 76.3%), followed by a data-driven cutpoint (26/169, 15.4%), such as the median. CONCLUSION It is common for subgroup analyses to use continuous variables to define subgroups. The vast majority dichotomize the continuous variable and, consequently, may lose substantial amounts of statistical information (equivalent to reducing the sample size by at least a third). More advanced methods that can improve efficiency, through optimally choosing cutpoints or directly using the continuous information, are rarely used.
Collapse
Affiliation(s)
- S Faye Williamson
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michael J Grayling
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Nurulamin M Noor
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Joshua S Savage
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - James M S Wason
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
| |
Collapse
|
21
|
The End of “One Size Fits All” Sepsis Therapies: Toward an Individualized Approach. Biomedicines 2022; 10:biomedicines10092260. [PMID: 36140361 PMCID: PMC9496597 DOI: 10.3390/biomedicines10092260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 12/20/2022] Open
Abstract
Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection, remains a major challenge for clinicians and trialists. Despite decades of research and multiple randomized clinical trials, a specific therapeutic for sepsis is not available. The evaluation of therapeutics targeting components of host response anomalies in patients with sepsis has been complicated by the inability to identify those in this very heterogeneous population who are more likely to benefit from a specific intervention. Additionally, multiple and diverse host response aberrations often co-exist in sepsis, and knowledge of which dysregulated biological organ system or pathway drives sepsis-induced pathology in an individual patient is limited, further complicating the development of effective therapies. Here, we discuss the drawbacks of previous attempts to develop sepsis therapeutics and delineate a future wherein interventions will be based on the host response profile of a patient.
Collapse
|
22
|
Martin TR, Zemans RL, Ware LB, Schmidt EP, Riches DWH, Bastarache L, Calfee CS, Desai TJ, Herold S, Hough CL, Looney MR, Matthay MA, Meyer N, Parikh SM, Stevens T, Thompson BT. New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021. Am J Respir Cell Mol Biol 2022; 67:284-308. [PMID: 35679511 PMCID: PMC9447141 DOI: 10.1165/rcmb.2022-0089ws] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.
Collapse
Affiliation(s)
- Thomas R. Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rachel L. Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Program in Cellular and Molecular Biology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric P. Schmidt
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David W. H. Riches
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Program in Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Anesthesia
| | - Tushar J. Desai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Stem Cell Institute, Stanford University School of Medicine, Stanford, California
| | - Susanne Herold
- Department of Internal Medicine VI and Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir M. Parikh
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
23
|
Vaara ST, Bhatraju PK, Stanski NL, McMahon BA, Liu K, Joannidis M, Bagshaw SM. Subphenotypes in acute kidney injury: a narrative review. Crit Care 2022; 26:251. [PMID: 35986336 PMCID: PMC9389711 DOI: 10.1186/s13054-022-04121-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/20/2022] [Indexed: 11/26/2022] Open
Abstract
Acute kidney injury (AKI) is a frequently encountered syndrome especially among the critically ill. Current diagnosis of AKI is based on acute deterioration of kidney function, indicated by an increase in creatinine and/or reduced urine output. However, this syndromic definition encompasses a wide variety of distinct clinical features, varying pathophysiology, etiology and risk factors, and finally very different short- and long-term outcomes. Lumping all AKI together may conceal unique pathophysiologic processes specific to certain AKI populations, and discovering these AKI subphenotypes might help to develop targeted therapies tackling unique pathophysiological processes. In this review, we discuss the concept of AKI subphenotypes, current knowledge regarding both clinical and biomarker-driven subphenotypes, interplay with AKI subphenotypes and other ICU syndromes, and potential future and clinical implications.
Collapse
Affiliation(s)
- Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, Meilahti Hospital, University of Helsinki and Helsinki University Hospital, PO Box 340, 00290, Helsinki, Finland.
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
- Sepsis Center of Research Excellence (SCORE), University of Washington, Seattle, USA
| | - Natalja L Stanski
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Blaithin A McMahon
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kathleen Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, USA
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| |
Collapse
|
24
|
The Clinical Efficacy and Economic Benefits of Recombinant Human Thrombopoietin for the Treatment of Chemotherapy or Chemoradiotherapy-Induced Thrombocytopenia. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2256690. [PMID: 35909587 PMCID: PMC9303501 DOI: 10.1155/2022/2256690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 12/25/2022]
Abstract
Even though cytopenia caused by either chemotherapy or radiotherapy is a common complication in cancer patients, chemoradiotherapy remains an essential treatment for the majority of patients. The purpose of this study was to look into the clinical efficacy and cost-effectiveness of recombinant human thrombopoietin (rhTPO) in treating chemo- or chemoradiotherapy-induced grade II, III, and IV thrombocytopenia. From December 2019 to November 2020, 233 lung cancer patients admitted to our hospital with chemotherapy- or chemoradiotherapy-induced thrombocytopenia were enrolled and treated with rhTPO. The study's findings revealed a significant disparity in the use of concurrent chemoradiotherapy in patients with grade II, III, and IV thrombocytopenia. All costs, including rhTPO treatment costs, platelet costs, drug costs, and nondrug costs, tended to rise as the severity of thrombocytopenia increased. In the treatment of chemotherapy or radiotherapy-induced thrombocytopenia, rhTPO has shown good clinical efficacy. In the treatment of grade II thrombocytopenia, rhTPO has a favorable economic evaluation. As a result, early intervention and thrombocytopenia treatment should be provided, which warrants further clinical investigation.
Collapse
|
25
|
Lemieux SM. Corticosteroids in acute respiratory distress syndrome: One size does not fit all. Am J Health Syst Pharm 2022; 79:1115-1117. [PMID: 35278305 DOI: 10.1093/ajhp/zxac078] [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: 12/15/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Collapse
Affiliation(s)
- Steven M Lemieux
- Department of Pharmacy, VA Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
26
|
Alipanah N, Calfee CS. Phenotyping in acute respiratory distress syndrome: state of the art and clinical implications. Curr Opin Crit Care 2022; 28:1-8. [PMID: 34670998 PMCID: PMC8782441 DOI: 10.1097/mcc.0000000000000903] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Decades of research in acute respiratory distress syndrome (ARDS) have led to few interventions that impact clinical outcomes. The pandemic of patients with ARDS due to the novel SARS-CoV-2 infection has stressed the need for more effective therapies in ARDS. Phenotyping may enable successful trials and precision therapeutics in this patient population. RECENT FINDINGS Clinical phenotypes that group patients by shared cause, time-course or radiographic presentation are of prognostic value, but their use is limited by misclassification. Physiological phenotypes, including the P/F ratio, ventilatory ratio and dead space fraction, predict poor outcomes but can rapidly change, making them unstable over time. Biologic phenotypes have prognostic value with composite clinical and biomarker sub-phenotypes additionally impacting treatment response but are yet to be prospectively validated. SUMMARY Although much progress has been made in ARDS phenotyping, implementation of precision medicine practices will depend on conducting phenotype-aware trials using rapid point of care assays or machine learning algorithms. Omics studies will enhance our understanding of biologic determinants of clinical outcomes in ARDS sub-phenotypes. Whether biologic ARDS sub-phenotypes are specific to this syndrome or rather more broadly identify endotypes of critical illness remains to be determined.
Collapse
Affiliation(s)
- Narges Alipanah
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco
- Department of Anesthesia, University of California San Francisco
| |
Collapse
|
27
|
IL-38 Alleviates Inflammation in Sepsis in Mice by Inhibiting Macrophage Apoptosis and Activation of the NLRP3 Inflammasome. Mediators Inflamm 2021; 2021:6370911. [PMID: 34955683 PMCID: PMC8709774 DOI: 10.1155/2021/6370911] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 12/27/2022] Open
Abstract
Interleukin- (IL-) 38 is an emerging cytokine with multiple functions involved in infection and immunity. However, the potential role of IL-38 in the host immune response during sepsis remains elusive. Herein, we investigated if macrophages in septic mice express IL-38, the molecular mechanisms behind its expression, and the downstream effects of its expression. In mouse peritoneal macrophages, lipopolysaccharide (LPS) upregulated IL-38 and its receptor IL-36R, and the resulting IL-38 shifted macrophages from a M1 to M2 phenotype. Moreover, exposure to IL-38 alone was sufficient to inhibit macrophage apoptosis and LPS-driven activation of the NOD-, LRR-, and pyrin domain-containing 3 (NLRP3) inflammasome. These effects were partly abrogated by IL-38 downregulation. In septic mice, IL-38 markedly lowered serum concentrations of proinflammatory cytokines and greatly improved survival. Conversely, IL-38 blockade aggravated their mortality. Collectively, these findings present IL-38 as a potent immune modulator that restrains the inflammatory response by suppressing macrophage apoptosis and activation of the NLRP3 inflammasome. IL-38 may help protect organs from sepsis-related injury.
Collapse
|
28
|
Tang XD, Ji TT, Dong JR, Feng H, Chen FQ, Chen X, Zhao HY, Chen DK, Ma WT. Pathogenesis and Treatment of Cytokine Storm Induced by Infectious Diseases. Int J Mol Sci 2021; 22:13009. [PMID: 34884813 PMCID: PMC8658039 DOI: 10.3390/ijms222313009] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022] Open
Abstract
Cytokine storm is a phenomenon characterized by strong elevated circulating cytokines that most often occur after an overreactive immune system is activated by an acute systemic infection. A variety of cells participate in cytokine storm induction and progression, with profiles of cytokines released during cytokine storm varying from disease to disease. This review focuses on pathophysiological mechanisms underlying cytokine storm induction and progression induced by pathogenic invasive infectious diseases. Strategies for targeted treatment of various types of infection-induced cytokine storms are described from both host and pathogen perspectives. In summary, current studies indicate that cytokine storm-targeted therapies can effectively alleviate tissue damage while promoting the clearance of invading pathogens. Based on this premise, "multi-omics" immune system profiling should facilitate the development of more effective therapeutic strategies to alleviate cytokine storms caused by various diseases.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - De-Kun Chen
- College of Veterinary Medicine, Northwest A&F University, Yangling District, Xianyang 712100, China; (X.-D.T.); (T.-T.J.); (J.-R.D.); (H.F.); (F.-Q.C.); (X.C.); (H.-Y.Z.)
| | - Wen-Tao Ma
- College of Veterinary Medicine, Northwest A&F University, Yangling District, Xianyang 712100, China; (X.-D.T.); (T.-T.J.); (J.-R.D.); (H.F.); (F.-Q.C.); (X.C.); (H.-Y.Z.)
| |
Collapse
|
29
|
Zhang YY, Ning BT. Signaling pathways and intervention therapies in sepsis. Signal Transduct Target Ther 2021; 6:407. [PMID: 34824200 PMCID: PMC8613465 DOI: 10.1038/s41392-021-00816-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by dysregulated host systemic inflammatory and immune response to infection. Over decades, advanced understanding of host-microorganism interaction has gradually unmasked the genuine nature of sepsis, guiding toward new definition and novel therapeutic approaches. Diverse clinical manifestations and outcomes among infectious patients have suggested the heterogeneity of immunopathology, while systemic inflammatory responses and deteriorating organ function observed in critically ill patients imply the extensively hyperactivated cascades by the host defense system. From focusing on microorganism pathogenicity, research interests have turned toward the molecular basis of host responses. Though progress has been made regarding recognition and management of clinical sepsis, incidence and mortality rate remain high. Furthermore, clinical trials of therapeutics have failed to obtain promising results. As far as we know, there was no systematic review addressing sepsis-related molecular signaling pathways and intervention therapy in literature. Increasing studies have succeeded to confirm novel functions of involved signaling pathways and comment on efficacy of intervention therapies amid sepsis. However, few of these studies attempt to elucidate the underlining mechanism in progression of sepsis, while other failed to integrate preliminary findings and describe in a broader view. This review focuses on the important signaling pathways, potential molecular mechanism, and pathway-associated therapy in sepsis. Host-derived molecules interacting with activated cells possess pivotal role for sepsis pathogenesis by dynamic regulation of signaling pathways. Cross-talk and functions of these molecules are also discussed in detail. Lastly, potential novel therapeutic strategies precisely targeting on signaling pathways and molecules are mentioned.
Collapse
Affiliation(s)
- Yun-Yu Zhang
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 200127, Shanghai, China
| | - Bo-Tao Ning
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 200127, Shanghai, China.
| |
Collapse
|
30
|
Wick KD, McAuley DF, Levitt JE, Beitler JR, Annane D, Riviello ED, Calfee CS, Matthay MA. Promises and challenges of personalized medicine to guide ARDS therapy. Crit Care 2021; 25:404. [PMID: 34814925 PMCID: PMC8609268 DOI: 10.1186/s13054-021-03822-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/09/2021] [Indexed: 02/08/2023] Open
Abstract
Identifying new effective treatments for the acute respiratory distress syndrome (ARDS), including COVID-19 ARDS, remains a challenge. The field of ARDS investigation is moving increasingly toward innovative approaches such as the personalization of therapy to biological and clinical sub-phenotypes. Additionally, there is growing recognition of the importance of the global context to identify effective ARDS treatments. This review highlights emerging opportunities and continued challenges for personalizing therapy for ARDS, from identifying treatable traits to innovative clinical trial design and recognition of patient-level factors as the field of critical care investigation moves forward into the twenty-first century.
Collapse
Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA.
| | - Daniel F McAuley
- Belfast Health and Social Care Trust, Royal Victoria Hospital and Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Djillali Annane
- Department of Intensive Care, FHU SEPSIS, and RHU RECORDS, Hôpital Raymond Poincaré (APHP), Garches, France
- Laboratory of Infection & Inflammation, School of Medicine Simone Veil, INSERM, University Versailles Saint Quentin, University Paris Saclay, Garches, France
| | - Elisabeth D Riviello
- Harvard Medical School and Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carolyn S Calfee
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
31
|
van der Poll T, Shankar-Hari M, Wiersinga WJ. The immunology of sepsis. Immunity 2021; 54:2450-2464. [PMID: 34758337 DOI: 10.1016/j.immuni.2021.10.012] [Citation(s) in RCA: 286] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/26/2021] [Accepted: 10/13/2021] [Indexed: 12/12/2022]
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to an infection. This recently implemented definition does not capture the heterogeneity or the underlying pathophysiology of the syndrome, which is characterized by concurrent unbalanced hyperinflammation and immune suppression. Here, we review current knowledge of aberrant immune responses during sepsis and recent initiatives to stratify patients with sepsis into subgroups that are more alike from a clinical and/or pathobiological perspective, which could be key for identification of patients who are more likely to benefit from specific immune interventions.
Collapse
Affiliation(s)
- Tom van der Poll
- Amsterdam University Medical Centers, University of Amsterdam, Center of Experimental and Molecular Medicine & Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
| | - Manu Shankar-Hari
- King's College London, Department of Infectious Diseases, School of Immunology and Microbial Sciences, London, UK; Guy's and St Thomas' NHS Foundation Trust, Department of Intensive Care Medicine, London, UK
| | - W Joost Wiersinga
- Amsterdam University Medical Centers, University of Amsterdam, Center of Experimental and Molecular Medicine & Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| |
Collapse
|
32
|
Giannini HM, Meyer NJ. Genetics of Acute Respiratory Distress Syndrome: Pathways to Precision. Crit Care Clin 2021; 37:817-834. [PMID: 34548135 DOI: 10.1016/j.ccc.2021.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Clinical risk factors alone fail to fully explain acute respiratory distress syndrome (ARDS) risk or ARDS death, suggesting that individual risk factors contribute. The goals of genomic ARDS studies include better mechanistic understanding, identifying dysregulated pathways that may be amenable to pharmacologic targeting, using genomic causal inference techniques to find measurable traits with meaning, and deconvoluting ARDS heterogeneity by proving reproducible subpopulations that may share a unique biology. This article discusses the latest advances in ARDS genomics, provides historical perspective, and highlights some of the ways that the coronavirus disease 2019 (COVID-19) pandemic is accelerating genomic ARDS research.
Collapse
Affiliation(s)
- Heather M Giannini
- University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 5038 Gates Building, Philadelphia, PA 19104, USA
| | - Nuala J Meyer
- University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 5038 Gates Building, Philadelphia, PA 19104, USA.
| |
Collapse
|
33
|
Nunnally ME, Ferrer R, Martin GS, Martin-Loeches I, Machado FR, De Backer D, Coopersmith CM, Deutschman CS. The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis. Intensive Care Med Exp 2021; 9:34. [PMID: 34212256 PMCID: PMC8249046 DOI: 10.1186/s40635-021-00400-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/07/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To identify priorities for administrative, epidemiologic and diagnostic research in sepsis. Design As a follow-up to a previous consensus statement about sepsis research, members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis. Methods Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified through a consensus process. Results The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?; (2) What is the epidemiology of sepsis susceptibility and response to treatment?; (3) What information identifies organ dysfunction?; (4) How can we screen for sepsis in various settings?; (5) How do we identify septic shock?; and (6) What in-hospital clinical information is associated with important outcomes in patients with sepsis? Conclusions There is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritize initiatives to improve an understanding of individual patient and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care.
Collapse
Affiliation(s)
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation (SODIR) Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Grady Memorial Hospital and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | | | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,The Feinstein Institute for Medical Research/ Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
| | | |
Collapse
|
34
|
Hu S, Pi Q, Luo M, Cheng Z, Liang X, Luo S, Xia Y. Contribution of the NLRP3/IL-1β axis to impaired vasodilation in sepsis through facilitation of eNOS proteolysis and the protective role of melatonin. Int Immunopharmacol 2021; 93:107388. [PMID: 33529913 DOI: 10.1016/j.intimp.2021.107388] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/27/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
Endothelial dysfunction is a typical characteristic of sepsis. Endothelial nitric oxide synthase (eNOS) is important for maintaining endothelial function. Our previous study reported that the NLRP3 inflammasome promoted endothelial dysfunction by enhancing inflammation. However, the effects of NLRP3 on eNOS require further investigation. Therefore, the present study aimed to investigate the role of NLRP3 on eNOS expression levels in cecal ligation and puncture-induced impaired endothelium-dependent vascular relaxation and to determine the protective effects of melatonin. eNOS expression levels were discovered to be downregulated in the mesenteric arteries of sepsis model mice. Inhibiting NLRP3 with 10 mg/ kg MCC950 or inhibiting IL-1β with 100 mg diacerein rescued the eNOS expression and improved endothelium-dependent vascular relaxation. In vitro, IL-1β stimulation downregulated eNOS expression levels in human aortic endothelial cells (HAECs) in a concentration- and time-dependent manner, while pretreatment with 1 µM of the proteasome inhibitor MG132 reversed this effect. In addition, treatment with 10 mg/kg MG132 also prevented the proteolysis of eNOS and improved endothelium-dependent vascular relaxation in vivo. Notably, treatment with 30 mg/kg melatonin downregulated NLRP3 expression levels and decreased IL-1β secretion, subsequently increasing the expression of eNOS and improving endothelium-dependent vascular relaxation. In conclusion, the findings of the present study indicated that the NLRP3/IL-1β axis may impair vasodilation by promoting the proteolysis of eNOS and melatonin may protect against sepsis-induced endothelial relaxation dysfunction by inhibiting the NLRP3/IL-1β axis, suggesting its pharmacological potential in sepsis.
Collapse
Affiliation(s)
- Shupeng Hu
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Qiangzhong Pi
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Minghao Luo
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Zhe Cheng
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Xiaoxue Liang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Suxin Luo
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Yong Xia
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China; Davis Heart and Lung Research Institute, Division of Cardiovascular Medicine, 473 West 12th Avenue, Columbus, OH 43210, USA.
| |
Collapse
|
35
|
Leong K, Gaglani B, Khanna AK, McCurdy MT. Novel Diagnostics and Therapeutics in Sepsis. Biomedicines 2021; 9:biomedicines9030311. [PMID: 33803628 PMCID: PMC8003067 DOI: 10.3390/biomedicines9030311] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Sepsis management demands early diagnosis and timely treatment that includes source control, antimicrobial therapy, and resuscitation. Currently employed diagnostic tools are ill-equipped to rapidly diagnose sepsis and isolate the offending pathogen, which limits the ability to offer targeted and lowest-toxicity treatment. Cutting edge diagnostics and therapeutics in development may improve time to diagnosis and address two broad management principles: (1) source control by removing the molecular infectious stimulus of sepsis, and (2) attenuation of the pathological immune response allowing the body to heal. This review addresses novel diagnostics and therapeutics and their role in the management of sepsis.
Collapse
Affiliation(s)
- Kieran Leong
- Division of Pulmonary & Critical Care, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Bhavita Gaglani
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University Hospital, Winston-Salem, NC 27157, USA; (B.G.); (A.K.K.)
| | - Ashish K. Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University Hospital, Winston-Salem, NC 27157, USA; (B.G.); (A.K.K.)
- Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Michael T. McCurdy
- Division of Pulmonary & Critical Care, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
- Correspondence:
| |
Collapse
|
36
|
Berlot G, Pintacuda S, Moro E, Paluzzano G, Scamperle A, Chillemi A, Longo I, Dattola R, Roman-Pognuz E, Tomasini A. Effects of tocilizumab versus hemoadsorption combined with tocilizumab in patients with SARS-CoV-2 pneumonia: Preliminary results. Int J Artif Organs 2021; 45:75-80. [PMID: 33573449 DOI: 10.1177/0391398821989334] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the variations of Interleukin-6 (IL-6) in patients with SARS-CoV-2 infection treated with Tocilizumab (TCZ) alone or in association with hemoadsorption (HA). DESIGN Retrospective. SETTING An Intensive Care Unit (ICU) admitting mechanically ventilated patients with SARS-CoV-2 pneumonia. PATIENTS Four adult patients. INTERVENTIONS We compared the blood values of IL-6, C-reactive protein (CRP) and of other biochemical variables including the PaO2/FiO2 in two patients who received TCZ alone and in other 2 in whom it was associated with the HA (TCZ-HA) due to the presence of impending or established organ failures other than the lung. All variables were measured before, during and after the treatment. MAIN RESULTS In all patients, the IL-6 increased during the treatment; after its termination, its values sharply decreased only in those treated also with HA; conversely, the CRP decreased in all patients; the PaO2/FiO2 increased in three patients and remained stable in the remaining one. Both the TCZ and the HA were well tolerated; all patients were weaned from the mechanical ventilation and discharged from the hospital. LIMITATIONS Although the limited number of patients does not allow to draw firm conclusions, the increase of the IL-6 of can be ascribed to its displacement from cellular and soluble receptors, whereas its decrease is likely due to the scavenging effect exerted by the HA. Although the association TCZ-HA could be valuable in the treatment of the Cytokine Release Storm (CRS) associated with the SARS-CoV-2, the HA could be more effective as it neutralizes a wider panel of inflammatory mediators.
Collapse
Affiliation(s)
- Giorgio Berlot
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Stefania Pintacuda
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Edoardo Moro
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Giacomo Paluzzano
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Alice Scamperle
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Antonino Chillemi
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Irene Longo
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Roberto Dattola
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| | - Ariella Tomasini
- Department of Anesthesia and Intensive Care Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Cattinara Hospital, Trieste, Italy
| |
Collapse
|
37
|
Matthay MA, Arabi YM, Siegel ER, Ware LB, Bos LDJ, Sinha P, Beitler JR, Wick KD, Curley MAQ, Constantin JM, Levitt JE, Calfee CS. Phenotypes and personalized medicine in the acute respiratory distress syndrome. Intensive Care Med 2020; 46:2136-2152. [PMID: 33206201 PMCID: PMC7673253 DOI: 10.1007/s00134-020-06296-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022]
Abstract
Although the acute respiratory distress syndrome (ARDS) is well defined by the development of acute hypoxemia, bilateral infiltrates and non-cardiogenic pulmonary edema, ARDS is heterogeneous in terms of clinical risk factors, physiology of lung injury, microbiology, and biology, potentially explaining why pharmacologic therapies have been mostly unsuccessful in treating ARDS. Identifying phenotypes of ARDS and integrating this information into patient selection for clinical trials may increase the chance for efficacy with new treatments. In this review, we focus on classifying ARDS by the associated clinical disorders, physiological data, and radiographic imaging. We consider biologic phenotypes, including plasma protein biomarkers, gene expression, and common causative microbiologic pathogens. We will also discuss the issue of focusing clinical trials on the patient's phase of lung injury, including prevention, administration of therapy during early acute lung injury, and treatment of established ARDS. A more in depth understanding of the interplay of these variables in ARDS should provide more success in designing and conducting clinical trials and achieving the goal of personalized medicine.
Collapse
Affiliation(s)
- Michael A Matthay
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA.
- Cardiovascular Research Institute, University of California, San Francisco, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA.
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Emily R Siegel
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lieuwe D J Bos
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Infection and Immunity, Amsterdam, The Netherlands
| | - Pratik Sinha
- Department of Anesthesiology, Washington University, Saint Louis, MO, USA
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean-Michel Constantin
- Department of Anesthesia and Critical Care, La Pitié Salpetriere Hospital, University Paris-Sorbonne, Paris, France
| | - Joseph E Levitt
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Carolyn S Calfee
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
- Cardiovascular Research Institute, University of California, San Francisco, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA
| |
Collapse
|
38
|
Subphenotypes in critical care: translation into clinical practice. THE LANCET RESPIRATORY MEDICINE 2020; 8:631-643. [PMID: 32526190 DOI: 10.1016/s2213-2600(20)30124-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/06/2020] [Accepted: 03/05/2020] [Indexed: 12/14/2022]
Abstract
Despite progress in the supportive care available for critically ill patients, few advances have been made in the search for effective disease-modifying therapeutic options. The fact that many trials in critical care medicine have not identified a treatment benefit is probably due, in part, to the underlying heterogeneity of critical care syndromes. Numerous approaches have been proposed to divide populations of critically ill patients into more meaningful subgroups (subphenotypes), some of which might be more useful than others. Subclassification systems driven by clinical features and biomarkers have been proposed for acute respiratory distress syndrome, sepsis, acute kidney injury, and pancreatitis. Identifying the systems that are most useful and biologically meaningful could lead to a better understanding of the pathophysiology of critical care syndromes and the discovery of new treatment targets, and allow recruitment in future therapeutic trials to focus on predicted responders. This Review discusses proposed subphenotypes of critical illness syndromes and highlights the issues that will need to be addressed to translate subphenotypes into clinical practice.
Collapse
|
39
|
Clark KEN, Collas O, Lachmann H, Singh A, Buckley J, Bhagani S. Safety of intravenous anakinra in COVID-19 with evidence of hyperinflammation, a case series. Rheumatol Adv Pract 2020; 4:rkaa040. [PMID: 32964179 PMCID: PMC7454860 DOI: 10.1093/rap/rkaa040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/07/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Anakinra is a selective IL-1 inhibitor, which has been used in the context of secondary haemophagocytic lymphohistiocytosis. Although usually given in the s.c. form, previous anecdotal reports have emphasized its utility when given i.v. Our aim is to report our experience on the beneficial effects of anakinra i.v. in patients with SARS-CoV-2 and evidence of hyperinflammation. METHODS We report four patients with severe COVID-19 infection requiring intensive care admission and ventilatory support. RESULTS All four patients showed evidence of deterioration, with hyperferritinaemia and increasing oxygen requirements and with superadded bacterial infections. Upon commencement of anakinra i.v., there was subsequent improvement in the patients clinically, with reduction in ventilatory support and inotropic support, and biochemically, with rapid improvement in inflammatory markers. CONCLUSION Anakinra is safe to use i.v. in patients with COVID-19 and evidence of superadded bacterial infection. Although its utility has not been confirmed in a randomized trial, current research in the COVID-19 pandemic aims to establish the utility of immunosuppression, including IL-1 blockade, on the outcomes of patients with moderate to severe disease. Our case series supports its use in patients with severe, life-threatening COVID-19 and evidence of hyperinflammation.
Collapse
Affiliation(s)
- Kristina E N Clark
- Department for Rheumatology and Connective Tissue Diseases, University College London
| | - Oliver Collas
- Department of Intensive Care, Royal Free Hospital London NHS Foundation Trust
| | - Helen Lachmann
- UK National Amyloidosis Centre, University College London
| | | | | | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free Hospital London NHS Foundation Trust, London, UK
| |
Collapse
|
40
|
Stancioiu F, Papadakis GZ, Kteniadakis S, Izotov BN, Coleman MD, Spandidos DA, Tsatsakis A. A dissection of SARS‑CoV2 with clinical implications (Review). Int J Mol Med 2020; 46:489-508. [PMID: 32626922 PMCID: PMC7307812 DOI: 10.3892/ijmm.2020.4636] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/09/2020] [Indexed: 02/06/2023] Open
Abstract
We are being confronted with the most consequential pandemic since the Spanish flu of 1918‑1920 to the extent that never before have 4 billion people quarantined simultaneously; to address this global challenge we bring to the forefront the options for medical treatment and summarize SARS‑CoV2 structure and functions, immune responses and known treatments. Based on literature and our own experience we propose new interventions, including the use of amiodarone, simvastatin, pioglitazone and curcumin. In mild infections (sore throat, cough) we advocate prompt local treatment for the naso‑pharynx (inhalations; aerosols; nebulizers); for moderate to severe infections we propose a tried‑and‑true treatment: the combination of arginine and ascorbate, administered orally or intravenously. The material is organized in three sections: i) Clinical aspects of COVID‑19; acute respiratory distress syndrome (ARDS); known treatments; ii) Structure and functions of SARS‑CoV2 and proposed antiviral drugs; iii) The combination of arginine‑ascorbate.
Collapse
Affiliation(s)
| | | | | | - Boris Nikovaevich Izotov
- Department of Analytical and Forensic Medical Toxicology, Sechenov University, 119991 Moscow, Russia
| | - Michael D. Coleman
- School of Life and Health Sciences, Aston University, B4 7ET Birmingham, UK
| | | | - Aristidis Tsatsakis
- Department of Analytical and Forensic Medical Toxicology, Sechenov University, 119991 Moscow, Russia
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71003 Heraklion, Greece
| |
Collapse
|
41
|
Xiong S, Hong Z, Huang LS, Tsukasaki Y, Nepal S, Di A, Zhong M, Wu W, Ye Z, Gao X, Rao GN, Mehta D, Rehman J, Malik AB. IL-1β suppression of VE-cadherin transcription underlies sepsis-induced inflammatory lung injury. J Clin Invest 2020; 130:3684-3698. [PMID: 32298238 PMCID: PMC7324198 DOI: 10.1172/jci136908] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022] Open
Abstract
Unchecked inflammation is a hallmark of inflammatory tissue injury in diseases such as acute respiratory distress syndrome (ARDS). Yet the mechanisms of inflammatory lung injury remain largely unknown. Here we showed that bacterial endotoxin lipopolysaccharide (LPS) and cecal ligation and puncture-induced (CLP-induced) polymicrobial sepsis decreased the expression of transcription factor cAMP response element binding (CREB) in lung endothelial cells. We demonstrated that endothelial CREB was crucial for VE-cadherin transcription and the formation of the normal restrictive endothelial adherens junctions. The inflammatory cytokine IL-1β reduced cAMP generation and CREB-mediated transcription of VE-cadherin. Furthermore, endothelial cell-specific deletion of CREB induced lung vascular injury whereas ectopic expression of CREB in the endothelium prevented the injury. We also observed that rolipram, which inhibits type 4 cyclic nucleotide phosphodiesterase-mediated (PDE4-mediated) hydrolysis of cAMP, prevented endotoxemia-induced lung vascular injury since it preserved CREB-mediated VE-cadherin expression. These data demonstrate the fundamental role of the endothelial cAMP-CREB axis in promoting lung vascular integrity and suppressing inflammatory injury. Therefore, strategies aimed at enhancing endothelial CREB-mediated VE-cadherin transcription are potentially useful in preventing sepsis-induced lung vascular injury in ARDS.
Collapse
Affiliation(s)
- Shiqin Xiong
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Zhigang Hong
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Long Shuang Huang
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Yoshikazu Tsukasaki
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Saroj Nepal
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Anke Di
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Ming Zhong
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Wei Wu
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Zhiming Ye
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaopei Gao
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Gadiparthi N. Rao
- Department of Physiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Dolly Mehta
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Jalees Rehman
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Asrar B. Malik
- Department of Pharmacology and Regenerative Medicine and
- Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago, Illinois, USA
| |
Collapse
|
42
|
Richendrfer HA, Levy MM, Elsaid KA, Schmidt TA, Zhang L, Cabezas R, Jay GD. Recombinant Human Proteoglycan-4 Mediates Interleukin-6 Response in Both Human and Mouse Endothelial Cells Induced Into a Sepsis Phenotype. Crit Care Explor 2020; 2:e0126. [PMID: 32695993 PMCID: PMC7314356 DOI: 10.1097/cce.0000000000000126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Sepsis is a leading cause of death in the United States. Putative targets to prevent systemic inflammatory response syndrome include antagonism of toll-like receptors 2 and 4 and CD44 receptors in vascular endothelial cells. Proteoglycan-4 is a mucinous glycoprotein that interacts with CD44 and toll-like receptor 4 resulting in a blockade of the NOD-like receptor pyrin domain-containing-3 pathway. We hypothesized that endothelial cells induced into a sepsis phenotype would have less interleukin-6 expression after recombinant human proteoglycan 4 treatment in vitro. DESIGN Enzyme-linked immunosorbent assay and reverse transcriptase-quantitative polymerase chain reaction to measure interleukin-6 protein and gene expression. SETTING Research laboratory. SUBJECTS Human umbilical vascular endothelial cells, human lung microvascular endothelial cells, and transgenic mouse (wild type) (Cd44 +/+/Prg4 +/+), Cd44 -/- (Cd44 tm1Hbg Prg4 +/+), Prg4 GT/GT (Cd44 +/+ Prg4 tm2Mawa/J), and double knockout (Cd44 tm1Hbg Prg4 tm2Mawa/J) lung microvascular endothelial cells. INTERVENTIONS Cells were treated with 100 or 250 ng/mL lipopolysaccharide-Escherichia coli K12 and subsequently treated with recombinant human proteoglycan 4 after 30 minutes. Interleukin-6 levels in conditioned media were measured via enzyme-linked immunosorbent assay and gene expression was measured via reverse transcriptase-quantitative polymerase chain reaction with ΔΔ-Ct analysis. Additionally, human umbilical vascular endothelial cells and human lung microvascular endothelial cells were treated with 1:10 diluted plasma from 15 patients with sepsis in culture media. After 30 minutes, either 50 or 100 µg/mL recombinant human proteoglycan 4 was administered. Interleukin-6 protein and gene expression were assayed. Proteoglycan 4 levels were also compared between control and sepsis patient plasma. MEASUREMENTS AND MAIN RESULTS Human umbilical vascular endothelial cell, human lung microvascular endothelial cell, and mouse lung microvascular endothelial cell treated with lipopolysaccharide had significantly increased interleukin-6 protein compared with controls. Recombinant human proteoglycan-4 significantly reduced interleukin-6 in human and mouse endothelial cells. Interleukin-6 gene expression was significantly increased after lipopolysaccharide treatment compared with controls. This response was reversed by 50 or 100 µg/mL recombinant human proteoglycan-4 in 80% of sepsis samples in human umbilical vascular endothelial cells and in 60-73% in human lung microvascular endothelial cells. In Cd44 -/- genotypes of the mouse lung microvascular endothelial cells, recombinant human proteoglycan-4 significantly reduced interleukin-6 protein levels after lipopolysaccharide treatment, indicating that Cd44 is not needed for recombinant human proteoglycan-4 to have an effect in a toll-like receptor 4 agonist inflammation model. Patient sepsis samples had higher plasma levels of native proteoglycan-4 than controls. INTERPRETATION AND CONCLUSIONS Recombinant human proteoglycan-4 is a potential adjunct therapy for sepsis patients and warrants future in vivo model studies.
Collapse
Affiliation(s)
- Holly A Richendrfer
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI
- Emergency Medicine Research Laboratory, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Mitchell M Levy
- Department of Medicine, Division of Pulmonary/Critical Care Medicine, Alpert Medical School at Brown University, Providence, RI
| | - Khaled A Elsaid
- Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy, Chapman University, Irvine, CA
| | - Tannin A Schmidt
- Biomedical Engineering Department, University of Connecticut Health Center, Farmington, CT
| | - Ling Zhang
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI
- Emergency Medicine Research Laboratory, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Ralph Cabezas
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI
- Emergency Medicine Research Laboratory, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Gregory D Jay
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI
- Emergency Medicine Research Laboratory, Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| |
Collapse
|
43
|
|
44
|
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Collapse
Affiliation(s)
- Jennifer G Wilson
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, USA
| | - Carolyn S Calfee
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA.
| |
Collapse
|
45
|
Bos LDJ, Scicluna BP, Ong DSY, Cremer O, van der Poll T, Schultz MJ. Understanding Heterogeneity in Biologic Phenotypes of Acute Respiratory Distress Syndrome by Leukocyte Expression Profiles. Am J Respir Crit Care Med 2020; 200:42-50. [PMID: 30645145 DOI: 10.1164/rccm.201809-1808oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rationale: Two biologic phenotypes of acute respiratory distress syndrome (ARDS) have been identified based on plasma protein markers in four previous studies. Objectives: To determine if blood leukocyte gene expression is different between the "reactive" and "uninflamed" phenotype. Methods: This is a new study adding blood leukocyte transcriptomics and bioinformatics analysis to an existing patient cohort of ARDS in patients with sepsis admitted to two ICUs during a 1.5-year period. Canonical pathway analysis was performed. Measurements and Main Results: A total of 210 patients with sepsis and ARDS were included, of whom 128 had a reactive and 82 an uninflamed phenotype. A total of 3,332/11,443 (29%) transcripts were significantly different between the phenotypes. Canonical pathway analysis showed upregulation of oxidative phosphorylation genes indicative of mitochondrial dysfunction (52% of genes in pathway). The uninflamed phenotype was characterized by upregulation of mitogen-activated protein kinase pathways. Conclusions: A third of genes are differentially expressed between biologic phenotypes of ARDS supporting the observation that the subgroups of ARDS are incomparable in terms of pathophysiology. These data provide additional support for biologic heterogeneity in patients with ARDS and suggests that a personalized approach to intervention focusing on oxidative phosphorylation is pivotal in this condition.
Collapse
Affiliation(s)
- Lieuwe D J Bos
- 1 Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology.,2 Department of Respiratory Medicine
| | - Brendon P Scicluna
- 3 Center of Experimental Molecular Medicine, and.,4 Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Infection and Immunity, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands
| | - David S Y Ong
- 5 Department of Microbiology, Julius Center for Health Sciences and Primary Care.,6 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, and
| | - Olaf Cremer
- 7 Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands; and
| | | | - Marcus J Schultz
- 1 Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology.,8 Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| |
Collapse
|
46
|
Abstract
PURPOSE OF REVIEW To provide an overview of the current research in identifying homogeneous subgroups and phenotypes in ARDS. RECENT FINDINGS In recent years, investigations have used either physiology, clinical data, biomarkers or a combination of these to stratify patients with ARDS into distinct subgroups with divergent clinical outcomes. In some studies, there has also been evidence of differential treatment response within subgroups. Physiologic approaches include stratification based on P/F ratio and ventilatory parameters; stratification based on P/F ratio is already being employed in clinical trials. Clinical approaches include stratification based on ARDS risk factor or direct vs. indirect ARDS. Combined clinical and biological data has been used to identify two phenotypes across five cohorts of ARDS, termed hyperinflammatory and hypoinflammatory. These phenotypes have widely divergent clinical outcomes and differential response to mechanical ventilation, fluid therapy, and simvastatin in secondary analysis of completed trials. Next steps in the field include prospective validation of inflammatory phenotypes and integration of high-dimensional 'omics' data into our understanding of ARDS heterogeneity. SUMMARY Identification of distinct subgroups or phenotypes in ARDS may impact future conduct of clinical trials and can enhance our understanding of the disorder, with potential future clinical implications.
Collapse
|
47
|
Abstract
Sepsis, a life threating syndrome characterized by organ failure after infection, is the most common cause of death in hospitalized patients. The treatment of sepsis is generally supportive in nature, involving the administration of intravenous fluids, vasoactive substances and oxygen plus antibiotics to eliminate the pathogen. No drugs have been approved specifically for the treatment of sepsis, and clinical trials of potential therapies have failed to reduce mortality - suggesting that new approaches are needed. Abnormalities in the immune response elicited by the pathogen, ranging from excessive inflammation to immunosuppression, contribute to disease pathogenesis. Although hundreds of immunomodulatory agents are potentially available, it remains unclear which patient benefits from which immune therapy at a given time point. Results indicate the importance of personalized therapy, specifically the need to identify the type of intervention required by each individual patient at a given point in the disease process. To address this issue will require using biomarkers to stratify patients based on their individual immune status. This article reviews recent and ongoing clinical investigations using immunostimulatory or immunosuppressive therapies against sepsis including non-pharmacological and novel preclinical approaches.
Collapse
|
48
|
Anderson BJ, Calfee CS, Liu KD, Reilly JP, Kangelaris KN, Shashaty MGS, Lazaar AL, Bayliffe AI, Gallop RJ, Miano TA, Dunn TG, Johansson E, Abbott J, Jauregui A, Deiss T, Vessel K, Belzer A, Zhuo H, Matthay MA, Meyer NJ, Christie JD. Plasma sTNFR1 and IL8 for prognostic enrichment in sepsis trials: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:400. [PMID: 31818332 PMCID: PMC6902425 DOI: 10.1186/s13054-019-2684-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/22/2019] [Indexed: 01/07/2023]
Abstract
Background Enrichment strategies improve therapeutic targeting and trial efficiency, but enrichment factors for sepsis trials are lacking. We determined whether concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1), interleukin-8 (IL8), and angiopoietin-2 (Ang2) could identify sepsis patients at higher mortality risk and serve as prognostic enrichment factors. Methods In a multicenter prospective cohort study of 400 critically ill septic patients, we derived and validated thresholds for each marker and expressed prognostic enrichment using risk differences (RD) of 30-day mortality as predictive values. We then used decision curve analysis to simulate the prognostic enrichment of each marker and compare different prognostic enrichment strategies. Measurements and main results An admission sTNFR1 concentration > 8861 pg/ml identified patients with increased mortality in both the derivation (RD 21.6%) and validation (RD 17.8%) populations. Among immunocompetent patients, an IL8 concentration > 94 pg/ml identified patients with increased mortality in both the derivation (RD 17.7%) and validation (RD 27.0%) populations. An Ang2 level > 9761 pg/ml identified patients at 21.3% and 12.3% increased risk of mortality in the derivation and validation populations, respectively. Using sTNFR1 or IL8 to select high-risk patients improved clinical trial power and efficiency compared to selecting patients with septic shock. Ang2 did not outperform septic shock as an enrichment factor. Conclusions Thresholds for sTNFR1 and IL8 consistently identified sepsis patients with higher mortality risk and may have utility for prognostic enrichment in sepsis trials.
Collapse
Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathleen D Liu
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aili L Lazaar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,GlaxoSmithKline R&D, Brentford, UK
| | | | - Robert J Gallop
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Mathematics, West Chester University, West Chester, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Erik Johansson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason Abbott
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Alejandra Jauregui
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Thomas Deiss
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathryn Vessel
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Annika Belzer
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Hanjing Zhuo
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
49
|
Anderson MR, Udupa JK, Edwin E, Diamond JM, Singer JP, Kukreja J, Hays SR, Greenland JR, Ferrante A, Lippel M, Blue T, McBurnie A, Oyster M, Kalman L, Rushefski M, Wu C, Pednekar G, Liu W, Arcasoy S, Sonett J, D'Ovidio F, Bacchetta M, Newell JD, Torigian D, Cantu E, Farber DL, Giles JT, Tong Y, Palmer S, Ware LB, Hancock WW, Christie JD, Lederer DJ. Adipose tissue quantification and primary graft dysfunction after lung transplantation: The Lung Transplant Body Composition study. J Heart Lung Transplant 2019; 38:1246-1256. [PMID: 31474492 PMCID: PMC6883162 DOI: 10.1016/j.healun.2019.08.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Obesity is associated with an increased risk of primary graft dysfunction (PGD) after lung transplantation. The contribution of specific adipose tissue depots is unknown. METHODS We performed a prospective cohort study of adult lung transplant recipients at 4 U.S. transplant centers. We measured cross-sectional areas of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) on chest and abdominal computed tomography (CT) scans and indexed each measurement to height.2 We used logistic regression to examine the associations of adipose indices and adipose classes with grade 3 PGD at 48 or 72 hours, and Cox proportional hazards models to examine survival. We used latent class analyses to identify the patterns of adipose distribution. We examined the associations of adipose indices with plasma biomarkers of obesity and PGD. RESULTS A total of 262 and 117 subjects had available chest CT scans and underwent protocol abdominal CT scans, respectively. In the adjusted models, a greater abdominal SAT index was associated with an increased risk of PGD (odds ratio 1.9, 95% CI 1.02-3.4, p = 0.04) but not with survival time. VAT indices were not associated with PGD risk or survival time. A greater abdominal SAT index correlated with greater pre- and post-transplant leptin (r = 0.61, p < 0.001, and r = 0.44, p < 0.001), pre-transplant IL-1RA (r = 0.25, p = 0.04), and post-transplant ICAM-1 (r = 0.25, p = 0.04). We identified 3 latent patterns of adiposity. The class defined by high thoracic and abdominal SAT had the greatest risk of PGD. CONCLUSIONS Subcutaneous, but not visceral, adiposity is associated with an increased risk of PGD after lung transplantation.
Collapse
Affiliation(s)
- Michaela R Anderson
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jayaram K Udupa
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan Edwin
- Columbia Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Joshua M Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan P Singer
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Steven R Hays
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - John R Greenland
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - Anthony Ferrante
- Columbia Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Matthew Lippel
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Tatiana Blue
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Amika McBurnie
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Michelle Oyster
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Rushefski
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caiyun Wu
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gargi Pednekar
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wen Liu
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Selim Arcasoy
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Joshua Sonett
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Frank D'Ovidio
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John D Newell
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Drew Torigian
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna L Farber
- Department of Surgery, University of California at San Francisco, San Francisco, California; Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York; Department of Microbiology and Immunology, Columbia University Medical Center, New York, New York
| | - Jon T Giles
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yubing Tong
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott Palmer
- Department of Medicine, Duke University & Duke Clinical Research Institute, Durham, North Carolina
| | - Lorraine B Ware
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne W Hancock
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Lederer
- Department of Medicine, Columbia University Medical Center, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York.
| |
Collapse
|
50
|
Abstract
Critical illness syndromes, including sepsis and the acute respiratory distress syndrome (ARDS), are identified using consensus definitions that are based on broad, clinically available criteria and include patients with heterogeneous biology. This heterogeneity is a barrier to developing and testing effective therapies for these syndromes. Biomarkers identify clinically distinct molecular phenotypes of ARDS and sepsis. These molecular phenotypes are associated with differences in mortality and predict response to several treatments in retrospective analyses of clinical trials. Biomarkers can be used for prognostic and predictive enrichment of clinical trials in critical illness to incorporate precision medicine in critical care.
Collapse
Affiliation(s)
- Aartik Sarma
- Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, Box 0111, San Francisco, CA 94143-0111, USA
| | - Carolyn S Calfee
- Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, Box 0111, San Francisco, CA 94143-0111, USA; Department of Anesthesia, University of California, San Francisco, 505 Parnassus Avenue, Box 0111, San Francisco, CA 94143-0111, USA; Cardiovascular Research Institute, University of California, San Francisco, 505 Parnassus Avenue, Box 0111, San Francisco, CA 94143-0111, USA
| | - Lorraine B Ware
- Department of Medicine, Vanderbilt University School of Medicine, T1218 MCN, 1161 21st Avenue South, Nashville, TN 37232-2650, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA; Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st Avenue South, Nashville, TN 37232-2650, USA.
| |
Collapse
|