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Lee GT, Ko BS, Kim DS, Kim M, Park JE, Hwang SY, Jeong D, Chung CR, Kang H, Oh J, Lim TH, Chae B, Kim WY, Shin TG. Diagnostic Accuracy of Plasma Renin Concentration and Renin Activity in Predicting Mortality and Kidney Outcomes in Patients With Septic Shock and Hypoperfusion or Hypotension: A Multicenter, Prospective, Observational Study. Ann Lab Med 2024; 44:497-506. [PMID: 38910340 PMCID: PMC11375189 DOI: 10.3343/alm.2023.0425] [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: 10/30/2023] [Revised: 01/22/2024] [Accepted: 03/12/2024] [Indexed: 06/25/2024] Open
Abstract
Background Lactate is a commonly used biomarker for sepsis, although it has limitations in certain cases, suggesting the need for novel biomarkers. We evaluated the diagnostic accuracy of plasma renin concentration and renin activity for mortality and kidney outcomes in patients with sepsis with hypoperfusion or hypotension. Methods This was a multicenter, prospective, observational study of 117 patients with septic shock treated at three tertiary emergency departments between September 2021 and October 2022. The accuracy of renin activity, renin, and lactate concentrations in predicting 28-day mortality, acute kidney injury (AKI), and renal replacement requirement was assessed using the area under the ROC curve (AUC) analysis. Results The AUCs of initial renin activity, renin, and lactate concentrations for predicting 28-day mortality were 0.66 (95% confidence interval [CI], 0.55-0.77), 0.63 (95% CI, 0.52-0.75), and 0.65 (95% CI, 0.53-0.77), respectively, and those at 24 hrs were 0.74 (95% CI, 0.62-0.86), 0.70 (95% CI, 0.56-0.83), and 0.67 (95% CI, 0.54-0.79). Renin concentrations and renin activity outperformed initial lactate concentrations in predicting AKI within 14 days. The AUCs of renin and lactate concentrations were 0.71 (95% CI, 0.61-0.80) and 0.57 (95% CI, 0.46-0.67), respectively (P=0.030). The AUC of renin activity (0.70; 95% CI, 0.60-0.80) was also higher than that of lactate concentration (P=0.044). Conclusions Renin concentration and renin activity show comparable performance to lactate concentration in predicting 28-day mortality in patients with septic shock but superior performance in predicting AKI.
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Affiliation(s)
- Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Da Seul Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minha Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Daun Jeong
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Bora Chae
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Pi D, Zheng L, Gao C, Xiao C, Yu Z, Fu Y, Li J, Chen C, Liu C, Zou Z, Xu F. RENIN AND ANGIOTENSIN (1-7) OFFER PREDICTIVE VALUE IN PEDIATRIC SEPSIS: FINDINGS FROM PROSPECTIVE OBSERVATIONAL COHORTS. Shock 2024; 62:488-495. [PMID: 39012767 DOI: 10.1097/shk.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
ABSTRACT Background: Pediatric sepsis is a common and complex syndrome characterized by a dysregulated immune response to infection. Aberrations in the renin-angiotensin system (RAS) are factors in several infections of adults. However, the precise impact of RAS dysregulation in pediatric sepsis remains unclear. Methods: Serum samples were collected from a derivation cohort (58 patients with sepsis, 14 critically ill control subjects, and 37 healthy controls) and validation cohort (50 patients with sepsis, 37 critically ill control subjects, and 46 healthy controls). Serum RAS levels on day of pediatric intensive care unit admission were determined and compared with survival status and organ dysfunction. Results: In the derivation cohort, the serum renin concentration was significantly higher in patients with sepsis (3,678 ± 4,746) than that in healthy controls (635.6 ± 199.8) ( P < 0.0001). Meanwhile, the serum angiotensin (1-7) was significantly lower in patients with sepsis (89.7 ± 59.7) compared to that in healthy controls (131.4 ± 66.4) ( P < 0.01). These trends were confirmed in a validation cohort. Nonsurvivors had higher levels of renin (8,207 ± 7,903) compared to survivors (2,433 ± 3,193) ( P = 0.0001) and lower levels of angiotensin (1-7) (60.9 ± 51.1) compared to survivors (104.0 ± 85.1) ( P < 0.05). A combination of renin, angiotensin (1-7) and procalcitonin achieved a model for diagnosis with an area under the receiver operating curve of 0.87 (95% CI: 0.81-0.92). Conclusion: Circulating renin and angiotensin (1-7) have predictive value in pediatric sepsis.
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Affiliation(s)
- Dandan Pi
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Lijun Zheng
- Molecular Biology Laboratory of Respiratory Disease, Key Laboratory of Clinical Laboratory Diagnostics (Ministry of Education), College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Caixia Gao
- Molecular Biology Laboratory of Respiratory Disease, Key Laboratory of Clinical Laboratory Diagnostics (Ministry of Education), College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Changxue Xiao
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Zhicai Yu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Yueqiang Fu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Jing Li
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Chengzhi Chen
- Department of Occupational and Environmental Health, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Chengjun Liu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | | | - Feng Xu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
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Möller Petrun A, Markota A. Angiotensin II-Real-Life Use and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1483. [PMID: 39336524 PMCID: PMC11433685 DOI: 10.3390/medicina60091483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/04/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024]
Abstract
Angiotensin II is a recently introduced vasopressor, which has been available since 2017. The novelty and the relatively high cost of angiotensin II currently limit its broader application. It induces vasoconstriction by activating the renin-angiotensin-aldosterone system and is currently the sole vasopressor functioning through this pathway. Beyond vasoconstriction, angiotensin II also affects various other physiological processes. Current evidence supports its use in managing vasoplegic and cardiogenic shock in patients who are unresponsive to catecholamines and vasopressin. However, due to limited data, the optimal timing for initiating therapy with angiotensin II, strategies for combining it with other vasopressors, and strategies for its discontinuation remain unclear. Ongoing and planned studies aim to address some of these uncertainties. This article reviews the physiological and pathophysiological effects of angiotensin II, describes its pharmacology, and provides a narrative review of the current literature.
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Affiliation(s)
- Andreja Möller Petrun
- Department of Anaesthesiology, Intensive Therapy and Pain Management, University Medical Centre Maribor, 2000 Maribor, Slovenia;
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
- Medical Intensive Care Unit, University Medical Centre Maribor, 2000 Maribor, Slovenia
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Fisler G, Murphy K, Mastroianni F, Schneider JB, Deutschman CS, Leisman DE, Taylor MD. Kidney Blood Flow and Renin-Angiotensin-Aldosterone System Measurements Associated With Kidney and Cardiovascular Dysfunction in Pediatric Shock. Crit Care Explor 2024; 6:e1134. [PMID: 39110074 PMCID: PMC11309640 DOI: 10.1097/cce.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
IMPORTANCE Pediatric acute kidney injury (AKI) is a prevalent and morbid complication of shock. Its pathogenesis and early identification remain elusive. OBJECTIVES We aim to determine whether renal blood flow (RBF) measurements by point-of-care ultrasound (POCUS) and renin-angiotensin-aldosterone system (RAAS) hormones in pediatric shock associate with vasoactive requirements and AKI. DESIGN, SETTING, AND PARTICIPANTS This is a single-center prospective, noninterventional observational cohort study in one tertiary PICU in North American from 2020 to 2022 that enrolled children younger than 18 years with shock without preexisting end-stage renal disease. MAIN OUTCOMES AND MEASURES RBF was measured by POCUS on hospital days 1 and 3 and plasma RAAS hormone levels were measured on day 1. The primary outcome was the presence of AKI by Kidney Disease Improving Global Outcomes criteria at first ultrasound with key secondary outcomes of creatinine, blood urea nitrogen (BUN), Vasoactive-Inotrope Score (VIS), and norepinephrine equivalent dosing (NED) 48 hours after first ultrasound. RESULTS Fifty patients were recruited (20 with AKI, mean age 10.5 yr, 48% female). POCUS RBF showed lower qualitative blood flow (power Doppler ultrasound [PDU] score) and higher regional vascular resistance (renal resistive index [RRI]) in children with AKI (p = 0.017 and p = 0.0007). Renin and aldosterone levels were higher in the AKI cohort (p = 0.003 and p = 0.007). Admission RRI and PDU associated with higher day 3 VIS and NED after adjusting for age, day 1 VIS, and RAAS hormones. Admission renin associated with higher day 3 creatinine and BUN after adjusting for age, day 1 VIS, and the ultrasound parameters. CONCLUSIONS AND RELEVANCE In pediatric shock, kidney blood flow was abnormal and renin and aldosterone were elevated in those with AKI. Kidney blood flow abnormalities are independently associated with future cardiovascular dysfunction; renin elevations are independently associated with future kidney dysfunction. Kidney blood flow by POCUS may identify children who will have persistent as opposed to resolving AKI. RAAS perturbations may drive AKI in pediatric shock.
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Affiliation(s)
- Grace Fisler
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
- Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY
| | - Kristina Murphy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
| | - Fiore Mastroianni
- Division of Pulmonary and Critical Care Medicine, New York University Grossman Long Island School of Medicine, Mineola, NY
| | - James B. Schneider
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
| | - Clifford S. Deutschman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
- Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY
| | - Daniel E. Leisman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Matthew D. Taylor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
- Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY
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See EJ, Chaba A, Spano S, Maeda A, Clapham C, Burrell LM, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Renin Levels and Angiotensin II Responsiveness in Vasopressor-Dependent Hypotension. Crit Care Med 2024; 52:1218-1227. [PMID: 38511994 DOI: 10.1097/ccm.0000000000006273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVES The relationship between renin levels, exposure to renin-angiotensin system (RAS) inhibitors, angiotensin II (ANGII) responsiveness, and outcome in patients with vasopressor-dependent vasodilatory hypotension is unknown. DESIGN We conducted a single-center prospective observational study to explore whether recent RAS inhibitor exposure affected baseline renin levels, whether baseline renin levels predicted ANGII responsiveness, and whether renin levels at 24 hours were associated with clinical outcomes. SETTING An academic ICU in Melbourne, VIC, Australia. PATIENTS Forty critically ill adults who received ANGII as the primary agent for vasopressor-dependent vasodilatory hypotension who were included in the Acute Renal effects of Angiotensin II Management in Shock study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After multivariable adjustment, recent exposure to a RAS inhibitor was independently associated with a relative increase in baseline renin levels by 198% (95% CI, 36-552%). The peak amount of ANGII required to achieve target mean arterial pressure was independently associated with baseline renin level (increase by 46% per ten-fold increase; 95% CI, 8-98%). Higher renin levels at 24 hours after ANGII initiation were independently associated with fewer days alive and free of continuous renal replacement therapy (CRRT) (-7 d per ten-fold increase; 95% CI, -12 to -1). CONCLUSIONS In patients with vasopressor-dependent vasodilatory hypotension, recent RAS inhibitor exposure was associated with higher baseline renin levels. Such higher renin levels were then associated with decreased ANGII responsiveness. Higher renin levels at 24 hours despite ANGII infusion were associated with fewer days alive and CRRT-free. These preliminary findings emphasize the importance of the RAS and the role of renin as a biomarker in patients with vasopressor-dependent vasodilatory hypotension.
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Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Rinaldo Bellomo
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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Picod A, Garcia B, Van Lier D, Pickkers P, Herpain A, Mebazaa A, Azibani F. Impaired angiotensin II signaling in septic shock. Ann Intensive Care 2024; 14:89. [PMID: 38877367 PMCID: PMC11178728 DOI: 10.1186/s13613-024-01325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/29/2024] [Indexed: 06/16/2024] Open
Abstract
Recent years have seen a resurgence of interest for the renin-angiotensin-aldosterone system in critically ill patients. Emerging data suggest that this vital homeostatic system, which plays a crucial role in maintaining systemic and renal hemodynamics during stressful conditions, is altered in septic shock, ultimately leading to impaired angiotensin II-angiotensin II type 1 receptor signaling. Indeed, available evidence from both experimental models and human studies indicates that alterations in the renin-angiotensin-aldosterone system during septic shock can occur at three distinct levels: 1. Impaired generation of angiotensin II, possibly attributable to defects in angiotensin-converting enzyme activity; 2. Enhanced degradation of angiotensin II by peptidases; and/or 3. Unavailability of angiotensin II type 1 receptor due to internalization or reduced synthesis. These alterations can occur either independently or in combination, ultimately leading to an uncoupling between the renin-angiotensin-aldosterone system input and downstream angiotensin II type 1 receptor signaling. It remains unclear whether exogenous angiotensin II infusion can adequately address all these mechanisms, and additional interventions may be required. These observations open a new avenue of research and offer the potential for novel therapeutic strategies to improve patient prognosis. In the near future, a deeper understanding of renin-angiotensin-aldosterone system alterations in septic shock should help to decipher patients' phenotypes and to implement targeted interventions.
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Affiliation(s)
- Adrien Picod
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France.
| | - Bruno Garcia
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antoine Herpain
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
- Department of Intensive Care Medicine, St. Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Mebazaa
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
- Department of Anesthesiology, Burns and Critical Care, Hopitaux Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Feriel Azibani
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
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Garcia B, Ter Schiphorst B, Santos K, Su F, Dewachter L, Vasques-Nóvoa F, Rocha-Oliveira E, Roncon-Albuquerque R, Uba T, Hartmann O, Picod A, Azibani F, Callebert J, Goldman S, Annoni F, Favory R, Vincent JL, Creteur J, Taccone FS, Mebazaa A, Herpain A. Inhibition of circulating dipeptidyl-peptidase 3 by procizumab in experimental septic shock reduces catecholamine exposure and myocardial injury. Intensive Care Med Exp 2024; 12:53. [PMID: 38849640 PMCID: PMC11161450 DOI: 10.1186/s40635-024-00638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Dipeptidyl peptidase 3 (DPP3) is a ubiquitous cytosolic enzyme released into the bloodstream after tissue injury, that can degrade angiotensin II. High concentrations of circulating DPP3 (cDPP3) have been associated with worse outcomes during sepsis. The aim of this study was to assess the effect of Procizumab (PCZ), a monoclonal antibody that neutralizes cDPP3, in an experimental model of septic shock. METHODS In this randomized, open-label, controlled study, 16 anesthetized and mechanically ventilated pigs with peritonitis were randomized to receive PCZ or standard treatment when the mean arterial pressure (MAP) dropped below 50 mmHg. Resuscitation with fluids, antimicrobial therapy, peritoneal lavage, and norepinephrine was initiated one hour later to maintain MAP between 65-75 mmHg for 12 h. Hemodynamic variables, tissue oxygenation indices, and measures of organ failure and myocardial injury were collected. Organ blood flow was assessed using isotopic assessment (99mtechnetium albumin). cDPP3 activity, equilibrium analysis of the renin-angiotensin system and circulating catecholamines were measured. Tissue mRNA expression of interleukin-6 and downregulation of adrenergic and angiotensin receptors were assessed on vascular and myocardial samples. RESULTS PCZ-treated animals had reduced cDPP3 levels and required less norepinephrine and fluid than septic control animals for similar organ perfusion and regional blood flow. PCZ-treated animals had less myocardial injury, and higher PaO2/FiO2 ratios. PCZ was associated with lower circulating catecholamine levels; higher circulating angiotensin II and higher angiotensin II receptor type 1 myocardial protein expression, and with lower myocardial and radial artery mRNA interleukin-6 expression. CONCLUSIONS In an experimental model of septic shock, PCZ administration was associated with reduced fluid and catecholamine requirements, less myocardial injury and cardiovascular inflammation, along with preserved angiotensin II signaling.
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Affiliation(s)
- Bruno Garcia
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium.
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France.
| | - Benoit Ter Schiphorst
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Fuhong Su
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Laurence Dewachter
- Laboratory of Physiology and Pharmacology, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Estela Rocha-Oliveira
- Cardiovascular R&D Center, Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Theo Uba
- 4TEEN4 Pharmaceuticals GmbH, Hennigsdorf, Germany
| | | | - Adrien Picod
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
| | - Feriel Azibani
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
| | - Jacques Callebert
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
- Department of Biochemistry, Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière, Paris, France
| | - Serge Goldman
- Department of Nuclear Medicine, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Filippo Annoni
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Raphaël Favory
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Louis Vincent
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jacques Creteur
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alexandre Mebazaa
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Antoine Herpain
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Liu L, Li Y, Li JX, Xiao X, Wan TT, Li HH, Guo SB. ACE2 Expressed on Myeloid Cells Alleviates Sepsis-Induced Acute Liver Injury via the Ang-(1-7)-Mas Receptor Axis. Inflammation 2024; 47:891-908. [PMID: 38240986 DOI: 10.1007/s10753-023-01949-5] [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: 09/24/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 06/04/2024]
Abstract
Sepsis-induced acute liver injury (ALI) is common in intensive care units. Angiotensin-converting enzyme 2 (ACE2) plays a vital role in hepatic fibrosis and steatosis; however, its role in sepsis-induced ALI remains unclear. This study found that hepatic ACE2 expression in cecal ligation and puncture (CLP)-treated mice significantly decreased 24 h after CLP. ACE2-transgenic (TG) mice exhibited a significant improvement in CLP-induced ALI, accompanied by the inhibition of hepatocyte apoptosis, oxidative stress, and inflammation, while ACE2-knockout mice demonstrated an opposite trend. During sepsis-induced ALI, ACE2-TG could also elevate the Ang-(1-7) and Mas receptor (MasR) levels in liver tissues. Interestingly, the MasR inhibitor A779 abrogated the favorable effects of ACE2 on CLP-induced ALI. In a bone marrow transplantation experiment, the ACE2-TG transplantation group showed significantly improved inflammation and liver dysfunction, less hepatocyte apoptosis, and reduced oxidative stress after CLP compared with the wild-type transplantation group. In contrast, the ACE2-knockout group showed poor inflammatory response and liver dysfunction, significantly more hepatocyte apoptosis, and elevated oxidative stress than the wild-type transplantation group after CLP. ACE2 protects against sepsis-induced ALI by inhibiting hepatocyte apoptosis, oxidative stress, and inflammation via the Ang-(1-7)-Mas receptor axis. Thus, targeting ACE2 may be a promising novel strategy for preventing and treating sepsis-induced ALI.
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Affiliation(s)
- Lei Liu
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China
| | - Ya Li
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China
| | - Jia-Xin Li
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China
| | - Xue Xiao
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China
| | - Tian-Tian Wan
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China
| | - Hui-Hua Li
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China.
| | - Shu-Bin Guo
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China.
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9
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Schaich CL, Leisman DE, Goldberg MB, Filbin MR, Khanna AK, Chappell MC. Dysfunction of the renin-angiotensin-aldosterone system in human septic shock. Peptides 2024; 176:171201. [PMID: 38555976 PMCID: PMC11060897 DOI: 10.1016/j.peptides.2024.171201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
Sepsis and septic shock are global healthcare problems associated with mortality rates of up to 40% despite optimal standard-of-care therapy and constitute the primary cause of death in intensive care units worldwide. Circulating biomarkers of septic shock severity may represent a clinically relevant approach to individualize those patients at risk for worse outcomes early in the course of the disease, which may facilitate early and more precise interventions to improve the clinical course. However, currently used septic shock biomarkers, including lactate, may be non-specific and have variable impact on prognosis and/or disease management. Activation of the renin-angiotensin-aldosterone system (RAAS) is likely an early event in septic shock, and studies suggest that an elevated level of renin, the early and committed step in the RAAS cascade, is a better predictor of worse outcomes in septic shock, including mortality, than the current standard-of-care measure of lactate. Despite a robust increase in renin, other elements of the RAAS, including endogenous levels of Ang II, may fail to sufficiently increase to maintain blood pressure, tissue perfusion, and protective immune responses in septic shock patients. We review the current clinical literature regarding the dysfunction of the RAAS in septic shock and potential therapeutic approaches to improve clinical outcomes.
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Affiliation(s)
- Christopher L Schaich
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcia B Goldberg
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Micheal R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital,Boston, MA, USA
| | - Ashish K Khanna
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Mark C Chappell
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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10
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Kotani Y, Chappell M, Landoni G, Zarbock A, Bellomo R, Khanna AK. Renin in critically ill patients. Ann Intensive Care 2024; 14:79. [PMID: 38775999 PMCID: PMC11111649 DOI: 10.1186/s13613-024-01304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
The renin-angiotensin system (RAS) constitutes one of the principal mechanisms to maintain hemodynamic and fluid homeostasis. However, most research until now on RAS primarily focuses on its relationship with hypertension and its role in critically ill hypotensive populations is not well understood. With the approval of angiotensin II (Ang II) in the United States and Europe, following a phase 3 randomized controlled trial showing efficacy in catecholamine-resistant vasodilatory shock, there is growing interest in RAS in critically ill patients. Among the fundamental components of RAS, renin acts as the initial stimulus for the entire system. In the context of hypotension, its release increases in response to low blood pressure sensed by renal baroreceptors and attenuated negative Ang II feedback loop. Thus, elevated renin could reflect disease severity and predict poor outcomes. Studies investigating this hypothesis have validated the prognostic accuracy of renin in various critically ill populations, with several reports indicating its superiority to lactate for mortality prediction. Accordingly, renin reduction has been used to assess the effectiveness of Ang II administration. Furthermore, renin holds potential to identify patients who might benefit from Ang II treatment, potentially paving the way for personalized vasopressor management. Despite these promising data, most available evidence is derived from retrospective analysis and necessitates prospective confirmation. The absence of a rapid, point-of-care and reliable renin assay presents another hurdle to its integration into routine clinical practice. This narrative review aims to describe the current understanding and future directions of renin as a biomarker during resuscitation of critically ill patients.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Mark Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Ashish K Khanna
- Section On Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
- Perioperative Outcomes and Informatics Collaborative, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
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11
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Kotani Y, Belletti A, Maiucci G, Lodovici M, Fresilli S, Landoni G, Bellomo R, Zarbock A. Renin as a Prognostic Marker in Intensive Care and Perioperative Settings: A Scoping Review. Anesth Analg 2024; 138:929-936. [PMID: 38358109 DOI: 10.1213/ane.0000000000006682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Serum renin increases in response to sympathetic nerve activation and hypotension. Recent studies have reported the association of serum renin levels with adverse clinical outcomes in acute care settings. This scoping review aimed to systematically review the available literature on renin as a prognostic marker in intensive care and perioperative patients. We searched for studies published since inception until March 31, 2023, which assessed the association between serum renin levels and clinical outcomes or the effect of synthetic angiotensin II administration on serum renin levels in critically ill and perioperative patients in PubMed, Embase, and the Cochrane Library. The primary outcome was mortality at the longest follow-up; the secondary outcomes were adverse renal outcomes (ie, acute kidney injury, the need for renal replacement therapy, and major adverse kidney events), hemodynamic instability, outcomes to angiotensin II administration, and prognostic performance for mortality when compared with lactate. Among the 2081 studies identified, we included 16 studies with 1573 patients (7 studies on shock, 5 on nonspecific critical illness, 2 on cardiac surgery, 1 on noncardiac surgery, and 1 on coronavirus disease 2019). A significant association between serum renin levels and poor outcomes was identified in 14 studies, with 10 studies demonstrating an association with mortality. One post hoc analysis found that angiotensin II administration reduced mortality in patients with markedly elevated renin values. Two studies showed that renin was superior to lactate as a prognostic marker of mortality. Our scoping review showed that elevated serum renin levels may be associated with clinically relevant outcomes among various perioperative and intensive care populations. Increased serum renin levels may identify patients in which synthetic angiotensin II administration improves clinical outcomes and may outperform serum lactate in predicting mortality.
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Affiliation(s)
- Yuki Kotani
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Alessandro Belletti
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Maiucci
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Lodovici
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
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12
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Leisman DE, Handisides DR, Busse LW, Chappell MC, Chawla LS, Filbin MR, Goldberg MB, Ham KR, Khanna AK, Ostermann M, McCurdy MT, Adams CD, Hodges TN, Bellomo R. ACE inhibitors and angiotensin receptor blockers differentially alter the response to angiotensin II treatment in vasodilatory shock. Crit Care 2024; 28:130. [PMID: 38637829 PMCID: PMC11027368 DOI: 10.1186/s13054-024-04910-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blockers (ARB) medications are widely prescribed. We sought to assess how pre-admission use of these medications might impact the response to angiotensin-II treatment during vasodilatory shock. METHODS In a post-hoc subgroup analysis of the randomized, placebo-controlled, Angiotensin Therapy for High Output Shock (ATHOS-3) trial, we compared patients with chronic angiotensin-converting enzyme inhibitor (ACEi) use, and patients with angiotensin receptor blocker (ARB) use, to patients without exposure to either ACEi or ARB. The primary outcome was mean arterial pressure after 1-h of treatment. Additional clinical outcomes included mean arterial pressure and norepinephrine equivalent dose requirements over time, and study-drug dose over time. Biological outcomes included baseline RAS biomarkers (renin, angiotensin-I, angiotensin-II, and angiotensin-I/angiotensin-II ratio), and the change in renin from 0 to 3 h. RESULTS We included n = 321 patients, of whom, 270 were ACEi and ARB-unexposed, 29 were ACEi-exposed and 22 ARB-exposed. In ACEi/ARB-unexposed patients, angiotensin-treated patients, compared to placebo, had higher hour-1 mean arterial pressure (9.1 mmHg [95% CI 7.6-10.1], p < 0.0001), lower norepinephrine equivalent dose over 48-h (p = 0.0037), and lower study-drug dose over 48-h (p < 0.0001). ACEi-exposed patients treated with angiotensin-II showed similarly higher hour-1 mean arterial pressure compared to ACEi/ARB-unexposed (difference in treatment-effect: - 2.2 mmHg [95% CI - 7.0-2.6], pinteraction = 0.38), but a greater reduction in norepinephrine equivalent dose (pinteraction = 0.0031) and study-drug dose (pinteraction < 0.0001) over 48-h. In contrast, ARB-exposed patients showed an attenuated effect of angiotensin-II on hour-1 mean arterial pressure versus ACEi/ARB-unexposed (difference in treatment-effect: - 6.0 mmHg [95% CI - 11.5 to - 0.6], pinteraction = 0.0299), norepinephrine equivalent dose (pinteraction < 0.0001), and study-drug dose (pinteraction = 0.0008). Baseline renin levels and angiotensin-I/angiotensin-II ratios were highest in ACEi-exposed patients. Finally, angiotensin-II treatment reduced hour-3 renin in ACEi/ARB-unexposed and ACEi-exposed patients but not in ARB-exposed patients. CONCLUSIONS In vasodilatory shock patients, the cardiovascular and biological RAS response to angiotensin-II differed based upon prior exposure to ACEi and ARB medications. ACEi-exposure was associated with increased angiotensin II responsiveness, whereas ARB-exposure was associated with decreased responsiveness. These findings have clinical implications for patient selection and dosage of angiotensin II in vasodilatory shock. Trial Registration ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).
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Affiliation(s)
- Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St., GRB 7-730, Boston, MA, 02114, USA.
| | - Damian R Handisides
- Innoviva Specialty Therapeutics, Inc - an Affiliate of La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, CA, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Marcia B Goldberg
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Center for Bacterial Pathogenesis, Massachusetts General Hospital, Boston, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Kealy R Ham
- Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher D Adams
- Innoviva Specialty Therapeutics, Inc - an Affiliate of La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Tony N Hodges
- Innoviva Specialty Therapeutics, Inc - an Affiliate of La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
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13
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Legrand M, Bagshaw SM, Bhatraju PK, Bihorac A, Caniglia E, Khanna AK, Kellum JA, Koyner J, Harhay MO, Zampieri FG, Zarbock A, Chung K, Liu K, Mehta R, Pickkers P, Ryan A, Bernholz J, Dember L, Gallagher M, Rossignol P, Ostermann M. Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials. Crit Care 2024; 28:92. [PMID: 38515121 PMCID: PMC10958912 DOI: 10.1186/s13054-024-04877-4] [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: 11/18/2023] [Accepted: 03/17/2024] [Indexed: 03/23/2024] Open
Abstract
Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.
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Affiliation(s)
- Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, UCSF, 521 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
- Kidney Research Institute, University of Washington, Seattle, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Ellen Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Koyner
- University Section of Nephrology, Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Department of Biostatistics, Epidemiology, and Informatics, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | | | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Ravindra Mehta
- Department of Medicine, University of California, San Diego, USA
| | - Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Abigail Ryan
- Chronic Care Policy Group, Division of Chronic Care Management, Center for Medicare and Medicaid Services, Center for Medicare, Baltimore, MD, USA
| | | | - Laura Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Patrick Rossignol
- FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, Université de Lorraine, Nancy, France
- Medicine and Nephrology-Hemodialysis Departments, Monaco Private Hemodialysis Centre, Princess Grace Hospital, Monaco, Monaco
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
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14
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Chakradhar A, Baron RM, Vera MP, Devarajan P, Chawla L, Hou PC. Plasma renin as a novel prognostic biomarker of sepsis-associated acute respiratory distress syndrome. Sci Rep 2024; 14:6667. [PMID: 38509149 PMCID: PMC10954703 DOI: 10.1038/s41598-024-56994-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
Sepsis-associated acute respiratory distress syndrome (ARDS) is a life-threatening condition in critical care medicine for which there is a substantial need for early prognostic biomarkers of outcome. The present study seeks to link plasma renin levels and 30-day mortality in sepsis-associated ARDS patients treated at our institution. The Registry of Critical Illness (RoCI) prospectively enrolled patients from the intensive care units (ICU) within a single academic medical center, and a convenience sample of patients with sepsis-associated ARDS was analyzed from this cohort. This study was approved by the Mass General Brigham Institutional Review Boards (IRB) as part of the RoCI, and all procedures performed were in accordance with the ethical standards of the institutional board. From April 2012 to February 2019, a cohort of 32 adult sepsis-associated ARDS patients with 500 µL of plasma samples available on Day 0 and Day 3 of their ICU stay were enrolled. Renin levels were measured twice, on Day 0 and Day 3 via the direct renin enzyme-linked immunosorbent assay (ELISA EIA-525) by DRG diagnostics. Day 0 and Day 3 renin were statistically evaluated via logistic regression to predict 30-day mortality. Direct renin levels of 64 samples were assayed from 32 sepsis-associated ARDS patients (50% male; mean ± SD, 55 ± 13.8 years old). The 30-day hospital mortality rate was 59.4%. Patients who died within 30 days of admission were more likely to have an elevated Day 3 Renin (Odds ratio [OR] = 6, 95% CI 1.25-28.84) and have received vasopressors (OR = 13.33, 95% CI 1.43-123.95). Adjusting for vasopressor use as a proxy for septic shock status, patients with an Elevated Day 3 Renin had a 6.85 (95% CI 1.07-43.75) greater odds of death than those with Low-Normal Day 3 Renin. Patients with sustained Elevated Renin levels from Day 0 to Day 3 had the highest risk of death in a 30-day window. In this study, we found that renin may be a novel biomarker that has prognostic value for patients with sepsis-associated ARDS. Future studies evaluating renin levels in patients with sepsis-associated ARDS are needed to validate these findings.
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Affiliation(s)
- Anjali Chakradhar
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mayra Pinilla Vera
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lakhmir Chawla
- Silver Creek Pharmaceuticals, Inc., San Francisco, CA, USA
| | - Peter C Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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15
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Teixeira JP, Perez Ingles D, Barton JB, Dean JT, Garcia P, Kunkel SJ, Sarangarm P, Weiss NK, Schaich CL, Busse LW, Nielsen ND. The scientific rationale and study protocol for the DPP3, Angiotensin II, and Renin Kinetics in Sepsis (DARK-Sepsis) randomized controlled trial: serum biomarkers to predict response to angiotensin II versus standard-of-care vasopressor therapy in the treatment of septic shock. Trials 2024; 25:182. [PMID: 38475822 DOI: 10.1186/s13063-024-07995-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Data to support the use of specific vasopressors in septic shock are limited. Since angiotensin II (AT2) was approved by the Food and Drug Administration in 2017, multiple mechanistically distinct vasopressors are available to treat septic shock, but minimal data exist regarding which patients are most likely to benefit from each agent. Renin and dipeptidyl peptidase 3 (DPP3) are components of the renin-angiotensin-aldosterone system which have been shown to outperform lactate in predicting sepsis prognosis, and preliminary data suggest they could prove useful as biomarkers to guide AT2 use in septic shock. METHODS The DARK-Sepsis trial is an investigator-initiated industry-funded, open-label, single-center randomized controlled trial of the use of AT2 versus standard of care (SOC) vasopressor therapy in patients admitted to the intensive care unit (ICU) with vasodilatory shock requiring norepinephrine ≥ 0.1 mcg/kg/min. In both groups, a series of renin and DPP3 levels will be obtained over the first 24 h of treatment with AT2 or SOC. The primary study outcome will be the ability of these biomarkers to predict response to vasopressor therapy, as measured by change in total norepinephrine equivalent dose of vasopressors at 3 h post-drug initiation or the equivalent timepoint in the SOC arm. To determine if the ability to predict vasopressor response is specific to AT2 therapy, the primary analysis will be the ability of baseline renin and DPP3 levels to predict vasopressor response adjusted for treatment arm (AT2 versus control) and Sequential Organ Failure Assessment (SOFA) scores. Secondary outcomes will include rates of acute kidney injury, need for mechanical ventilation and kidney replacement therapy, lengths of stay in the ICU and hospital, ICU and hospital mortality, and rates of prespecified adverse events. DISCUSSION With an armamentarium of mechanistically distinct vasopressor agents now available, sub-phenotyping patients using biomarkers has the potential to improve septic shock outcomes by enabling treatment of the correct patient with the correct vasopressor at the correct time. However, this approach requires validation in a large definitive multicenter trial. The data generated through the DARK-Sepsis study will prove crucial to the optimal design and patient enrichment of such a pivotal trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05824767. Registered on April 24, 2023.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - David Perez Ingles
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Jordan B Barton
- Investigational Drug Services Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - James T Dean
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Pablo Garcia
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Susan J Kunkel
- Investigational Drug Services Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | | | - Natalie K Weiss
- Clinical Trials Unit, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Section of Transfusion Medicine and Therapeutic Pathology, Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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16
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See EJ, Russell JA, Bellomo R, Lawler PR. Renin as a Prognostic and Predictive Biomarker in Sepsis: More Questions Than Answers? Crit Care Med 2024; 52:509-512. [PMID: 38381014 DOI: 10.1097/ccm.0000000000006133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Emily J See
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, NSW, Australia
- Department of Critical Care, University of Melbourne, Parkville, NSW, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, NSW, Australia
- Department of Critical Care, University of Melbourne, Parkville, NSW, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Patrick R Lawler
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Busse LW, Schaich CL, Chappell MC, McCurdy MT, Staples EM, Ten Lohuis CC, Hinson JS, Sevransky JE, Rothman RE, Wright DW, Martin GS, Khanna AK. Association of Active Renin Content With Mortality in Critically Ill Patients: A Post hoc Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) Trial. Crit Care Med 2024; 52:441-451. [PMID: 37947484 PMCID: PMC10876175 DOI: 10.1097/ccm.0000000000006095] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Sepsis is a leading cause of mortality. Predicting outcomes is challenging and few biomarkers perform well. Defects in the renin-angiotensin system (RAS) can predict clinical outcomes in sepsis and may outperform traditional biomarkers. We postulated that RAS dysfunction (elevated active renin, angiotensin 1-7 [Ang-(1-7)], and angiotensin-converting enzyme 2 (ACE2) activity with depressed Ang-II and ACE activity) would be associated with mortality in a cohort of septic patients. DESIGN Post hoc analysis of patients enrolled in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized controlled trial. SETTING Forty-three hospitals across the United States. PATIENTS Biorepository samples of 103 patients. INTERVENTIONS We analyzed day 0 (within 24 hr of respiratory failure, septic shock, or both) and day 3 samples ( n = 103 and 95, respectively) for assessment of the RAS. The association of RAS values with 30-day mortality was determined using Cox proportional hazards regression with multivariable adjustments for age, sex, VICTAS treatment arm, systolic blood pressure, Sequential Organ Failure Assessment Score, and vasopressor use. MEASUREMENTS AND MAIN RESULTS High baseline active renin values were associated with higher 30-day mortality when dichotomized to the median of 188.7 pg/mL (hazard ratio [HR] = 2.84 [95% CI, 1.10-7.33], p = 0.031) or stratified into quartiles (Q1 = ref, HR Q2 = 2.01 [0.37-11.04], HR Q3 = 3.22 [0.64-16.28], HR Q4 = 5.58 [1.18-26.32], p for linear trend = 0.023). A 1- sd (593.6 pg/mL) increase in renin from day 0 to day 3 was associated with increased mortality (HR = 3.75 [95% CI, 1.94-7.22], p < 0.001), and patients whose renin decreased had improved survival compared with those whose renin increased (HR 0.22 [95% CI, 0.08-0.60], p = 0.003). Ang-(1-7), ACE2 activity, Ang-II and ACE activity did not show this association. Mortality was attenuated in patients with renin over the median on day 0 who received the VICTAS intervention, but not on day 3 ( p interaction 0.020 and 0.137, respectively). There were no additional consistent patterns of mortality on the RAS from the VICTAS intervention. CONCLUSIONS Baseline serum active renin levels were strongly associated with mortality in critically ill patients with sepsis. Furthermore, a greater relative activation in circulating renin from day 0 to day 3 was associated with a higher risk of death.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Erin M Staples
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Ashish K Khanna
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
- Perioperative Outcomes and Informatics Collaborative, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
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18
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Coloretti I, Genovese A, Teixeira JP, Cherian A, Ferrer R, Landoni G, Leone M, Girardis M, Nielsen ND. Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:13. [PMID: 38383521 PMCID: PMC10882873 DOI: 10.1186/s44158-024-00150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.
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Affiliation(s)
- Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy.
| | - Andrea Genovese
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Anusha Cherian
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, India
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Giovanni Landoni
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc Leone
- Anesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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19
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Garcia B, Zarbock A, Bellomo R, Legrand M. The role of renin-angiotensin system in sepsis-associated acute kidney injury: mechanisms and therapeutic implications. Curr Opin Crit Care 2023; 29:607-613. [PMID: 37861190 DOI: 10.1097/mcc.0000000000001092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the relationship between the renin angiotensin system (RAS) and sepsis-associated acute kidney injury (SA-AKI), a common complication in critically ill patients associated with mortality, morbidity, and long-term cardiovascular complications. Additionally, this review aims to identify potential therapeutic approaches to intervene with the RAS and prevent the development of AKI. RECENT FINDINGS Recent studies have provided increasing evidence of RAS alteration during sepsis, with systemic and local RAS disturbance, which can contribute to SA-AKI. Angiotensin II was recently approved for catecholamine resistant vasodilatory shock and has been associated with improved outcomes in selected patients. SUMMARY SA-AKI is a common condition that can involve disturbances in the RAS, particularly the canonical angiotensin-converting enzyme (ACE) angiotensin-II (Ang II)/angiotensin II receptor 1 (AT-1R) axis. Increased renin levels, a key enzyme in the RAS, have been shown to be associated with AKI and may also guide vasopressor therapy in shock. In patients with high renin levels, angiotensin II administration may reduce renin concentration, improve intra-renal hemodynamics, and enhance signaling through the angiotensin II receptor 1. Further studies are needed to explore the role of the RAS in SA-AKI and the potential for targeted therapies.
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Affiliation(s)
- Bruno Garcia
- Department of Anesthesia & Peri-operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital
- Australian and New Zealand Intensive Care Research Centre, Monash University
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthieu Legrand
- Department of Anesthesia & Peri-operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
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20
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Garcia B, Zarbock A, Bellomo R, Legrand M. The alternative renin-angiotensin system in critically ill patients: pathophysiology and therapeutic implications. Crit Care 2023; 27:453. [PMID: 37986086 PMCID: PMC10662652 DOI: 10.1186/s13054-023-04739-5] [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: 09/29/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023] Open
Abstract
The renin-angiotensin system (RAS) plays a crucial role in regulating blood pressure and the cardio-renal system. The classical RAS, mainly mediated by angiotensin I, angiotensin-converting enzyme, and angiotensin II, has been reported to be altered in critically ill patients, such as those in vasodilatory shock. However, recent research has highlighted the role of some components of the counterregulatory axis of the classical RAS, termed the alternative RAS, such as angiotensin-converting Enzyme 2 (ACE2) and angiotensin-(1-7), or peptidases which can modulate the RAS like dipeptidyl-peptidase 3, in many critical situations. In cases of shock, dipeptidyl-peptidase 3, an enzyme involved in the degradation of angiotensin and opioid peptides, has been associated with acute kidney injury and mortality and preclinical studies have tested its neutralization. Angiotensin-(1-7) has been shown to prevent septic shock development and improve outcomes in experimental models of sepsis. In the context of experimental acute lung injury, ACE2 activity has demonstrated a protective role, and its inactivation has been associated with worsened lung function, leading to the use of active recombinant human ACE2, in preclinical and human studies. Angiotensin-(1-7) has been tested in experimental models of acute lung injury and in a recent randomized controlled trial for patients with COVID-19 related hypoxemia. Overall, the alternative RAS appears to have a role in the pathogenesis of disease in critically ill patients, and modulation of the alternative RAS may improve outcomes. Here, we review the available evidence regarding the methods of analysis of the RAS, pathophysiological disturbances of this system, and discuss how therapeutic manipulation may improve outcomes in the critically ill.
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Affiliation(s)
- Bruno Garcia
- Department of Anesthesia and Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, 3084, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Matthieu Legrand
- Department of Anesthesia and Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
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21
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Nádasy GL, Balla A, Szekeres M. From Living in Saltwater to a Scarcity of Salt and Water, and Then an Overabundance of Salt-The Biological Roller Coaster to Which the Renin-Angiotensin System Has Had to Adapt: An Editorial. Biomedicines 2023; 11:3004. [PMID: 38002004 PMCID: PMC10669630 DOI: 10.3390/biomedicines11113004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Angiotensin II (Ang II) is a hormone with much more complex actions than is typical for other agonists with heterotrimeric G protein-coupled receptors (GPCRs) [...].
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Affiliation(s)
- György L. Nádasy
- Department of Physiology, Faculty of Medicine, Semmelweis University, 37-47 Tűzoltó Street, 1094 Budapest, Hungary; (G.L.N.); (A.B.)
| | - András Balla
- Department of Physiology, Faculty of Medicine, Semmelweis University, 37-47 Tűzoltó Street, 1094 Budapest, Hungary; (G.L.N.); (A.B.)
- Laboratory of Molecular Physiology, Eötvös Loránd Research Network, Research Centre for Natural Sciences, 2 Magyar Tudósok Körútja, 1117 Budapest, Hungary
| | - Mária Szekeres
- Department of Physiology, Faculty of Medicine, Semmelweis University, 37-47 Tűzoltó Street, 1094 Budapest, Hungary; (G.L.N.); (A.B.)
- Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, 17 Vas Street, 1088 Budapest, Hungary
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22
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García-Álvarez R, Arboleda-Salazar R. Vasopressin in Sepsis and Other Shock States: State of the Art. J Pers Med 2023; 13:1548. [PMID: 38003863 PMCID: PMC10672256 DOI: 10.3390/jpm13111548] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.
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Affiliation(s)
- Raquel García-Álvarez
- Department of Anesthesiology and Surgical Intensive Care, University Hospital 12 de Octubre, 28022 Madrid, Spain
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23
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Guzzo I, Paglialonga F. Critically ill children with septic shock: time to rediscover renin? Pediatr Nephrol 2023; 38:2907-2910. [PMID: 37087478 DOI: 10.1007/s00467-023-05985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Isabella Guzzo
- Pediatric Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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24
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Stanski NL, Pode Shakked N, Zhang B, Cvijanovich NZ, Fitzgerald JC, Jain PN, Schwarz AJ, Nowak J, Weiss SL, Allen GL, Thomas NJ, Haileselassie B, Goldstein SL. Serum renin and prorenin concentrations predict severe persistent acute kidney injury and mortality in pediatric septic shock. Pediatr Nephrol 2023; 38:3099-3108. [PMID: 36939916 PMCID: PMC10588759 DOI: 10.1007/s00467-023-05930-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Studies in critically ill adults demonstrate associations between serum renin concentrations (a proposed surrogate for renin-angiotensin-aldosterone system dysregulation) and poor outcomes, but data in critically ill children are lacking. We assessed serum renin + prorenin concentrations in children with septic shock to determine their predictive ability for acute kidney injury (AKI) and mortality. METHODS We conducted a secondary analysis of a multicenter observational study of children aged 1 week to 18 years admitted to 14 pediatric intensive care units (PICUs) with septic shock and residual serum available for renin + prorenin measurement. Primary outcomes were development of severe persistent AKI (≥ KDIGO stage 2 for ≥ 48 h) in the first week and 28-day mortality. RESULTS Among 233 patients, day 1 median renin + prorenin concentration was 3436 pg/ml (IQR 1452-6567). Forty-two (18%) developed severe persistent AKI and 32 (14%) died. Day 1 serum renin + prorenin predicted severe persistent AKI with an AUROC of 0.75 (95% CI 0.66-0.84, p < 0.0001; optimal cutoff 6769 pg/ml) and mortality with an AUROC of 0.79 (95% CI 0.69-0.89, p < 0.0001; optimal cutoff 6521 pg/ml). Day 3/day 1 (D3:D1) renin + prorenin ratio had an AUROC of 0.73 (95% CI 0.63-0.84, p < 0.001) for mortality. On multivariable regression, day 1 renin + prorenin > optimal cutoff retained associations with severe persistent AKI (aOR 6.8, 95% CI 3.0-15.8, p < 0.001) and mortality (aOR 6.9, 95% CI 2.2-20.9, p < 0.001). Similarly, D3:D1 renin + prorenin > optimal cutoff was associated with mortality (aOR 7.6, 95% CI 2.5-23.4, p < 0.001). CONCLUSIONS Children with septic shock have very elevated serum renin + prorenin concentrations on PICU admission, and these concentrations, as well as their trend over the first 72 h, predict severe persistent AKI and mortality. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Naomi Pode Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | | | - Julie C Fitzgerald
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Jeffrey Nowak
- Children's Minnesota, 2525 Chicago Ave, Minneapolis, MN, 55404, USA
| | - Scott L Weiss
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Dr, Hershey, PA, 17033, USA
| | | | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
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25
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Adan D, Batte A, Namazzi R, Mufumba I, Kazinga C, Mellencamp KA, Bond C, Opoka RO, John CC, Conroy AL. Renin as a Biomarker of Acute Kidney Injury and Mortality in Children With Severe Malaria or Sickle Cell Disease. Cureus 2023; 15:e45124. [PMID: 37842390 PMCID: PMC10569743 DOI: 10.7759/cureus.45124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Globally, a very high percentage of acute kidney injury (AKI) occurs in low- and middle-income countries (LMICs) where late recognition contributes to increased mortality. There are challenges with using existing biomarkers of AKI in LMICs. Emerging evidence suggests renin may serve as a biomarker of kidney injury that can overcome limitations in creatinine-based diagnostics. METHODS Two study populations in Uganda were assessed. Cohort #1 was a two-site, prospective cohort study enrolling 600 children with severe malaria (SM). Cohort #2 was a prospective cohort study enrolling 185 children with sickle cell disease (SCD) hospitalized with a vaso-occlusive crisis. Plasma or serum renin concentrations were measured in both cohorts of children at the time of hospital admission using Luminex® (Luminex Corporation, Austin, Texas, United States) or enzyme-linked immunosorbent assay (ELISA), respectively. We assessed the ability of renin to discriminate between children with or without AKI and between children who survived and children who died using receiver operating characteristic curves. RESULTS In both cohorts, renin concentrations were strongly associated with AKI and mortality. Renin was able to discriminate between children with or without AKI with an area under the curve (AUC) of 0.70 (95%CI, 0.65-0.74) in children with SM and 0.72 (95%CI, 0.6co3-0.81) in children with SCD. Renin was able to discriminate between children who survived and children who died with an AUC of 0.73 (95%CI, 0.63-0.83) in children with SM and 0.94 (95%CI, 0.89-0.99) in children with SCD. In Cohort #2, we compared renin against urine neutrophil gelatinase-associated lipocalin (NGAL) as the leading biomarker of AKI, and it had comparable performance in discriminating AKI and predicting mortality. CONCLUSIONS In two independent populations of children at risk of AKI with key differences in the etiology of kidney injury, renin was strongly associated with AKI and mortality and had moderate to good diagnostic performance to predict mortality.
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Affiliation(s)
- Daniel Adan
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Anthony Batte
- Child Health and Development Centre (CHDC), Makerere University College of Health Sciences, Kampala, UGA
| | - Ruth Namazzi
- Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, UGA
| | - Ivan Mufumba
- CHILD Laboratory, Global Health Uganda, Kampala, UGA
| | | | - Kagan A Mellencamp
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Caitlin Bond
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Robert O Opoka
- Undergraduate Medical Education, Aga Khan University Medical College, Nairobi, KEN
| | - Chandy C John
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
- Center for Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Andrea L Conroy
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
- CHILD Laboratory, Global Health Uganda, Kampala, UGA
- Center for Global Health, Indiana University School of Medicine, Indianapolis, USA
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26
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Pode-Shakked N, Ceschia G, Rose JE, Goldstein SL, Stanski NL. Increasing angiotensin-converting enzyme concentrations and absent angiotensin-converting enzyme activity are associated with adverse kidney outcomes in pediatric septic shock. Crit Care 2023; 27:230. [PMID: 37308975 PMCID: PMC10259008 DOI: 10.1186/s13054-023-04518-2] [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: 03/27/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Sepsis-induced endothelial dysfunction is proposed to cause angiotensin-converting enzyme (ACE) dysfunction and renin-angiotensin-aldosterone system (RAAS) derangement, exacerbating vasodilatory shock and acute kidney injury (AKI). Few studies test this hypothesis directly, including none in children. We measured serum ACE concentrations and activity, and assessed their association with adverse kidney outcomes in pediatric septic shock. METHODS A pilot study of 72 subjects aged 1 week-18 years from an existing multicenter, observational study. Serum ACE concentrations and activity were measured on Day 1; renin + prorenin concentrations were available from a previous study. The associations between individual RAAS components and a composite outcome (Day 1-7 severe persistent AKI, kidney replacement therapy use, or mortality) were assessed. RESULTS 50/72 subjects (69%) had undetectable ACE activity (< 2.41 U/L) on Day 1 and 27/72 (38%) developed the composite outcome. Subjects with undetectable ACE activity had higher Day 1 renin + prorenin compared to those with activity (4533 vs. 2227 pg/ml, p = 0.017); ACE concentrations were no different between groups. Children with the composite outcome more commonly had undetectable ACE activity (85% vs. 65%, p = 0.025), and had higher Day 1 renin + prorenin (16,774 pg/ml vs. 3037 pg/ml, p < 0.001) and ACE concentrations (149 vs. 96 pg/ml, p = 0.019). On multivariable regression, increasing ACE concentrations (aOR 1.01, 95%CI 1.002-1.03, p = 0.015) and undetectable ACE activity (aOR 6.6, 95%CI 1.2-36.1, p = 0.031) retained associations with the composite outcome. CONCLUSIONS ACE activity is diminished in pediatric septic shock, appears uncoupled from ACE concentrations, and is associated with adverse kidney outcomes. Further study is needed to validate these findings in larger cohorts.
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Affiliation(s)
- Naomi Pode-Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA
- Sackler Faculty of Medicine, Tel-Aviv University, P.O. Box 39040, 6997801, Tel Aviv, Israel
| | - Giovanni Ceschia
- Pediatric Nephrology Unit, Department of Women's and Children's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - James E Rose
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA
| | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
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Wieruszewski PM, Bellomo R, Busse LW, Ham KR, Zarbock A, Khanna AK, Deane AM, Ostermann M, Wunderink RG, Boldt DW, Kroll S, Greenfeld CR, Hodges T, Chow JH. Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: an exploratory post-hoc analysis of the ATHOS-3 clinical trial. Crit Care 2023; 27:175. [PMID: 37147690 PMCID: PMC10163684 DOI: 10.1186/s13054-023-04446-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/17/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND High dose vasopressors portend poor outcome in vasodilatory shock. We aimed to evaluate the impact of baseline vasopressor dose on outcomes in patients treated with angiotensin II (AT II). METHODS Exploratory post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial data. The ATHOS-3 trial randomized 321 patients with vasodilatory shock, who remained hypotensive (mean arterial pressure of 55-70 mmHg) despite receiving standard of care vasopressor support at a norepinephrine-equivalent dose (NED) > 0.2 µg/kg/min, to receive AT II or placebo, both in addition to standard of care vasopressors. Patients were grouped into low (≤ 0.25 µg/kg/min; n = 104) or high (> 0.25 µg/kg/min; n = 217) NED at the time of study drug initiation. The primary outcome was the difference in 28-day survival between the AT II and placebo subgroups in those with a baseline NED ≤ 0.25 µg/kg/min at the time of study drug initiation. RESULTS Of 321 patients, the median baseline NED in the low-NED subgroup was similar in the AT II (n = 56) and placebo (n = 48) groups (median of each arm 0.21 µg/kg/min, p = 0.45). In the high-NED subgroup, the median baseline NEDs were also similar (0.47 µg/kg/min AT II group, n = 107 vs. 0.45 µg/kg/min placebo group, n = 110, p = 0.75). After adjusting for severity of illness, those randomized to AT II in the low-NED subgroup were half as likely to die at 28-days compared to placebo (HR 0.509; 95% CI 0.274-0.945, p = 0.03). No differences in 28-day survival between AT II and placebo groups were found in the high-NED subgroup (HR 0.933; 95% CI 0.644-1.350, p = 0.71). Serious adverse events were less frequent in the low-NED AT II subgroup compared to the placebo low-NED subgroup, though differences were not statistically significant, and were comparable in the high-NED subgroups. CONCLUSIONS This exploratory post-hoc analysis of phase 3 clinical trial data suggests a potential benefit of AT II introduction at lower doses of other vasopressor agents. These data may inform design of a prospective trial. TRIAL REGISTRATION The ATHOS-3 trial was registered in the clinicaltrials.gov repository (no. NCT02338843). Registered 14 January 2015.
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Affiliation(s)
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - Kealy R Ham
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, University Münster, Munster, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Boldt
- Department of Anesthesiology and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Stew Kroll
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | | | - Tony Hodges
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, 2700 M St. NW, 7Th Floor, Room 709, Washington, DC, 20037, USA.
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28
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Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock. Anesthesiol Clin 2023; 41:1-25. [PMID: 36871993 DOI: 10.1016/j.anclin.2022.11.002] [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: 03/07/2023]
Abstract
Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.
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Harazim M, Tan K, Nalos M, Matejovic M. Blood urea nitrogen - independent marker of mortality in sepsis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:24-29. [PMID: 35373784 DOI: 10.5507/bp.2022.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This retrospective study examines the relationship between admission Blood Urea Nitrogen (BUN) levels and clinical outcomes in patients with sepsis from two separate cohorts in the Czech Republic and the United States. METHODS The study included 9126 patients with sepsis between January 2014 and December 2018. Kaplan-Meier survival curves and Cox regression were used to analyse the data. An optimal cut-off was calculated by means of the Youden-Index. RESULTS BUN at ICU admission was categorized as 10-20, 20-40 and >40 mg/dL. Comparing the group with the highest BUN levels to the one with lowest levels, we found HR for 28 days mortality 2.764 (CI 95% 2.37-3.20; P<0.001). We derived an optimal cut-off for prediction of 28 days mortality of 23 mg/dL. The association between BUN and 28 days mortality remained significant after adjusting for potential confounders - for APACHE IV (HR 1.374; 95%CI 1.20-1.58; P<0.001), SAPS2 (HR 1.545; 95%CI 1.35-1.77; P<0.001), eGFR (HR 1.851; 95%CI 1.59-2.16; P<0.001) and several other variables in an integrative model. CONCLUSIONS Our findings support the BUN level as an independent and easily available predictor of 28 days mortality in septic critically ill patients admitted to an ICU.
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Affiliation(s)
- Martin Harazim
- ICU, Department of Internal Medicine I, Faculty of Medicine, Charles University and University Hospital Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine, Charles University in Pilsen, Czech Republic.,Department of Gastroenterology and Internal Medicine, Masaryk University and University Hospital Brno, Czech Republic
| | - Kaiquan Tan
- Nepean Clinical School, Sydney Medical School and University of Sydney Penrith, Australia
| | - Marek Nalos
- ICU, Department of Internal Medicine I, Faculty of Medicine, Charles University and University Hospital Pilsen, Czech Republic.,Nepean Clinical School, Sydney Medical School and University of Sydney Penrith, Australia.,Department of Intensive Care Medicine, Nepean Hospital Penrith, Australia
| | - Martin Matejovic
- ICU, Department of Internal Medicine I, Faculty of Medicine, Charles University and University Hospital Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine, Charles University in Pilsen, Czech Republic
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Leone M, Einav S, Antonucci E, Depret F, Lakbar I, Martin-Loeches I, Wieruszewski PM, Myatra SN, Khanna AK. Multimodal strategy to counteract vasodilation in septic shock. Anaesth Crit Care Pain Med 2023; 42:101193. [PMID: 36621622 DOI: 10.1016/j.accpm.2023.101193] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/26/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023]
Abstract
Early initiation of a multimodal treatment strategy in the management of vasopressors during septic shock has been advocated to reduce delays in restoring adequate organ perfusion and to mitigate side effects associated with the administration of high-dose catecholamines. We provide a review that summarises the pathophysiology of vasodilation, the physiologic response to the vascular response, and the different drugs used in this situation, focusing on the need to combine early different vasopressors. Fluid loading being insufficient for counteracting vasoplegia, norepinephrine is usually the first-line vasopressor used to restore hemodynamics. Norepinephrine sparing is discussed in further detail through the concomitant use of adrenergic, vasopressinergic, and renin-angiotensin systems and the optimisation of endothelial reactivity with methylene blue. A blueprint for the construction of new studies is outlined to address the question of vasopressor selection and timing in septic shock.
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Affiliation(s)
- Marc Leone
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
| | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - François Depret
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Ignacio Martin-Loeches
- Intensive Care Unit, Trinity Centre for Health Science HRB-Wellcome Trust, St James's Hospital, Dublin, Ireland
| | | | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
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Hasegawa D, Lee YI, Prasitlumkum N, Chopra L, Nishida K, Smith RL, Sato R. Premorbid angiotensin converting enzyme inhibitors or angiotensin II receptor blockers in patients with sepsis. Am J Emerg Med 2022; 62:69-77. [DOI: 10.1016/j.ajem.2022.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
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Abstract
SARS-CoV-2 gains cell entry via angiotensin-converting enzyme (ACE) 2, a membrane-bound enzyme of the "alternative" (alt) renin-angiotensin system (RAS). ACE2 counteracts angiotensin II by converting it to potentially protective angiotensin 1-7. Using mass spectrometry, we assessed key metabolites of the classical RAS (angiotensins I-II) and alt-RAS (angiotensins 1-7 and 1-5) pathways as well as ACE and ACE2 concentrations in 159 patients hospitalized with COVID-19, stratified by disease severity (severe, n = 76; non-severe: n = 83). Plasma renin activity (PRA-S) was calculated as the sum of RAS metabolites. We estimated ACE activity using the angiotensin II:I ratio (ACE-S) and estimated systemic alt-RAS activation using the ratio of alt-RAS axis metabolites to PRA-S (ALT-S). We applied mixed linear models to assess how PRA-S and ACE/ACE2 concentrations affected ALT-S, ACE-S, and angiotensins II and 1-7. Median angiotensin I and II levels were higher with severe versus non-severe COVID-19 (angiotensin I: 86 versus 30 pmol/L, p < 0.01; angiotensin II: 114 versus 58 pmol/L, p < 0.05), demonstrating activation of classical RAS. The difference disappeared with analysis limited to patients not taking a RAS inhibitor (angiotensin I: 40 versus 31 pmol/L, p = 0.251; angiotensin II: 76 versus 99 pmol/L, p = 0.833). ALT-S in severe COVID-19 increased with time (days 1-6: 0.12; days 11-16: 0.22) and correlated with ACE2 concentration (r = 0.831). ACE-S was lower in severe versus non-severe COVID-19 (1.6 versus 2.6; p < 0.001), but ACE concentrations were similar between groups and correlated weakly with ACE-S (r = 0.232). ACE2 and ACE-S trajectories in severe COVID-19, however, did not differ between survivors and non-survivors. Overall RAS alteration in severe COVID-19 resembled severity of disease-matched patients with influenza. In mixed linear models, renin activity most strongly predicted angiotensin II and 1-7 levels. ACE2 also predicted angiotensin 1-7 levels and ALT-S. No single factor or the combined model, however, could fully explain ACE-S. ACE2 and ACE-S trajectories in severe COVID-19 did not differ between survivors and non-survivors. In conclusion, angiotensin II was elevated in severe COVID-19 but was markedly influenced by RAS inhibitors and driven by overall RAS activation. ACE-S was significantly lower with severe COVID-19 and did not correlate with ACE concentrations. A shift to the alt-RAS axis because of increased ACE2 could partially explain the relative reduction in angiotensin II levels.
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Renin as a Marker of Tissue Perfusion, Septic Shock and Mortality in Septic Patients: A Prospective Observational Study. Int J Mol Sci 2022; 23:ijms23169133. [PMID: 36012398 PMCID: PMC9409106 DOI: 10.3390/ijms23169133] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by the dysregulation of the host’s response to an infection, where the dominant mechanism is tissue hypoperfusion. Currently, the marker used to define tissue disorders is lactate levels, which may be elevated in other disease states as well. Renin is an essential hormone for the proper functioning of the renin-angiotensin-aldosterone (RASS) system. It is secreted in the glomerular apparatus in response to hypoperfusion. This study aimed to assess the usefulness of renin as a marker of tissue hypoperfusion in patients with sepsis and septic shock. A final group of 48 patients treated for sepsis and septic shock in the intensive care unit was included. Blood samples for renin quantification were collected in the morning as a part of routine blood analysis on the first, third, and fifth days. Sepsis was diagnosed in 19 patients (39.6%), and septic shock was diagnosed in 29 patients (60.4%). There was no significant difference in renin concentration between patients who received and did not receive continuous renal replacement therapy (CRRT) on any study day. Therefore, all samples were analyzed together in subsequent analyses. There was a significant difference in renin concentration between sepsis survivors and non-survivors on the third (31.5 and 119.9 pg/mL, respectively) and fifth (18.2 and 106.7 pg/mL, respectively) days. As a survival marker, renin was characterized by 69% and 71% overall accuracy if determined on the third and fifth days, respectively. There was a significant difference in renin concentration between sepsis and septic shock patients on the first (45.8 and 103.4 pg/mL, respectively) and third (24.7 and 102.1 pg/mL, respectively) days. At an optimal cut-off of 87 pg/mL, renin had very good specificity and a positive likelihood ratio. Renin was a strong predictor of mortality in patients with sepsis and septic shock. Further, the level of renin in patients with septic shock was significantly higher than in patients with sepsis. In combination with the assessment of lactate concentration, renin seems to be the optimal parameter for monitoring tissue hypoperfusion and could be helpful for septic shock diagnosis, as well as for identifying candidate patients for CRRT.
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Cho EJ, Lee MS, Kwon WY, Shin J, Suh GJ, Jung YS, Song WJ, Yeo G, Jo YH. Hypernatremia is associated with poor long-term neurological outcomes in out-of-hospital cardiac arrest survivors. Am J Emerg Med 2022; 59:30-36. [PMID: 35772225 DOI: 10.1016/j.ajem.2022.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/20/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Brain oedema after cardiac arrest is strongly associated with poor neurological outcomes. Excessive sodium supplementation may increase serum osmolarity and facilitate brain oedema development in cardiac arrest survivors. We aimed to investigate the association of serum sodium levels with long-term neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. METHODS This retrospective observational study used a multicentre prospective cohort registry of OHCA survivors collected between December 2013 and February 2018. We analyzed the association of serum sodium levels at the return of spontaneous circulation (ROSC) (Sodium 0H) and at 24 h after ROSC (Sodium 24H) with 1-year neurological outcomes in OHCA survivors. Patients with 1-year cerebral performance categories (CPC) 1 and 2 were included in the good outcome group while those with CPC 3, 4, and 5 were included in the poor outcome group. RESULTS Among 277 patients, 84 (30.3%) and 193 (69.7%) were in the good and poor outcome groups, respectively. Compared with the good outcome group, the poor outcome group showed significantly higher Sodium 24H levels (140 mEq/L vs. 137.4 mEq/L, p < 0.001). Increased serum sodium levels per 1 mEq/L increased the risk of poor 1-year CPC by 13% (adjusted odds ratio = 1.13; 95% CI, 1.04⎼1.23; p = 0.004). CONCLUSIONS Relatively high Sodium 24H levels showed a strong and independent association with poor long-term neurological outcomes in OHCA survivors. These findings may be applied in therapeutic strategies for improving neurological outcomes in OHCA survivors.
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Affiliation(s)
- Eun Joo Cho
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sung Lee
- Medical Research Team, Medical AI, 163 Yangjaecheon-ro, Gangnam-gu, Seoul, Republic of Korea.
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea.
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Yoon Sun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Won Ji Song
- Department of Dermatology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gyeongyeon Yeo
- Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
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Ammar MA, Ammar AA, Wieruszewski PM, Bissell BD, T Long M, Albert L, Khanna AK, Sacha GL. Timing of vasoactive agents and corticosteroid initiation in septic shock. Ann Intensive Care 2022; 12:47. [PMID: 35644899 PMCID: PMC9148864 DOI: 10.1186/s13613-022-01021-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/09/2022] [Indexed: 12/20/2022] Open
Abstract
Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.
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Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA.
| | - Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA
| | - Patrick M Wieruszewski
- Departments of Anesthesiology and Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Micah T Long
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI, USA
| | - Lauren Albert
- Department of Pharmacy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Center for Biomedical Informatics, Perioperative Outcomes and Informatics Collaborative, Medical Center Boulevard, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue, Hb-105, Cleveland, OH, USA
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Leisman DE, Mehta A, Thompson BT, Hacohen N, Filbin MR, Goldberg MB. Reply to Akin et al.: High Renin Concentrations in Severe COVID-19 Are Indicative for a Hypo-Renin-Angiotensin-System State. Am J Respir Crit Care Med 2022; 205:1253-1254. [PMID: 35348420 PMCID: PMC9872805 DOI: 10.1164/rccm.202202-0292le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Daniel E. Leisman
- Massachusetts General HospitalBoston, Massachusetts,Corresponding author (e-mail: )
| | - Arnav Mehta
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts,Broad Institute of Massachusetts Institute of Technology and HarvardCambridge, Massachusetts,Dana-Farber Cancer InstituteBoston, Massachusetts
| | - B. Taylor Thompson
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts
| | - Nir Hacohen
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts,Broad Institute of Massachusetts Institute of Technology and HarvardCambridge, Massachusetts
| | - Michael R. Filbin
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts,Broad Institute of Massachusetts Institute of Technology and HarvardCambridge, Massachusetts
| | - Marcia B. Goldberg
- Massachusetts General HospitalBoston, Massachusetts,Harvard Medical SchoolBoston, Massachusetts,Broad Institute of Massachusetts Institute of Technology and HarvardCambridge, Massachusetts
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38
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Krenn K, Tretter V, Kraft F, Ullrich R. The Renin-Angiotensin System as a Component of Biotrauma in Acute Respiratory Distress Syndrome. Front Physiol 2022; 12:806062. [PMID: 35498160 PMCID: PMC9043684 DOI: 10.3389/fphys.2021.806062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major concern in critical care medicine with a high mortality of over 30%. Injury to the lungs is caused not only by underlying pathological conditions such as pneumonia, sepsis, or trauma, but also by ventilator-induced lung injury (VILI) resulting from high positive pressure levels and a high inspiratory oxygen fraction. Apart from mechanical factors that stress the lungs with a specific physical power and cause volutrauma and barotrauma, it is increasingly recognized that lung injury is further aggravated by biological mediators. The COVID-19 pandemic has led to increased interest in the role of the renin-angiotensin system (RAS) in the context of ARDS, as the RAS enzyme angiotensin-converting enzyme 2 serves as the primary cell entry receptor for severe acute respiratory syndrome (SARS) coronavirus (CoV)-2. Even before this pandemic, studies have documented the involvement of the RAS in VILI and its dysregulation in clinical ARDS. In recent years, analytical tools for RAS investigation have made major advances based on the optimized precision and detail of mass spectrometry. Given that many clinical trials with pharmacological interventions in ARDS were negative, RAS-modifying drugs may represent an interesting starting point for novel therapeutic approaches. Results from animal models have highlighted the potential of RAS-modifying drugs to prevent VILI or treat ARDS. While these drugs have beneficial pulmonary effects, the best targets and application forms for intervention still have to be determined to avoid negative effects on the circulation in clinical settings.
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA. .,Outcomes Research Consortium, Cleveland, OH, USA.
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Leisman DE, Mehta A, Thompson BT, Charland NC, Gonye ALK, Gushterova I, Kays KR, Khanna HK, LaSalle TJ, Lavin-Parsons KM, Lilley BM, Lodenstein CL, Manakongtreecheep K, Margolin JD, McKaig BN, Rojas-Lopez M, Russo BC, Sharma N, Tantivit J, Thomas MF, Parry BA, Villani AC, Sade-Feldman M, Hacohen N, Filbin MR, Goldberg MB. Alveolar, Endothelial, and Organ Injury Marker Dynamics in Severe COVID-19. Am J Respir Crit Care Med 2022; 205:507-519. [PMID: 34878969 PMCID: PMC8906476 DOI: 10.1164/rccm.202106-1514oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
Rationale: Alveolar and endothelial injury may be differentially associated with coronavirus disease (COVID-19) severity over time. Objectives: To describe alveolar and endothelial injury dynamics and associations with COVID-19 severity, cardiorenovascular injury, and outcomes. Methods: This single-center observational study enrolled patients with COVID-19 requiring respiratory support at emergency department presentation. More than 40 markers of alveolar (including receptor for advanced glycation endproducts [RAGE]), endothelial (including angiopoietin-2), and cardiorenovascular injury (including renin, kidney injury molecule-1, and troponin-I) were serially compared between invasively and spontaneously ventilated patients using mixed-effects repeated-measures models. Ventilatory ratios were calculated for intubated patients. Associations of biomarkers with modified World Health Organization scale at Day 28 were determined with multivariable proportional-odds regression. Measurements and Main Results: Of 225 patients, 74 (33%) received invasive ventilation at Day 0. RAGE was 1.80-fold higher in invasive ventilation patients at Day 0 (95% confidence interval [CI], 1.50-2.17) versus spontaneous ventilation, but decreased over time in all patients. Changes in alveolar markers did not correlate with changes in endothelial, cardiac, or renal injury markers. In contrast, endothelial markers were similar to lower at Day 0 for invasive ventilation versus spontaneous ventilation, but then increased over time only among intubated patients. In intubated patients, angiopoietin-2 was similar (fold difference, 1.02; 95% CI, 0.89-1.17) to nonintubated patients at Day 0 but 1.80-fold higher (95% CI, 1.56-2.06) at Day 3; cardiorenovascular injury markers showed similar patterns. Endothelial markers were not consistently associated with ventilatory ratios. Endothelial markers were more often significantly associated with 28-day outcomes than alveolar markers. Conclusions: Alveolar injury markers increase early. Endothelial injury markers increase later and are associated with cardiorenovascular injury and 28-day outcome. Alveolar and endothelial injury likely contribute at different times to disease progression in severe COVID-19.
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Affiliation(s)
- Daniel E. Leisman
- Department of Anesthesiology, Critical Care, and Pain Medicine
- Department of Medicine
| | - Arnav Mehta
- Massachusetts General Hospital Cancer Center
- Department of Medicine
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Anna L. K. Gonye
- Center for Cancer Research
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Irena Gushterova
- Center for Cancer Research
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | | | | | - Thomas J. LaSalle
- Center for Cancer Research
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | | | | | | | - Kasidet Manakongtreecheep
- Center for Cancer Research
- Center for Immunology and Inflammatory Diseases, and
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | | | | | - Maricarmen Rojas-Lopez
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine
- Department of Microbiology, and
| | - Brian C. Russo
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine
- Department of Microbiology, and
| | - Nihaarika Sharma
- Center for Cancer Research
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Jessica Tantivit
- Center for Cancer Research
- Center for Immunology and Inflammatory Diseases, and
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Molly F. Thomas
- Center for Cancer Research
- Center for Immunology and Inflammatory Diseases, and
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | | | - Alexandra-Chloé Villani
- Massachusetts General Hospital Cancer Center
- Department of Medicine
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Moshe Sade-Feldman
- Massachusetts General Hospital Cancer Center
- Department of Medicine
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Nir Hacohen
- Massachusetts General Hospital Cancer Center
- Department of Medicine
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Michael R. Filbin
- Department of Emergency Medicine, and
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
| | - Marcia B. Goldberg
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine
- Department of Microbiology, and
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, Massachusetts; and
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Zarbock A, Chawla L, Bellomo R. Why the renin-angiotensin-aldosterone system (RAAS) in critically ill patients can no longer be ignored. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:389. [PMID: 34775967 PMCID: PMC8590862 DOI: 10.1186/s13054-021-03816-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/04/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Munster, Germany.
| | | | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Flannery AH, Ortiz-Soriano V, Li X, Gianella FG, Toto RD, Moe OW, Devarajan P, Goldstein SL, Neyra JA. Serum renin and major adverse kidney events in critically ill patients: a multicenter prospective study. Crit Care 2021; 25:294. [PMID: 34391450 PMCID: PMC8364694 DOI: 10.1186/s13054-021-03725-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/04/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Preliminary studies have suggested that the renin-angiotensin system is activated in critical illness and associated with mortality and kidney outcomes. We sought to assess in a larger, multicenter study the relationship between serum renin and Major Adverse Kidney Events (MAKE) in intensive care unit (ICU) patients. METHODS Prospective, multicenter study at two institutions of patients with and without acute kidney injury (AKI). Blood samples were collected for renin measurement a median of 2 days into the index ICU admission and 5-7 days later. The primary outcome was MAKE at hospital discharge, a composite of mortality, kidney replacement therapy, or reduced estimated glomerular filtration rate to ≤ 75% of baseline. RESULTS Patients in the highest renin tertile were more severely ill overall, including more AKI, vasopressor-dependence, and severity of illness. MAKE were significantly greater in the highest renin tertile compared to the first and second tertiles. In multivariable logistic regression, this initial measurement of renin remained significantly associated with both MAKE as well as the individual component of mortality. The association of renin with MAKE in survivors was not statistically significant. Renin measurements at the second time point were also higher in patients with MAKE. The trajectory of the renin measurements between time 1 and 2 was distinct when comparing death versus survival, but not when comparing MAKE versus those without. CONCLUSIONS In a broad cohort of critically ill patients, serum renin measured early in the ICU admission is associated with MAKE at discharge, particularly mortality.
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Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Victor Ortiz-Soriano
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fabiola G Gianella
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert D Toto
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA.
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Renin Kinetics Are Superior to Lactate Kinetics for Predicting In-Hospital Mortality in Hypotensive Critically Ill Patients. Crit Care Med 2021; 50:50-60. [PMID: 34166293 DOI: 10.1097/ccm.0000000000005143] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Whole blood lactate concentration is widely used in shock states to assess perfusion. We aimed to determine if the change in plasma renin concentration over time would be superior to the change in lactate concentration for predicting in-hospital mortality in hypotensive patients on vasopressors. DESIGN Prospective, observational cohort study. SETTING Tertiary academic ICU. PATIENTS Adult patients on vasopressors for greater than 6 hours to maintain a mean arterial pressure greater than or equal to 65 mm Hg during January 2020. INTERVENTIONS Plasma renin concentrations were measured at enrollment and at 24, 48, and 72 hours. Whole blood lactate measurements were performed according to normal standard of care. Logistic regression was performed to evaluate whether the change in renin or lactate concentration could predict in-hospital mortality. Generalized estimating equations were used to analyze the association between renin and lactate concentration and in-hospital mortality. The area under the receiver operating characteristics curve was performed to measure the discriminative ability of initial and peak renin and lactate concentration to predict mortality. The association between renin and lactate concentration above the upper limit of normal at each timepoint with in-hospital mortality was also examined. MEASUREMENTS AND MAIN RESULTS The study included 197 renin and 148 lactate samples obtained from 53 patients. The slope of the natural log (ln) of renin concentration was independently associated with mortality (adjusted odds ratio, 10.35; 95% CI, 1.40-76.34; p = 0.022), but the slope of ln-lactate concentration was not (adjusted odds ratio, 4.78; 95% CI, 0.03-772.64; p = 0.55). The generalized estimating equation models found that both ln-renin (adjusted odds ratio, 1.18; 95% CI, 1.02-1.37; p = 0.025) and ln-lactate (adjusted odds ratio, 2.38; 95% CI, 1.05-5.37; p = 0.037) were associated with mortality. Area under the receiver operating characteristics curve analysis demonstrated that initial renin could predict in-hospital mortality with fair discrimination (area under the receiver operating characteristics curve, 0.682; 95% CI, 0.503-0.836; p = 0.05), but initial lactate could not (area under the receiver operating characteristics curve, 0.615; 95% CI, 0.413-0.803; p = 0.27). Peak renin (area under the receiver operating characteristics curve, 0.728; 95% CI, 0.547-0.888; p = 0.01) and peak lactate (area under the receiver operating characteristics curve, 0.746; 95% CI, 0.584-0.876; p = 0.01) demonstrated moderate discrimination. There was no significant difference in discriminative ability between initial or peak renin and lactate concentration. At each study time point, a higher proportion of renin values exceeded the threshold of normal (40 pg/mL) in nonsurvivors than in survivors, but this association was not significant for lactate. CONCLUSIONS Although there was no significant difference in the performance of renin and lactate when examining the absolute values of each laboratory, a positive rate of change in renin concentration, but not lactate concentration, over 72 hours was associated with in-hospital mortality. For each one-unit increase in the slope of ln-renin, the odds of mortality increased 10-fold. Renin levels greater than 40 pg/mL, but not lactate levels greater than 2 mmol/L, were associated with in-hospital mortality. These findings suggest that plasma renin kinetics may be superior to lactate kinetics in predicting mortality of hypotensive, critically ill patients.
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Use of Angiotensin II in Severe Vasoplegia After Left Pneumonectomy Requiring Cardiopulmonary Bypass: A Renin Response Analysis. Crit Care Med 2021; 48:e912-e915. [PMID: 32931196 DOI: 10.1097/ccm.0000000000004502] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Describe a case of post-pneumonectomy vasoplegia managed with angiotensin II. Plasma renin activity was measured at specific time intervals to describe the relationship between endogenous renin activity and exogenous angiotensin II supplementation. DESIGN Case report. SETTING Spectrum Health Cardiothoracic Critical Care Unit. PATIENTS Fifty-seven-year-old male. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma renin activity at five pre-determined time points. Angiotensin II caused a significant increase in mean arterial pressure and a rapid reduction in catecholamine vasopressor doses from 0.75 to 0.31 mcg/kg/min norepinephrine equivalents. Plasma renin activity drawn immediately before angiotensin II initiation was 40 ng/mL/hr (normal, 0.6-3.0 ng/mL/hr) with resultant drop to 22 and 12 ng/mL/hr at 2 and 6 hours after angiotensin II initiation, respectively. The patient suffered no end-organ damage and achieved a positive outcome, discharging home on postoperative day 11. CONCLUSION Exogenous angiotensin II reduced catecholamine vasopressor doses and had an apparent effect in reducing endogenous renin production in this case. Prospective research is warranted to determine the utility of angiotensin II and to better understand it effects on the dysfunctional renin-angiotensin-aldosterone system during vasoplegic shock.
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Chow JH, Wittwer ED, Wieruszewski PM, Khanna AK. Evaluating the evidence for angiotensin II for the treatment of vasoplegia in critically ill cardiothoracic surgery patients. J Thorac Cardiovasc Surg 2021; 163:1407-1414. [PMID: 33875258 DOI: 10.1016/j.jtcvs.2021.02.097] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Jonathan H Chow
- Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC
| | - Erica D Wittwer
- Anesthesiology & Critical Care Medicine, Mayo Clinic School of Medicine, Rochester, Minn
| | - Patrick M Wieruszewski
- Anesthesiology & Critical Care Medicine, Mayo Clinic School of Medicine, Rochester, Minn
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, Ohio.
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Krenn K, Höbart P, Poglitsch M, Croizé A, Ullrich R. Equilibrium Angiotensin Metabolite Profiling in Patients with Acute Respiratory Distress Syndrome Indicates Angiotensin-Converting Enzyme Inhibition. Am J Respir Crit Care Med 2020; 202:1468-1471. [PMID: 32628511 DOI: 10.1164/rccm.201912-2504le] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | | | | | - Adrien Croizé
- Hospital of Wiener Neustadt, Wiener Neustadt, Austria
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48
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Bellomo R, Forni LG, Busse LW, McCurdy MT, Ham KR, Boldt DW, Hästbacka J, Khanna AK, Albertson TE, Tumlin J, Storey K, Handisides D, Tidmarsh GF, Chawla LS, Ostermann M. Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock. A Clinical Trial. Am J Respir Crit Care Med 2020; 202:1253-1261. [PMID: 32609011 PMCID: PMC7605187 DOI: 10.1164/rccm.201911-2172oc] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Rationale: Exogenous angiotensin II increases mean arterial pressure in patients with catecholamine-resistant vasodilatory shock (CRVS). We hypothesized that renin concentrations may identify patients most likely to benefit from such therapy. Objectives: To test the kinetic changes in renin concentrations and their prognostic value in patients with CRVS. Methods: We analyzed serum samples from patients enrolled in the ATHOS-3 (Angiotensin II for the Treatment of High-Output Shock) trial for renin, angiotensin I, and angiotensin II concentrations before the start of administration of angiotensin II or placebo and after 3 hours. Measurements and Main Results: Baseline serum renin concentration (normal range, 2.13–58.78 pg/ml) was above the upper limits of normal in 194 of 255 (76%) study patients with a median renin concentration of 172.7 pg/ml (interquartile range [IQR], 60.7 to 440.6 pg/ml), approximately threefold higher than the upper limit of normal. Renin concentrations correlated positively with angiotensin I/II ratios (r = 0.39; P < 0.001). At 3 hours after initiation of angiotensin II therapy, there was a 54.3% reduction (IQR, 37.9% to 66.5% reduction) in renin concentration compared with a 14.1% reduction (IQR, 37.6% reduction to 5.1% increase) with placebo (P < 0.0001). In patients with renin concentrations above the study population median, angiotensin II significantly reduced 28-day mortality to 28 of 55 (50.9%) patients compared with 51 of 73 patients (69.9%) treated with placebo (unstratified hazard ratio, 0.56; 95% confidence interval, 0.35 to 0.88; P = 0.012) (P = 0.048 for the interaction). Conclusions: The serum renin concentration is markedly elevated in CRVS and may identify patients for whom treatment with angiotensin II has a beneficial effect on clinical outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 02338843).
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Affiliation(s)
- Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine & Radiology, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lui G Forni
- Intensive Care Unit, Royal Surrey Hospital Foundation Trust, Guildford, United Kingdom.,Department of Clinical & Experimental Medicine, School of Biosciences & Medicine, University of Surrey, Guildford, United Kingdom
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, and
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Kealy R Ham
- Department of Critical Care, Regions Hospital, University of Minnesota, St. Paul, Minnesota
| | - David W Boldt
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Johanna Hästbacka
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California-Davis, Northern California Health System, Mather, California
| | - James Tumlin
- Renal Division, Department of Medicine, Emory University Medical Center, Emory University, Atlanta, Georgia
| | | | | | - George F Tidmarsh
- La Jolla Pharmaceutical Company, San Diego, California.,Stanford University, Palo Alto, California
| | - Lakhmir S Chawla
- La Jolla Pharmaceutical Company, San Diego, California.,Department of Medicine, Veterans Affairs Medical Center, San Diego, California; and
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St. Thomas' Hospital, King's College London, London, United Kingdom
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Abstract
The recent demonstration of the significant reduction in mortality in patients with septic shock treated with adjunctive glucocorticoids combined with fludrocortisone and the effectiveness of angiotensin II in treating vasodilatory shock have renewed interest in the role of the mineralocorticoid axis in critical illness. Glucocorticoids have variable interactions at the mineralocorticoid receptor. Similarly, mineralocorticoid receptor-aldosterone interactions differ from mineralocorticoid receptor-glucocorticoid interactions and predicate receptor-ligand interactions that differ with respect to cellular effects. Hyperreninemic hypoaldosteronism or selective hypoaldosteronism, an impaired adrenal response to increasing renin levels, occurs in a subgroup of hemodynamically unstable critically ill patients. The suggestion is that there is a defect at the level of the adrenal zona glomerulosa associated with a high mortality rate that may represent an adaptive response aimed at increasing cortisol levels. Furthermore, cross-talk exists between angiotensin II and aldosterone, which needs to be considered when employing therapeutic strategies.
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50
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Leisman DE, Fernandes TD, Bijol V, Abraham MN, Lehman JR, Taylor MD, Capone C, Yaipan O, Bellomo R, Deutschman CS. Impaired angiotensin II type 1 receptor signaling contributes to sepsis-induced acute kidney injury. Kidney Int 2020; 99:148-160. [PMID: 32882263 DOI: 10.1016/j.kint.2020.07.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 07/16/2020] [Accepted: 07/24/2020] [Indexed: 12/26/2022]
Abstract
In sepsis-induced acute kidney injury, kidney blood flow may increase despite decreased glomerular filtration. Normally, angiotensin-II reduces kidney blood flow to maintain filtration. We hypothesized that sepsis reduces angiotensin type-1 receptor (AT1R) expression to account for this observation and tested this hypothesis in a patient case-control study and studies in mice. Seventy-three mice underwent cecal ligation and puncture (a sepsis model) or sham operation. Additionally, 94 septic mice received losartan (selective AT1R antagonist), angiotensin II without or with losartan, or vehicle. Cumulative urine output, kidney blood flow, blood urea nitrogen, and creatinine were measured. AT1R expression was assessed using ELISA, qPCR, and immunofluorescence. A blinded pathologist evaluated tissue for ischemic injury. AT1R expression was compared in autopsy tissue from seven patients with sepsis to that of the non-involved portion of kidney from ten individuals with kidney cancer and three non-infected but critically ill patients. By six hours post ligation/puncture, kidney blood flow doubled, blood urea nitrogen rose, and urine output fell. Concurrently, AT1R expression significantly fell 2-fold in arterioles and the macula densa. Creatinine significantly rose by 24 hours and sham operation did not alter measurements. Losartan significantly exacerbated ligation/puncture-induced changes in kidney blood flow, blood urea nitrogen, creatinine, and urine output. There was no histologic evidence of cortical ischemia. Significantly, angiotensin II prevented changes in kidney blood flow, creatinine, and urine output compared to vehicle. Co-administering losartan with angiotensin-II reversed this protection. Relative to both controls, patients with sepsis had low AT1R expression in arterioles and macula densa. Thus, murine cecal ligation/puncture and clinical sepsis decrease renal AT1R expression. Angiotensin II prevents functional changes while AT1R-blockade exacerbates them independent of ischemia in mice.
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Affiliation(s)
- Daniel E Leisman
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Tiago D Fernandes
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Vanesa Bijol
- Department of Pathology, North Shore University Hospital, Manhasset, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Mabel N Abraham
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Jake R Lehman
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Matthew D Taylor
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Christine Capone
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Omar Yaipan
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Rinaldo Bellomo
- Data Analytics, Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Centre of Integrated Critical Care, University of Melbourne, Melbourne, Australia; School of Medicine, University of Melbourne, Melbourne, Australia
| | - Clifford S Deutschman
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
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