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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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Shrestha DB, Sedhai YR, Oli PR, Proskuriakova E, Adelkhanova A, Shtembari J, Khan TMA, Singh K, Ahmed MA, Waheed I, Kazimuddin N, Steff R, Acharya R, Patel NK. Prior Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers and Clinical Outcomes of Sepsis and Septic Shock: A Systematic Review and Meta-analysis. J Cardiovasc Pharmacol 2024; 83:16-22. [PMID: 37815234 DOI: 10.1097/fjc.0000000000001491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/15/2023] [Indexed: 10/11/2023]
Abstract
ABSTRACT Sepsis and septic shock are life-threatening conditions that are associated with high mortality and considerable health care costs. The association between prior angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) use and outcomes after sepsis is elusive. The aim of this study was to evaluate the role of the prior use of ACEi or ARBs and outcomes after sepsis and septic shock. A relevant literature review was performed in 4 databases from inception until July 2022. Independent reviewers first screened the title, abstract, and full text, and then, data extraction and analysis were performed. One post hoc analysis of a trial and 6 retrospective cohort studies were included in this review. There were 22% lower odds of in-hospital/30-day mortality among patients who have used ACEi/ARBs in the past [23.83% vs. 37.20%; odds ratio (OR), 0.78, 95% confidence interval (CI), 0.64-0.96], and reduced 90-day mortality (OR, 0.80, 95% CI, 0.69-0.92). ACEi/ARBs users were found to have 31% lesser odds of developing acute kidney injury as compared with nonusers (OR, 0.69, 95% CI, 0.63-0.76). There was no significant difference in the length of hospital stay (MD 1.26, 95% CI, ‒7.89 to 10.42), need for renal replacement therapy (OR, 0.71, 95% CI, 0.13-3.92), mechanical ventilation (OR, 1.10, 95% CI, 0.88-1.37) or use of vasopressors (OR, 1.21, 95% CI, 0.91-1.61). Based on this analysis, prior use of ACEi/ARBs lowers the risk of mortality and adverse renal events in patients with sepsis and septic shock.
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Affiliation(s)
| | - Yub Raj Sedhai
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Nepal
| | | | - Alla Adelkhanova
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL
| | - Tahir Muhammad Abdullah Khan
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Karan Singh
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Muhammad Altaf Ahmed
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Irfan Waheed
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Nisarfathima Kazimuddin
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Rodney Steff
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Roshan Acharya
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; and
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, School of Medicine, Richmond, VA
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Tibi S, Zeynalvand G, Mohsin H. Role of the Renin Angiotensin Aldosterone System in the Pathogenesis of Sepsis-Induced Acute Kidney Injury: A Systematic Review. J Clin Med 2023; 12:4566. [PMID: 37510681 PMCID: PMC10380384 DOI: 10.3390/jcm12144566] [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: 05/28/2023] [Revised: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Sepsis is a life-threatening condition responsible for up to 20% of all global deaths. Kidneys are among the most common organs implicated, yet the pathogenesis of sepsis-induced acute kidney injury (S-AKI) is not completely understood, resulting in the treatment being nonspecific and responsive. In situations of stress, the renin angiotensin aldosterone system (RAAS) may play a role. This systematic review focuses on analyzing the impact of the RAAS on the development of S-AKI and discussing the use of RAAS antagonists as an emerging therapeutic option to minimize complications of sepsis. METHODS Studies were identified using electronic databases (Medline via PubMed, Google Scholar) published within the past decade, comprised from 2014 to 2023. The search strategy was conducted using the following keywords: sepsis, S-AKI, RAAS, Angiotensin II, and RAAS inhibitors. Studies on human and animal subjects were included if relevant to the keywords. RESULTS Our search identified 22 eligible references pertaining to the inclusion criteria. Treatment of sepsis with RAAS inhibitor medications is observed to decrease rates of S-AKI, reduce the severity of S-AKI, and offer an improved prognosis for septic patients. CONCLUSION The use of RAAS antagonists as a treatment after the onset of sepsis has promising findings, with evidence of decreased renal tissue damage and rates of S-AKI and improved survival outcomes. REGISTRATION INPLASY202360098.
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Affiliation(s)
- Sedra Tibi
- School of Medicine, California University of Science and Medicine, Colton, CA 92324, USA
| | - Garbel Zeynalvand
- School of Medicine, California University of Science and Medicine, Colton, CA 92324, USA
| | - Hina Mohsin
- School of Medicine, California University of Science and Medicine, Colton, CA 92324, USA
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Association of systolic, diastolic, mean, and pulse pressure with morbidity and mortality in septic ICU patients: a nationwide observational study. Ann Intensive Care 2023; 13:9. [PMID: 36807233 PMCID: PMC9941378 DOI: 10.1186/s13613-023-01101-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/21/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Intensivists target different blood pressure component values to manage intensive care unit (ICU) patients with sepsis. We aimed to evaluate the relationship between individual blood pressure components and organ dysfunction in critically ill septic patients. METHODS In this retrospective observational study, we evaluated 77,328 septic patients in 364 ICUs in the eICU Research Institute database. Primary exposure was the lowest cumulative value of each component; mean, systolic, diastolic, and pulse pressure, sustained for at least 120 min during ICU stay. Primary outcome was ICU mortality and secondary outcomes were composite outcomes of acute kidney injury or death and myocardial injury or death during ICU stay. Multivariable logistic regression spline and threshold regression adjusting for potential confounders were conducted to evaluate associations between exposures and outcomes. Sensitivity analysis was conducted in 4211 patients with septic shock. RESULTS Lower values of all blood pressures components were associated with a higher risk of ICU mortality. Estimated change-points for the risk of ICU mortality were 69 mmHg for mean, 100 mmHg for systolic, 60 mmHg for diastolic, and 57 mmHg for pulse pressure. The strength of association between blood pressure components and ICU mortality as determined by slopes of threshold regression were mean (- 0.13), systolic (- 0.11), diastolic (- 0.09), and pulse pressure (- 0.05). Equivalent non-linear associations between blood pressure components and ICU mortality were confirmed in septic shock patients. We observed a similar relationship between blood pressure components and secondary outcomes. CONCLUSION Blood pressure component association with ICU mortality is the strongest for mean followed by systolic, diastolic, and weakest for pulse pressure. Critical care teams should continue to follow MAP-based resuscitation, though exploratory analysis focusing on blood pressure components in different sepsis phenotypes in critically ill ICU patients is needed.
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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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Cruz-López EO, Ye D, Wu C, Lu HS, Uijl E, Mirabito Colafella KM, Danser AHJ. Angiotensinogen Suppression: A New Tool to Treat Cardiovascular and Renal Disease. Hypertension 2022; 79:2115-2126. [PMID: 35904033 PMCID: PMC9444253 DOI: 10.1161/hypertensionaha.122.18731] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple types of renin-angiotensin system (RAS) blockers exist, allowing interference with the system at the level of renin, angiotensin-converting enzyme, or the angiotensin II receptor. Yet, in particular, for the treatment of hypertension, the number of patients with uncontrolled hypertension continues to rise, either due to patient noncompliance or because of the significant renin rises that may, at least partially, overcome the effect of RAS blockade (RAS escape). New approaches to target the RAS are either direct antisense oligonucleotides that inhibit angiotensinogen RNA translation, or small interfering RNA (siRNA) that function via the RNA interference pathway. Since all angiotensins stem from angiotensinogen, lowering angiotensinogen has the potential to circumvent the RAS escape phenomenon. Moreover, antisense oligonucleotides and small interfering RNA require injections only every few weeks to months, which might reduce noncompliance. Of course, angiotensinogen suppression also poses a threat in situations where the RAS is acutely needed, for instance in women becoming pregnant during treatment, or in cases of emergency, when severe hypotension occurs. This review discusses all preclinical data on angiotensinogen suppression, as well as the limited clinical data that are currently available. It concludes that it is an exciting new tool to target the RAS with high specificity and a low side effect profile. Its long-term action might revolutionize pharmacotherapy, as it could overcome compliance problems. Preclinical and clinical programs are now carefully investigating its efficacy and safety profile, allowing an optimal introduction as a novel drug to treat cardiovascular and renal diseases in due time.
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Affiliation(s)
- Edwyn O Cruz-López
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
| | - Dien Ye
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
| | - Congqing Wu
- Saha Cardiovascular Research Center (C.W., H.S.L.), University of Kentucky.,Department of Surgery (C.W.), University of Kentucky
| | - Hong S Lu
- Saha Cardiovascular Research Center (C.W., H.S.L.), University of Kentucky.,Department of Physiology (H.S.L.), University of Kentucky
| | - Estrellita Uijl
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
| | | | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
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Initial Arterial Blood Pressure Targets in Patients With Septic Shock: One Size Fits All or Made to Measure? Crit Care Med 2021; 49:719-721. [PMID: 33731615 DOI: 10.1097/ccm.0000000000004900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cove ME, MacLaren G, Brodie D, Kellum JA. Optimising the timing of renal replacement therapy in acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:184. [PMID: 34059096 PMCID: PMC8165519 DOI: 10.1186/s13054-021-03614-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
The optimal timing of renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) has been much debated. Over the past five years several studies have provided new guidance for evidence-based decision-making. High-quality evidence now supports an approach of expectant management in critically ill patients with AKI, where RRT may be deferred up to 72 h unless a life-threatening indication develops. Nevertheless, physicians’ judgment still plays a central role in identifying appropriate patients for expectant management.
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Affiliation(s)
- Matthew E Cove
- Department of Medicine, National University Singapore, NUHS Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Daniel Brodie
- Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
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